Inspection on 30/03/09 for Glasshouse Hill

This inspection was carried out on 30th March 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Applegarth

Thornham Grove

Hunter`s Lodge

Conifer Lodge

Manor Court

92 Black Prince Avenue

Agnes House

The Manor House

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: Glasshouse Hill 100 Glasshouse Hill Codnor Near Ripley Derbyshire DE5 9QT     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: Bridgette Hill     Date: 3 0 0 3 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: Glasshouse Hill 100 Glasshouse Hill Codnor Near Ripley Derbyshire DE5 9QT 01773570450 01773513168 175manager@voyagecare.com www.milburycare.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Milbury Care Services Ltd care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia physical disability sensory impairment Additional conditions: The maximum number of service users who can be accommodated is 11. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Physical Disability - Code PD Sensory Impairment - Code SI Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection 11 11 11 Over 65 0 0 0 Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home Glasshouse Hill is a purpose built care home which specialises in providing care for adults 18 - 65 of both genders with acquired brain injury. Nursing care is not provided at the home. It is situated on a bus route near to local shops in the town of Codnor. The home has an outdoor seating area overlooking woodland. No smoking is allowed in the home but an outdoor area for residents to smoke in is available. The home provides spacious bedrooms for up to 11 residents all bedrooms have large en suite shower rooms. Additional bathing facilities are available including some specialist baths to aid those with mobilty difficulties. Three of the rooms are described as flats offering a self contained kitchen and seating area which allows residnets a high degree of independance whilst still having staff at hand to give support as required. The fees charged at the home are typically £1400.00 per week with some possible variance depending on individual assessed needs, this includes 1 hour of physio. Not included in the fees are toileteries, newspapers, hairdressing or other aspects of personal expenditure. 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 inspection was an unannounced one. The purpose of this inspection was to assess all key standards. The service is a relatively new one with residents first being admitted in August 2008 and this inspection was the homes first key inspection. Prior to the inspection the owner had completed an Annual Quality Assurance Assessment and survey information had been obtained from both service users, relatives and staff working for the service. This was considered as part of the planning process prior to the visit to the service. A variety of documentation was also seen, including relevant policies and procedures, staffing files, training records and care records from service users homes. Additionally, a process of case tracking was used, which involved selecting two service users and tracking the care they receive through review of their records. Care Homes for Adults (18-65 years) Page 6 of 30 During our visit we also spoke to the Manager, staff and residents. The Manager Christine Cooper was on duty during the inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Adults (18-65 years) Page 8 of 30 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 are fully assessed and involved in the care that is provided to them. Evidence: The Annual Quality Assurance Assessment (Aqaa) told us that initial assessments are carried out that identify basic information and contact details as well as information on areas such as communication skills, specific health needs, daily living skills etc. We talk to service users, other carers, care managers and family to try and get as much information as possible to make an accurate assessment of the ability of the service to meet the persons support needs, wishes and aspiration. During our visit the Manager told us they always assessed prospective residents in their current environment and we had opportunity to view the assessment and meet a person who was viewing the home. We were told the person had received a brochure but that Service User Guides were issued to each resident after admission. The prospective resident was observed asking relevant questions during the visit which were answered openly. They were able to Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: choose their own bedroom and had a meal during their visit where they were accompanied by relatives. A care file had also been commenced with the assessment and other information in which had been gathered. Some files we looked at contained a range of assessments form Care Managers or other healthcare professionals if they were involved. Information about the home such as the Statement of Purpose and Service User Guide was made available to residents in the entrance hallway. As this was the first key inspection of the service a full report was yet available for residents to access. 