Inspection on 07/01/09 for Kintyre

This inspection was carried out on 7th January 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kintyre 23/01/07

Kintyre 21/02/06

Kintyre 07/10/05

Kintyre 20/12/04

Kintyre 14/06/04

Kintyre 10/03/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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: Kintyre 1 Newton Road Weston Super Mare North Somerset BS23 1YP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Paul Chapman     Date: 0 7 0 1 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.csci.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: Kintyre 1 Newton Road Weston Super Mare North Somerset BS23 1YP 01934620341 01934620575 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) : Western Counselling Services Limited care home 9 Number of places (if applicable): Under 65 Over 65 0 0 past or present alcohol dependence past or present drug dependence Additional conditions: 9 9 May accommodate up to 9 persons aged 17 - 64 years Date of last inspection Brief description of the care home Western Counselling Services is registered with the Commission for Social Care Inspection (CSCI) and provides primary and secondary programmes of rehabilitation for up to 65 people between the ages of 17 and 64 years who have alcohol and/or drug dependencies. The bulk of the primary counselling programme takes place at a day centre and there are two houses (Meijer and St Davids), which provide accommodation for mixed sex groups on primary programmes. Three other houses, Larkhill, Kintyre and Clarence Park Lodge provide accommodation for single sex groups receiving secondary programmes. Kintyre provides up to 9 places. The counselling is based upon the twelve-step Minnesota model. These homes have a private arrangement with a local GP practice to provide medical support and assessments, especially for those who are in the initial part of the primary programme. Care Homes for Adults (18-65 years) Page 4 of 30 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 peterchart Concerns, complaints and protection Environment Staffing Conduct and management of the home Poor Adequate Good Excellent How we did our inspection: Before completing this site visit we reviewed the previous inspection report, other information gathered since the previous inspection and the AQAA (Annual Quality Assurance Assessment). The AQAA provides us with information about what the manager feels the service does well, what has improved since the previous inspection was completed and what improvements are planned for the next 12 months. In addition to this information it also provides us with a dataset, this is information about staffing, procedures, complaints, training and health and safety. This inspection site visit was completed over a period of 3 hours in January 2009. The registered manager oversees 2 homes and we had spent 3 hours in the other home with them before this. Care Homes for Adults (18-65 years) Page 6 of 30 We examined recent admissions to the centre, the assessment process, care plans, risk assessments and other associated paperwork, in addition to this we completed a tour of the premises with the manager. Each of the people staying in the centre were asked if they would like to speak with us but declined. Two CSCI inspectors have been involved in inspecting Western Counselling Services recently. As a result of this it was decided that the outcome areas for Staffing and Conduct and management of the home would only be inspected by one inspector. As a result of this the evidence in these outcome areas are the findings of Juanita Glass (Regulatory Inspector). What the care home does well: What has improved since the last inspection? What they could do better: The manager must ensure when they are completing future admissions to the home that they follow the organisations policy and complete all of the necessary paperwork. Care Homes for Adults (18-65 years) Page 8 of 30 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 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. Thorough needs assessments completed by the manager before admission minimise the risk of people being admitted to the service whose needs cannot be met. People admitted to the service are clear about what is expected of them and the consequences of breaking the rules of residence in secondary care. Evidence: We were supplied with a copy of the organisations information pack. This provides people that may potentially use the service with a wide range of information to enable them to make an informed decision about whether the service can meet their needs. Kintyre has a detailed admission/assessment procedure. The registered manager is highly experienced in the treatment of substance misuse with over 20 years of experience in the field. Speaking with the manager they gave a detailed explanation of how any admission to the service is managed. We saw 2 examples of admissions to the service and examined them in detail with the manager. One admission to the service had been from the organisations primary treatment service and a person is Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: expected to complete a self-assessment where they give their opinion on their progress in primary care, and their expectations of what they want to a achieve in secondary care. In addition to the person completing this document their counsellor will also give their opinion. Once this document has been completed the person will be invited to spend 24 hours in the service, during this period the manager will complete a thorough assessment with the person and start developing care plans. Unfortunately in the case of the file we were examining the documents had not been completed. The manager stated that they had not completed the assessment documents but had spoken to the person to identify their needs. The manager must ensure that the organisations procedures are followed and that the appropriate