Inspection on 14/10/08 for Penberth House

This inspection was carried out on 14th October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Penberth House 15/10/07

Penberth House 21/02/07

Penberth House 24/02/06

Penberth House 14/11/05

Penberth House 21/01/05

Penberth House 20/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Penberth House 29 Penberth Road Catford London SE6 1ET     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sean Healy     Date: 1 4 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Penberth House 29 Penberth Road Catford London SE6 1ET 02086974430 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ms Jenny White Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 3 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 3 The maximum number of service users who can be accommodated is: 3 The registered person may provide the following category/ies of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Penberth House is a small care home registered for three people. It is an older house that has been extensively modernised and decorated to a high standard. The property is well located in terms of community facilities; it is well served by public transport and local shops, both within a short walking distance of the home. The home offers single bedroom accommodation with adequate communal space including a garden at the rear of the home. The registered provider/manager currently lives at the home and at the time of this Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home inspection there were two vacancies. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. The recent CSCI report is currently kept at the home in the dining room. The manager agreed to explain it?s content to service users. At 14th October 2008, the homes fees are set at 1400 pounds per week for accommodation and support. The referring social services authority meets the majority of these costs. This includes cost of food. Transport is not provided by the home and any costs are payable by each resident. Residents have to pay for other personal expenses such as hairdressing and personal shopping. The provider?s email address is: j.schoeffer@btinternet.com At the time of the inspection there was one resident living at the home and two resident vacancies Care Homes for Adults (18-65 years) Page 5 of 32 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 last key inspection on this service was completed on 15/10/07. During todays inspection I spoke with the manager of the home who as yet has not registered with CSCI. I also spoke with one resident and two member of the care staff. An annual quality assurance audit (AQAA) was provided by the registered provider. During the inspection I also spoke with a care consultant employed by the registered provider about the care planning and risk assessment processes. I inspected one care plan and three staff employment files. Care Homes for Adults (18-65 years) Page 6 of 32 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 32 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 8 of 32 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make a decision about whether to live at the home. Their care needs are fully assessed and they know that the home can meet their needs and aspirations. Residents are given individual written contracts about the service they can expect. Evidence: The resident had only moved into the home today, and is the only resident at the home currently. He had a full assessment of care needs provided by the placing authority Bromley social services. Learning Disability and mental health support needs, together with some personal care, medication and finance management support needs by the main types of care to be provided for. All health needs were outlined in the assessment, and professionals such as psychiatry, psychology and social services were involved in the placement. The resident said that he had come to visit to home before moving in, and that he was happy in the choice of home. Care Homes for Adults (18-65 years) Page 9 of 32 Evidence: The resident had been provided with a Statement of Purpose and Service user Guide, and with a written contract which fully outlined the terms and conditions and fees associated with staying at the home. The resident confirmed that he had seen this contract, but contract had not been signed and dated by him or by the homes management. The home must ensure that this contract is signed and dated by both parties. (Refer to RequirementYA5) Care Homes for Adults (18-65 years) Page 10 of 32 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not yet know that their needs and personal goals are reflected in their individual plan. Residents are supported to make decisions about their lives but there is a need to improve the quality of risk assessments to better protect residents and staff. Evidence: To the resident had just moved into the home on the week of the inspection. He said that he already had developed a good rapport with the staff and manager, and that they had asked her about the things he would like to do to fill his day. The resident is very independent in many ways and said he willing to speak with the staff and manager about things he wanted to do. The manager and 2 consultants employed by the home to provide specific mental health support, emphasised the need to develop the care plan in full consultation with the resident, and that this had not been possible before moving in. There was a clear commitment in writing outlining the process for Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: developing the care plan in given the complex needs identified in the residents history it does seem appropriate to have avoided preconceived ideas about what the resident would be doing after moving in, and instead allowed the resident to get to know his surroundings and the staff, and be fully motivated to build a care plan for social/leisure activities and personal development. Discussion with the resident showed that he was in agreement with this approach. In the meantime there was evidence to show that all health care needs were being addressed. The home needs to ensure that a full care plan is in place for this resident showing a full range of health, leisure, social and educational needs, and a plan for meeting these needs. (Refer to Requirement YA6) The resident is fully able to contribute to decision-making about what he will do on a daily basis. he had said that he liked football, and that he was aware of the need to avoid meeting people who believed would not benefit his development. The home has in place a system for supporting residents to manage their money safely, but as for this resident had only just moved into the home there was not yet a clear decision made as to who would be responsible for the residents benefits and bank accounts. The home must ensure that a clear decision is made regarding