Inspection on 28/10/09 for Ethel Road (7)

This inspection was carried out on 28th October 2009.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ethel Road (7) 21/04/10

Ethel Road (7) 23/10/08

Ethel Road (7) 22/11/07

Ethel Road (7) 03/05/07

Ethel Road (7) 09/10/06

Ethel Road (7) 03/02/06

Ethel Road (7) 21/10/05

Ethel Road (7) 24/01/05

Ethel Road (7) 11/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Ethel Road (7) 7 Ethel Road Ashford Middlesex TW15 3RB     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Suzanne Magnier     Date: 2 8 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 45 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 45 Information about the care home Name of care home: Address: Ethel Road (7) 7 Ethel Road Ashford Middlesex TW15 3RB 01784240646 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Vaughan Charlton,Mrs Victoria Charlton care home 1 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 1 The registered person may provide the following category of service only: Care home only(PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category : Learning disability ( LD) Date of last inspection Brief description of the care home The home is privately owned and is registered as a care home which currently supports one adult with a learning disability. The resident has their own single bedroom and has sole use of a bathroom and toilet situated in close proximity to their bedroom. Care and support is provided by the registered providers. The resident has a choice to share the communal lounge, dining room, conservatory and part of an enclosed garden and domestic style kitchen with members of the family. Care Homes for Adults (18-65 years) Page 4 of 45 Over 65 0 1 2 3 1 0 2 0 0 8 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 0 zero stars. This means the people who use this service experience poor quality outcomes. This inspection of the care home was an unannounced Key Inspection carried out by Ms S Magnier Regulation Inspector. The resident lives in a family home and it is acknowledged that the expectations of the regulation of the national Minimum Standards may differ marginally from that of a larger residential care establishment. This has been taken into account during the inspection process yet where standards in the home need to be improved for the safety and well being of the resident these have been addressed within the report. The inspection was undertaken during the morning and also during the afternoon due to the familys prior commitments during the half term. The registered manager represented the service throughout the inspection. For the purpose of the report the individual using the service is referred to as the resident. Care Homes for Adults (18-65 years) Page 5 of 45 The inspector arrived at the service at 08.45 until 11.00 and returned from 14.45 until 16.30. It was a thorough look at how well the home is doing and took into account information provided by the home and any information that the commission had received about the service since the last inspection on the 23rd October 2008. The inspector looked at how well the service was meeting standards and some additional standards have been assessed during the inspection. Judgements about the standard of the service have been documented within the report. The home had submitted the Annual Quality Assurance Assessment AQAA prior to the inspection. The document was discussed with the registered manager as the content of the document was brief and did not fully reflect the current care and services provided to the resident. Following the completion of the report it was identified that some of the information included within the AQAA was factually incorrect and misleading. It is the expectation that future AQAAs be completed be accurately and is presented in more detail regarding the care and support and facilities offered at the home in order that the commission can ascertain the robustness of the service. The commission did not request any written comments, in the form of surveys, from people associated with the service. These will be requested for the next key inspection. The inspector spent time talking to the resident and observing the morning routine in the home. The residents views and opinions about the service were sought and have been documented within the report. The communal areas and the residents bedroom and bathroom were evidenced. Documents sampled prior and during the inspection included the homes Annual Quality Assurance Assessment AQAA, the Statement of Purpose and Service User Guide, the residents care plan and risk assessments, the medication policy and procedure, the health and safety policy and procedures including complaints and safeguarding. The registered manager advised that a large quantity of the homes documents were stored on a computer which was not working properly during the inspection. The inspector requested documents to be emailed to the commission without delay following the inspection, which would inform the inspection and have bearing on the findings of the inspection process yet these have not been received by the commission prior to the report being sent to the registered providers in draft form. No complainant has contacted the Commission directly with information concerning a complaint made to the service yet one safeguarding referral has been made since the last inspection which has yet to be concluded. Care Homes for Adults (18-65 years) Page 6 of 45 What the care home does well: What has improved since the last inspection? What they could do better: The management and administration of the home is not robust. There was insufficient information within the homes Statement of Purpose and Service User Guide in order to reflect that the resident, or any future resident, continues to have a right to be informed about the services and facilities in their home. The information is not in an available format which meets the capacity of the resident. The residents needs appeared to be met however the homes records are poor and need to be improved. The residents support and personal care needs within the care plan contain basic information and the management of risk assessments does not fully promote the residents rights to safety and well being. Documented evidence regarding meaningful activities the resident participates in were not current. There was no evidence regarding the planning of menus or evidence to demonstrate that a nutritious varied and balanced diet was available to the resident. The medication procedures would not ensure that medication is administered in a safe and appropriate way. The complaints and safeguarding protocols do not promote the residents rights to raise concerns and their rights to be protected from harm and abuse are not robust. Standards of cleanliness and hygiene in the residents bedroom and bathroom need to be improved in order to ensure the safety and well being of the resident. The registered providers did not provide evidence of a robust system for their training and development in order to demonstrate that they have appropriate skills and abilities to meet the changing needs of the resident. The residents views and opinions and those of others associated with the home are not actively promoted or recorded. The residents general safety and welfare is not promoted and improvements need to Care Homes for Adults (18-65 years) Page 7 of 45 be made regarding the health and safety concerns in the home. An improvement plan has been requested which must be completed by the registered providers to inform the commission how the home intends to make the necessary changes to comply with the regulations and improve outcomes for the resident within the timescales agreed. Failure to meet the requirements made may lead to enforcement action being considered. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 45 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 45 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is insufficient information available to the resident, or any future resident, about the home and the statement of purpose and service user guide do not reflect that the resident continues to have a right to be informed and information is available in a format which meets the capacity of the resident. The homes records were insufficient to demonstrate that the residents needs are well monitored and changes fully documented and actions implemented in order to ensure and promote the welfare and wellbeing of the resident. Evidence: The home continues to offer a service to one resident who has resided at Ethel Road since the home was granted registration in July 2001. The Annual Quality Assurance Assessment AQAA advises that no admissions are planned at the registered premises. The Statement of Purpose was sampled and it was noted is written in plain English and gave descriptions regarding the services and facilities offered by the home. The Service User Guide was sampled and the document contained a variety of shortfalls which included no documentation regarding the terms and conditions in respect of the Care Homes for Adults (18-65 years) Page 10 of 45 Evidence: residents accommodation, provision of food and personal care, details of the fees payable, arrangements in place for paying and charging for additional services, a standard form of a contract for the provision of services, the most recent inspection report, a summary of the complaints procedure and the telephone number and address of the current commission. A requirement has been made that the Statement of Purpose and Service User Guide are updated and both documents are written in a format which can be understood by the resident for example pictures or symbols. Written documentation, in the form of reviews and daily records were not available, as the registered manager advised the computer monitor had broken down. It has been required that records must be available to evidence that any changes in the residents care and support needs are clearly documented to ensure the residents welfare and well being continue to be monitored and actions are taken to address any changes. Care Homes for Adults (18-65 years) Page 11 of 45 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents support and personal care needs within the care plan contain basic information and the care plans must be developed to promote a person centred approach. The management of risk assessments does not fully promote the residents rights to safety and well being. Clear evidence of auditing care plans and risk assessments must be made available to ensure that the residents needs continue to be met. Evidence: During the inspection the registered manager demonstrated a good understanding of the resident and reinforced that the home is run as a family home with the resident being very much part of the family. It was observed that the resident had some control over their life and moved freely around the downstairs part of their home which included their bathroom, the communal kitchen and dining room. The care plan sampled consisted of the daily routine of the resident which is centred around when they were or were not at college and includes basic information Care Homes for Adults (18-65 years) Page 12 of 45 Evidence: necessary to deliver the residents care. The care plan included how the resident is supported to get up by prompting and encouraging to promote a level of independence with personal care and dressing. It was observed during the inspection that, although delayed, the routine which was recorded within the residents care plan was undertaken with the support from the registered manager. The care plan sampled did not indicate that the resident had been involved with the development of the care plan and it was noted that it was in a locked filing cabinet and not readily accessible to the resident. The registered manager advised that the care plan sampled was a current document yet when advised of several shortfalls it was agreed that the care plan required further development. Requirements have been made that a care plan is developed and includes a person centred approach, the resident has involvement in producing their care plan, the care plan is regularly reviewed and review dates are recorded in order that the care plans can be audited, includes the residents goals or aspirations, their strengths and references to their diversity, their communication abilities and preferred communication style, their skills and abilities and how they make choices in their life and direct the service they receive. The residents daily records could not be accessed due to the difficulties with the homes computer to give examples of how the resident had spent their day and their general demeanour and the document was requested to be sent by email to the commission without delay yet this had not been received prior to the report being sent in draft form to the registered providers. Several risk assessments were sampled by the inspector which included assessments for eating and choking, community activities, medication whilst in the community, environment disaster plan, waiting in the porch and bathing. The format of the risk assessments were complex and had been adapted from another source and included a section entitled re assessment following implementation of control measures or review which was the section for review but had not been completed on all the assessments sampled. The risk assessment were stored electronically and had not been signed by the registered manager who had completed them. Some risk assessments referred to the resident by name, some with the word client and some referred to the establishment with no reference to the resident or the support they may require in the event of a disaster at the home. The residents eating and drinking risk assessment regarding dehydration had not been correctly assessed and rated regarding the severity of the hazard as the section of the risk assessment had not been completed. Care Homes for Adults (18-65 years) Page 13 of 45 Evidence: Requirements have been made that the standard and format of the risk assessments are revised and improved to ensure that the current