Inspection on 11/08/09 for Langdon Park 18

This inspection was carried out on 11th August 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Langdon Park 18 22/06/10

Langdon Park 18 13/02/09

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Langdon Park 18 18 Langdon Park Teddington Middlesex TW11 9PS     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Simon Smith     Date: 1 1 0 8 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Adults (18-65 years) Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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 27 Information about the care home Name of care home: Address: Langdon Park 18 18 Langdon Park Teddington Middlesex TW11 9PS 02089432255 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.stepforward.org.uk Metropolitan Support Trust care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who may be accommodated is: 7 The Registered Person may provide the following categories of care only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD Date of last inspection Brief description of the care home Langdon Park is a purpose built care home that provides care and accommodation for a maximum of seven adults with learning disabilities. Staffing is available to residents 24 hours a day. The service is managed by Metropolitan Support Trust. The home is situated in a quiet residential area close to local shops and public transport links. There is a good standard of decoration throughout the home and a well-maintained garden. Each resident has a single room with en-suite bathroom. 1 7 0 2 2 0 0 9 7 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 27 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: The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. We used information from a range of sources when making this judgement about the home. This included visiting the home unannounced and speaking to people who live there, the manager and staff. We checked some written records including service users files and health and safety checks. We also took into account any information the home had sent us since the last inspection. This included notifications of any accidents, incidents, complaints or safeguarding alerts. Care Homes for Adults (18-65 years) Page 5 of 27 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 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 6 of 27 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 7 of 27 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 home now has up to date information about service users individual needs. Service users must be given more information about the terms and conditions of their accommodation. Evidence: The last key inspection report said that the home must reassess service users needs and issue service users with a written tenancy agreement so that their rights were protected. There was evidence that the previous acting manager had done some good work in reviewing service users needs. The assessments were thorough and addressed areas including communication, eating and drinking, personal care, medication and health and social interaction, which means that the home now has up to date information about service users individual needs. The acting manager said that he had been advised by Metropolitan Support Trust that the organisation is unable to issue tenancy agreements to individual service users as the placing authority, the London Borough of Richmond, is formally the tenant in the Care Homes for Adults (18-65 years) Page 8 of 27 Evidence: arrangement. In this case Regulation 5(3) of the Care Homes Regulations (2001) applies. The regulation states Where a local authority has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the registered person shall supply to the service user a copy of the agreement specifying the arrangements made. Metropolitan Support Trust must give each service user a copy of the agreement between themselves and the London Borough of Richmond. The agreement should set out the terms and conditions of service users accommodation. Care Homes for Adults (18-65 years) Page 9 of 27 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 standard of support plans has improved since the last inspection. The standard of recording needs to improve to demonstrate that service users receive support to achieve the goals set out in their support plans. The home needs to work with service users to understand their communication needs better and to improve the support Service users get to make choices about their lives. Evidence: The previous acting manager has reviewed service users support plans since the last key inspection. As a result of her input the plans are thorough and provide guidance for staff about how to work with service users so that service users receive care consistently and in the way they prefer. There was also evidence that risk assessments had been reviewed since the last Care Homes for Adults (18-65 years) Page 10 of 27 Evidence: inspection. These included risk assessments covering moving and handling and guidelines for staff about how to support service users with personal care and when transferring. These guidelines were drawn up with the input of a physiotherapist. Whilst the standard of support plans has improved since the last inspection, the standard of recording has not. As a result there was insufficient evidence that service users get support to achieve the goals set out in their care plans. For example service users support plans identify goals such as attending church regularly and engaging in the local community but the Evaluation Sheets on support plans fail to demonstrate that these goals are achieved. Evaluation sheets also fail to demonstrate that service users get enough opportunities to take part in leisure activities and hobbies or to socialise. The home also needs to work with service users to understand their communication needs better. For example the acting manager said that at least one service user has knowledge of Makaton but that staff do not. The acting manager is keen to address this issue and said that he had engaged a speech and language therapist to train staff and work with service users in a Total Communication project. Care Homes for Adults (18-65 years) Page 11 of 27 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. There are not enough organised activities that reflect service users individual interests. Some of the working practices at the home restrict service users ability to make choices. Staff do not always act upon suggestions made by service users. Evidence: Since the closure of local day services the onus has fallen on care homes to provide service users with opportunities to take part in activities that they choose. As highlighted in the previous section of this report support plans do not provide evidence that service