Inspection on 11/11/08 for Proctor Residential Home Ltd

This inspection was carried out on 11th November 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Proctor Residential Home Ltd 16/10/07

Proctor Residential Home Ltd 28/11/06

Proctor Residential Home Ltd 09/05/06

Proctor Residential Home Ltd 20/01/06

Proctor Residential Home Ltd 27/09/05

Proctor Residential Home Ltd 12/01/05

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Proctor Residential Home Ltd 40 Filton Avenue Horfield Bristol BS7 0AG     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: Sandra Jones     Date: 1 2 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 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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 32 Information about the care home Name of care home: Address: Proctor Residential Home Ltd 40 Filton Avenue Horfield Bristol BS7 0AG 01179354403 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Michael Edward Kendall Type of registration: Number of places registered: Proctor Residential Home Ltd care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: May accommodate up to 5 persons, 2 of whom can be 65 years and over Date of last inspection Brief description of the care home Proctor House is a care home providing personal care for five service users aged between eighteen and sixty four years. The home is situated in a suburban area, and located on a bus route that gives access to local shops, leisure and other amenities. The home is in keeping with the local neighbourhood. The home has undergone reregistration with the Commission for Social Care Inspection as the business has moved from a sole trader to a limited company. In addition the manager of the home has changed from Mrs Kendall to Mr Kendall (the son). Mrs Kendall remains the provider. The home primarily provides personal care to service users with a mental disorder. It is a quiet home that would best be suited to those who prefer a quieter lifestyle. Fees range from #600.00 - #1000.00 per week. 5 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 32 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: This key inspection was conducted unannounced over two days in November 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. The Annual Quality Assurance Assessment (AQAA) was sent to the home for completion, with Have your Say surveys for people at the home and social and health care professional. The manager returned the AQAA and two surveys from the people at the home. Prior to the visit some time was spent examining documentation Care Homes for Adults (18-65 years) Page 6 of 32 accumulated through reports, surveys and the AQAA. This information was used to plan the inspection visit. The four people living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The homes policies and procedures were also used to confirm the findings. The views of the manager, staff and three people using the service were gathered through face to face discussions. 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 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 9 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. People wishing to live at the home have up to date information to make decisions about moving into the home. The needs of people wishing to live are assessed to ensure the staff have the skills to meet the individuals needs. Evidence: The manager has updated the Statement of Purpose to ensure that people wishing to live at the home have up to date information to base their decisions about the home. It is stated that the home enables people with mental health care needs to have ordinary lives. Achievable by encouraging people to be integrated into the community and participate in activities. There is one current vacancy and the admission procedure for the home is defined in the Statement of Purpose. It is made clear through the admission criteria that admissions to the home are based on assessments of need. Needs assessments from social workers and homes initial assessments will be completed to ensure the staff can meet the needs of people wishing to live at the home. Introductory visits and trial Care Homes for Adults (18-65 years) Page 10 of 32 Evidence: periods are also offered to ascertain the persons compatibility with the people already living there. The manager said that its the intention to include in the Statement of Purpose the arrangements for introductory visits. Care Homes for Adults (18-65 years) Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals at the home are enabled to achieve independant lifestyles. This is achieved through effective care planning, decision makingand risk taking. Evidence: The quality of the information included in the care plans has vastly improved. All aspects of the individuals assessed needs form part the care plans with associated risk assessments. Social workers or the Inner City Mental Health team reviews care plans annually. Individuals are present during their review meeting and home staff and agencies involved are invited to the meetings. The manager explained that following care plan reviews, home care plans are ammended with the person from information gathered through questionnaires and review minutes. This will ensure the home can meet the individuals changing needs. It is the intention to ask people to sign their care plans from the next review to evidence their agreement with the plan of action. Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: Two staff on duty were consulted about their responsibilities towards the care planning process. Staff said that they develop care plans with the person and record the progress of the care plan. The other member of staff said that because their induction is ongoing the expectation is that they read care plans and make daily entries. At present there is one person under section of the Mental Health Act, which means that if they do not comply with the conditions of the section this person may be recalled. The manager said the decision to contact outside agencies for noncompliance falls on senior staff. The actions to be taken by the staff for noncompliance of conditions must be listed in the individuals care plan. This will ensure that there is a consistent approach for people under section of the Mental Health Act. Two people can at times become aggressive and violent and the care plans for these individuals instruct staff to move away. Care action plans must be more detailed about the way they are to diffuse or divert aggressive and violent behaviours. Staff at the home were asked about the homes policy on managing aggression and violence. Staff confirmed that the procedure for violent and aggressive behaviour is to make the situation calm. People at the home are able to make decisions and these can be made verbally and the manager said that people at the home make day to day decisions. A consultant psychiatrist is currently visiting the home to determine one individuals capacity to make decisions. This shows that the home involves outside agencies to ensure that where possible people at the home are empowered to make decisions. Staff were consulted about the way they empower people to make decisions and it was stated that the people at the home can make decisions although at times staff will give advise. A daily and staff report book is used to report daily events, outcome of visits, activities and decisions made by the person. Information is factual, objectives, which is signed and dated by the person making the entry. Risk assessments form part of the care plans. Where activities involve an element of risk, the action to be taken to reduce the level of risk is included. The actions that must be taken for people that smoke outside of the designated areas is incorporated into the care plans. For one individuals Health & Safety checks are undertaken in their bedroom. Members of staff are instructed to check for structural damage and electrical equipment to maintain a safe environment for people living at the home. Care Homes for Adults (18-65 years) Page 13 of 32 Care Homes for Adults (18-65 years) Page 14 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support systems in place ensure that people living at the home can maintain appropriate and fulfilling lives in and out of the home. People at the home are supported to maintain contact with family and friends. The home served cultural meals to people that have cultural needs. Evidence: It is stated in the Statement of Purpose that the aim is to provide individuals with a lifestyle that satisfies the individuals social, cultural, spiritual and recreational needs. The activity book shows that two trips to Blackpool were organised, people visit pubs and one person visits the local sports centre. Two people consulted confirmed that they had gone on the Blackpool trips. Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: There is an activity of daily living element in the care plan and for some individuals maintaining contact with the local community, independent living skills, outings and spiritual needs are identified through the care plans. Staff were consulted about the way people are supported to maintain their preferred lifestyle. The individuals and group activities undertaken in and out the home were described by the staff. Another member of staff said that taking people to local coffee shops and supporting them with routines were individual activities undertaken. The manager said that three people are independent in the community and one person is assisted by staff because of their mobility needs. One person living at the home said that the freedom to leave the home independently was an important part of their lifestyle. Another person said that transport to visit the local community is provided by the manager. The homes visiting policy is described within the Statement of Purpose, and recognises the importance of maintaining links with family and friends. Visiting at the home is open between 9:00 am and 23:00 pm each day and private areas and bedrooms are available for private visits. Relatives visiting during the inspection were consulted and stated that they feel welcome by the staff when they visit and can undertake visits in private areas of the home. They are kept informed about important issues, invited to reviews and standards of care are the same irrespective of the time they visit. Individuals are informed about their rights through the Statement of Purpose. Their rights to privacy and dignity are made clear, they ways staff observe them and rules in terms of smoking are described in the Statement of Purpose. The manager was consulted about staff expectation that people are treated with respect. It was explained that the principles of care are part of staff training at the home and people can raise complaints if their rights are not respected. The rules of the home and expectations are listed in the terms and conditions of residency. Staff were asked about the way they respect people as individuals. The staff consulted gave examples on the ways peoples rights were respected. Examples included knocking on bedroom doors before entering and focusing on the person rather that the disabilities. Another member of staff said being sensitive and supporting people to maintain their lifestyle ensures they are respected. People at the home are not expected to undertake household chores. Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: Menus are varied and include cultural dishes to meet the diversity needs of the people at the home. The range of fresh, frozen and tinned foods kept demonstrates that people have a varied diet. People at the home said the food was OK and West Indian foods are served. Care Homes for Adults (18-65 years) Page 17 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. People at the home receive sensitive personal and health care. Medication systems are safe. Evidence: Personal and health care form part of the individuals care plans. While people at the home have personal care needs, its generally through prompts and reminders from staff and information held in bedrooms. Staff consulted about the level of personal care provided said that people are usually prompted to undertake personal care. Health care needs including medication and mental health care needs are elements of the individuals care plan. It is evident