Inspection on 01/04/09 for Grafton House

This inspection was carried out on 1st April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Grafton House 03/04/07

Grafton House 19/09/05

Grafton House 01/12/04

Grafton House 07/07/04

Grafton House 22/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Grafton House Grafton House 49 The Drive Kingsley Northamptonshire NN1 4SH     The quality rating for this care home is:   one star adequate 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: Ansuya Chudasama     Date: 0 1 0 4 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 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2010) 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 31 Information about the care home Name of care home: Address: Grafton House Grafton House 49 The Drive Kingsley Northamptonshire NN1 4SH 01604791635 01604711988 Jlanghorne@partnershipsincare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Jill Mary Langhorne Type of registration: Number of places registered: Partnerships In Care Ltd care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: All service users accommodated will have an acquired Brain Injury. No one falling within the category MD may be admitted into the home where there are 3 Service Users of this category already accommodated within the home The age range of the Service Users accommodated are between 30 - 60 years To be able to admit the named person of category MD named in variation application dated 19/02/2005 Number: V000017870 Date of last inspection 3 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 31 Brief description of the care home 49 The Drive is a care home providing personal care and accommodation for 3 service users from the age of 30 to 65 years with an acquired brain injury. The home is owned by Partnerships in Care Limited. The Home is situated in a suburb of Northampton close to a local shopping centre and park, easily accessible by public transport and within a mile and a half of the town centre and its amenities. The property consists of a large semi-detached house with front and rear gardens. Single bedrooms are provided for all service users on the first floor. The communal rooms include a lounge; separate dining room, conservatory, and service users have the use of the kitchen. The home does not have a lift and is not suitable for people with mobility problems. The current fees are two thousand and one hundred and twenty two pounds and thirty eight pence per week and additional charges are made for hairdressing, toiletries, newspapers, magazines and gym membership. 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: one star adequate 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 carried out in accordance with the Commission for Social Care Inspections (CSCI) policy and methodologies which require review of key standards for the provision of a care home for younger adults, that takes account of the service users views and information received about the service since the last inspection. Evidence used and judgments made within the main body of the report include information from this visit. The report refers to we this is because the report is written on behalf of the commission. We last inspected this service on the 11/4/07. This key inspection was carried out on the 1/04/09. The administrator of the home and staff in the home helped out with the inspection process. The acting manager of the home was available for some parts of Care Homes for Adults (18-65 years) Page 6 of 31 the inspection. During this inspection we tracked the care of two people who use this service. This involved reading their care records and also talking to them wherever possible to obtain their views on the service. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to most of the staff who were on duty and a tour of the home was also conducted. The home had not sent us their Annual quality assurance assessment (AQAA) when we asked for this information. We received staff and the peoples surveys when we asked for them. 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 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 Care Homes for Adults (18-65 years) Page 8 of 31 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 people and their representative are given information and have needs assessments carried out prior to admission to ensure that their needs will be met. Evidence: The home has a Statement of Purpose and this document needs to be reviewed to ensure that the right information about the Quality Care Commission (QCQ) is recorded. The information about the complaints procedure needs to be recorded with the telephone numbers of the relevant agencies. The information about the previous manager is still recorded on the document. However the new managers details needs to be updated on the document and needs to be individualised to the home. A service user guide was seen and the acting manager said that this would be further developed to make it more user friendly with pictures. The home had admitted a new person to the home last year. Discussion with the person stated that they had visited the home prior to their admission. A needs assessment was carried out for this person. We were told that the other people also had assessments, which were undertaken by the home when they came to live at the Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: home. All the people in the home have contracts and the people had signed these. One of the people spoken to said that they had signed their contract and understood what this was about. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people have care planning documents and these needed reviewing to ensure that the staff have the information needed to meet the needs of the people. Evidence: We looked at two peoples care plans and discussed their care needs with staff on duty. The staff had very good understanding of the needs of all the people in the home. The home had two files for individual people. One copy of the file was kept with the administrator, and another copy was provided for the staff. The two files did not have the same information. The Staff we spoke to were not able to say why two copies of the peoples files were kept. Discussion with staff showed that it was not necessary to have two files with the same information. Management needs to have one file for each person, with is kept up to date. We were told that the care plans were being reviewed on a regular basis. This was observed but this information was not being updated in the main care plans. For example one plan Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: seen was implemented in 2007. Some of the information read in the plans was no longer relevant. This was discussed with the acting manager who agreed that all the care plans would be reviewed with the people. Risk assessments are in place that enables the people to take risks as part of an independent lifestyle. The information on risk needed to be in the hazard section and information on hazards needed to be in the risk section. Discussion with the acting manager showed that the risk assessments were going to be reviewed with the people and these would be developed in a format that the they would understand. This was very positive. The care plans were stored in locked filing cabinets in the office. During the inspection we saw staff talking to people in a friendly and supportive way. They supported people to make decisions and choices for themselves. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The routines and activities of the home are planned in a way, which meets the choices and wishes of the people. Evidence: The people had their individual programmes for activities they undertook. The records looked at showed that the people go to the local pubs, shops, the park, to the cinema, and town. They also go on holiday and we were told that the holiday was booked for this summer. A risk assessment needs to be undertaken for this activity. There were photographs seen of the people when they had been on activities and holidays. Some of the people in the home maintain contact with their families/friends. The lounge provided a homely atmosphere where the people could relax and enjoy a quite moment watching the TV or read a book. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: We had lunch with staff and one of the people living in the home. This was eaten in a relaxed atmosphere with good conversation and banter taking place between the staff and the person. . We were told by the person that they choose what they wanted to eat and helped staff with preparing meals. This was observed at lunchtime. The meals recorded were healthy and staff had good understanding of the food the people liked. We were also told that the staff encouraged the people to try different food to increase their choices. One person in the home told us that I like the food and the staff are nice and helpful. They also said that they like their bedroom and like living at the home. Each persons bedroom seen showed that the home supported the people to pursue their chosen hobbies. The people were supported to clean their rooms and do their laundry work. We observed the daily routines of the people and they told us that the staff helped them to promote their independent living skills. The garden was lovely and we were told that all the people enjoyed sitting in the garden. The furniture in the garden looked old and worn out. New furniture that met the needs of the people was needed for the garden. The home has house meetings where people have an opportunity to take part in making decisions. 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. The peoples personal and health care needs are met by the home. Evidence: The care plans we saw clearly set out peoples support needs and preferences in receiving personal care. The staff we spoke to were very knowledgeable about the people they care for. We observed staff interaction and noticed that they talked to people in a respectful manner and were careful to preserve their dignity. There was evidence in the peoples files to show that the people are offered support for their physical and emotional health needs. There are records of general practitioner, clinical psychologist and hospital appointments, and people have access to the district nurse, opticians, dentists, and other health care professionals. The people told us that if they did not feel well, they would tell the staff. The staff spoken to also had good understanding of the peoples health care needs. The staff that gave out medication had received the accredited medication training. The medication records looked at were satisfactory. The people had signed the Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: consent form for staff to give out their medication. The staff spoken to had good understanding of the medication the people took. 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 staff have good understanding of the peoples behaviours to ensure they are protected from any abuse. Evidence: The staff on duty told us that they had completed the safe guarding of vulnerable adults procedures training. They had good understanding of this and understood the peoples behaviours to know when they were unhappy or not feeling well. The home had carried out risk assessments and put in support systems for the people when out in the community on their own. The people in the home were capable of informing staff if they had any concerns. They told us that they would tell the manager or staff if they were not happy about any thing. This was observed on the day of the inspection. The home had not received any complaints since the last inspection. No safe guarding referrals had been made to Social Services safe guarding team. Care Homes for Adults (18-65 years) Page 19 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. The home is pleasantly decorated and provides a relaxing atmosphere for the people living at the home. Evidence: The home is clean and homely. The pictures and ornaments made by the people are displayed in the home. The main corridors of the home are light and airy and