Inspection on 06/11/08 for Northfield House

This inspection was carried out on 6th November 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Northfield House 16/11/06

Northfield House 23/11/05

Northfield House 14/07/05

Northfield House 15/02/05

Northfield House 17/08/04

Northfield House 09/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Northfield House Tower Hill Williton Somerset TA4 4JR     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: kathy McCluskey     Date: 0 6 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect 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 29 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 29 Information about the care home Name of care home: Address: Northfield House Tower Hill Williton Somerset TA4 4JR 01984633810 Telephone number: Fax number: Email address: Provider web address: uf@northfield58.freeserve.co.uk Name of registered provider(s): Name of registered manager (if applicable) Miss Marianne Seager Type of registration: Number of places registered: Voyage Ltd care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Registered for 10 persons in Categories LD and PD Date of last inspection Brief description of the care home Northfield House is a large detached property located on the outskirts of Williton. Accommodation is provided on two levels. The home has ten bedrooms all have ensuite facilities. There are ground floor bedrooms and facilities for people who have the use of a wheelchair, including a bathroom with an overhead hoist and a walk-in shower. There are further bedrooms and a shower room and bathroom on the second floor. The extensive garden and patio areas of the home are beautifully presented. Northfield House is registered with the Commission for Social Care Inspection to provide personal care for up to 10 people who have a learning disability and physical disability. Northfield House is not registered to provide nursing care. Voyage Ltd owns the home and the responsible individual is Mr Steven Rees. The registered manager is Marianne Seager. Fees are based on the assessed needs of an individual. Fees do not Care Homes for Adults (18-65 years) Page 4 of 29 10 10 Over 65 0 0 Brief description of the care home include personal items, toiletries etc. People contribute part of their DLA mobility allowance to cover the homes transport. Care Homes for Adults (18-65 years) Page 5 of 29 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: This unannounced key inspection was conducted over one day (5.25hrs) by CSCI Regulation Inspector Kathy McCluskey. The registered manager was available throughout this inspection. Ten people were living at the home and we were able to meet with the majority of them. We were also able to speak with three members of staff. We were given unrestricted access to the home and all records required for this inspection were made available to us. The Commission sent comment cards to staff and people using the service, though Care Homes for Adults (18-65 years) Page 6 of 29 none were received at the time of this report. The home returned to the Commission, its Annual Quality Assurance Assessment (AQAA). The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We would like to thank all concerned for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. 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.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 8 of 29 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 29 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. People are provided with the information needed to enable them to make an informed decision about moving to the home. The home ensures that peoples needs are fully assessed and that they are given the opportunity to test drive the home. People are provided with a contract which states the terms and conditions of residence. Evidence: The home has produced a Statement of Purpose and Service User Guide which provide people at the home and those thinking about using the service, with information about the home and the services offered. The Service User Guide has recently been updated to provide information in a more accessible format for people. The registered manager informed us that there are plans to include this information in a DVD. We were also informed that the home is in the process of providing each person at the home with a Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: copy of the revised Service User Guide. There has been one admission to the home since the last inspection and on examination of the individuals care records, we were able to see evidence that appropriate assessments had been obtained prior to the person being offered a placement at the home. The individual had been able to visit the home on several occasions, including overnight stays, so that they were able to be sure that the placement was right for them. Detailed records were available, including records made by the individual. The pre-admission assessment process and transitional process also allows the home to ensure that they are able to meet the assessed needs and aspirations of an individual. It also gives the opportunity to explore whether the peer mix is appropriate. Care records contained a contract/statement of terms and conditions and a copy of the local authoritys financial agreement. Care Homes for Adults (18-65 years) Page 11 of 29 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 homes care planning procedures promote a person centred approach to care. People are supported to maintain an independent lifestyle through a risk assessment process. People are involved in all aspects of life at the home. Evidence: Each person has a care support plan and we examined two at this inspection. Care plans contained very detailed information regarding the assessed needs of individuals. Information for staff as to how peoples needs should be met were very clear and included information regarding the preferences of the individuals. Short and long term goals had been identified as had the strengths and abilities of the individual. One care plan contained information that had been written by the person using the service. This clearly identified how they wanted their needs to be met. Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: Care plans also contained detailed information about peoples likes and dislikes covering all aspects of their lives. The two care plans examined evidenced that people are supported to manage their own finances. Care plans were in place which gave clear information on the abilities of the individual and the amount of staff support required. It was very apparent that people were fully involved in the day to day life at the home. People are supported to clean their rooms and all are involved in shopping and cooking. Regular meetings are held where peoples views and comments about all aspects of life at the home, including staff, are encouraged. Minutes are maintained. The home are in the process of developing a newsletter. The home support people to live an independent lifestyle through a risk assessment process. We were able to see that risk assessments had been developed where appropriate. These clearly identified any risk and detailed the action to be taken by staff to support the individual. The home has policies and procedures in place for staff relating to confidentiality. Each care plan also contained information about confidentiality and accessing information in line with the Data Protection Act 1998. All records pertaining to people using the service were seen to be appropriately stored. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to develop and maintain skills which enable people to live an independent lifestyle. The home supports people to pursue leisure, educational and employment opportunities in line with their needs and preferences. People are fully involved in menu planning, shopping and cooking and support is given to maintain a healthy lifestyle. Evidence: The home ensure that people are given the opportunity for personal development. Needs and abilities are clearly set out in the individual plan of care. Those examined contained information on supporting the individuals with communication, social and Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: emotional needs. During the inspection we observed staff interacting with and supporting people in a manner appropriate to their needs. People appeared relaxed in the presence of staff and interactions were positive. Two people at the home are currently being supported to continue with work placements in the local community. We were able to meet with one of the individuals who was very positive about the support they received. The home has established very good links with the local community. There are regular trips to the local village and to the town of Minehead. Many people were getting ready to go on a trip to Minehead on the afternoon of the inspection. During the morning a number of people had attended a fitness for fun group in Minehead. They told us that they had really enjoyed it. Care plans contained information about peoples hobbies and interests. Each person has a weekly activity plan which is developed with each individual. This takes into account their preferences. The homes completed AQAA told us that people have access to a wide range of activities and that the staff team are flexible to ensure that peoples social needs are met. It also told us that the home offers the provision of quality holidays which have included; Gran Canaria, Cornwall and Reading. It said that these locations had been requested by people using the service. Care plans also contained contact information about individuals family and friends and we were able to see that people are supported to maintain contact in line with their wishes. This was also confirmed by people spoken with during the inspection. Throughout the inspection people were observed moving freely around the home and it was apparent that they could choose where to spend their time. Through discussion with staff and people at the home, it was apparent that peoples privacy was respected and that staff only entered a persons bedroom where necessary or where invited. We noticed that not all bedrooms have the provision of a lock. One person told us that they would like to lock their bedroom but were unable to. We noticed that some bedrooms had been fitted with an inappropriate star locking devise. It has been strongly recommended that these are removed and replaced with an appropriate lock which can be accessed by people using the service and by staff in the event of an emergency. People at the home are fully involved in menu planning, shopping and cooking. The homes completed AQAA told us that people are encouraged to follow a healthy eating Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: plan as far as possible and that encouragement and information is provided using external professionals such as GPs and dietitians. We were able to see evidence of this in one of the care plans examined. We were invited to join people for lunch. People were busy in the kitchen preparing their chosen meal. Staff support was available. The lunch time experience was relaxed and inclusive with all staff eating with the people at the home. The main meal is enjoyed in the evening as many people are out during the day. At the end of the inspection, two people were in the kitchen preparing the evening meal. People spoken with were very positive about the meals at the home and told us that there was plenty to eat. Snacks are available as is fresh fruit. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that people receive the support they need to meet their personal care needs and that support is given in line with their preferences. The homes arrangements for ensuring people have access to appropriate health care professionals is good and individuals are supported to maintain a level of Independence. The home ensures that the procedures for the management and administration of peoples medication are safe. Evidence: Care plans examined contained information about the level of staff support needed to meet the individuals personal care needs. In one care plan, the individual had written their own plan, which clearly stated their abilities and preferences. The homes completed AQAA stated that people are involved in putting together their own personal care routine which outline their own preferences, who they would like support from and how they want to be supported. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: When we asked, people told us that staff treated them with respect. We were able to see that any assistance with personal care was delivered in a sensitive and dignified manner. Care plans contained evidence that people have access to appropriate health care professionals. The completed AQAA told us that the home support people to make their own appointments with health care professionals and to write letters or obtain advice. During this inspection we observed one person being supported to compile a letter to a health care professional. This is very positive. We examined the homes procedures for the management and administration of peoples medication. The home uses the Boots monitored dosage system (MDS), with pre-printed medication administration records (MAR). All medicines were seen to be securely stored and administered. MAR charts had been fully completed. Records of medicines received into the home and returned to the pharmacy were being appropriately recorded. We were informed that there were no controlled medicines currently prescribed or maintained at the home. We were informed that medicines are administered by senior staff, all of whom had received appropriate training. It has been recommended that protocols for the use of as required medication, are maintained within the MAR charts so that this information is easily accessible to staff. Care Homes for Adults (18-65 years) Page 18 of 29 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 home has effective complaints procedures in place and there are plans to further develop these to make them more accessible to the people living there. Procedures are in place to reduce the risk of harm or abuse to the people living at the home though these can be improved by the home obtaining a copy of local Safeguarding Adults procedures. Evidence: The home has a complaints procedure which is available in each persons bedroom. Care plans examined also contained evidence that the individuals relative had been provided with a copy. The complaints procedure has been produced in symbol format for people and we were informed that there are plans to make it available in a DVD. People spoken with told us that they would feel confident in raising concerns if they had any. No concerns were raised with us during this inspection. The home have investigated one complaint since the last inspection of which the Commission were aware. This was fully investigated by the home and appropriate health care professionals had been involved in the process. No concerns about the home have been raised directly with the Commission. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: The home has a range of policies in place to reduce the risk of harm or abuse to the people living there. These include acceptance of gifts, restraint and managing challenging behavior. Although the home has a policy on vulnerable adults/abuse, it has been strongly recommended that the home obtain a copy of Somersets revised policy (May 2007) on Safeguarding Adults and that staff are made aware of this policy. We were informed that staff have received training in the protection of vulnerable adults and this was confirmed by the three staff members spoken with during the inspection. Staff told us that they were aware of how to raise concerns and that they would feel confident in doing so. Care Homes for Adults (18-65 years) Page 20 of 29 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 provides people with a comfortable and well maintained environment. People have their own bedrooms which they can personalise. The standard of cleanliness is good and procedures are in place to reduce the risk of the spread of infection. Evidence: During this inspection we viewed all communal areas of the home and two bedrooms. All areas were noted to be well maintained and comfortably furnished. People living at the home appeared very relaxed in their surroundings. All bedrooms are for single occupancy. The homes completed AQAA told us that in the last twelve months, all bedrooms have been redecorated and that each person had been fully involved, with their key workers, in planning and designing their rooms. People spoken with during this inspection told us that they really liked their bedrooms. Not all bedrooms have the provision of a lock and some locks in use are not appropriate (Refer to standard 16). Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: People choose where they spend their day. During the inspection people were observed utilising all communal areas. The home has a very spacious dining area, two lounges and spacious kitchen. The standard of cleanliness is good and staff hand washing facilities are appropriately sited throughout the home. Care Homes for Adults (18-65 years) Page 22 of 29 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. Peoples needs are met by staff who are appropriately trained and the home ensure that appropriate numbers of staff are on duty at all times. The home follows appropriate staff recruitment procedures which reduce the risk of harm or abuse to the people living there. Systems are in place to ensure that staff are appropriately supported and supervised. Evidence: Staff told us that the training opportunities at the home were good. They also told us that they had the training and skills needed to meet the needs of people living at the home. The homes completed AQAA told us that all staff receive mandatory and specialised training. A staff training matrix was made available to us and this evidenced that staff had received up to date mandatory training. Certificates were available in the two staff files examined which identified other sprecialised training which had taken place. It has been recommended that the home develops a training matrix for any additional specialised training undertaken by staff as this was difficult to ascertain without looking at each persons recruitment file. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: The homes completed AQAA told us that 10 of the 18 permanent care staff have achieved a minimum of an NVQ Level 2 in Care. This equates to 56 which exceeds the recommended 50 of the National Minimum Standards. We were informed that staffing levels are adjusted as required, to meet the needs of the people using the service. We were told that minimum staffing levels are five carers during the day, three in the evening and two waking staff at night. Staff spoken with during the inspection did not express any concerns about staffing levels. We were told that staffing levels were increased as required, to meet the social needs of people at the home. People benefit from a stable staff team. Staff turnover is relatively low and the home have not had to use agency staff. Regular meetings are held for all staff. Minutes of the most recent meeting held in October were seen. We were informed that staff meetings take place on a monthly basis. We examined the homes procedures for staff recruitment. We looked at two files relating to staff most recently employed. We were able to see evidence that all required documentation had been obtained prior to the staff member commencing employment. This included an enhanced criminal records check (CRB) and protection of vulnerable adults check (POVA). On commencing employment, staff undertake an induction programme which follows the Skills for Care Common Induction Standards. We were also shown a computerised training programme which staff complete. This tests staffs knowledge and understanding of a range of mandatory and specialised topics. Staffs progress can be monitored by the management who are then able to offer additional support as necessary. Staff spoken with were positive about this training tool. Staff records examined contained evidence that staff received appropriate supervision sessions. Detailed records were in place. Care staff spoken with confirmed that they felt well supported. Care Homes for Adults (18-65 years) Page 24 of 29 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 which is effectively managed. Systems are in place to seek the views of people living at the home and other stakeholders. Procedures are in place to ensure the health and safety of persons at the home. Evidence: The registered manager, Marianne Seager has worked at the home for 9 years. She has a management qualification and has many years experience in caring for people with a learning disability. Ms Seager is currently working towards an NVQ level 4 in Care. Ms Seager is supported by a deputy manager who has worked at the home for over 5 years and has held the deputy manager post for 2 years. The deputy manager informed us that they are currently working towards an NVQ level 4 in social care and management. Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: The home has a quality assurance programme in place which seeks the views of relatives and care managers on an annual basis. We were shown 14 completed questionnaires from a recent survey and results were noted to be positive. We were able to see that the responsible individual visits the home on a monthly basis to check on the quality of the service provided. Reports are maintained at the home. Monthly meetings are held for people living at the home. The minutes of a meeting held in October were made available to us and it was evident that people are encouraged to express their views on all aspects of life at the home. People are also given information about any forthcoming staff changes. The home has procedures in place to ensure the health and safety of persons at the home. Equipment servicing records were up to date and we were informed that servicing was due again during the month of November. Training records confirmed that staff had received up to date training in fire safety. Annual servicing by external contractors was up to date and the home carry out appropriate in-house checks on fire detection systems, fire fighting equipment and emergency lighting. Up to date checks on electrical equipment had taken place. The home maintain appropriate records for all accidents in the home and results are regularly analysed to identify any traits. The home notify the Commission of all significant events at the home. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 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 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 16 It is strongly recommended that star locks are removed from bedroom doors and that they are replaced by an appropriate lock which are accessible to people using the service and can be accessed by staff in the event of an emergency. The home should ensure that protocols for the use of as required prescribed medication are maintained within the medication administration records (MAR). It is strongly recommended that the home obtain a copy of Somersets revised policy (May 2007) on Safeguarding Adults and that all staff are made aware of this policy. The home should consider devising a training matrix to include all additional specialised training undertaken by each staff member. 2 20 3 23 4 35 Care Homes for Adults (18-65 years) Page 28 of 29 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. 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