Inspection on 26/02/09 for Fairfax Road

This inspection was carried out on 26th February 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairfax Road 23/03/07

Fairfax Road 28/10/05

Fairfax Road 26/04/05

Fairfax Road 14/12/04

Fairfax Road 27/09/04

Fairfax Road 23/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Fairfax Road 19 Fairfax Road Leeds West Yorkshire LS11 8SY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Paul Newman     Date: 2 6 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 30 Information about the care home Name of care home: Address: Fairfax Road 19 Fairfax Road Leeds West Yorkshire LS11 8SY 01132778842 F/P01132778842 Telephone number: Fax number: Email address: Provider web address: www.milburycare.com Name of registered provider(s): Type of registration: Number of places registered: Milbury Care Services Ltd care home 4 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home 19 Fairfax Road is situated at the end of a quiet cul de sac but within 2 miles of Leeds City Centre. There are a wide range of shops and leisure facilities within easy reach of the property. The home is a 4 bed roomed detached bungalow with a carport and large garden. The bedrooms are all single rooms with washbasins and decorated to individual taste and choice. Service users are encouraged to buy personal items for their own use, which helps to create a comfortable atmosphere within the home. There is a lounge and open plan kitchen/dining room allowing service users to choose either to participate in or to observe domestic activity within the home. There is a bathroom and separate shower room. There is also a separate laundry room. Service users are encouraged to make full use of the entire house and garden and the facilities within, including the television as well as video and music systems. The current charge at the home is one thousand and forty two pounds per week. Additional charges are made for Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 4 4 Brief description of the care home music therapy, toiletries, some leisure activities, holidays and taxis. Care Homes for Adults (18-65 years) Page 5 of 30 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: two star good 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: This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means that the people who use the service experience good quality outcomes. The accumulated evidence in this report has included, the previous key inspection, an annual service review carried out in March 2008, information we have received from the provider since the last inspection, what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement, relevant information from other organisations and information from people living at the home, relatives, staff and other health care professionals. One inspector made an unannounced visit to the home that lasted five hours on 26 Care Homes for Adults (18-65 years) Page 6 of 30 February 2009. Before the inspection visit, we asked the manager to complete an Annual Quality Assurance Assessment (AQAA). This is a self assessment that if completed thoroughly, should tell us how the home is meeting National Minimum Standards, where we can find the evidence for this, what improvements have been made since we last inspected and what improvements are planned in the next year. The AQAA that was returned was completed well and gave enough information for us to plan for the inspection visit and know where to focus our attention. During the visit a number of pre selected documents were looked at and all areas of the home used by people living there were inspected, including bedrooms. Apart from spending time with the manager, a good proportion of time was spent speaking with staff and people living in the home. Time was spent in the kitchen dining room watching what was going on and checking how the staff cared for and supported people. Surveys were sent out prior to the inspection to the people people living at the home, staff and health care professionals. Feedback was provided to the manager at the end of the visit. What the care home does well: What has improved since the last inspection? What they could do better: Good outcomes for people have been sustained. This inspection found three requirements. We found that staff were using the code O when making some entries on the medication administration records (MAR). The meaning of the code was not explained anywhere and must be so that everyone knows the reason a drug was not administered. The occupational therapist had made a recommendation that a a special height adjustable bath with an integral hoist be fitted in the bathroom for a person who mobility needs needs have changed significantly. The recommendation was made a year ago and whilst plans have been drawn up and a commitment given to make the adaptation it still has not been done. We feel for everyones comfort and safety this should be done in the next three months and there be no further delay. Finally, although reports are written by the operations manager following their monthly visits to check how the home is operating, copies must be available in the home and the last one available was in May 2008. This needs to be addressed. Care Homes for Adults (18-65 years) Page 8 of 30 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 set out 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 9 of 30 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 10 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good written information about the home in a format they can understand that helps them decide if the home will be suitable for them to live in. People are properly assessed and they can spend time in the home before a decision is made that the home can meet their needs. Evidence: The statement of purpose and service user guide have been reviewed in the last twelve months