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. Care plans were well detailed and the care residents received was that as was described therefore their needs were being met. Evidence: The Annual Quality Assurance Assessment completed by the home told us from the point at which service users move into Glasshouse Hill they are encouraged to develop and express individual needs and choices from choosing day to day activities/routine to more complex choices of being involved in completing their support plans which includes risk assessment. We looked at two care records during our visit to establish if identified needs were documented and staff were given instructions on how to deliver care. One staff member on a survey told us care plans were regularly updated and staff required to read and sign they had read them. The care documents were well ordered, typed and easy to read. Each plan of care was Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: well documented and was individualised giving staff clear instruction on approaches, communication and promoted choice and independence in the way care was delivered. One resident told us that they were consulted about the care plans and some residents had signed the plans of care. Each care plan was supported by an assessment of risk. Additional risk assessments had also been completed for example a moving and handling assessment. It was identified that despite having some nutritional needs the home did not use a nutritional assessment tool. Detailed food intake records and weights of residents were recorded to provide ongoing monitoring. No routine assessments of the mental capacity of residents were completed however there were some documents which demonstrated that staff were aware of the Mental Capacity Act and an Independent Mental Capacity Advocate had been consulted. Staff monitored progress through log records which were written regularly. These demonstrated promotion of Independence had been encouraged and residents had been offered choices. 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. The home offers residents opportunities and choices which enables them to lead individual lifestyles that promote their Independence. Evidence: There are few residents in the home at present and whilst this was the case the Manager told us that the structure and provision of leisure and social activities was very personalised. The Manager acknowledged that with more residents it would be more difficult to offer each resident a choice everyday as to what they did and more structure may need to be introduced. At present residents were asked what they wanted to do and various activities and trips out had been completed. These had included shopping trips for clothes, garden centres, local areas of interest and trips out for meals. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The home had a car which was put to good use as residents frequently decided they wished to go out. From care files and discussions with residents it was evident that there good relationships and contact with families. Residents were able to spend time with their family and friends sometimes on visits out and on leave overnight. One staff survey told us that the service offers individual tailored support, uses a holistic approach and involves families at all levels. There were risk assessments and care plans in place for social and leisure time. These included details of where the residents were independent and went out alone or whether staff support was required. Menu planning was completed in consultation with residents and residents also got involved with the shopping for the food. A training kitchen was available to promote cooking skills but this was little used at present due to their being few residents. Some residents were currently highly independent shopping and cooking for themselves with a view to returning to independent living. 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. The healthcare needs of residents are being met. Medicines are competently handled to ensure residents receive prescribed treatment. Evidence: For each resident there was a Health Action Plan which was a file with health related records in it. This recorded GP and outpatient visits as well as the specialist healthcare provision which some residents accessed such as Survival skills for head injuries group. Part of the fee paid included physiotherapy input on a regular basis and one record indicated that the support was helping to improve the residents balance. Other specialist assessments were also on record such as Occupational assessments on the activities of daily living which had been undertaken with the aim of improving Independence. The home is a relatively new one and the Manager was in the process of establishing links with opticians and dentists however where these had been required so far Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: residents records indicated that visits had been arranged. One staff survey told us they considered the service offers individual tailored support, uses a holistic approach and involves families at all levels. This was supported by some care records which indicated family involvement in healthcare appointments and reviews. We examined medicines management during our visit. At present few medicines are being manged as there are few residents. Suitable storage was in place and there appeared to be good record keeping demonstrating that residents were receiving their treatments. If there were any changes such as the timing medicines were given due to social leave these were recorded. Audits of medicines was possible due to recording medicines in and out of the home. Staff we spoke to had completed medicines training as had other staff according to the training records. A fridge for medicines was available and the temperature was recorded daily however this was not the maximum and minimum temperatures which would ensure suitable temperatures were being maintained at all times. One care plan we looked at recorded the gender and age preference of staff the resident preferred when personal care was needed. 