hazards in the residents life are fully documented, the measures and actions taken to reduce the hazards are clearly recorded and that review dates are recorded in order that the risk assessments can be audited to promote the residents best interests and safety and ensure their well being as far as reasonably practicable. Care Homes for Adults (18-65 years) Page 14 of 45 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The resident is able to exercise some choice about their lifestyle and meaningful relationships are promoted and maintained. Documented evidence regarding meaningful activities the resident participates in were not current and there was no evidence regarding the planning of menus or evidence to demonstrate that a nutritious, varied and balanced diet was available. Evidence: The inspection was undertaken during the half term school holidays and it was observed that the residents foster brothers were entertaining friends during the morning and had been asked to stay upstairs with the homes five dogs due to the inspection taking place. The atmosphere in the home was noisy and chaotic with the dogs barking and the children shouting upstairs. The resident stated he had got used to the dogs barking. When the children came downstairs it was noted that there was no interaction from the children toward the resident. Care Homes for Adults (18-65 years) Page 15 of 45 Evidence: During discussion with the registered manager she advised that due to the residents change of health she is with the resident during the day as they had not been attending college for 5 weeks due to their health problems as the college were unable support the resident due to their care needs. The registered manager advised that the care manager had been informed of this arrangement yet following the inspection the care manager confirmed to the commission that they were not aware the resident had not been attending college for the such a length of time. The care plan and the activities programme, dated 2002, were sampled and did not reflect the current changes in the residents lifestyle. It has been required that an up to date activities programme is developed which details the current meaningful activities undertaken by the resident both within the home and the local community. The AQAA submitted includes details that there has been no contact with family, friends or an advocate in the last 12 months yet the the resident confirmed that they enjoyed special relationships with people and went to visit family members when it was convenient with them. It was confirmed by the resident that they have a special relationship and they were going to meet their friend at the cinema during the early afternoon. Whilst speaking with the resident in their room it was observed that the room contained a variety of DVDs and Cds, a music centre, disco lights and a large screen television. The resident confirmed that they liked to stay in bed and would stay there all day if they could and liked to watch movies. The registered manager confirmed that the resident joined his foster brothers in playing with the Wii games but generally preferred to watch television in his own room as the movies would not be suitable for young children. A person known to the family and the resident is referred to as an advocate and it was confirmed by the registered manager that the registered providers are only acquaintances of the individual and do not mix socially. It was confirmed that where a family holiday had been arranged the resident had invited their advocate. The registered manager advised that the advocate supports the resident to church when they want to go and also the resident will attend church during festivities and attend school presentations by their foster brothers. The fridge and freezer were well stocked and the registered manager stated that this was because it was half term. Meals continue to be prepared and taken in a domestic manner. It was observed that the resident had access to the homes kitchen and was able to communicate to the registered manager what they wanted for breakfast when Care Homes for Adults (18-65 years) Page 16 of 45 Evidence: offered a choice of cereals. There was no evidence available to support that the resident was receiving or not receiving a balanced and healthy diet as no menus were available. It has been required that arrangements must be made that records of food provided to the resident are in sufficient detail to enable the person inspecting the record to determine whether the diet is satisfactory in relation to nutrition in order to promote the residents health and well being. Care Homes for Adults (18-65 years) Page 17 of 45 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents needs appeared to be met however the homes records are poor and need to be improved. The residents choice and dignity is promoted. Medication procedures do not ensure that medication is administered in a safe and appropriate way. Evidence: Whilst sampling the residents care plan it was observed that the registered manager has some written guidelines that give information about how the resident is supported regarding personal and health care support. There was no evidence that the guidelines, as previously documented, had been discussed with the resident and if they have been involved in making the decisions regarding their preferences of receiving support. It was evident through observation that the registered manager continues to encourage the resident to develop and maintain their independence skills, privacy and dignity when bathing and getting dressed. The AQAA states that the client has ongoing health care needs. The resident always attends health appointments on time, and every check up i.e dentist, eyes, heart ecg, and the recently diagnosed problem, are always done every six months. Care Homes for Adults (18-65 years) Page 18 of 45 Evidence: There was limited evidence to support that a range of health care professionals are involved in the ongoing health care support needs of the resident as the only records available were those of the district nurse who visits the home every six weeks to offer specialised support. The registered manager stated that the resident had made frequent visits to their general practitioner yet there were no records of visits available during the inspection and no records of discharge from a recent spell in hospital. The registered manager confirmed that no dietitian, speech and language therapist, with regard to the residents history of difficulty in swallowing, continence advisory service other than the district nurse team, were currently involved in the care of the resident. Whilst sampling the care plan with the registered manager it was noted that the care plan could be misleading as it states the resident has a soft diet but also says that they can eat sausages, chicken, chips and toast. No records were available regarding the residents body weight which the registered manager advised was measured regularly by the residents general practitioner. In addition the AQAA submitted indicated that the registered