and are produced in easy read pictorial form. They give detailed and accurate information about the home. They are available in the entrance hall of the home for visitors and each person living in the home has their own copy. There have been no new admissions to the home and the four people living at the home are the same people who were present at the last inspection visit in March 2007. There were no issues about their pre admission assessment at that time, so these were not checked at this visit. The AQAA sets out in good detail how the home would approach a new admission and a full in depth assessment of needs would be Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: made, including risk assessments, a current health and social service assessment of care programme and getting to know you sessions are common practice. All the people living in the home have a contract that they keep in their bedroom. Care Homes for Adults (18-65 years) Page 12 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples changing needs and personal goals are reflected in their individual support plan, which means that all staff members know how to support each person to achieve these. Risk assessments are in place and are reviewed regularly. People are encouraged to make choices in everyday matters, even if they are not able to take an active part in decision-making about life in the home. Evidence: The support plans are developed in a way that tries to make sure that all aspects of a persons needs and aspirations are identified. There were some minor shortfalls noted in the last inspection report and the support plan that was checked showed that these had been addressed. The focus was on one person whose needs have changed quite significantly over the last year. The plan had good detail and guidance for staff to follow and were person centered. The reader had a good picture of who the person was, their life history, their primary care needs, their lifestyle preferences and choices. The home has introduced a key worker system and the staff spoken with said that this made sure that there was good oversight of the care being given and making sure Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: that changing needs are identified early and action taken to update and amend the support plan where it is needed. There was good evidence of this in the care plan that was checked. The plan had risk assessments that were up to date and regularly reviewed and the guidance for staff especially in relation to the persons mobility and moving and handling needs was very clear. During the visit there were a number of opportunities to watch staff with the person and they followed the plan to the letter. Conversations with staff showed that they know the people they care for well. There was also good evidence of people being involved in making decisions about what they want to do, where they want to spend their time and what they want to eat. Staff encouraged and prompted people. Staff were good at picking up the non verbal communication of people who do not speak and as a consequence people were settled and happy. Care Homes for Adults (18-65 years) Page 14 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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 and eat healthily with varied and nutritious meals and snacks. Evidence: The home tries to make sure that people have access to a range of regular external and internal activities. The support plans identify people likes, dislikes, lifestyle preferences and interests. The plans detail how the person maintains relationships, what personal care they need and how they like to receive it and there was good attention to the detail that made sure their privacy in dignity was maintained. This was seen in practice during the day. One person was keen to show some craft work that she had done and during the day did some further art work. Another went out with a member of staff to the local supermarket for some shopping and lunch. One Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: person goes out to church on a regular basis. Although peoples preferred routines are identified, there is a large degree of flexibility to take advantage of good weather or doing something on impulse. The home is relaxed and the people seem happy in their environment and the manager said that sometimes staff need to be reminded to encourage people to get out. Although the home did have its own vehicle, its use was restricted because there was only one driver. Now public transport and taxis are used but this does not appear to reduce the opportunities that people are offered and enjoy. There was an air of excitement because everyone is going for a holiday to Whitby during a period when the kitchen is going to be refurbished. Staff were meeting during the afternoon to make plans for the holiday and do risk assessments. Previous holiday risk assessments were seen in the support plan that was checked. The people have been to the especially adapted cottage before and there were photographs of the last holiday that one person talked about and said that she loved going there. Menus are planned and peoples likes and dislikes are known. People are involved in going out to do the shopping and making suggestions about the meals. The lunch was a social time with everyone sat around the kitchen table and people getting good support where it was needed. Lunch is a light meal and on the day of the visit it was sandwiches and salad followed by yogurt. The main meal was being prepared later and this was a beef casserole. People who were able to express their views said that the food is always good and they enjoy it. They ate well at lunchtime. The records of the meals provided were seen and an individual record is kept for each person. The kitchen dining area is the focal point of the home and people seemed very much at ease. Care