users have sufficient opportunities to take part in activities that they enjoy. There are some regular activities available to service users, for example a Care Homes for Adults (18-65 years) Page 12 of 27 Evidence: music therapist visits weekly, and service users go out for walks, drives and visits to shops, cafes and pubs but there are few organised activities that reflect individual interests. Some of the working practices at the home restrict service users choices. For example staff on the late shift finish work at around 9pm and night staff come on duty. There are not enough staff on the night shift to enable service users to go out, restricting service users to activities that finish before 9pm. Evidence suggested that staff do not always act upon suggestions made by service users. For example the minutes of two service user meetings held in May 2009 record that service users are looking forward to their holidays but the acting manager said that no service users had had a holiday in 2009. Care staff cook and prepare meals, which is appropriate given the size of the home. All staff attend food hygiene training. The homes menu indicated that residents receive a varied and well balanced diet. There was evidence that a speech and language therapist had provided guidance about how to support service users who have specific need around eating and drinking. Care Homes for Adults (18-65 years) Page 13 of 27 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. Service users get treatment when they need it. Referrals are made to the local community team when appropriate. There was evidence of some poor practice in the administration of medication that must be addressed. Evidence: Care plans provided evidence that service users get treatment when they need it and that healthcare professionals are involved in service users care when necessary. Referrals are made to the local community team psychology and challenging needs team when appropriate. There was also evidence that service users with ongoing conditions such as epilepsy have access to appropriate care and regular monitoring by specialist professionals. Health action plans are in place but some of these were incomplete. These should be completed, ideally using a format that is more accessible to service users. The home has appropriate storage for medication and there is a written medication Care Homes for Adults (18-65 years) Page 14 of 27 Evidence: procedure. Staff who give medication attend training before they are authorised to do so. There was evidence of some poor practice in the administration of medication that must be addressed. The practice involves the member of staff responsible for medication giving the medication to another member of staff to administer it. This practice is open to error and must not occur. Care plans provided evidence that service users get treatment when they need it and that healthcare professionals are involved in service users care when necessary. Referrals are made to the local community team psychology and challenging needs team when appropriate. There was also evidence that residents with ongoing conditions such as epilepsy have access to appropriate care and regular monitoring by specialist professionals. Health action plans are in place but some of these were incomplete. These should be completed, ideally using a format that is more accessible to service users. The home has appropriate storage for medication and there is a written medication procedure. Staff who give medication attend training before they are authorised to do so. There was evidence of some poor practice in the administration of medication that must be addressed. The practice involves the member of staff responsible for medication giving the medication to another member of staff to administer it. This practice is open to error and must not occur. Care Homes for Adults (18-65 years) Page 15 of 27 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. There are appropriate procedures to manage complaints. Service users monies are now stored more securely and financial procedures and checks have improved. Evidence: Metropolitan Support Trust has a complaints procedure for people who use its services. There is a symbol assisted version of this document. Metropolitan Support Trust also has a whistle-blowing procedure, which enables staff to report any concerns they have about poor practice. The last key inspection found evidence of two incidents where money belonging to service users had gone missing from the home. Only one of these incidents was reported to the police, local authority and CSCI and then not until approximately a month after the money went missing. The London Borough of Richmond hosted a strategy meeting in February 2009 to draw up a protection plan for service users and to identify improvements the home must make around safeguarding service users. The meeting identified concerns that the home did not keep service users money in a secure place, report the incidents to the appropriate agencies in good time or check service users monies often enough to identify when the funds went missing. This visit found that service users monies are now kept securely and that cash Care Homes for Adults (18-65 years) Page 16 of 27 Evidence: balances are checked daily. Three service users cash books and balances were checked during the inspection and found to be accurate, with appropriate records of transactions in place. The acting manager said that he carries out regular spot checks on service users finances. Care Homes for Adults (18-65 years) Page 17 of 27 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 comfortable, safe and well maintained. The communal areas of the home are spacious and homely. Service users bedrooms reflect individual preferences. The home is clean and hygienic. Evidence: The home is situated in a quiet residential location close to local shops, open spaces and public transport links. The house is well decorated and has spacious communal areas including a large open plan kitchen/dining room, separate dining area, a lounge and conservatory. There is a well maintained rear garden. Each service user has a large bedroom with en suite bathroom facilities. Adaptations are in place where necessary to meet service users mobility needs such as ceiling track hoists, adjustable beds and adapted baths. All parts of the home were clean and hygienic at the time of inspection. Care Homes for Adults (18-65 years) Page 18 of 27 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. It is important that Metropolitan Support Trust recruit to the vacant posts to establish an effective team and to provide consistent support to service users. Metropolitan Support Trust makes appropriate checks on new staff before they start work. Staff have access to training relevant to their