Inspection on 12/09/08 for Fairmount

This inspection was carried out on 12th September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Fairmount 41 Lower Waites Lane Fairlight East Sussex TN35 4DB     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: Caroline Johnson     Date: 1 2 0 9 2 0 0 8 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. the things that people have said are important to them: They reflect 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 31 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Fairmount 41 Lower Waites Lane Fairlight East Sussex TN35 4DB 01424813956 01424751641 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Jonathan B Dass Type of registration: Number of places registered: Hastings and Rother Primary Care Trust care home 6 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 6. The registered person may provide the following category/ies 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 categories: Learning disability (LD). Date of last inspection Brief description of the care home Fairmount is a purpose built detached care home situated in the village of Fairlight. Ore with its shops and access to bus and rail routes is approximately three miles away. All accommodation is situated at ground floor level. There are six single bedrooms, a lounge, dining room and rear garden with patio. At the front of the house are carparking facilities. The home is registered to accommodate six adults with a learning disability, who have challenging needs. In April 2008 Hastings and Rother PCT became the registered providers for this service taking over form the Kent & Medway NHS and Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 6 Brief description of the care home Social Care Partnership Trust. The Trust manages nine other homes within the Hastings, St Leonards and Rother area. See summary section for details of the fees. Care Homes for Adults (18-65 years) Page 5 of 31 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: The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term service user to describe those living in care home settings. For the purpose of this report those living at Fairmount will be referred to as residents. This key inspection included an unannounced visit to the home on 12 September 2008 between the hours of 09.30 and 5.00pm. The registered manager facilitated the inspection. Over the course of the inspection there was an opportunity to meet and have lunch with the residents. In addition time was spent with two members of staff in private. A full tour of the home was Care Homes for Adults (18-65 years) Page 6 of 31 undertaken. Two care plans were examined in detail. In addition records seen included; staff rotas, training, medication, menus, health and safety, quality assurance and leisure activities. In advance of the inspection process service user surveys and four health care professional surveys were sent to the home to distribute. One service user survey and one health professional survey was returned. The resident survey was completed by a staff member on behalf of the resident but contained the views of the staff member, as the resident has no verbal communication. The health professional advised that they had only had contact with one resident but noted that staff were very professional, astute in their interpretations and concerned for their patients welfare. They were well-informed about the processes and showed good confidentiality. The range of fees for the service are from 1,331 to 1,366 pounds. What the care home does well: What has improved since the last inspection? What they could do better: Monthly visits carried out by the senior management team need to be more detailed, they need to identify shortfalls observed, how they are being managed and any impact the shortfalls have on the quality of care received by the residents. Care Homes for Adults (18-65 years) Page 8 of 31 Whilst the assessment of individual residents needs are detailed one area missed has been in relation to meeting any spiritual needs. Not all residents were receiving their weekly programme of activities from the day care provider. Although a review of the day activities had been undertaken it is essential that a further review be held to ensure that all residents have appropriate access to day activities. 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 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 31 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. The home ensures that prospective residents receive appropriate information about the service on offer. Evidence: The statement of purpose has been updated since the last inspection of the home. However, due to the change of ownership the document is currently under review again. A working party was set up to produce a generic document for all homes within the PCT. The document has been completed and circulated to each of the homes. The manager advised that he now needs to add specific information about Fairmount. He anticipated completing the document quickly and said that a copy would be given to all residents and/or their representatives. The updated version of the terms and conditions of residence and license agreement with the housing association has yet to be completed. All of the residents have a copy of the homes service user guide. Two guides were seen and one was in a written format and the second was in a pictorial format. A simplified version of the complaints procedure is included in the guide. Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: There were no vacancies at the time of inspection. There is a detailed assessment in place of each residents abilities and needs and this is updated at regular intervals. In each of the care plans seen there was detailed information provided on how to communicate effectively with the residents. Care Homes for Adults (18-65 years) Page 12 of 31 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. Good progress has been made with the introduction of person centered planning and this could be enhanced even further with better record keeping in some areas. Evidence: Two care plans were examined in detail. Each included very detailed information about the residents, their abilities and their needs. The person centered planning approach is used to record all information. Risk assessments are both generic and individual and work is underway to make the risk assessments more person centered. All risk assessments are reviewed and updated where necessary every six months. Each of the residents has at least one goal that they are working towards achieving. Goals seen were clearly identified and all progress made in achieving them was well documented. A daily record sheet is used to record information about the activities that residents have participated in throughout the day. There is also space to record what worked well and what didnt work so well. Record keeping in this area is not Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: detailed and might say appeared to enjoy or that someone opted out of an activity after a period of time. If the activity was assisting with dinner preparation it doesnt say what they actually did, if the activity is reading 1:1, it doesnt say what was read. Reviews are held every six months and attention is given to ensuring that they are carried out using the person centered approach. Individual residents aspirations, hopes and dreams are documented and over the course of the next six months it is the key workers responsibility to try to make sure that where possible they can be met. The home is also in the process of introducing a how to support me folder for each resident. This includes information about the people that are important to the resident, places they like to go and activities that they like to participate in. In one folder there were various photos of the resident participating in various activities. It is hoped that as the bank of photos increases the folder will be a good tool to assist in increasing levels of communication but also in encouraging residents to make a wider range of choices and decisions. Staff were observed offering choices to residents at lunchtime and residents responded well to the choices and were able to make appropriate decisions. One resident was also able to indicate that they wanted more and this was provided. There is a new communication board on display in the home showing pictures of all the staff that are on duty on a particular day. Care Homes for Adults (18-65 years) Page 14 of 31 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. Residents are offered a variety of activities that are based on meeting their individual interests and wishes. Evidence: Each resident has a weekly planner which includes leisure activities and opportunities to make full make use of the local amenities on offer. MCCH which is the day care provider that is contracted to provide activities for the home for an allocated number of hours each week. Staff from MCCH either spend time in the home providing activities or take residents out to various activities in the community. Staff reported that following a review of day care arrangements in April the new arrangements were working well but that more recently due to staffing problems at the day centre, residents are not always receiving their allocated hours of day care. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: Additionally, the house car is often required to take residents to activities and this means that it is often not available for other residents. The home is currently exploring the cost of having two smaller cars instead of one people carrier. The manager advised that during the summer they use a local bus service but it is a fair distance to the bus stop and not always appropriate during winter months. Records showed that residents do have access to a wide range of activities including, trampolining, bowling and swimming. In addition one resident enjoys regular horse riding and attends a cookery course at a local college. Residents also enjoy regular meals out and cafe trips. Emphasis has also been placed on encouraging residents to be involved in recycling, wherever possible. The weekly planners are a guide and often the planned activity does not take place but an alternative is provided. The reason for the change of plan is not always documented. For example one resident had not gone horse riding and when asked why this had not taken place the carer advised that the activity is during term time only. It was reported that residents are supported to maintain contact with families and friends. Keyworkers ensure that relatives are invited to all reviews and are kept informed of any changes in the wellbeing of their relative. There was no information recorded about the spiritual needs fo the residents. The manager advised that this information had been assessed in the past but has not been transferred over to the new care plan system. He agreed to look into this area again. There is a four-week menu in place, which is varied and well balanced. The home is currently building up a bank of photographs of the meals that are provided and each of the photos is then laminated. It is hoped that when this has been completed they will be able to use the photos to encourage more involvement in menu planning and in assisting residents to make more choices about the food they wish to eat. A member of staff spoken with stated that they completed a course on nutrition recently and they have been able to use the knowledge gained from this to ensure that the menus provided are well balanced. Care Homes for Adults (18-65 years) Page 16 of 31 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. There are good arrangements in place to ensure that the healthcare needs of the residents are met. Evidence: Each resident has a health action plan in place which clearly sets out how their health needs are to be met. Records showed that the home ensures that these needs are being met. One of the residents had recently had a spell in hospital and a second resident had also been in receipt of specialist healthcare advice and treatment. In addition residents attend regular chiropody, dental and optician appointments. Residents weights are monitored monthly but in the care plans seen these records were last updated in June 2008. The arrangements in place for the storage and handling of medication are also in order. The home uses a monitored dosage system and there are a series of daily, weekly and monthly checks in place to ensure that the system is working smoothly and that record keeping is in order. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: New staff receive training on medication as part of their induction to the home. In addition they are then assessed on three separate occasions until they are deemed competent to administer medication in the home. Following this staff are given the opportunity to attend refresher training. Some of the residents see professionals periodically in relation to managing their particular health needs. Where necessary there are guidelines in place to assist in ensuring consistency of staff approach and these are kept up to date. Staff observed in the course of their duties were courteous and treated residents with respect. Care Homes for Adults (18-65 years) Page 18 of 31 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. The procedures in place ensure that anyone wishing to make a complaint can do so. Evidence: There is a detailed complaint procedure in place. A simplified version is also included as part of the service user guide. The manager advised that there have been no complaints to the home since the last inspection. The home has a copy of the Sussex multi-agency guidelines on the protection of vulnerable adults in the office for all staff to refer to. All staff have opportunities to attend training on the protection of vulnerable adults and the manager advised that 80-90 of the staff team are trained in this area. Staff spoken with during the course of the inspection were clear about the action they would take if they suspected abuse. Records for the management of residents finances were not examined on this occasion. However, during the examination of care plans it was noted in the minutes of a review that there was a statement saying that a resident could not afford a new carpet. The manager agreed that it would not be expected that a resident would have to pay for their own carpet and agreed to look into the reason why this had been documented. He also confirmed that any expenditure over 100 pounds would have to be sanctioned by the manager and he would not give agreement to a resident having to purchase a carpet. Care Homes for Adults (18-65 years) Page 19 of 31 Care Homes for Adults (18-65 years) Page 20 of 31 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. Residents live in a homely and comfortable environment. Evidence: The building is well maintained and is decorated to a good standard. Communal areas consist of a large lounge area and a separate large dining room. There is also a large and pleasant private garden to the rear of the property. It was reported that since the last inspection of the home the carpets in the hallway, dining room and lounge have been replaced. There is a contract in place to ensure that the carpets are cleaned on a regular basis. New pictures have been added to the lounge area and a new pelmet and curtains have also been fitted which has helped to create a more homely environment for the residents. Although none of the residents are disabled, there is a disabled toilet which is mainly used by one resident. It was noted that the wash basin and mirror are positioned very low and that the hand towels are then positioned quite high. Bedrooms are decorated well and have been personalised. A number of the residents have sensory equipment in their bedrooms. One resident has a keyboard and staff are currently putting together a communication board for another resident which will be Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: used to display objects of reference to assist the resident in everyday communication. Residents are supported to clean their individual bedrooms and to assist in dealing with their own laundry. All of the staff team have had training on infection control. Care Homes for Adults (18-65 years) Page 22 of 31 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. The staff team are well trained and equipped to meet the needs of the residents accommodated. Evidence: It was reported that there are now always four staff on duty unless a member of staff phones in sick. The manager is now supernumerary but on these occasions he would then work on shift. The rota does not always show the shifts when he is counted in the numbers. On the day of inspection there were three care staff and the manager on duty. It was reported that since the PCT have taken over the home, the stability in the staffing levels along with consistency in approach have significantly reduced the incidences of challenging behaviour in the home. There were no staff vacancies in the home at the time of the inspection but the manager advised that whenever there is a vacancy he will be more involved in staff recruitment. Prospective staff will be invited to visit the home to meet with the residents and as residents have no verbal communication interactions will be recorded. All staff complete training in behaviour management techniques (ProAct Scip) and all Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: staff are up to date with this training. Staff must attend three sessions a year and if this is not achieved they have to attend a three day course. Mental Capacity Act (MCA) training is also provided. There is a staff training matrix on display which is colour colded to reflect when staff have completed a course, when it is due to run out, and when it needs to be updated. The majority of the staff team are up to date on mandatory training although it was noted that five staff have to complete a refresher course on medication. Two of the five have been booked to attend this course. In addition to the mandatory training there are courses that are classed as essential for staff working at Fairmount. These include Proact scip, epilepsy, MCA, pova and communication. The organisations training officer is also looking to find an appropriate communication course for staff. Records showed that most of the staff team have had at least two formal supervisions since April 2008. Twelve