assessment forms are completed at all future admissions to the service. Although the majority of people using the service are admitted from the organisations primary treatment service others may be admitted from other organisations and directly from prison. Where this is the case the initial assessment can be completed over the telephone with a member of appropriately trained staff from the organisations office. From the information we examined relating to admissions to the service it is clear that the service thoroughly assess peoples needs and this minimises the risk of the service admitting people whose needs cannot be met. But the manager must complete the paperwork as required to evidence this. All people that are admitted to the service sign residency contracts and a document named Rules of Secondary which identifies the rules by which people must abide whilst in secondary care. This is good practise and clearly identifies actions that could lead to a disciplinary, or even discharge from the service. We looked at the recorded figures for secondary care discharges throughout 2007. This showed that 83 of people completed the secondary care programme. The AQAA completed by the organisations general manager states that over the next 12 months they will continue to review the admission process to ensure that it meets the objectives of the service, the service users and the service purchasers. 1 person using the service commented in their questionnaire that they received information on secondary care from primary stage, and from secondary peers. 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. The plans of care we examined provided the reader with a good level of detail which enabled a consistent approach to meeting peoples care needs. The agreed goals were appropriate for the period of time being spent in the service to minimise the risk of people failing to achieve their goals. People are empowered to make decisions about their lives. Risk assessments are in place that minimise potential risks to people using the service. Evidence: We saw care plans for 2 people residing in the service. The care plans we examined were detailed and provided the reader with clear information about what the person wanted to achieve. The service is staffed by one member of staff who is a trained counsellor, this provides a high level of continuity as they are also the person who completed the admission assessment. All care plans are reviewed regularly and daily notes by the member of staff provide evidence of people working towards, or achieving there goals. The agreed goals we saw were realistic considering the the short period of Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: time (12 weeks) that the person will be resident in secondary care. With Western Counselling providing both primary and secondary care for people the manager spoke about being able to be very flexible about the programmes that are offered to people. Where it is judged and agreed that people may need to re-visit part of their primary care programme the manager is able to support the person with this. This is a strength of the organisation and its staff. Secondary care settings in the treatment of substance misuse start to empower people in making more decisions for themselves and a number of restrictions imposed in primary care are lifted. Examples of this include people being able to access the local community more frequently, as long as this does not interfere with the daily programme. Speaking to the services cook she stated that people choose what they have to eat and people are encouraged to be involved in the preparation. All people using the service are asked to attend a minimum of 3 AA/NA (Alcoholics/Narcotics Anonymous meetings) per week, but can chose to attend more if they wish. Another example of people being empowered to make decisions about their lives is them being supported to attend college courses and complete voluntary work locally. The manager completes a range of risk assessments for each person. The manager stated that they review them weekly, although these are not written reviews. We spoke to the general manager of the organisation about this process and they agreed that there is no expectation for written reviews over the twelve weeks people are in secondary treatment. The manager of the service stated that if risk assessments are updated as required. It is a recommendation that there should be some form of written review completed at least once during this period. The AQAA showed that over the coming 12 months the aim is for further development of care plans, consolidating the improvements in the treatment programme and incorporating alternative therapies. 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. Although there are restrictions on peoples freedom and choice there is a range of activities for people to be involved in as part of their continued treatment. People are empowered to choose what they would like to eat and learn new cooking skills through their involvement in preparing meals. Evidence: As stated earlier in this report secondary care relaxes some of the restrictions on a persons freedom and choice, but a number of restrictions are still in place. People are made aware of these restrictions before they move into the service via the service user guide and people they know already completing secondary care. When a person is assessed for secondary care they are asked to sign the Rules of secondary which explains this explicitly. