Inspection on 06/02/09 for Lynfords

This inspection was carried out on 6th February 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lynfords 14/02/08

Lynfords 05/01/07

Lynfords 18/01/06

Lynfords 23/08/05

Lynfords 24/01/05

Lynfords 09/09/04

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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: Lynfords 3a Nursery Close Hailsham East Sussex BN27 2PX     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: Caroline Johnson     Date: 0 6 0 2 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 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 03000 616161 (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 28 Information about the care home Name of care home: Address: Lynfords 3a Nursery Close Hailsham East Sussex BN27 2PX 01323440843EX22 01323449555 nursery@regard.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Regard Partnership Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 6 The maximum number of service users to be accommodated is 6. The registered person may provide the following category/ies of service only: Care home only - (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 (LD). Date of last inspection Brief description of the care home Lynfords is a purpose built bungalow, situated in a quiet residential area of Hailsham. The home shares the same site and manager as The Marshes, another home owned by the same organisation. Resident accommodation provides six single bedrooms, a large communal lounge and a kitchen/diner. The two bathrooms are fitted with the necessary adaptations. The grounds are secure and provide a well-maintained garden and ample parking. The home is registered to accommodate six adults with learning disabilities between the ages of 18-65 on admission. The Registered Providers of the service are The Regard Partnership. This organisation Care Homes for Adults (18-65 years) Page 4 of 28 Brief description of the care home owns a large number of homes across England and Wales. Information regarding fees can be seen in the summary section of this report. More detailed information about the services provided at Lynfords can be found in the homes Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from The Regard Partnership. Latest CSCI inspection reports are on available on request from the home. Care Homes for Adults (18-65 years) Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: For the purpose of this report the people living at Lynfords will be referred to as residents. As part of the inspection process a site visit was carried out on 6th February 2009 and it lasted from 10:00am until 5.20pm. The appointed manager facilitated the inspection. Over the course of the inspection there was an opportunity to meet and have lunch with four of the residents. In addition time was spent with two members of staff in private. A full tour of the home was undertaken. Two care plans were examined in detail. In addition records seen included; staff rotas, training, medication, menus, health and safety, quality assurance and leisure activities. Care Homes for Adults (18-65 years) Page 6 of 28 An AQAA (Annual Quality Assurance Assessment) was received prior to the inspection and information contained within the AQAA has been used within this report. Following the last inspection a registered manager from one of the sister homes took on the management of the home on a temporary basis. Since then she has become the appointed manager for the home and is about to submit her application to register as manager for Lynfords. Fees for the service are 1,315 pounds per week based on a block contract. 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 –03000 616161. Care Homes for Adults (18-65 years) Page 8 of 28 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 28 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. Prospective residents receive information about the services on offer in a format that can be easily understood. Evidence: There is a detailed statement of purpose in place. Within each care plan there is a service user guide that has been prepared using symbols. This had been updated in November 2008. Discussion was held about how the guide could be made available in a wider range of formats to suit the individual needs of the residents accommodated. There was also a terms and conditions of residence contract in place. There have been no new admissions to the home since 2004. Each of the residents needs and abilities are assessed at six monthly intervals and their care plan is then updated as a result. Care Homes for Adults (18-65 years) Page 10 of 28 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 quality of the support plans in place is very good and with better record keeping in some areas this could be enhanced even further. Evidence: Two support plans were examined on this occasion. It was noted that extensive work has been carried out since the last inspection to make care plans more person centred. There is a detailed pen portrait in place. Information is also included about how best to support the individual. There are photos of the people that are important to the resident. In addition there are lists of each individuals likes and dislikes in relation to food and activities. From the assessment of abilities and needs there are individual care plans setting out how the needs are to be met. They provide staff with detailed information about how to support each resident. In addition there is a risk assessment checklist in place. This Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: considers each area where there could be a perceived risk, the likelihood of the risk occurring and if a risk management plan is required. From this risk assessment management plans are then put in place. In both the care plans seen there were a wide range of risk assessments. It was noted that even following the implementation of safety measures the risk assessments were all showing that the risk was still considered