Inspection on 23/12/08 for Grafton Manor Head Injury & Rehabilitation Unit

This inspection was carried out on 23rd December 2008.

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 Manor Head Injury &... 18/04/07

Grafton Manor Head Injury &... 01/12/05

Grafton Manor Head Injury &... 13/07/05

Grafton Manor Head Injury &... 22/11/04

Grafton Manor Head Injury &... 29/04/04

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: Grafton Manor Head Injury & Rehabilitation Unit Grafton Regis Manor Nursing Home Bozenham Mill Lane Grafton Regis Towcester Northants NN12 7SS     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: 2 3 1 2 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. 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: Grafton Manor Head Injury & Rehabilitation Unit Bozenham Mill Lane Grafton Regis Manor Nursing Home Grafton Regis Towcester Northants NN12 7SS 01908543131 01908542644 mamos@partnershipsincare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Partnerships In Care Ltd care home 26 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 26 No one falling within the category MD may be admitted into the home where there are 26 service users of this category already accommodated within the home. That one bedroom within the chantry measures 10 square meters with additional en suite as agreed in variaiton application number V000020532 Date of last inspection Brief description of the care home Situated halfway between Northampton and Milton Keynes, Grafton Manor is a magnificent building dating back to the 15th Century. Set in 7 acres of landscaped gardens, it provides a relaxing environment for assessment and rehabilitation programmes. The accommodation comprises of 13 single rooms in the main manor house with a further 6 bedrooms in the Chantry along with a cottage, bed-sit and flat offering a choice of accommodation to suit individual needs. There is a range of communal areas within the different units and the people are able to enjoy the garden areas. Weekly fees range from three thousand two hundred and thirty one pounds for Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home rehabilitation and two thousand and three hundred and ninty six pounds for long term care. 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: 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 home has 1 star rating and this means that the people using the service receive an adequate service. We inspected the home on the 23rd of December 08. The manager of the home assisted with the inspection. On the day of the inspection there were 15 people in the home. The manager told us that there were two vacancies. We spoke to the staff and some of the people living in the home, and looked at information about policies and procedures, which tells the staff how to do things in the home. We looked at the training staff carried out to look after the people. The manager gave us a tour of the home and we spent most of our time in the main Manor house. Care Homes for Adults (18-65 years) Page 6 of 30 We were told by the manager that this is the area the people are admitted to when they first come to the the home. We looked at information about some of the people to find out how their needs are being met by the home. This is called case tracking. We watched how the people and staff got along together. This inspection was the outcome of concerns that were raised to the CSCI about the care and the safety of staff and the people living in the home. 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 7535. Care Homes for Adults (18-65 years) Page 8 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 9 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 adequate 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 representatives are provided with information about the home prior to making a decision to stay Evidence: The home has a Statement of Purpose and a Service User Guide. Both documents need to have the number, relevant qualifications, and the experience of staff working at the home. Information about any kind of restraints to be used in the home to manage any persons behavior needs to be recorded in the documents. A copy of the service user guide is given to the people using the service. The information about the Commission for Social Care Inspection needs to be recorded in full in the Statement of Purpose and should not be referred to as the commissions. This is so that the people know which organisation they are talking to when making a complaint. The complaints procedure needs to be recorded in the Statement of Purpose so the persons representatives know how to make a complaint to the home. Some of the people spoken to said that they had visited the home with their family or Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: their social worker before they moved into the home. The preliminary visit information form seen had the date of the visit recorded. The form was not signed or fully completed to say who was involved in the assessment process. The homes assessment needs to include all the information stated in the needs assessment standard. The names of the people involved in the assessment process needs to be recorded. The contact details of the persons next of the kin was noted to be the the partner of the person that they had been living with before they moved into the home. However other forms seen said that the persons next of kin was was the persons family member. This was confusing and there was no information recorded to state when this information was changed. Each person has a contract and a copy seen was signed by the person living in the home. Care Homes for Adults (18-65 years) Page 11 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home have care planning documents but these needed developing further to ensure that all the information stated in the standard was recorded to meet their assessed needs. Evidence: People living in the home had care planning documents and we were told that these were drawn up by the staff. The people or their representative had not been involved in this process. Those people spoken to confirmed that they were not involved in drawing up their care plan. The plans seen did not describe any restrictions on choice, and freedom. A treatment plan was inspected and this was not signed or dated by the person completing this information. The plan was updated by dates recorded but there was no information to say if any changes had been made. For cooking skills the plan talked about goals and objectives but did not state how these goals were to be achieved with time scales. It said that cooking was to take place once a month but the person spoken to stated that they wanted to do this more often as they enjoyed this. Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: The plans need to be recorded in a language that the people would understand and needs to explain the process in how the goals will be achieved. The plan also needs to be updated when changes occur. For example one plan read said that the person was to have access to their room at pre-arranged times for privacy and talked about having a key to their room. But the process of how this was to be achieved was not recorded. The person spoken to stated that they already had the key to their room. For their future plan it stated that the person would move into one of the organisations homes, but discussion with the person stated that they had different plans to what was recorded in their file. We were told that the service could do better and this was by involving all the people concerned with the person being cared for by having them in the planning and discussion meetings. It was also said that the information needed to be more accessible in the peoples folder. The home undertook risk assessments for people living in the home but these needed looking at as discussed at the inspection. The people in the home need to be involved when staff are writing their risk assessments, and they need to be written in a language that the people and staff can understand. The information in the risk assessment needs to be fully completed. There were risk assesments seen for activities but this information was not recorded in the care planning document. Regular reviews of the people were being undertaken by the professionals. Care Homes for Adults (18-65 years) Page 13 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people in the home discuss meals in their meetings and enjoy the food they are served. Evidence: One person said that that they had been at the home for nearly a year and it was said that they did not like it when they first arrived. But they say now its OK and I like it and staff are good. They said that they use the gym in the home and enjoyed this. We were told that they do go out a bit but said that this depended on what staff are on duty. They said that they had been to the pictures and had a meal out. The concerns raised to the CSCI stated that there were not enough staff on duty to take people out in the community as stated in the activity plan. So there fore the activities some times had to be canceled due to being short staffed. The people had weekly activities time tables. We looked at one and this did not have a date or when this was Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: started. But the others that were seen had this information and had good information about the daily activities for recorded for each day. We sat with the people when a staff member was doing a quiz activity with 8 people in the main lounge. We observed that not all the people were involved in the activity, and some people were observed sleeping, and others did not understand the activity. We observed that only three people were seen participating in the activity. The staff were observed helping the people in a supportive way. We were told by one person that we just sit here and another person said that they wanted to go out and they had not been out for three days. This was confirmed by talking to staff. We were informed that different and new ideas for the sessions is required to maintain peoples participation. Concerns were raised to us by some of the people because the lounge smelled of tobacco smoke. A door in the lounge which lead into the garden was used by the people to go out to smoke. Every time this happened the smoke drifted into the lounge. Some people also complained that every time the door opened. the cold air was let in the room. We observed this on the day of the inspection. A risk assessment needs to be undertaken when the people are accessing the door to go out. This is because they have to use a few steps to get in and out of the door and they could slip if the weather was wet. We observed when the people were coming in and out of this door and the doors were being locked and unlocked in the lounge area, this did not give the room a homely feel to it. We were told that the people discussed the meals in their meetings and the cook choose the menu for the day. Most of the people spoken to said that they enjoyed the food. It was said that they had two options and a salad was available every day. We were told by some people that they would like a roast meal put on the menu more often. The menu was displayed in the dining room and the people could view this at breakfast time. The people had a residents meeting every six weeks to voice their opinion and the home also discussed issues with them. The people in the lounge did not all sit together when having their lunch. We were told that there were different seatings for the people due to their needs and behaviours. The people spoken to said that they had to wait until it was their time to have their meal. Observation showed that this practice of the people, and staff coming and going out of the dinning room, as well as the dinning room being locked did not provide a relaxed atmosphere. We were informed that the dinning room door should not have been locked. Some people spoken to said that they wanted to get involved in the preparation of meals. The people spoken to were excited because they were going home for Christmas and Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: evidence showed that their familys visited the home. The people also had diaries so they are able to write down what they had done on the day. This was to help them remember and to tell their families what they had been doing at the home. This was good. We were told by the people spoken to that the staff did their laundry and cleaned their rooms. The people did not get involved with these tasks. 