from the care plans examined that two people have health care needs and action plans in place ensure people have healthy lifestyles. For example, some people special diets are provided to ensure they remain healthy. The manager said that it is usual for staff to accompany people on GPs visits. A record of health care appointments is maintained and described is the nature of the appointment. The outcome of the visit must be included to ensure that all staff follow Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: medical advice. Staff confirmed that they accompany people on health care visits and individuals consulted named the member of staff that would usually support them on these visits. The mental health care needs and they way it manifests itself and actions to be taken is specified within the individuals care plan. Three people at present have input from the Inner City Mental Health team, psychiatrists and psychiatrist nurses visit people at the home. Medications are administered from a monitored dosage system. Records of administration show that staff sign the records after administration and use correct codes for medications not administered. Medical profiles are in place for individuals that have prescribed medications, which describe the purpose of the medication and their side effects. Medications form an element of the care planning process and lists the individuals willingness to take their medications and the actions that must be taken including agencies that must be contacted for medications refused. For example, staff must contact the Out Reach team for whenever medications are refused. A best interest decisions was made by health care professionals for one individuals that refused medications that control their delusions. This medication is concealed and documentation regarding this decision is kept on file. One individual has when required medications and the manager said that this individual will usually ask for the medications. This protocol must form part of the individuals care plan. Care Homes for Adults (18-65 years) Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home responds to individuals concerns and feedback about the standards of care. Policies and procedures show a commitment to safeguarding people from abuse. Evidence: The homes Complaints procedure is included in the Statement of Purpose. It confirms that complaints are taken seriously, investigated and further action is possible for unresolved complaints with, the names of agencies that can be contacted for unresolved complaints are included. Staff at the home were consulted about the way they support people at the home to make complaints. It was stated that the complaints procedure would be followed and then passed to the manager. There were no complaints received at the home since the last inspection. The Whistle blowing and Abuse policy shows the homes commitment towards safeguarding people from abuse. Through the Whistle Blowing policy the home endorses that staff who raise concern about the standards of care will be protected from reprisals. To fully confirm the homes responsibility towards safeguarding people from abuse, staffs duty to report poor practise must be included within the policy. Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: The factors of abuse are described within the Abuse policy along with the actions to be taken for alleged abuse. Care Homes for Adults (18-65 years) Page 21 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately maintained and individuals benefit from living in a comfortable and clean environment Evidence: Proctor House is a terrace property in a residential environment and has the appearance of a domestic dwelling arranged over three floors. The ground and first floor are used by individuals living at the home, with bedrooms and shared space on each floor. The property is close to shops, amenities and bus routes, which are used regularly by the people at the home. The manager said that since the last inspection the corridor was repainted and the visitors room was redecorated. It was also confirmed by the service provider that room 3 will be redecorated after Christmas. Bedrooms are single and the opportunity was taken to view a number of bedrooms. The furniture and fittings are provided by the home and personal belongings reflect the personality of the person. It was noted that bedrooms are lockable and individuals have a lockable facility in their rooms. There is a hand washbasin, adequate floor covering, nurse calls and a radiator in each room. Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: A full bathroom is located on the first floor and a shower and toilet on the ground floor. The ratio of bathrooms and toilets are less that three people sharing. This is above the National Minimum Standards of three people sharing. There is a sitting/dining room, conservatory and visitors room. The combined seating and dining room has seating for four people and dining space for four people. The conservatory is used as a designated smoking area with additional facilities for making light snacks and refreshments. The visitors room is accessible to residents and used for private visits. The laundry area is adjacent to the kitchen and has the washing machine and a locked COSHH cabinet. The floor covering and painted walls ensures easy cleaning. The washing machine is domestic and has can reach 95 degrees C. Care Homes for Adults (18-65 years) Page 23 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. The staff employed are suitable to work with vulnerable adults. The induction programme in place ensures that new staff have insight into the needs of the people at the home. Members of staff must undertake Safeguarding Adults training to ensure that people at the home are safe from abuse. Evidence: One person was employed at the home since the last inspection and their personnel files were examined. Completed applications forms, two written references and Criminal Records Bureau (CRB) disclosures obtained are kept pm file. During the inspection, the manager amended the application form to seek from candidates through the application form the names of two referees. The signatures of the staff employed at the home illustrated that new staff are provided with copies of the homes handbook and General Social Care Code of Conduct. Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: At present there are two staff undertaking induction, one was recently employed and for the other its refresher training. The induction programme follows Skills for Care Common Induction and covers familiarisation with the building, the role of the worker and the needs of the people at the home. One member of staff on duty was consulted about the induction programme in place. It was stated that the induction programme is linked to vocational qualifications Staff at the home must attend Mental Health, First Aid and Food Hygiene training. However, not all staff have attended Safeguarding Adults training. Members of staff at the home must attend Safeguarding Adults training. This will ensure staff are aware of their responsibilities towards safeguarding people from abuse. Individual supervision occurred with staff in March 2008 where staffs performance and training needs were discussed. Supervision with staff to discuss performance and personal development needs must take place more often. NMS recommend that staff have at least six supervisions per year. Care Homes for Adults (18-65 years) Page 25 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. The manager is qualified to manage the home and ensures the aims and objectives of the home are fulfilled. The manager must ensure that people live in a safe environment and standards are subject to ongoing monitoring. Evidence: The manager was consulted about the way the homes aims and objectives are fulfilled. It was stated that there is continuous improvement of the environment to ensure that people live in a homely environment. Feedback from a variety of sources that include outside agencies are used to maintain the standards of the home and through robust recruitment, staff that are suitable to work with vulnerable adults are employed. Supervisions, staff meetings and handovers when shift changes occur are the systems used to ensure consistency of care is provided. It was further stated by the manager Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: that having a open minded approach and training ensure that the home operates within good practise guidelines. The staff on duty were consulted about the management style used at the home. It was stated that the manager is approachable, they advise staff on best practise and are available at all times. Staff confirmed that handovers when shift changes occur, supervision and monthly staff meetings ensure standards are consistent. The manager said that the homes Quality Assurance system will be developed from CSCIs Annual Quality Assurance Assessment (AQAA). A Quality Assurance system must be introduced to ensure standards are subject to ongoing monitoring. The staff rota in place shows that two care assistants are rostered to work 8:00-4:00 with the manager and service provider. Staffing levels fall to one person from 4:30 p.m. with the manager. The manager said that cash is not held in safekeeping on behalf of the people living at the home. The fees at the home range from 644.00 to 1555.00 pounds per week. The home complies with Health and Safety legislation. Contractors visit the home annually to service the gas boiler and to conduct portable equipment tests. Fire risk assessments were completed in January 2008 and must be reviewed annually. Fire risk assessments must include the frequency for checking fire alarm systems and emergency lighting. This will ensure that steps are taken to prevent the potential for fire in the property. Care Homes for Adults (18-65 years) Page 27 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 39 24 The Quality Assurance system must be further develop to ensure residents views are reflected into future reviews and planning for the home 12/11/2009 2 42 23 (4) The manager must seek advise about fire risk assessments from the Fire Authority 30/01/2008 Care Homes for Adults (18-65 years) Page 28 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 1 39 24 The provider shall establish 01/12/2009 and maintain a system for evaluating the quality of the service provided at the home The manager must introduce a Quality Assurance System 2 42 23 The provider must ensure that the requirements of Regulatory Reform (Fire Safety) Order 2005 are complied Fire risk assessments must be reviewed to include the practises and checks undertaken to prevent an outbreak of fire. 30/03/2009 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 19 12 The registered person shall 30/01/2009 make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. A protocol must be developed for people that have when required Care Homes for Adults (18-65 years) Page 29 of 32 medications to ensure its administered consistently. 2 23 12 The registered person shall make arrangements, by training staff or by other measures, to prevent services being harmed or suffering abuse or being placed at risk of harm or abuse. The Whistle Blowing policy must inform staff that its their duty to report poor practise and may be subject to disciplinary procedures if they witness poor practise and do not report it. 3 35 12 The registered person shall make arrangements, by training staff or by other measures, to prevent services being harmed or suffering abuse or being placed at risk of harm or abuse. Members of staff must attend safeguarding adults training 20/03/2009 30/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 6 The restrictions for non-compliance of restrictions along with the actions to be taken by the staff for people under section of the Mental Health Act must be included in the care plan Care action plans must be clear about the way staff must diffuse and divert aggressive and violent situations Members of staff must have at least six supervision Page 30 of 32 2 3 6 36 Care Homes for Adults (18-65 years) sessions per year Care Homes for Adults (18-65 years) Page 31 of 32 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 © (2008) Commission for Social Care Inspection (CSCI). 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