manager has noted that it is not applicable for the home to carry out nutritional screening or to take action to meet the needs of the resident who may be at risk of malnutrition. Reference within a risk assessment has also been made to the importance of monitoring the residents fluid and output yet no documents were seen which indicated how the residents fluid intake and output were recorded. As previously documented there were no records of visits or health care plans available to sample during the inspection and it has been required that the home must keep documented evidence of any plans relating to the resident in respect of fluid intake and output, body weight, special diets prepared and taken by the resident, and records of appointments attended with health care professionals in order to promote the residents health and well being. The medication policy and procedure was sampled and was noted to be an adapted policy and procedure from another organisation which had little bearing on how the resident may prefer to take their prescribed medication. The policy and procedure referred to the National Care Standards Commission which has not been operational since 2005 yet the AQAA submitted indicated that the medication policy and procedure had been updated in March 2009. The registered manager advised that the resident was not currently taking any medication yet this information was not included in the homes AQAA. During the key Care Homes for Adults (18-65 years) Page 19 of 45 Evidence: inspection on 22nd November 2007 it was reported that the requirement made that the registered manager or her husband to undertake training in the safe handling and administration of medication was met. It has been required that a relevant medication policy and procedure is developed which includes the arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home in order to ensure the safety and welfare of the resident. Care Homes for Adults (18-65 years) Page 20 of 45 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints and safeguarding protocols do not promote the residents rights raise to concerns and their rights to be protected from harm and abuse are not robust. Evidence: The AQAA submitted indicated that the homes complaints procedure had been updated in February 2009. The complaints procedure and a complaints log sampled during the inspection had been adapted from another organisations procedure and was dated 2002. There was little relevance of the procedure for the home and there was no evidence that a procedure was available in picture or symbol form for the resident to use should they wish to raise a complaint or concern regarding any matter in their life. It has been required that arrangements must be made that a complaints procedure is developed for considering complaints which must include all details outlined in Regulation 22 of the Care Homes Regulations in order to ensure that any person, including the resident who may wish to raise a complaint has the correct information and are assured their views and opinions about the service will be listened to and acted upon. The AQAA submitted indicated that the home has not been subject to any safeguarding referrals however the registered manager is aware that the home have been subject to one safeguarding vulnerable adult referral which has not been concluded. The registered manager, on request, supplied the local authority multi agency safeguarding vulnerable adults policy document dated 2001 during the Care Homes for Adults (18-65 years) Page 21 of 45 Evidence: inspection. She advised that she knew they were not the most current stating that she had the 2005 policy document on the computer which was the most current. It was evident that the registered manager was unaware that the most recent local authority multi agency safeguarding vulnerable adults policy document is dated 2008 and that these were not within the homes premises. There was evidence available that the home has some safeguarding information which included an easy read safeguarding summary. During previous inspections requirements had been made that the registered manager undertake safeguarding vulnerable adults training and this was confirmed as met during 23rd October 2008 key inspection. The AQAA submitted indicated that the home do not have a whistle blowing policy and no safeguarding vulnerable adults policy regarding safeguarding the resident was supplied during the inspection. The AQAA submitted indicated that the homes code of conduct policy had been updated in February 2009. A policy document entitled Code of Conduct Staff and Client relationship policy was sampled which was a document that been adapted from another organisations procedure and within the policy it stated Where the allegation appears to implicate a member of staff the Authoritys disciplinary procedures will be invoked and the allegation investigated without delay and in accordance with the procedures requirements. The document was considered not relevant to the care home or in compliance with the local authority multi agency safeguarding protocols. The AQAA submitted indicated that the home does not have a policy and procedure regarding physical intervention and restraint however the inspector was provided with a document which had been adapted from another organisation and was titled policy on restrictive physical interventions dated June 2007. The policy states that staff at Ethel Road have no powers to punish service users but are empowered to use agreed methods to control an individuals behaviour to prevent harm to themselves other people and property. It also states that service user and their families must be involved in the process of devising plans and agreeing on the type of interventions to be used. These details were discussed with the registered person and it was agreed that the policy was not compliant with the recent legislation regarding the Mental Capacity Act and the Deprivation of Liberty Safeguards. During the course of the inspection the registered manager advised that due to the residents current health she was throwing away the residents clothes and bed linen which could not be laundered. It was advised that the residents care manager was aware of the current situation however there was no documented evidence to support Care Homes for Adults (18-65 years) Page 22 of 45 Evidence: that the resident or the care manager had agreed for clothing or bed linen to be thrown away and no evidence of a clothing inventory to document a current account of the clothes and bed linen owned by the resident. The AQAA submitted indicated that the homes missing person policy had been updated in March 2009. The missing person policy provided during the inspection was a generic policy and was not dated, did not contain information for example a description or photograph of the resident, and contained incorrect information regarding the contact details of the commission. The registered providers are the sole carers of the resident and their Criminal Records Bureaus disclosure numbers were not sampled as part of this key