Homes for Adults (18-65 years) Page 16 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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. People are supported to take their prescribed medication when they need it and in a safe way. Evidence: The reason for choosing one particular support plan to check, was because the persons healthcare needs had significantly changed over the last year. The last inspection report had noted that the home should make sure that referrals are made to healthcare professionals as the need arises, so this was a good opportunity to see if they are now doing this. The support plan identifies the professional support network for each individual and identifies the persons medication, any allergies and their dietary needs. There is a specific health support plan supported by risk assessments, in this persons case her fluid intake and visits from health professionals. The support plan for personal care was good in its detail and guidance for staff. The persons mobility needs had begun to change about a year ago. This was clearly identified and referrals made to the Doctor, hospital and occupational therapist. There Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: was a clear trail of how the home was supporting the person and the advice and guidance from healthcare people was noted in the plan. The mobility support plan was also clear and specific in its guidance to staff on how to support the person in each setting in the home, for example how to assist getting in and out of the dining chair, the settee and personal care situations, and each setting was mapped out stage by stage with additional diagrams to guide the staff in the bathroom situation. It was noted that the occupational therapist had made a report on the bathroom equipment and had recommended that a height adjustable bath with integral hoist would be the best and safest option for the person and for staff. Although a commitment has been given by the housing association to install this, a year later this has not been done and should be. (See Environment). When staff were asked about this they felt that they were managing safely with the current arrangements, but would welcome the recommended bath. As the day went on there were several opportunities to watch staff assist the person with personal care and they followed the guidance in the support plan and paid attention to the dignity matters that were also noted. In discussions about the other people living at the home it was clear that the home had sought the advice of health professionals for a person who has difficulty swallowing. The medication policies and procedures were discussed and the administration of some medication was observed in practice. These were sound and staff spoken with were clear of their responsibilities. When the medication administration records (MAR)were checked it was noted that staff were using the code O, at some points when medication was not administered. The code is not identified on the MAR and must be, so that everyone is clear why medication has not been administered. The support plan that was checked included a plan for ageing and death that was clear and had been discussed with relatives. Care Homes for Adults (18-65 years) Page 18 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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. Evidence: There is a clear complaints procedure that is included in the service user guide and there is an easy read version for people who need it. The AQAA told us that there have been no complaints and the results of the homes own surveys to people and their relatives suggest they are all very happy. One CSCI survey returned from one person living in the home said that if they felt unhappy about anything they would speak to staff. Part of the key worker responsibility is to make sure that if people have the opportunity to discuss concerns. During the day staff were regularly checking that people were happy and were good at picking up non verbal behavior or communication that suggested someone might be feeling uncomfortable. The regular visits made by representatives of the company also check that people have no concerns and are happy and receiving the care they need. The training records and conversations with staff show that they have received training on the indicators of abuse and the procedures they must follow if it is found or suspected. The company has clear policies and procedures that must be followed. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: Other checks made during the visit on things like money held for people and recruitment practices met requirements. Care Homes for Adults (18-65 years) Page 20 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable and well maintained home that is clean, pleasant and hygienic. An adaptation must be made to the bathroom on the recommendation of an occupational therapist. Evidence: The home is situated at the end of a quiet cul de sac not far from Leeds City centre. There are a range of shops and leisure facilities close by. There are good, safe and well kept gardens that have garden furniture and a gazebo. All areas of the home were checked. It is an inviting and friendly environment that is well maintained and furnished. The kitchen dining room is the focal point of the home and is where people spend a lot of time chatting and interacting and watching what is going on. The kitchen is due to be refurbished. The bedrooms are all individualised with furniture and decor chosen by the individuals and the rooms reflect their personalities and interests. The home was very clean, fresh smelling and tidy. Staff were seen to wear protective clothing when it was needed and they confirmed that they have received training in health and safety, infection control and food hygiene. The last inspection report raised an issue about hand sluicing