roles. Some staff had not had one to one supervisions regularly enough. Evidence: The home had a number of vacancies on the staff team at the time of inspection, which meant that a lot of agency staff were being used. The acting manager had not been advised of when recruitment to the vacant posts was likely to happen. It is important for effective team building and for the consistency of support to service users that Metropolitan Support Trust address this issue and appoint staff to fill the vacant posts. Previous rotas have provided evidence that some staff worked too many days in a row to allow sufficient rest. The rotas seen at this visit found that this issue has largely Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: been resolved but there was still one member of staff who had had one day off in twelve. Metropolitan Support Trust obtains a Criminal Records Bureau Disclosure, proof of identity and two references for all staff before they start work at the home. The acting manager said that the agencies used by the home provide regular updates on the Criminal Records Bureau Disclosure status of agency staff. The training record showed that staff attend core training in areas including moving and handling, fire, medication, infection control, health and safety, first aid, food hygiene and safeguarding vulnerable adults. The acting deputy manager said that the service has good access to training through Metropolitan Support Trust and the London Borough of Richmond. Records showed that some staff had not had one to one supervisions regularly enough. All staff must have supervision at least six times a year. Care Homes for Adults (18-65 years) Page 20 of 27 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 absence of a permanent manager has had an adverse impact on the service throughout the year. This issue must be addressed by Metropolitan Support Trust. The home seeks service users views about what they would like to do but does not always act upon their suggestions. Health and safety records were generally in good order but some weekly fire alarm checks had been missed. Evidence: The absence of a permanent manager has had an adverse impact on the service throughout the year. The registered manager has been away from the service during that time and the post has been held by a series of acting managers. The current acting manager had worked at the home for eight weeks at the time of inspection. The deputy manager is also in an acting capacity. Both are keen to develop and improve the service but are uncertain whether they will have a permanent role at the home. Metropolitan Support Trust needs to address the situation regarding the management Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: of the service and to establish a consistent management team that can set to work addressing the areas in which the home needs to improve. There was evidence that the home seeks service users views about what they would like to do but less evidence that these views are acted upon. For example the minutes of both service users meetings held in May 2009 recorded that service users said they were looking forward to their holidays but the acting manager said that no service users have been supported to take a holiday this year. We checked health and safety records and found that: The Landlords Gas Safety Record was issued in March 2009 The five year Electrical Installation Certificate was issued in November 2004 Portable electrical appliances were tested for safety in September 2008 The water system test certificate was issued in October 2008 The home had appropriate employers liability insurance at the time of inspection. The home has an appropriate fire alarm system. There was evidence that the fire alarm, emergency lighting and fire fighting equipment were serviced in June 2009. The last fire drill took place in July 2009. There was evidence that staff check the fire alarm weekly using different call points but monthly monitoring visits by Metropolitan Support Trust noted that sometimes these checks are missed. The home must ensure that all weekly fire alarm tests are carried out and recorded. Care Homes for Adults (18-65 years) Page 22 of 27 Are there any outstanding requirements from the last inspection? Yes R 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 action 1 5 5 The Registered Person must 30/03/2009 issue residents with a formal tenancy agreement to ensure that their rights as tenants are protected. Residents rights must be protected. 2 36 18 The Registered Person must 30/03/2009 ensure that all staff have supervision at least six times a year. Staff must receive regular supervision and support. 3 39 12 The Registered Person must 30/03/2009 ensure that residents wishes are acted upon. Residents must be consulted about the service they receive. Care Homes for Adults (18-65 years) Page 23 of 27 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 5 5 Provide each service user with a copy of the agreement between Metropolitan Support Trust and the London Borough of Richmond that sets out the terms and conditions of service users accommodation. Improve the standard of recording on support plans to demonstrate that service users receive appropriate support to achieve their goals. Make sure that staff are aware of service users communication needs and are equipped with the skills to meet these needs. 30/10/2009 2 6 15 30/10/2009 3 7 12 30/10/2009 Care Homes for Adults (18-65 years) Page 24 of 27 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 4 13 16 Make sure that service users 30/10/2009 choices are not restricted by the working practices of the home. Make sure that service users 30/10/2009 have access to a range of activities that reflects individual interests. Make sure that service users 30/10/2009 have the opportunity to take an annual holiday. Make sure that all medication is administered safely. 09/10/2009 5 14 16 6 14 16 7 20 13 8 33 18 Recruit to the vacant posts 30/10/2009 to establish an effective team and to provide consistent support to service users. 9 36 18 Hold individual supervision sessions for all staff at least six times a year. Address the situation regarding the management of the service and establish a consistent management team. 30/10/2009 10 37 9 30/10/2009 Care Homes for Adults (18-65 years) Page 25 of 27 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 11 39 16 Make sure that service 30/10/2009 users views and suggestions are are acted upon. Ensure that all weekly fire alarm tests are carried out and recorded. 30/10/2009 12 42 23 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 19 Make sure that each service user has an up to date health action plan in an accessible format. Care Homes for Adults (18-65 years) Page 26 of 27 Helpline: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!