inspection and the AQQA does not detail any evidence when the checks were last issued. It was confirmed that the resident has an advocate and as previously reported the registered manager advised that the providers are only acquaintances of the individual and do not mix socially. No records were sampled regarding the involvement of the advocate and the AQAA submitted indicates that the home do not have a policy or procedure or code of practise regarding working with volunteers. During previous inspections the issue of obtaining a Criminal Records Bureaus disclosure for the advocate was addressed yet there has been no evidence supplied to indicate if a disclosure has been obtained in order to promote the residents rights to safety and protection. It has been required that arrangements must be made that the home develop a code of practise regarding working with volunteers and that evidence of safe vetting in the form of a Criminal Bureaus check is confirmed with the commission regarding the volunteer advocate in order to safeguard the resident, volunteer and registered providers from any allegation of abuse or harm. It has been required that arrangements must be made that the home obtain the current local authority multi agency safeguarding protocols, develop a whistle blowing policy and safeguarding policy related to the care home, undertake training regarding the Mental Capacity Act and Deprivation of Liberty safeguards, review the homes policies related to codes of conduct and restraint and intervention and develop a documented inventory of the resident furniture and clothing in order to promote the residents rights to protection from harm or abuse or being placed at risk of harm or abuse. Care Homes for Adults (18-65 years) Page 23 of 45 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home currently enables the residents independence. Maintenance of cleanliness and hygiene standards regarding the residents bedroom and bathing facilities need to be strengthened in order to ensure the safety and well being of the resident. Evidence: The registered managers home continues to offer the resident a familiar homely environment where they can be supported as part of the family and have access to the communal parts of the home. The resident was observed moving freely around the kitchen area which was observed as lived in and some areas for example the kitchen cupboards and drawers needed upgrading. The registered manager advised that the owners were considering moving and the home had been recently viewed. The home is cosy and part of a secluded garden is available for the resident to use. The home has several pets, which include five dogs which the resident said they didnt mind. The resident told the inspector that their bedroom used to be a garage. The room was small with several items of furniture including a small wardrobe with drawers and a Care Homes for Adults (18-65 years) Page 24 of 45 Evidence: separate chest of drawers. A TV screen had been mounted onto the wall and there were several shelves which contained a variety of Cds and DVDs which the resident said they enjoyed watching. There was no additional seating in the residents bedroom for visitors to use and the inspector sat on the residents bed, with the residents permission, to talk with the resident on their own before they got up. The resident stated that their bed was comfortable and they would stay there all day if they could. They said they spent a lot of their time in their room. It was noted that the pillows were not covered with pillow slips and the laminate flooring was bare apart from a small rag rug at the entrance of the room. The floor was clean yet needed to be swept and a pot of emulsion paint was in the residents room as it looked as if some emulsion on the walls of the bedroom had been recently painted. The bathing and toilet facility, situated along a small corridor from the residents bedroom, is solely used by the resident. It was noted that the bath was not clean prior to the resident using it yet it was noted that as part of the residents care plan they are expected to clean the bath following using it. The inspector observed that the bathing facilities in the home met their current needs. Facilities for washing and drying clothes were available and the registered manager said they were in working order. It was observed that clothing for washing would be brought through the kitchen area to be placed in the washing machine or the linen basket which was observed in the small area by the back door and clothes were observed draped over the dining room radiator or a clothes airer in the conservatory area. A mop and bucket were seen in the kitchen which was used to wipe the floor following a fouling by one of the homes five dogs and the mop placed back into the bucket. The AQAA submitted indicated that the home has an action plan to deliver best practise in the prevention and control of infection and that one staff member has received training in the prevention and control of infection in the home. The policy documents or training records were not sampled during the inspection and the commission advise these will be sampled at the next inspection. The registered manager confirmed that clinical waste is disposed of using domestic facilities and the odour in the residents bedroom and in the home had partly diminished during the afternoon inspection. It is acknowledged that the home is a family home and the home had a lived in feel. It has been required that arrangements must be made for further attention to be paid to Care Homes for Adults (18-65 years) Page 25 of 45 Evidence: the maintenance of general cleanliness and hygiene standards in the residents bedroom and bathing facilities in order to ensure the well being and welfare of the resident. Care Homes for Adults (18-65 years) Page 26 of 45 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered providers are the sole members of staff who provide support to the resident. The registered providers did not provide evidence of a robust system for training and development in order to demonstrate that the registered providers have the appropriate skills and abilities to meet the changing needs of the resident. Evidence: The AQAA submitted indicates that there are two permanent full time carers one male and one female. The registered manager confirmed during the inspection that she provides care and support and her husband works in other employment therefore the information supplied to the commission could have been clearer. As previously recorded a requirement has been made that the home develop a code of practise regarding working with volunteers in order that the home can evidence that the vetting of people working with the resident is robust and promotes the resident right to protection from abuse or harm. It was observed that the registered manager demonstrated an understanding of the particular day to day needs of the resident and provided for their care and the resident appeared at ease in her presence. Care Homes for Adults (18-65 years) Page 27 of 45 Evidence: The AQAA indicates that