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The manager is a trained counsellor and runs 3 group sessions per week with people using the service. These sessions are aimed at giving people the opportunity to talk about their fears and any day to day problems. As mentioned earlier in this report people are expected to attend a minimum of 3 AA/NA/OA/CA fellowship meetings per week. Records showed that some people attend meetings more frequently than required. As part of the treatment programme people are given the opportunity to visit family/carers in weeks 4 to 5. speaking to the manager about this part of treatment it is clear that it is well planned and people are appropriately supported throughout their time away from the service. At the time of this site visit 1 persons family were visiting them and they were out in Weston. People are able to go out and about in the local community whilst they are in secondary care. People are not allowed to go out alone and must be accompanied by at least 1 other person. The Western Counselling day service is within easy walking distance from the service and people attend the day service for group sessions. People from both primary and secondary care attend the day service and this enables people completing primary care to meet people from secondary care. As part of the inspection of Western Counselling services people that we spoke to said that it was really helpful as when they moved from primary care to secondary care they knew people and what to expect. In addition to the activities already mentioned people attend college courses, complete voluntary work, use a local gym and make use of parks, etc for other sporting activities. People are encouraged to take part in team sports. Whilst people are in secondary care they are expected to take responsibility for household chores. There is a television in the lounge and viewing is restricted. During weekdays people are able to watch it between 1600hrs and 2330hrs, at weekends people can watch it between 1300hrs and 0030hrs. We spoke to the cook at the service about the meals offered and the amount of choice/input by people using the service. Examining the menu it showed that a wide Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: range of meals were available and that where needed special dietary requirements were met. 1 person we spoke to said the food was really good and they were able to choose what they wished. The cook is employed 5 days a week and on the other 2 days people using the service are expected to share the cooking duties. This is not just limited to the weekend and people and the cook says that she supports people with cooking during the week. The cook explained that as well as helping people to learn new cooking skills they have learnt new recipes from people. Snacks are available at all times. Planned improvements identified in the AQAA for the next 12 months are to work with local agencies/religious groups to incorporate the clients into the community, i.e. undertaking community voluntary work. This could include tidying communal areas and clearing pensioners gardens. Care Homes for Adults (18-65 years) Page 17 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. Current procedures for the administration of medication in the service minimise potential risks to people. Evidence: All of the people staying in the service are expected to be clean, tidy and appropriately dressed at all times. This is strictly observed as it is felt it raises peoples feeling of self-worth. People are responsible for their own personal care. Records seen in the 2 files we examined provided good evidence of peoples medical needs being addressed as required. The previous inspection report made a recommendation that risk assessments should identify potential risks and possible triggers that may cause relapse or disciplinary discharge. These risk assessments had not been completed and we discussed the need for them to be implemented. It was agreed that the steps taken by the manager when people moved on from the service negated the need for these assessments to be completed. Where ever possible the manager gives a comprehensive handover to a Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: new service provider and this would cover the area of triggers that may cause relapse or disciplinary discharge. Medication like homely remedies are held by people living in the service. All other medications are held by the organisation and administered by a staff member responsible for managing all of the medication. The staff member signs medication sheets to confirm that people have received the medication. Care Homes for Adults (18-65 years) Page 19 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. The service provides people with a complaints procedure that enables them to voice concerns if they are unhappy with the service they are receiving. Evidence: There have been no complaints made to the manager or the CSCI since the last inspection was completed. When people enter secondary care they are given a copy of the complaints procedure as part of their service users guide. We received 6 completed CSCI questionnaires from people using in the service, all people said that they knew who to talk to if they were unhappy. 5 of the 6 people said they knew how to make a complaint. There was a copy of the services complaints procedure on the wall in the properties hallway. Each person receives 21 pounds every Friday from the manager who holds everyones bank cards whilst they are completing secondary treatment. People are expected to manage this weekly budget, if people require extra money for a specific purchase they will have to seek consent from their counsellor. This information is clearly identified in the service user guide. The AQAA completed by the organisations general manager states that all staff have received, or are booked to complete safeguarding adults training. Care Homes for Adults (18-65 years) Page 20 of 30 Care Homes for Adults (18-65 years) Page 21 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 property provides people with a comfortable, clean and homely environment that meets their needs whilst completing secondary care. Evidence: The previous inspection report made a couple of comments about different aspects of the accommodation. These included comments by people in the service about the