and this practice has stopped. Staff said they now use Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: soluble bags in the sluice cycle washing machine. During the checks made in a support plan it was noted that the occupational therapist had recommended a specific height adjustable bath with an integral hoist for one person whose mobility needs had changed. The recommendation was made a year ago and still has not been implemented although the manager said that a commitment had been made by the housing association and plans drawn up. For the comfort and safety of the person and staff who assist with bathing there must be no further delays and we feel the work must be carried out in the next three months. Care Homes for Adults (18-65 years) Page 22 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by well trained and competent staff who get the supervsion and support they need. They can have confidence in the staff at the home because checks have been done to make sure that they are suitable to work with vulnerable people. Evidence: The staff on duty were efficient and effective and had a good warm and friendly relationships with the people they care for. The duty rotas were checked and these show that there are enough staff on duty and the shifts are planned around the needs of people. Three CSCI surveys were returned by staff and all confirmed that they feel there are always enough staff on duty, that they get the right kind of training and support, there is good communication between the staff team and manager. In answer to what they thought the home did well, one said we look after the needs of the ladies and keep staff well informed with matters that need dealt with. The staff on duty included a senior and another member of staff who had been fairly recently appointed. They too, talked about the good team work and it being a good place to work. Both talked about their training which was up to date and relevant to the people they work with including ageing. Staff are beginning to get training on the Mental Capacity Act. The home has achieved targets outlined in National Minimum Standards for the number of staff who should have a National Vocational Qualification (NVQ). Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: The files of the two most recently appointed staff were checked to make sure that good recruitment policies and procedures are followed. These showed that the right documentation is kept and that staff have been properly vetted and checked. As people are getting older, their care needs will change and they will become more dependant so the manager will need to keep staffing levels under review. Care Homes for Adults (18-65 years) Page 24 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People get the right support because the home is well managed and organised in their best interests. They live in a home that is safe because regular health and safety checks are completed. Evidence: The manager is experienced in the care sector and is currently completing a recognised management qualification and has completed the companys management development programme. The staff spoken to and the surveys that were returned indicate that feel that they are well managed and there is a good team spirit. Throughout the day both in their practice and the things they said, it is clear that staff are organised and managed in a way that has the best interests of the people they care as the focus for the things they do. The company surveys relatives on a regular basis and there is a high degree of satisfaction. The company has sound policies and procedures for staff to follow. The operations manager visits the home at least once a month. Part of the purpose of these visits is to check the home is operating as it should be. Although monthly reports that have to Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: be written have been done there were no copies available since May 2008 and regulations require that a copy is available in the home. The most recent monthly service review was available and it is clear that this is a thorough process and itemises actions that need to be taken. This kind of self monitoring gives confidence that standards will be maintained. Other records that were checked were up to date and well organised. There are a series of weekly and monthly health and safety checks that are made and although the AQAA confirmed these were up to date, the records of fire safety were checked during the visit. These checks make the home a safe place to live and work in. Care Homes for Adults (18-65 years) Page 26 of 30 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 27 of 30 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 20 13 Codes used on the MAR charts must be clearly identified. This will make it clear of the reason why medication has not been administered. 30/04/2009 2 27 23 The recommendations for a new specialist bath made by the occupational therapist must be followed without further delay. This will be more comfortable and safe for the person who needs it and for staff who assist. 30/06/2009 3 31 23 The recommendations for a new specialist bath made by the occupational therapist must be followed without further delay. This will be more comfortable and safe for the person who needs it and for staff who assist. 30/06/2009 Care Homes for Adults (18-65 years) Page 28 of 30 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 4 41 26 A copy of the monthly reports that are written about the way the home is operating must be kept in the home. This fully demonstrates that the home is self monitoring. 30/04/2009 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 33 The manager should keep staffing levels under review as peoples needs change and they become more dependent. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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