a member of staff has achieved an NVQ Level 2 or above in Care or Health and Social Care but does not indicate which registered person has attained the achievement. Whilst it is acknowledged that the home only supports one resident and not all mandatory training may be applicable it had been recommended on previous inspections that the registered manager undertake some mandatory training courses which are relevant to the home and these would include Moving and Handling, Basic Food Hygiene and Health and Safety. The recommendations as part of good practise have not been acted upon as there were no accessible or available records in the home to confirm the registered providers attendance of mandatory training. Any evidence of training was requested to be forwarded to the commission without delay following the inspection yet had not been received prior to the draft report being sent to the registered providers. It has been required that arrangements must be made that the registered providers receive training appropriate to the work they are to perform and documented evidence of training is available in order to ensure the safety and well being of the resident. Care Homes for Adults (18-65 years) Page 28 of 45 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care provided to the resident is generally good due to the family environment however the service is registered as a care home and basic requirements relating to the required records and documentation are not in place therefore the management and administration of the home is not robust. The home is run in the best interests of the resident yet their views and opinions and those of other associated with the home are not actively promoted or recorded. The residents general safety and welfare is not promoted and improvements need to be made regarding the health and safety concerns in the home. Evidence: The registered manager confirmed that the home did not have the current Care Homes Regulations updated 2006. It has been required that arrangements must be made that the registered providers obtain a copy of the Care Homes Regulations 2001, updated 2006, in order to ensure that the registered service is compliant with the Care Home Regulations. As previously documented throughout the report the home is run by the registered Care Homes for Adults (18-65 years) Page 29 of 45 Evidence: providers and the resident lives as a member of the family. The AQAA submitted indicates that the registered manager has a Chartered Management Institute Qualification yet it is unsure what this relates to regarding the registered home and the commission have requested clarification of the qualification. The registered manager advised that she had worked in a day centre supporting people with physical and learning difficulties and has a B-Tec certificate in social care. As previously reported the commission have requested updated information regarding the training that the registered providers have each undertaken. The commission acknowledge that the resident may not be able to complete a quality assurance questionnaire in writing yet it was observed throughout the inspection that they were capable of communicating their needs to the registered manager and getting those needs met. During previous inspections it has been recommended as part of good practise that the registered providers review the quality of care by completing a Quality Assurance review which would include written feedback from the residents family, friends, advocate, college tutors and any health care professionals involved in the residents care and welfare. It was not noted that this recommendation has not been considered over several years and a requirement has been made that arrangements must be made that the home undertakes an annual Quality Assurance review within the timescales set in order to promote a culture of self monitoring and take the views of the resident and their representatives into account regarding the services and the manner in which the services are provided to the resident. It was noted that cleaning fluids and materials were stored and kept securely in compliance with the control of substances hazardous to health COSHH guidance in order to ensure the health and safety of the resident. The fridge and freezer were well stocked yet it was difficult to ascertain due to the quantity of food stored if food had been stored in compliance with the current food safety regulations and the registered providers are reminded of their responsibility to abide by the food safety regulations in order to protect the resident from hazards to their health and well being. The registered manager confirmed that water temperatures were taken prior to the resident having a bath to ensure their safety and showed the inspector a water thermometer. A documented risk assessment for bathing was sampled and as previously reported the format of the risk assessments were complex and had been adapted from another source. The risk assessment stated that it had been completed in September 2009 and that only an employee or visitor may be affected by the water temperature being too high yet the population particularly at risk are the disabled, in Care Homes for Adults (18-65 years) Page 30 of 45 Evidence: addition contamination from soiled clothing would also affect the employee and the disabled. It was noted that the registered manager offered support to the resident in bare feet yet the risk assessment states that all staff must wear appropriate footwear when supporting clients in the bath. It has been required that arrangements must be made that a safe bathing policy, including an up to date risk assessment is documented which includes the checking and recording of water temperatures before the resident enters the bath water and periodic monitoring, recording and auditing of the outlet temperature of the bath water using a bath thermometer are undertaken and records maintained in order to ensure the safety of the resident whilst bathing. As previously recorded there was no evidence of a menu in the home during the inspection and the resident advised the inspector what they had had to eat the previous evening which differed from what the registered manager advised. It has been required, in the Lifestyle section of the report that the registered providers develop a menu. The home had some information regarding the electrical testing yet it was unsure if the documentation related to the domestic electrical installation certificate. A British Gas Homecare checklist was sampled by the inspector and was dated 17.10.2008 and the return date for the engineer was 29.10.09 . There were no certificates available to confirm that current Gas and Electric safety certificates were within the home. The current insurance indemnity certificate was not displayed in the home and the certificate sampled had expired in September 2009. The registered manager advised that another certificate had been sent to the home but this could not be located. It is noted that the concerns regarding lack of certification regarding insurance cover at the home have