this issue and that any agreement is fully authorised by the resident and his representatives. (Refer to Requirement YA7) A range of areas of risk had been fully identified in the care assessment of these include address such as physical aggression, use of drugs and other areas associated with mental health support needs. No structured risk assessments had been provided by the placing authority, but the management was active in developing a full range of risk assessments and guidance for staff. Staff and the manager were able to demonstrate a clear knowledge of risks associated with providing care for this resident, and seemed confident in their ability and the support provided to do so. The home had employed the services of two experienced and well qualified professionals to help in the development of care plans in risk assessments, and one of these told me that they had been consulting with staff and homes management, and had almost completed in writing relevant risk assessments. in the meantime there was adequate information available to staff. There must be a full range of written risk assessments put in place as soon as possible and staff must be fully informed about them. (Refer to Requirement YA9) Care Homes for Adults (18-65 years) Page 12 of 32 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are not yet able to take part in appropriate activities, but are supported to be introduced to their local community. They are supported to maintain good relationships with families and friends, and their rights are respected. A healthy diet is provided. Evidence: The resident has only recently moved into the home within the last few days, and is in the process of developing activities appropriate to his needs. The resident said that staff and the manager have been speaking with him about what he would like to do and places you would like to go, and that he felt confident they would help him to develop a range of activities. He had already been supported to go out, and said that Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: they were activities he would like to take part in which included football and playing pool. The home needs to be given time to develop appropriate activities with the resident and to ensure he feels motivated and confident to participate in agreed activities. Overall there remains of need to ensure that there is a range of opportunities for residents to develop a range of social leisure and educational activities. (Refer to Requirement YA12) The residents said that they is aware that they can have friends and family visit at any time and that the staff and the management of the home would provide support and advice if asked. To homes policy is to encourage and facilitate residents to keep in contact with friends and family and to develop relationships. There are no restrictions placed on visitors. The residents said that staff are respectful and speak with them regularly. Each resident have their own room and staff only enter residents rooms with their permission. I saw the staff interact in a very positive way with residents speaking with them regularly, and including them in conversation. Residents can have their own key to the home and to the bedrooms The home helps residents in shopping and cooking in line with their care plans. The menus maintained at the home show a good range of food being offered. A rolling menu is used, but residents are offered choices each day. Care Homes for Adults (18-65 years) Page 14 of 32 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. This judgement has been made using available evidence including a visit to this service. Residents are asked about how they would like to be supported in personal care, and their physical and emotional needs are included in care planning. The homes Medication policy supports residents wishes or abilities in relation to management of their medication. Evidence: The residents personal care support needs have been fully considered in the care planning procedure, and a resident is very independent in the bathroom and in all aspects of personal care, only requiring some prompting. The resident said that staff that are very sensitive and helpful in providing personal care support when needed. Religious needs and are supported by the home, but little support is requested by the resident at this time. All health care needs are included in the residents care plan and there is good involvement from the GP as and when necessary. Psychiatry is also involved in Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: providing support, and there is clear information available regarding support needs in this area. All health care information is well managed and recorded. The home has contracted independent psychology support to provide specialist support in the areas of mental health and behaviour management. As the resident has only recently moved the has not been a lot of over input from health care providers, but the home has fully considered health care needs of residents in the care planning. The resident has signed a request asking the home to administer her medication on her behalf and this has been recorded in the care plans. Records of storage and administration of medication were well kept with consistent recording happening daily. Care Homes for Adults (18-65 years) Page 16 of 32 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do feel that their views listened to and acted on, and the homes policy on Adult Protection does protect residents from abuse, neglect, or self-harm. Evidence: There have been no complaints or allegations made since the last inspection. The home has a complaints policy and a safeguarding adult policy which is up-to-date and was reviewed in 2008 and reflects the local authority policy. The training prospectus for the home includes management of complaints and protection of vulnerable adults. Two staff demonstrated in responses to my questions, and responsible attitude to reporting any suspicions to the manager immediately Care Homes for Adults (18-65 years) Page 17 of 32 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very comfortable, safe and homely, and toilets and bathrooms are in good order and are private. The home is well maintained and clean. Evidence: The home is provides good facilities for three residents. It is an older property, which has been extensively modernised and decorated to a high standard. It is near to public transport and local shops, and provides single bedroom accommodation for each resident. There are good communal spaces within the home, with a well-maintained garden at the back of the home. The owner has added ensuite facilities to three of the bedrooms and all bedrooms are for single occupancy. The house is open, bright, well decorated and maintained, and has a modern central heating system, and access to the garden from the ground floor. There is a modern kitchen on the