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 peoples health care needs are being well met by the home. Evidence: The people spoken to said that they were able to do their own personal care and they bought their own clothes. We were also told that the staff knocked on their doors before they entered their room. Staff had good understanding of how the peoples personal and health care needs were being met by the home. Health Care records inspected showed that health professionals were being accessed by the home. The people informed us and evidence showed from inspecting a weekly activity plan that the person was having one to one session with a Nero psychologist once a week. Discussion with the person stated that they were doing well and understood their condition and behaviours better. The person was also having psychology work seven days a week for half an hour, and once a week there was anxiety and anger management session with the occupational therapist for one hour. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: We were told that the medication was given out by qualified nurses and medication is monitored by the home. The home also has qualified nurses on duty 24 hours a day. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints procedure and the people living in the home know who to speak to if they are not happy but the procedures for reporting incidents and accidents of concern to the appropriate agencies do not always happen and therefore put the safety of people living at the home at a risk. Evidence: The home has a complaints procedure and the people living in the home know how to make a complaint if they are not happy.The complaints book looked at showed that the complaints manager had followed the proper procedures when dealing with most of the complaints. However there were complaints that needed to be reported to the safe guarding team of social services and CSCI due to the nature of the concern. A complaint was received by CSCI from a relative of a former resident. The complainant provided CSCI with evidence that a former member of senior staff at the home had made detrimental unsubstantiated declaration about the resident and his family. This was recorded in an assessment document dated 6/10/06. The home undertook an investigation and concluded that there was no evidence in the case notes of the resident and the person concerned was no longer in their employment. There was no evidence that the home had taken any action regarding the assessment document. Records showed that people who had unexplained bruises on their body, when medication errors had happened, and when people were physically aggressive to Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: each other was not being reported to the safe guarding team of social services or to the CSCI under regulation 37 notifications. Concerns were raised to CSCI saying that the staff were concerned about the physical aggression to wards them and the people. The staff records and those spoken to stated that they had done training on safe guarding of vulnerable adults procedures. They gave examples of how they would be able to tell if a person in the home was unhappy and it was said that this was by understanding the peoples behaviors and knowing the person. We observed that many of the communal doors in the home were locked by staff and the people had to ask staff to open the doors. The staff accompanied them to where they wanted to go. We were told that the doors in the home were locked to protect the staff and the people. None of the people in the home had an assessment carried out under the mental capacity act to state that they were not able to make decisions. There was no information recorded in the peoples care plans or their contracts regarding the restrictions of locking doors. The management of the home need to review this practice urgently to ensure that any restrictions placed on the people are legal, appropriately assessed and documented and in the best interests of the individuals concerned. One person informed us that the home did not manage their finances but they had the support from an advocate to help them with this. 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 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 clean and tidy with a rolling programme to improve the decoration, fittings and fixtures to meet the peoples needs but restrictions put in place for the people living at the home means that they do not have the freedom of the home. Evidence: The tour of the home showed that it was clean and tidy and all the bedrooms had en suite facilities and these were pleasantly decorated. The hall, stairs, and landing in the Manor building had been redecorated. We were told that the peoples rooms were all locked by staff when they are not in their room. The main lounge and dinning room doors were also kept locked. The swimming pool had been turned into a development centre. We were told that the home recently had a concert in this room and every one that attended enjoyed this. There were still areas like the kitchen, which we were told is currently under construction, which was still not safe to use. There was a small gym and one of the people spoken to said that they used this facility and enjoyed this. We were told by the manager that when the people first come to the home, they go to the main building for assessment. Following this residents may be discharged to other Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: facilities or transfer to the chantry, which is a long term unit. We spent time in the main building. The home had a flat and a cottage but no one was living in either of the places. We were told that the cottage was used when families visited to give them privacy. 