been raised at previous inspections. It has been required that arrangements must be made that the registered providers must obtain an up to date insurance certificate providing adequate cover for the resident in relation to death, injury, public liability damage or other loss and also obtain current Gas and Electric safety certificates to ensure the safety, protection and welfare of the resident . The recent admission of the resident to hospital was discussed with the registered manager who advised that the commission had been informed yet the commission had not received any notifications. A requirement has been made that the registered providers must report any incidences to the commission without delay of any event that affects the well being and welfare of resident in order to ensure that the commission are aware of any incident of note in the Registered Care Home that affects the welfare and well being of the resident. Care Homes for Adults (18-65 years) Page 31 of 45 Evidence: As documented throughout the report the majority of the homes policies and procedures had been adapted from other organisations procedures and those sampled were not not relevant to the care home. It has been required that arrangements must be made that the registered providers review all the home policies and procedures, codes of practise and that records are signed by the registered providers and are dated, monitored, reviewed and amended in order that the documents comply with current legislation and recognised professional standards to protect and support the resident. No records were available regarding the the homes health and safety checks, fire equipment checks, fridge and freezer temperatures and records of water temperatures, and food temperature checks including meat, as the registered manager advised these were stored electronically and could not be evidenced during the inspection due to the computer monitor not working. The inspector requested these be sent by email without delay yet these had not been received prior to the report being sent in draft form to the registered providers. It has been required that arrangements must be made that all records are available in the home in order to demonstrate that the registered providers take into consideration the health and safety of the resident. A fire risk assessment was not sampled and the registered providers are reminded that as best practise the fire risk assessment should be documented alongside the guidance of shared living schemes formally referred to as Adult Placement Schemes. As recorded throughout the report there are a significant number of aspects of the homes management that are potentially putting the health, safety and welfare of the resident at risk due to the management and administration of the home not being robust. These include insufficient information within the homes Statement of Purpose and Service User Guide in order to reflect that the resident continues to have a right to be informed about the services and facilities in their home and the information is not available in a format which meets the capacity of the resident. The homes records were insufficient to demonstrate that the residents needs are well monitored and changes fully documented and actions implemented to ensure and promote the welfare and well being of the resident. The residents support and personal care needs within the care plan contain basic information and the management of risk assessments does not fully promote the residents rights to safety and well being. Documented evidence regarding meaningful activities the resident participates in were not current and there was no evidence regarding the planning of menus or evidence to demonstrate that a nutritious, varied and balanced diet was available. There was little recorded evidence to support that the residents physical, emotional and health care needs were monitored and met. Medication procedures do not ensure that medication Care Homes for Adults (18-65 years) Page 32 of 45 Evidence: would be administered in a safe and appropriate way. The complaints and safeguarding protocols do not promote the residents rights to raise concerns and their rights to be protected from harm and abuse are not robust. Standards of cleanliness and hygiene in the residents bedroom and bathroom need to be improved in order to ensure the safety and well being of the resident. The registered providers did not provide evidence of a robust system for training and development in order to demonstrate they have received current appropriate training in order to fully support the resident. The residents views and opinions and those of others associated with the home are not actively promoted or recorded. The residents general safety and welfare through robust health and safety checks. It has been required that the registered providers must forward to the Care Quality Commission an improvement plan detailing how the home intends to improve the services provided in the home to ensure the safety and well being of resident in their home. These requirements have a bearing on the safety of, and outcomes for the resident and the failure to comply with the regulations is an offence and may lead to enforcement action being considered. Care Homes for Adults (18-65 years) Page 33 of 45 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 34 of 45 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 Arrangements must be made that the homes Statement of Purpose and Service User Guide be updated in compliance with the Care Homes Regulations 2001. Both documents are written in a format which can be understood by the resident for example pictures or symbols. 19/02/2010 2 2 15 Arrangements must be 19/02/2010 made that records must be available to evidence that any changes in the residents care and support needs are clearly documented. In order to ensure the residents welfare and well being continue to be monitored and actions are taken to address any changes. Care Homes for Adults (18-65 years) Page 35 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 6 15 Arrangements must be 19/02/2010 made that a care plan is developed to include a person centred approach and the resident has involvement in producing their care plan, the care plan is regularly reviewed and review dates are recorded. In order that the care plan can be audited to reflect the current needs and support the resident requires. 4 9 13 Arrangements must be 19/02/2010 made that the standard and format of the risk assessments are revised and improved. In order to ensure that the current hazards in the residents life are fully documented, the measures and actions taken to reduce the hazards are clearly recorded and that review dates are recorded in order that the risk assessments can be audited to promote the residents best interests and safety and ensure the residents well being as far as reasonably practicable. Arrangements must be made that an up to date activities programme is 19/02/2010 5 12 16 Care Homes for Adults (18-65 years) Page 36 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action developed which details the current meaningful activities undertaken by the resident both within the home and the local community. In order that records are up to date to evidence the meaningful activities enjoyed by the resident to reflect their lifestyle preferences. 