ground floor, with a ground floor toilet, and a separate bathroom on the first floor. The home is very clean throughout, and is well maintained, and the owner pays good Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: attention to maintaining high hygiene standards. Care Homes for Adults (18-65 years) Page 19 of 32 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. This judgement has been made using available evidence including a visit to this service. The registered provider can now demonstrate that the homes staff and are competent and qualified. The home cannot fully demonstrate that residents are protected by the homes recruitment procedures. The staff do not have adequate training plans and do not receive regular structured supervision. Evidence: Since last inspection the resident who lived at the home then has now moved on and a new resident has recently moved into the home. the staff team is set to be is set to be seven full-time staff but currently there are four vacancies. This is due to the fact that the resident has only recently moved in and employment to some of these posts is being planned. In order to ensure consistency of care the home must recruit to at least two of these posts as soon as possible. (Refer to Requirement YA33) The rota for the home showed that there are always two members of staff available to provide support for the one resident who lives at the home. During todays inspection three staff files were examined and I interviewed one staff member. The staff member interviewed had been employed at the home for the past 12 months and currently worked for approx. 20 hours a week. She confirmed that she had an induction for Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: about a week when she started which included going through a range of key policies and procedures, meeting the resident and being shown around the home. Discussion with her showed she had a good knowledge of the residents needs and was clear on the procedures for reporting complaints and adult protection issues. At the last inspection there was no evidence to show that staff had been properly inducted and a requirement was made for the home to ensure that all staff be inducted in line with Skills for Care procedures, and that records of this induction be maintained. This is now happening and this requirement is now met. Three staff files showed evidence of a formal induction being recorded and the home has introduced and begun to use an induction procedure, which is in line with Skills For Care. The home therefore now has in place an induction and foundation training system that is in accordance with sector skills requirements, and is in the process of completing this induction for a number of staff. This will be again examined at the next inspection to check that the home can fully demonstrate that it has been applied to all staff. The home has an adequate recruitment policy in place, and the manager conducts all interviews. The policy shows that it is the homes practice to take up references, and to carry out POVA and CRB checks for all staff prior to commencement of employment. Wherever examination of three staff files showed that one of these did not have adequate documentation to show that a full enhanced CRB check had been done prior to employment. The home must ensure that all staff have an enhanced CRB check carried out and completed prior to commencement of employment. (Refer to Requirement YA34) The home has begun having staff trained to Skills for Care standards. Training includes: mental health, fire safety, health and safety, food hygiene, adult protection, complaints, medication and health and safety. There is now a commitment to having all staff trained to the appropriate NVQ levels and all three of the current permanent staff have the NVQ 2/3 qualification. However given the specific support needs of a new resident, the home must ensure that the staff training plans include the following training, management of aggression, breakaway techniques, and bipolar disorder. (Refer to Recommendation YA35) Three staff files examined showed that staff are consistently being formally supervised six times a year as is to requirement for this home. The manager said that there had been quite busy introducing new staff and in setting of care for the resident recently admitted to the home. The home must ensure that all staff receive regular supervision at least every eight weeks and that this is formally recorded on their files. Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: (Refer to Requirement YA36) Care Homes for Adults (18-65 years) Page 22 of 32 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. This judgement has been made using available evidence including a visit to this service. The Registered Manager is not yet qualified to NVQ level 4, and the home does not benefit from regular monitoring checks by the provider. Residents views on how the home is run are not yet included the home self-monitoring and development practices. The homes health and safety practices do protect staff and residents. Evidence: The registered manager is experienced in the area of mental health and care and has been working at the home since August 2008. However she does not yet hold and NVQ4 qualification in care in management, though she now holds NVQ3 and intends to enrol on a suitable NVQ course to achieve a level 4 qualification. This is a now a requirement. (Refer to Requirement YA37) The manager is experienced in the areas of learning disability and mental health support and demonstarted a good knowledge of the care needs of the residents. Residents have significant complex needs an the provider has contracted expert Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: support from appropriate consultants to develop care plans, risk assessments and to generally provide advice and support for the service development. I spoke with one of these consultants who was in the process of finalising a range of support plans and risk assessments for one resident. These appeared to be well structured and appropriate for the residents support needs. The manager has not yet registered with CSCI and must do so as soon as possible. (Refer to Requirement YA37) The previous registered manager who is also the owner/registered provider has now stepped down from the role of registered manager and is now as the registered provider not in day to day control of the home. As such she is now required to carry out monthly regulation 26 management visits to the home and to provide brief written reports of her findings to be held at the home for inspections and to be used by the homes manager to address any problems identified. There were no written reports of these management visits available at the home for inspection. The registered provider must ensure that these monthly monitoring visits take place and that written reports of these visits are