high. This was discussed further with staff and it was agreed that if appropriate measures have been taken to reduce the risk of an accident/injury then this should bring the risk level down. However, it was reported that it is company policy for the risk level to remain high. A requirement was made at the last inspection in relation to people not being restricted unnecessarily and the need to look at the least restrictive alternatives. The manager advised that they have looked at times when residents could be perceived to be restricted and considered if there is a need to have a risk assessment in place. In relation to one resident a new chair has been ordered. Another example given was that one of the residents now has their seating altered so that they are not spending too much time in the same position for long periods. Goal and skill building plans were being written at the time of inspection but had not yet been typed. It was reported that they would be ready to be introduced in a couple of weeks. Keyworker meetings are held monthly with each resident and the home reviews each care plan every six months. Records of these meetings were detailed and showed that a wide range of issues had been discussed. Where there are issues of consent and the resident has not been assessed as being able to give consent then a best interest meeting is arranged so that the subject can be discussed at a multi-disciplinary setting, including the resident, and agreement reached on how to deal with the issue. The placement authority also carries out an annual review of the placement. Daily records seen varied in terms of the quality. Some staff wrote detailed accounts of what had happened over the course of the day for individual residents, such as the choices and decisions they made, what activities they had done and the outcome and what care had been provided. Other staff wrote a much more limited account of the day. Residents also have house meetings where they discuss activities and menus, and records are kept of the outcome. Care Homes for Adults (18-65 years) Page 12 of 28 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. Residents are offered a good range of varied and stimulating activities to meet their individual needs. Improved record keeping detailing progress with activities could enhance this further. Evidence: Following the last inspection it was reported that the home arranged for the local college co-ordinator to come to the home to discuss with residents the various options for courses. As a result of this, courses attended by residents include flower arranging, cook and eat, pottery and transport. Individual planners showed that residents have opportunities to do bowling, cafe trips, watching DVDs, shopping and arts and crafts. At the time of inspection an aromatherapist was in the home to spend time with three of the residents. There was an Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: activity planner on the wall in the dining room. It was noted that very few of the residents were actually doing the activities that were planned but they were involved in alternative activities. Staff spoken with started that they try to be spontaneous and offer choice. However, record keeping does not show if the activity was offered or had to be changed through the residents choice or to fit in with the daily routine and how the alternative had been chosen. Three of the residents were going to the theatre on the evening of the inspection to see an Abba tribute. It was reported that one resident loves going to the cinema and another two residents occasionally choose to go to church. On an annual basis the company hires the local community centre for the residents families Christmas party. In addition every other week there is a club night at the community centre. Residents from each of the local Regard homes are invited to attend this. A planning meeting is held once a month to decide what activities residents would like. New equipment has just been purchased so that they can have bingo nights and a parachute has also been ordered. At the time of inspection residents were preparing for a Valentines night. A local music entertainer had been booked to provide music for the party. One of the residents was seen supporting a staff member to cook the main meal of the day. He showed obvious delight when residents and staff commented on the quality of the food. Another resident was seen preparing the food for the cats and she was proud that this was her responsibility and she showed the book where she writes a noted to staff to let them know when they are running low on cat food. A staff member advised that they have folders with pictures of meals and vegetables and that they work on a one to one with residents to encourage them to make food choices. They vary the choices presented to the resident to ensure that a balanced diet is provided. Record keeping shows the choice made by residents but not the options provided. Meals are planned one week in advance but residents can choose an alternative to the main meal. A staff member said that the house is quite close to shops so if a resident chooses something different they are able to pick up the ingredients easily. Records show that the alternatives provided are omelettes, jacket potatoes, salads and ready meals. Menus showed that there is a themed night once a week. The week prior to the inspection was Chinese food and on the week of inspection it was Italian food. Care Homes for Adults (18-65 years) Page 14 of 28 Care Homes for Adults (18-65 years) Page 15 of 28 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. Residents are protected by the systems in place to manage their healthcare needs. Evidence: The arrangements in place for the storage and handling of medication were in order. Since the last inspection of the home a number of improvements have been made to the way medication is handled. Each resident has a medication cabinet in their individual room and record keeping