6 17 17 Arrangements must be made that records of food provided to the resident are in sufficient detail. In order to enable the person inspecting the record to determine whether the diet is satisfactory in relation to nutrition to promote the residents health and well being. 7 19 17 Arrangements must be 19/02/2010 made that the home keep documented evidence of any plans relating to the resident in respect of fluid intake and output, body weight, special diets prepared for the resident, and records of appointments attended with health care professionals. 19/02/2010 Care Homes for Adults (18-65 years) Page 37 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action In order to promote the residents health and well being. 8 20 13 Arrangements must be made that a relevant medication policy and procedure is developed which includes the arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In order to ensure the safety and welfare of the resident when receiving prescribed medicines. 9 22 22 Arrangements must be 19/02/2010 made that a complaints procedure is developed for considering complaints which must include all details outlined in Regulation 22 of the Care Homes Regulations. In order to ensure that any person, including the resident who may wish to raise a complaint has the correct information and are assured their views and opinions about the service will be listenned to and 19/02/2010 Care Homes for Adults (18-65 years) Page 38 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action acted upon. 10 23 13 Arrangements must be 19/02/2010 made that the home obtain the current local authority multi agency safeguarding protocols, develop a whistle blowing policy and safeguarding policy related to the care home, undertake training regarding the Mental Capacity Act and Deprivation of Liberty safeguards, review the homes policies related to codes of conduct and restraint and intervention and develop a documented inventory of the resident furniture and clothing. In order to promote the residents rights to protection from harm or abuse or being placed at risk of harm or abuse. Arrangements must be 19/02/2010 made that the home develop a code of practise regarding working with volunteers and that evidence of safe vetting, in the form of a Criminal Bureau check, is confirmed with the commission regarding the volunteer advocate. 11 23 13 Care Homes for Adults (18-65 years) Page 39 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action In order to safeguard the resident, volunteer and registered providers from any allegation of abuse or harm. 12 30 23 Arrangements must be 19/02/2010 made for further attention to be paid to the maintenance of general cleanliness and hygiene standards in the residents bedroom and bathing facilities. In order to ensure the safety and well being of the resident. Arrangements must be 19/02/2010 made that the registered providers receive training appropriate to the work they are to perform and documented evidence of training is available. In order to ensure the safety and well being of the resident. 14 37 1 Arrangements must be made that the registered providers obtain a copy of the Care Homes Regulations 2001, updated 2006. In order to ensure that the registered service is 19/02/2010 13 35 18 Care Homes for Adults (18-65 years) Page 40 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action compliant with the Care Home Regulations. 15 39 24 Arrangements must be made that the home undertakes an annual Quality Assurance review within the timescales set. In order to promote a culture of self monitoring and take the views of the resident and their representatives into account regarding the services and the manner in which the services are provided to the resident. 16 40 17 Arrangements must be 19/02/2010 made that the registered providers review all the home policies and procedures, codes of practice and that records are signed by the registered providers and are dated, monitored, reviewed and ammended. In order that the documents comply with current legislation and recognised professional standards to protect and support the resident. Arrangements must be made that the homes health 19/02/2010 19/02/2010 17 40 17 Care Homes for Adults (18-65 years) Page 41 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action and safety checks which include fire equipment checks, fridge and freezer temperatures and records of water temperatures, and food temperature checks including meat are documented and available in the home. In order to demonstrate that the registered providers take into consideration the health and safety of the resident. 18 42 13 Arrangements must be 19/02/2010 made that the registered providers must obtain an up to date insurance certificate providing adequate cover for the resident in relation to death, injury, public liability damage or other loss and also obtain current Gas and Electric safety certificates. In order to ensure the safety, protection and welfare of the resident. 19 42 13 Arrangements must be made that a safe bathing policy, including an up to date risk assessment is documented which includes the checking and recording of water temperatures before the resident enters the bath water and periodic 19/02/2010 Care Homes for Adults (18-65 years) Page 42 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action monitoring, recording and auditing of the outlet temperature of the bath water using a bath thermometer are undertaken and records maintained. In order to ensure the safety of the resident whilst bathing. 20 42 37 Arrangements must be 19/02/2010 made that the the registered providers must report any incidences to the commission without delay of any event that affects the well being and welfare of resident. In order to ensure that the commission are aware of any incident of note in the Registered Care Home that affects the welfare and well being of the resident. 21 42 24A Arrangements must be 19/02/2010 made that the registered providers must forward to the Care Quality Commission an improvement plan detailing how the home intends to improve the services provided in the home. In order to ensure the safety Care Homes for Adults (18-65 years) Page 43 of 45 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action and well being of the resident in their home. Failure to comply with the regulations is an offence and may lead to enforcement action being considered. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 23 It has been recommended that the registered manager update their safeguarding training to ensure that they are fully aware of the current policies and procedures in order to promote the residents rights to protection from harm or abuse. Care Homes for Adults (18-65 years) Page 44 of 45 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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