maintained at the home. (Refer to Requirement YA37) The home holds residents meetings on a monthly basis to allow residents to be given the opportunity to discuss how they are feeling about how the home is run with the management and staff. Currently there is not an annual quality audit or development plan in place for the home. This may be explained by the fact that there is only one resident in the home at the moment, having recently moved in, and needs to have such processes introduced slowly and in a meaningful way so as t include residents views. There is a residents survey system in operation but currently there is not a practice of drawing up an Annual Development Plan for the home or including the residents views. The provider must put in place an annual development plan for the home based on a sound quality assurance process which includes residents views on how the home is managed. (Refer to Requirement YA39) Comments received from staff and residents were complimentary about how the home is managed. There was a requirement made at the last inspection for the home to have all required policies and proceedures required by the Care Standards Act in place and ensure these are up to date. This is now met and all of these were reviewed in 2008. The home has good facilities for storage of dangerous liquids and substances. There is a health and safety policy in place, which was last reviewed in 2008. This policy is adequate in its content and would suffice to protect staff and service users if fully implemented. The public liability insurance is in date and is displayed in the hallway. Health and safety, fire safety, moving and handling, and food hygiene are included in Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: the induction of staff. There was a requirement at the last inspection for the home to have a fire detection system installed, in keeping with the Fire Officers last report recommendations. This has now been done and this requirement is met. All other health and safety proceedures and documentation are well managed and up to date. Care Homes for Adults (18-65 years) Page 25 of 32 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 26 of 32 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 5A The registered provider and manager must ensure that the contract between the home and the resident is signed and dated to show agreement. This is to show the resident is aware of his rights and responsibilities while living at the home and that these are fully protected. 31/05/2009 2 6 15 The registered provider and 31/05/2009 manager must ensure that a care plan is in place for residents showing a full range of health, leisure, social and educational needs, and outlining how the home will meet these needs. This is to ensure that the residents assessed needs are met and that residents and staff are fully protected 3 7 13 The registered provider and manager must ensure that in consultation with the 31/05/2009 Care Homes for Adults (18-65 years) Page 27 of 32 resident and social services a decision is made about who will be responsible for management of personal finances for the resident This is to ensure that residents are protected from financial abuse, and are fully supported to manage their finances. 4 9 13 The registered provider or 31/05/2009 manager must ensure that a full range of a written risk assessments and guidance for staff are placed on the residents care plan and staff are fully informed about them. This is to ensure that residents and staff are protected from potential harm 5 12 15 The registered provider and 31/05/2009 manager must ensure that there is a range of opportunities agreed in the residents care plan, to enable them to access social leisure and educational activities appropriate to their needs. This is to ensure that residents had the opportunity for personal development including education and work 6 33 18 The registered provider must ensure that there are enough permanent staff employed to provide the 30/09/2009 Care Homes for Adults (18-65 years) Page 28 of 32 care required, and in doing so must recruit to at least two of the vacant staff posts This is to ensure that there are enough experienced staff working at the home to provide for the health and welfare of service users 7 34 19 The registered provider 31/05/2009 must ensure that the home has requested and received an acceptable enhanced CRB check for all care staff prior to commencement of employment and that these are kept at the home for inspection This is in order to protect the welfare and safety of residents 8 36 18 The registered provider 31/05/2009 must ensure that all care staff receive formal supervision from the homes manager at least six times a year and that written records of these are maintained at the home This is to ensure that staff performance is monitored and that they recieve frequent management support and guidance 9 37 26 The registered provider must ensure that monthly management monitoring visits are carried out at the home and that a written report of each of these is maintained at the home 31/05/2009 Care Homes for Adults (18-65 years) Page 29 of 32 This is to ensure that the homes care quality and environment is monitored and maintained and that there is written evidence available for inspection purposes 10 37 8 The registered provider 31/08/2009 must ensure that the registered provider submits an application for the registration of a registered care manager who will have a day to day presence in the home This is to ensure that the home has consistent management presence by a manager who is registered with the Care Quality Commission (formerly CSCI) 11 39 24 The registered provider 29/09/2009 must ensure that as part of the homes quality assurance system that an annual quality audit and development plan for the home be produced which includes the views of residents regarding any developments and improvements needed This is to ensure that the home fully includes residents and plans for continuous improvement Recommendations These recommendations are taken from the best practice described in the National Care Homes for Adults (18-65 years) Page 30 of 32 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 35 The registered provider should eninclude management of agression, breakaway training and bi-polar disorder training in all care staff training plans to ensure their safety and to ensure a good understanding of important care needs of residents The registered provider should ensure that the homes manager is enrolled on and NVQ4 course in management and care The registered provider should ensure that the homes manager receive additional training at managerial level in safeguarding adults and in the implications of the Mental Capacity Act 2007 2 37 3 37 Care Homes for Adults (18-65 years) Page 31 of 32 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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