of the staff team have completed NVQ at either level two or above. In addition one staff member is currently working words level three and another towards level four. Care Homes for Adults (18-65 years) Page 24 of 31 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. The home is well run and the systems in place ensure that the health, safety and wellbeing of the residents and staff is protected. More detailed record keeping in relation to quality assurance could enhance this further. Evidence: The manager is a qualified nurse holding the RNMH qualification. He has also completed the Registered Managers Award (RMA) and brings a wealth of skills and experience to this post. The deputy manager is also a qualified nurse. The manager advised that since the home was taken over in April the whole ethos of the organisation and the way they operate has changed and it is a pleasure to manage the home. Monthly managers meetings are held and these are very useful as part of the meeting is devoted to exchanging ideas for good practice and discussing problems. Staff spoken with felt well supported. They stated that the regular staff team meetings are also very useful and that everyone is encouraged to share their views and concerns. Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: There is a good system in place for staff handover between shifts. Records kept show the names of the staff that have been on duty. There is also information about residents finances, routines, who supported which resident and which of the house tasks were undertaken. As part of the quality assurance system the organisation completed a corporate action plan for the service. Each individual home was then asked to respond to this action plan detailing the measures they have in place to demonstrate that they are meeting the national minimum standards. The manager advised that this work has been completed for Fairmount. Staff have also been delegated responsibilities for areas such as health and safety and food safety. The manager advised that he oversees that tasks in these areas are carried out and that occasionally he signs that he has checked these areas but the system could be formalised more. Satisfaction questionnaires are sent to relatives via the head office. The manager advised that responses are then collated and the home receives feedback on the outcome. If necessary the manager would put together an action plan detailing any action taken as a result. A designated person also visits the home once a month on an unannounced basis to report on the conduct of the home. Visits generally last one and a half to two hours in duration. During this time they meet with staff and residents and examine a wide range of records including one care plan. The views of the staff met with are not recorded. In addition the problem identified in relation to the provision of day care activities was not documented. The manager confirmed that this area has been fully discussed and that his views and the views of the staff team on this subject have been shared. Prior to the inspection a range of surveys were sent to the home for them to distribute to residents and any visiting professionals. One resident survey and one professional survey was received. The resident survey was completed by a staff member on behalf of the resident but contained the views of the staff member as the resident has no verbal communication. The health professional advised that they had only had contact with one resident but noted that staff were very professional, astute in their interpretations and concerned for their patients welfare. They were well-informed about the processes and showed good confidentiality. Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: The homes fire risk assessment was completed on 9/6/08 and there is one issue that still needs attention. It was noted that there is no timescale for this yet. A member of staff has been delegated the task of fire warden and he has had training and provides training for the staff team every 6 months. The last fire drill was held on 20/7/08. Fire records showed that in one bedroom the door frame was damaged and would not provide an effective seal. In addition in relation to another bedroom the door was stuck open on new carpet. The manager advised that these areas have been addressed. Portable appliance testing was last carried out on 7/2/07, so is now overdue. A number of the homes policies and procedures require reviewing and updating. The manager advised that the PCT are gradually updating all the policies and procedures and as each one is updated a copy is sent to the home. Care Homes for Adults (18-65 years) Page 27 of 31 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 28 of 31 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 2 12 The registered person must ensure that an up to date assessment of each service user’s spiritual needs is in place. The wishes of residents in relation to their spiritual needs must be assessed and if necessary arrangements must be made to ensure that they are met. 30/01/2009 2 12 16 The registered person must ensure that a further review of the day care arrangements be carried out. The arrangements for day care must be reviewed for the benefit of all the residents. 15/01/2009 3 39 26 The registered provider 30/12/2008 must ensure that more effective monitoring is achieved through Regulation 26 conduct visits of the home. Care Homes for Adults (18-65 years) Page 29 of 31 The provider must be kept informed of all improvements/shortfalls in order to gain an informed opinion of the conduct of the home. 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 2 3 6 13 33 Support records should detail the action taken to support an individual and more information about the outcome. Records should show the reason why a planned activity has not taken place. The rota should show details of the hours that the manager is working on shift. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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). 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. Care Homes for Adults (18-65 years) Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!