is located in the cabinet. Any returns are sent back and a record is kept of the pharmacy signature. A weekly medication audit is carried out. In the records for one of the residents case tracked it was noted that a detailed homely remedies list had been prepared but the GP had yet to sign the document. It was reported that staff receive training on the administration of medication every three years. However, they are also expected to complete e-learning medication training also. E-learning is completed on the homes computer and the course is then certificated. Every year they are supervised on between two to three occasions Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: administering medication and a record is kept of this. At the time of the last inspection there was some secondary dispensing of medication. However, it was noted that this practice has ceased and there is now a protocol in place for the administration of medication. Each of the residents has a health action plan in place and it is reviewed regularly to ensure that individual needs continue to be met. The GP had reviewed each of the residents prescribed medication in January 2009. The home uses the advice and support of external professionals where necessary to meet the health needs of the residents. As the majority of residents have been assessed as not having capacity to give consent, best interest meetings are now held to discuss health issues. This was evident in relation to both the residents case tracked. However, in relation to one, whilst there was a meeting to discuss consent to a minor operation there was no information in the care plan about the diagnosed condition and how it could affect an individual. It was noted that the home had sought advice and support in relation to one resident around refusing personal care. Discussion was had about one persons right to refuse and other residents right to live in an environment that is clean and hygienic. The manager acknowledged that further work should be carried out to find a solution that would be agreeable to all concerned. There was a very good rapport observed between staff and residents and there was a lively and jovial atmosphere in the home. Questionnaires had been sent to the relatives of residents asking their views on the subject of dying and death and the outcome was included in care plans. Care Homes for Adults (18-65 years) Page 17 of 28 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 procedures in place enable anyone wishing to make a complaint can do so. Evidence: There is a detailed complaint procedure in place and in addition there is a simplified version of the procedure in place, which is also available in a range of formats. There was one complaint on record since the last inspection of the home. Record keeping showed how the complaint had been investigated and the outcome, which was resolved to the satisfaction of the complainant. Records are also kept of any compliments made to the home and it was noted that there were four compliments recorded. There is a detailed procedure in place in relation to adult protection and prevention of abuse. Records showed that all staff have received training on this subject. Staff spoken with were clear about the action they would take if they suspected abuse. Care Homes for Adults (18-65 years) Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained and provides a good standard of accommodation for the residents. Evidence: The building is well maintained and decorated to a good standard. The property is spacious with a large lounge and a separate dining room/kitchen area. There is a staff notice board on display in the hallway showing which staff are on duty on each shift. Responsibility for keeping this up to date is detailed in the shift planner. All of the bedrooms are very individual and reflect the personalities and tastes of the residents. There are bed rails on some of the beds and it was noted that an occupational therapist had visited the home recently in relation to one resident and protectors for the bed rails have been ordered. One bedroom was very cluttered and there was a very strong odour from this room that was emanating into the corridor. It was reported that residents choose the colour scheme for their bedrooms when they are redecorated. There is a parker bath in one of the bathrooms and it was noted that the tiling in the shower room need re-grouting. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: There is a garden to the rear of the property with a patio area where there is seating provided. One of the residents has planted a number of flowerpots and she regularly tends to these. Residents use the laundry room with staff support. It was noted that the washing machine was not working at the time of inspection but a new machine had been ordered and was due to be delivered within a week. In the interim the home were using the facilities at the sister home, which is on the same site. Records showed that four staff had completed training in infection control and it was reported that further training had been booked. Care Homes for Adults (18-65 years) Page 20 of 28 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 receive good training opportunities that equip them well in meeting the complex needs of the residents. Evidence: The rota shows that there is generally three care staff on duty throughout the day and in addition to this an extra carer works a 9.30am until 5.00pm shift. At night there is a waking staff member and a sleep-in staff member covers both Lynfords and the Marshes, which is the sister home on the same site. It was also reported that there is an on call manager or deputy and an on call area director. Records seen in relation to staff recruitment showed that the home is very thorough in ensuring that appropriate checks are carried out. Staff complete a very detailed induction to the home and new staff commence mandatory training via e-learning as soon as possible after commencing work in the home. Since e-learning has been introduced there is the possibility of a new staff member actually completing their mandatory training whilst they are waiting for their CRB (criminal records bureau) coming through. A staff member spoken with stated that when they commenced working in the home they shadowed staff for five days and did not carry out any new tasks until they felt competent to do so. Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: Records showed that five staff have completed NVQ (national vocational qualification) at level two, three at level three and a further three staff are studying for level three. The staff-training matrix showed that all staff had up to date training in health and safety, protection of vulnerable adults, fire safety training, epilepsy and manual handling. There were some gaps in other areas of training but courses were being booked. Five staff have completed training on dementia and another course has been booked. This is also the same for infection control. A staff member spoken with advised that they have been able to use parts of their recent training in relation to reminiscence and sensory work with one of the residents and this has been a particularly valuable experience. There is a very good system in place for recording and tracking the provision of monthly supervisions and annual observations and appraisals. One staff member stated that the manager is very approachable and staff are now guided correctly. Another stated that her supervisor is approachable and lovely. Care Homes for Adults (18-65 years) Page 22 of 28 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. There are some good systems in place to ensure that the home is managed well and these are continuing to be developed and improved upon. Evidence: The appointed manager had just commenced in post at the time of the last inspection. She advised that her application for registration is currently with their head office and will be forwarded on to Commission as soon as possible. She has completed NVQ level four and the Registered Managers Award. A staff member spoken with stated that working in the home is fantastic. Since the manager came to the home she has gradually turned the home around and the standard of care has improved. She is confident, has a world of experience and staff are now guided correctly. Staff meetings are held regularly and notes show that a wide range of issues are discussed. It was also noted that issues raised at best interest meetings and reviews Care Homes for Adults (18-65 years) Page 23 of 28 Evidence: are also carried forward to the staff meetings to ensure that all staff are kept up to date the health needs of the residents and with changes in care practices. There is a daily shift plan in place that shows which staff members have taken responsibility for administering medication, cleaning tasks, carrying out health and safety checks and updating the staff and activity boards. As part of the homes quality assurance system satisfaction questionnaires were sent to the relatives of the residents at the beginning of February. At the time of the inspection two questionnaires had been returned. Both responses were positive. The format used to gain views is limiting and could be expanded upon to seek views in a wider range of areas. It was reported that questionnaires would be sent to visiting professionals in April and to care managers in October. The company have a questionnaire format for seeking the views of service users but this is not currently used. A discussion was had about how this could be achieved. A representative visits the home on behalf of the company once a month and prepares a report on the running of the home. In addition a more detailed audit is carried out every six months. The home is currently in the process of resolving difficulties that they have had in relation to accessing residents monies from their bank accounts. They have enlisted appropriate assistance to resolve this issue and are hopeful that this will soon be concluded. In the interim the company is ensuring that residents have money as and when needed and there are detailed records in place showing all expenditure made on behalf of residents. A requirement was made in relation to food hygiene at the last inspection. It was confirmed that staff have had training in food safety and correct procedures are being followed. Information provided in advance of the inspection confirmed that equipment is tested and serviced at regular intervals. Care Homes for Adults (18-65 years) Page 24 of 28 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 25 of 28 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 12 16 The registered person must ensure that they can demonstrate that individual activity programmes have been offered and the outcome recorded. Service users must have opportunities to engage in appropriate activities. 30/04/2009 2 30 16 The registered person must ensure that all areas of the home are kept clean and free from odours. The home must be kept clean and hygienic. 15/04/2009 3 37 9 The registered provider must ensure that the appointed manager submits an application for registration. Service users benefit from a well run home. 30/04/2009 Care Homes for Adults (18-65 years) Page 26 of 28 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 7 The home should find ways of demonstrating more clearly how residents are making choices and decisions. Following the implementation of safety measures to reduce the risk of an accident/incident occurring this should reduce the level of the risk of such an event occurring and record keeping should reflect this. Agreement should be reached with the GP about which homely remedies are safe to use in the home. The home should adapt the format for service user and relatives questionnaires to enable more detailed information to be obtained. 2 9 3 4 20 39 Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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