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. Policies and procedures were in place that assisted in ensuring that the welfare of residents was safeguarded. Evidence: The aqaa told us that there had not been any complaints or safeguarding concerns since the home opened. The Manager confirmed at the visit that this had not changed. Residents were made aware of how to complaint by a Letting us know what you think card, this available in alternative languages for residents for whom English was not their first language. Residents were also given worry cards that they could complete and post to the Provider directly if they did not feel able to raise concerns with anyone at the home. The complaints procedure included timescales that residents could expect responses to their complaints and relevant addresses of other organisations who could also be contacted. One survey told us Yes I do know how to make a complaint but simply have had no need to, there has been an excellent job done by staff at Glasshouse. Staff spoken with at the visit were conversant with how to raise concerns as they told us that Safeguarding Adults training had been completed. The training matrix Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: indicated that apart from a few newer staff all staff had received Safeguarding Adults training. The surveys we received from staff also indicated that staff knew how to handle any concerns. The safeguarding adult procedure in place included definitions of abuse and advised staff what to look out for. The procedure referred to locally agreed procedures that should be followed if allegations were made. Staff had access to a whistle blowing policy to advise them how to raise concerns. The home stored some monies safely for residents, these were small amounts for sundry items. There were suitable records and receipts retained. We checked a sample of balances which evidenced accurate recording to the amount of residents money held. Two signatures were on receipt slips but not on the actual ongoing record. The Manager told us there had not been a need to use any restraint techniques and that staff had received training in crisis interventions. 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. The home is well presented, clean and a comfortable home for residents to live. Evidence: The home is a purpose built one which is relatively new. The occupancy of the home is low as it has only been open since August 2008 therefore alot of bedrooms are not being used. Some of the bedrooms are described as flats as they have a kitchen and seating area as well as a bedroom. These are being used to promote independent living. We spoke to one resident who was using this facility and was told that they were able to cook their own meals, do laundry and live a largely independent life going out when they wished. One resident told us they felt safe as houses at the home and the home had good heating and hot water and you couldnt find a better place. The home offers two lounges, one on each floor. The heart of the home is the open plan kitchen/dining room. This has doors leading out to a paved area with seating which offers views over a wooded area. Residents who smoked were observed using this area as there is no smoking allowed in the building. An additional training kitchen is also available to enable residents to develop cooking skills. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: The home had some features which made it suitable for users with disabilities such as variable height worktops in kitchens, a tracking hoist, handrails in toilets and lower level light switches. The home provides spacious bedrooms with en suite toilet, wash basins and showers. Additional specialist bathing facilities are available for resident with mobility difficulties. Where equipment has been assessed as being required for residents such as specialist beds these were seen in place in residents rooms. We looked at the fire safety records and when we entered the home staff informed us the arrangements in place and nearest exits should there be a fire during our visit. The records were up to date including personalised evacuation plans for each resident. Staff had received fire safety training although for some staff on nights updates were due but not yet planned. The home was clean and tidy throughout. A suitable lockable storage area was outside of the building for clinical waste and liquid soap and paper hand towels were provided. We discussed with the Manager if the Department of Health essential steps tool for infection control had been completed and was told it hadnt. This may be useful as some improvements could be made such as ensuring toilet roll holders are in use to prevent frequent handling and higher risk of cross infections. The laundry area has one washer and dryer and is used by all residents including those using the flats. The washer had a sluice programme to wash soiled clothing appropriately and the laundry was clean and tidy. Maintenance was arranged through the Providers head office and records indicated there was some slight delays in getting attention to some repairs. 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. Staff at the home are suitably recruited and trained to ensure they have the right skills to care for residents. Evidence: The home is a relatively new one although some staff have been transferred in from other homes within the same company and bring with them relevant experience. The current levels of staff for 3 residents were 2 staff members for daytime shifts and at night there was one waking and one sleeping staff member. The Provider had a scale for staffing hours in place which described the number of staff required in relation to how many residents were in the home. Any absences due to sickness or holidays were covered by existing staff or the Providers own bank of staff. A clear staff structure was in place with a Deputy Manager, senior Support staff and support workers. Staff files contained job descriptions for each role. The Aqaa told us that processes for recruiting staff with all required checks being in place were followed. We looked at two staff files and these confirmed that references and Criminal Records Bureau checks were completed with proof of identity and employment histories to evidence staff were suitably recruited. Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: The home had a small staff compliment as it was the service was developing and evolving. There were staff in post who were suitably trained with 5 out of 9 care staff having achieved NVQ level 2 or above. A training matrix was in place and the staff group had completed a range of training, this included mandatory training such as safeguarding adults, moving and handling and food safety. Additional training had also been completed that was specific to the residents being cared for such acquired brain injury, diabetes, non violent interventions and the Mental capacity Act. In staff files we saw completed induction forms that had been signed by senior staff to confirm completion. The induction list was heavily based on policies and procedures and was not a skill based one. We were told that an induction that is skill based is on the electronic learning system the home uses. One resident survey said of the staff, Staff couldnt treat you any better than they have. Completely 100 excellent staff, no ifs or buts. Staff at Glasshouse cannot be praised enough for the excellent job they have all done, would recommend glasshouse to anyone needing support or certain types of care, theres nothing to say that is bad, because its all good - simple. 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. The home is a relatively new one which is establishing and developing good foundations to provide a service that is run in the best interests of residents. Evidence: The Manager of the home is suitably qualified and has experience in previous roles of working with adults with acquired brain injuries. The training record for the Manager demonstrated an ongoing commitment to learning. One staff survey told us that the Manager conducts regular appraisals and supervisions alongside staff meetings and the Manager is always available and approachable. A staff member during the visit also told us the Manager was supportive. The home has only been open since August 2008 and no quality assurance surveys have yet been undertaken. The Manager told us at present formats for this were being looked at. Some feedback on the service had been given from relatives and visiting professionals in the comments book in the entrance hallway. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: All the comments in the book were positive and came from a range of people including relatives and visiting professionals. They described staff as being friendly with a can do attitude. One resident said they had received excellent support from the service. No residents meeting had formally been held due to there being few residents. The Manager told us informal consultations did take place and gave us an example that residents had been asked about development of the garden area and suggestions of getting tubs of plants for the patio had been completed. There had been some staff meetings held which looked at a range of topics such as handovers, fire safety activities and daily routines. Some reviewing and discussions of residents care was also documented in the minutes which may lead to information being missed from the care file and generally being disseminated. The operations manager for the company had completed some monthly visits to monitor quality. These were not clearly dated and it was not possible to establish the exact frequency of these. A format was in place focussing on different area each month. A range of records was examined each visit and staff and residents were spoken with. From the findings an action plan was generated to ensure any identified actions were taken. Consideration was given to protecting the health and safety of residents with restricters being fitted to upstairs windows and thermostatic controls on water outlets. regular temperature checks were recorded with adjustments made if necessary to prevent scalds. Some health and safety audits had been completed and where actions required these were noted such as light bulb replacement. Where there had been accidents there were records to record these and actions taken were considered to be appropriate. Where incidents had occurred that we needed to be told about them under the regulations forms had been completed. A legionella risk assessment had been completed but some of the aspects to be checked such as the hot water storage temperature and bacteriological checks had not yet been completed and staff at the . We looked at a range of other service checks which were all found to be in date. 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 39 24 There must be formal consultations with residents and other stakeholders to monitor quality at the home This is to allow residents and stakeholders to air their views and allow the service to develop into one where residents are actively consulted 29/05/2009 2 42 23 Staff at the home must be conversant with the content of the legionella risk assessment and ensure that any required actions to limit the risk are completed. This will ensure residents are protected as far as is possible from legionella 29/05/2009 Care Homes for Adults (18-65 years) Page 28 of 30 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 1 The Service User Guide should be made available to people before admission to ensure they have as much information as possible about what to expect from their stay. Routine assessments regarding residents Mental Capacity should be completed and the abilities of the resident be incorporated throughout the care plan The home should utilise a nutritional assessment tool to identify potential risks which may need further investigation or specialist referral. The fridge temperature reading should be recorded at its maximum and minimum to ensure that medicines were not affected by adverse changes of temperature Regular fire safety training dates should be planned to ensure they are delivered when due. The home should consider using the Department of Health Essential Steps tool for infection control to ensure all risks are identified and appropriate action taken The Regulation 26 visits should be clearly dated with an actual day of the visit to accurately demonstrate the frequency of the visits Information relating to residents should be recorded on the their individual records to ensure there is one source for all known information and this will ensure adherence to Data Protection recording principals are maintained. 2 7 3 9 4 20 5 6 24 30 7 39 8 41 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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