bath and shower rooms being claustrophobic and with limited ventilation. We completed a tour of the premises with the manager. All of the communal areas were seen to be nicely decorated and furnished comfortably with good quality fittings. There was a homely warm feel to the property. Since the previous inspection was completed the bath and shower rooms have been re-fitted and decorated. None of the inhabited bedrooms were seen on this occasion. There is a covered smoking area in the rear garden. People do not smoke inside the property. At the time of this site visit the property was clean and tidy. People living in the service are expected to take responsibility for domestic chores as part of their recovery programme. Care Homes for Adults (18-65 years) Page 22 of 30 Care Homes for Adults (18-65 years) Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a staff team who are competent and qualified and trained to meet the needs of people attending a treatment centre for Drug and Alcohol Abuse. They are also protected by clear policies and procedures for the recruitment of new staff and supervision of existing staff in the home. Evidence: The service is not staffed between 1700hrs and 0800hrs every day. During this period there is an on call system where people can contact a range of staff via the phone. The service employs 2 staff - the manager and the cook. Speaking with staff they both agreed that the organisation provided them with training to meet their needs. We looked at the personnel files and they showed that all staff had a job description, which clearly stated what their roles and responsibilities were to support people in achieving the treatment program. Records to evidence that people had been encouraged to attend training were in place and showed us that they had all attended both mandatory training and training Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: relevant to their role at the treatment centre or the house people are accommodated in. People demonstrated that they were well aware of the needs of people in the centre and how to meet them. The expert by experience said that people indicated staff were knowledgeable and helped them in the program. Surveys we received said that staff were excellent and understood their roles as counsellors and support workers. Records kept by the manager following the recruitment of staff showed that Western Counselling follows very strict policies and procedures ensuring that all the appropriate checks are carried out before a person starts work at either the treatment centre or the individual houses. Staff records also confirmed that they received regular supervision from management and we saw documentation that showed all staff had attended supervision meetings, counsellors are also able to attend counselling sessions run by an outside organisation. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a home that is well managed in an open and approachable way, which considers peoples personal input into the day to day running of the home as far as is possible within the constraints of the centre. Health and safety practises in the home safeguard people living there. Evidence: The previous inspection report made 2 requirements against Standard 42. The 1st requirement was to ensure potential risks to people being scolded by hot water outlets were minimised. At this inspection we saw that all hot water outlets now had signs to warn people of hot water. In respect of the baths and showers the manager informed us that thermostats had been installed. The 2nd requirement relates to smoking in the service, as previously mentioned in the report a shelter has been built in the rear garden and people no longer smoke in the property. Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: The registered manager for the home is Alun Davies he is very experienced and continues to work closely with the client group in the primary stage of treatment. The managing director Amanda Lea has worked within the addiction Field since 1993 and has extensive knowledge and experience of treatment services and their management. Amanda has been awarded the Registered Managers Award NVQ4, she is primarily responsible for the assessment and admission of clients,treatment and quality of care. Quality Assurance in the home includes client satisfaction surveys on completion or on leaving the home. The managing directors use these to look at what changes can be implemented to improve the quality of care they provide. The organisation also keeps a record of retention and completion rates. Monthly audits are undertaken and these also contribute to an complete overview of the home, the quality of care and the progress people who have completed primary stage and moved on to secondary treatment. Clients are encouraged to meet and discuss the service provided and any variations or considerations they would like made at any point during their treatment programme. The implementation of health and safety within the home was satisfactory. All residents have personal risk assessments. Generic risk assessments are in place and reviewed regularly. A review of the fire-log showed all tests, training and drills were being carried out to Local Fire Brigade guidelines. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes  No  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 actio Care Homes for Adults (18-65 years) Page 28 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 The manager must ensure that the services admission procedures are followed. Failure to follow the services admission procedure may increase the potential risk of someone being admitted to the service whose needs cannot be met. 28/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 Risk assessments should be reviewed on at least one occasion during a persons stay at the service. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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