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 have good understanding of the needs of the people being cared for in the home. Evidence: The staff recruitment files seen showed that the home was obtaining the relevant information required to keep the people safe in the home. However one of the staffs CRB information was not available. The manager said that they would send this information to the CSCI. The staff told us that they have staff meetings and they get on well together as a team. They also enjoyed working at the home and said that the people living in the home get good care. The people spoken to said that the staff were very nice and helped them to do things. We observed staff working well with the people in the home. The staff did the induction training when they first started and shadowed staff until they felt confident to work by them selves. This was confirmed by a new member of staff spoken to. We were told that the home had a high turnover of staff and this did not provide continuity of work to the people in the home. This was confirmed by talking to the people. We were informed that some people sometimes had to wait if they needed two Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: staff to meet their personal needs. We had a discussion with the manager about staffing. We were told that the home had difficulty recruiting staff and getting them to stay. One of the problems of recruiting staff was due to the location of the home. The manager was looking at different ideas as well as providing transport to recruit more staff. The home used agency and bank staff when short staffed. We were told that two new nurses were starting employment with the home and the home had over 50 of staff with NVQ level training. The staff had also completed the statutory training for safe working practices. Records showed that the staff did not get regular supervision and this should be done at least 6 times per year. 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 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 managed by an experienced and qualified manager however several areas require further work to meet the necessary standards. Evidence: The manager of the home assisted with the inspection. She has the relevant qualifications and experience to run the home. Discussion with the manager showed that they had a good understanding of the areas that needed improving. We were concerned about the number of locked doors and how this impacted on the freedom and liberty of the people who live at the home. There was no evidence as to how decision regarding the locked door had been made. We spoke to the manager about this. The staff spoken to stated that the manager was supportive however we were also told that some staff did not see the manager as they were based too far away from them. We were not provided information about the homes quality assurance systems or Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: provided information of any analysis undertaken from the peoples questionnaires. The accidents and incidents that occurred at the home were not being reported to the relevant agencies under regulation 37 of the Care Standards Act and under safe guarding procedures. (see section on concerns and complaints). The staff were not getting regular supervision to monitor their practice. We were told that the communication file needed to be kept up to date. Records in the home needed to be completed fully and dated and signed by the person completing the form. Fire drills were undertaken on a monthly basis and this was good however the names of people involved needs to be recorded in full. Weekly fire drills and monthly emergency lighting was carried out. A fire risk assessment was also carried out for the home. The staff had training on health and safety practices. 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 2 14 Assessments of peoples needs must be completed in full and linked to the care plan This is to make sure that all the peoples needs will be met by staff. 31/03/2009 2 6 15 Care plans must include all 30/04/2009 the information stated in the standard and changes need to be updated so that they actually reflect the needs of each person. This is so that staff have relevant and correct guidance to meet the individual needs at all times to maintain the peoples safety. 3 23 12 People must at all times have freedom of movement so that they are not restrained at anytime and have free access throughout the home and its external facilities. Care must be 23/02/2009 Care Homes for Adults (18-65 years) Page 28 of 30 provided in accordance with the mental capacity act. Regulation 12 and 13 This is to ensure the peoples civil liberties and rights are upheld 4 39 24 Provide a clear quality assurance system that is easy to understand on an annual basis and ensure the analysis from the process is displayed. This is so the people and their representatives can view it to find out how the home is meeting the needs of the people the home. 5 42 13 Accidents and incidents must be reported in accordance with the homes policy, to the relevant agencies and under regulation 37 to CSCI. This is to ensure that people receive the support from the multi agency group to ensure people living at the home are protected. 30/03/2009 30/05/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 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). 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. 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