the communal areas were plesantly decorated. The peoples bedrooms seen are homely and comfortable and individualised to the person. All the people have single rooms. The home has an office on the second. A conservatory to the rear of the dining room was used as a designated smoking area, which led into a pleasant garden. The people need garden furniture that is sturdy and meets their need. At present we observed a broken umbrella, and old plastic chairs and a table, which were not suitable to meet the peoples needs. The dinning room wall needed painting, as the paint was looking old. The toilet seat in the bathroom was loose and we were told that the maintenance man would sort this out. The kitchen and the laundry rooms were clean and well organised. Information read in the office stated that the organisation was considering putting a door in the dinning room so the people and staff can walk through to the sister home. Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: The information read about the people living in the two homes showed that this would have a detrimental effect on their well being. The staff spoken to also confirmed this. The two homes are at present registered as individual homes with the commission. The organisation would need to apply to the registration team before any changes can be made to the home. Care Homes for Adults (18-65 years) Page 21 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff have good understanding of the needs of the people however the staffing rota needed reviewing to ensure there are adequate staff on duty to meet the needs of the people. Evidence: The administrator and staff in the home assisted with the inspection. This was because the acting manager was also finding their way around the office to find out where information was being kept. They also had to go out to undertake an assessment of a new person interested in coming to live at the home. The acting manager went with a member of staff from another sister home. We were told that the staff would like the opportunity to expand their skills further in getting involved in carrying out needs assessments. Management should there fore consider involving experienced senior staff from this home on these assessments. The staff recruitment files for three staff were looked at in detail. Evidence showed that the home was obtaining all the relevant information required to safe guard the people in the home. Staff spoken to and records showed that not all the staff were receiving supervision on a regular basis. This is to monitor the work staff do at the home and to look at their training and development needs, and needs to be recorded with the date this took place and not just the month and year. Evidence also showed Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: that not all staff were getting annual appraisals. The staff working rota showed that they sometimes worked on their own. This also included people who are bank staff and newly appointed people. We were told that staff struggled when they have to look after some who is not well. This is because they still have to work with the other people, and have to do their daily chores such as cleaning, cooking, shopping, give out medication, and complete the records. We were also told that some of the people can get aggressive in a split second and when you have no support this is extremely hard to deal with on your own and keeping other residents away from aggressive situations. We also noted that sometimes staff worked three shifts to cover the working hours. This was because the staff wanted to provide continuity to the people. The staff working rota needs to be reviewed to ensure that there are adequate numbers of staff on duty to meet the needs of the people. Staff files read said that staff moral in the home was low. This was noted at the inspection by talking to staff. The surveys returned had comments such as we feel abandoned. The key worker programmes were not always being completed because staff were working on their own and support from management was not available. We observed that the role of the house coordinators included having to do extra duties, such as maintaining care plans, programmes, supervision, fire training, appointments, appraisals, and risk assessment. The staff working rota showed that these staff also at times worked on their own. This was observed on the day of the inspection. We were told that they received one day a month to complete their extra duties and they worked extra hours in their own time to get their work completed. Management needs to reassess the duties of the coordinators to find out if one day is adequate to undertake their extra duties. Some of the people who had come back from leave did not feel supported by management. The staff in the home were not aware that they were returning from leave. We were also told that some staff did not feel part of the team. The staff enjoyed working at the home and it was said that the team do a fantastic job and meet the peoples needs. They say that they have worked hard to keep the place going and this was especially in the last six months. We were told that the home had not had a full staff meeting for a long time and more meetings were needed with management. The acting manager said that she would start this. We were told that the training provided by staff from one of the sister home was not Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: good. It was also said that the training given by one of the sister home was not appropriate to the home that they worked at. This was discussed with management and we were told that all the training provided for staff would be accredited. Staff also asked for training in behaviour modification, equal opportunities, sexual orientation, race, faith, medication, assertiveness, assessment writing and deprivation of liberty Act training. We were told that some staff want to do NVQ training and have asked for this for a long time but this had not happened. New staff file looked at showed that the staff had an induction at the home and had completed the skills in care induction training. We were also told that new staff had to shadow an experienced member of staff until they were confident to work on their own. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interest of the people and management is aware of the areas they need to make improvements to meet the needs of the people. Evidence: We were informed on the 9th of June 08 that the registered manager of this home was going to be managing another sister home whilst the manager of that home was on leave. We were told that another member of staff was going to manage this and the sister home next door. The manager did not return back to the home as they were promoted at the other sister home. The new acting manager of the home was present and we were told that they had recently been appointed to this position in January 09. We were informed that they managed this home and the sister home next door for three days a week. The other two days a week they worked as a programme coordinator at another sister home. The acting manager found it difficult to switch from the two roles that they worked for the organisation. This did not give the person the opportunity to get to understand their role as the manager of the two homes. Discussion with the acting manager showed that they had good understanding of the areas that needed improving in the home. Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: The staff spoken to, and anonymous concerns raised with CSCI, and surveys received stated that staff morale was low and they felt that they have been abandoned. It was also said when management support is not available, staff biker. Some staff spoken to asked for a team building day and this was discussed with the acting manager who stated that they were going to do this. We were told that the new acting manager was very nice but it was said that this person did not spend much time at the home. They wanted a manager that was going to work at the two homes full time. We were told that the staff worked very hard but management do not recognise this and they do not feel valued for all the hard work they do. Staff said that they all do above their job to meet the peoples needs. We were also told that better communication and support from management was needed to help improve staff morale. We received a letter from the organisation to inform us that the acting manager was successful in getting the permanent position of managing the two homes full time. We were told that management from another sister home would be supporting the manager in undertaking this role. We saw regulation 26 visit reports for the 31st of January 08 and 29th of February 08. The staff were unable to tell us if these visits were being carried out. They were also not able to find other regulation 26 visit reports. The home had not carried out the peoples surveys, to get their views about living at the home. The home had not send us the AQAA when we asked for this information. It is important that you send us this document urgently. It is an offence under Regulation 24 and 43 of the Care Homes Regulations 2001 not to fill in and send to us the information we ask for in AQAA part 1 and 2 because If you do not send us this information you may be committing an offence under Section 31 (9) of the Care Standards Act 2000. We will consider taking enforcement action if we do not receive both parts of the AQAA. The paperwork in the office needed to be better managed because information was difficult to find. We were informed that when the administrator was off on maternity leave, the administration side of the work had lapsed. We are aware that since the administrator has been back from leave, they have to work at this and another sister home. However it would be a good idea for this person to spend more time getting the filling up to date in the office in this home. Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: The fire alarm system was being tested on a weekly basis. The emergency lighting was done on a monthly basis. We were told that fire drill practice was happening four times a year. Both the people and staff on duty were involved with this. A fire risk assessment was carried out on the 2/1/09 . The staff had training on health and safety, infection control and food hygiene. Not all staff knew how to use the fire extinguishers. Records showed that five staff had done this training. The fire policies and procedures needed updating and fire zone panels were needed for the home. The fire marshals needed to have refresher training as they have not had this for a long time. We were told that not all staff had received in house fire training. 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 6 15 Review the care plans with the people. This is to ensure that the information recorded is up to date so the staff can meet the peoples needs 23/07/2009 2 33 18 Review the staffing working rota. This is to ensure the needs of the people are met. 30/05/2009 3 39 24 The AQAA must be completed and sent to CQC when asked for. Regulation 24 and 43 of the Care Homes Regulations 2001 This is important to help us plan our future regulation of your service. 23/05/2009 4 39 24 Provide a clear quality assurance system that is easy to understand on annual basis. 30/06/2009 Care Homes for Adults (18-65 years) Page 29 of 31 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 This is to find out how the needs of the people are being met. 5 42 13 All staff must receive in house fire training. This is to ensure that the peoples safety is maintained. 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 23/05/2009 1 2 3 4 24 35 36 39 Provide suitable furniture for the garden that meets the peoples needs Provide training as stated in the report. Provide supervision at least six times per year. Undertake regulation 26 visits on a monthly basis. Care Homes for Adults (18-65 years) Page 30 of 31 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 © (2010) 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. 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