Inspection on 06/01/09 for Ravenhill Way, 240-242

This inspection was carried out on 6th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ravenhill Way, 240-242 01/03/07

Ravenhill Way, 240-242 15/02/06

Ravenhill Way, 240-242 28/06/05

Ravenhill Way, 240-242 23/12/04

Ravenhill Way, 240-242 28/06/04

Ravenhill Way, 240-242 08/03/04

Ravenhill Way, 240-242 12/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Ravenhill Way, 240-242 Lewsey Park Luton LU4 0XZ     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: Andrea James     Date: 0 9 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. 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: Ravenhill Way, 240-242 Lewsey Park Luton LU4 0XZ 01582477145 Telephone number: Fax number: Email address: Provider web address: ravenhillway@together-uk.org Name of registered provider(s): Name of registered manager (if applicable) William George Angus Type of registration: Number of places registered: Together Working for Wellbeing care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Ravenhill Way Care Home provides accommodation for ten adults with mental health problems. The provider is Together Working for Wellbeing and the owner of the property Aldwyck Housing Association. The building consists of two houses linked together by a conservatory with five single rooms available in each house. Each house has separate facilities, lounge/diner, kitchen, bathrooms and toilets. There is a shared garden with patio area to the rear. The houses both have four floors with no lift. The home is situated next to a small shop in a predominately residential area with local amenities and public transport routes near by. There is parking available to the side and front, shared by the shop. 10 Over 65 0 Care Homes for Adults (18-65 years) Page 4 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: 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 was an unannounced inspection undertaken over a 2 day period on the 6th and 9th of January 2009. It took place over a period of 10 hours inspecting time. The inspection process was enabled by the support of care staff on day one and the acting manager on day two. The inspection followed a case tracking methodology where a sample of people was randomly selected to speak to. These peoples files were inspected and where possible their key workers spoken to. The report consists of information gathered from people who use the service, care staff, surveys that were received by the Commission and evidence gathered through Care Homes for Adults (18-65 years) Page 5 of 29 inspection of records or observations undertaken at the time of the inspection. What the care home does well: What has improved since the last inspection? What they could do better: The service should ensure the safety of people using the service by providing safe water temperatures throughout the home. They should ensure the risk of fire in the home is minimised and people are protected through the recruitment policies and procedures. The service should also ensure a registered manager is employed as soon as possible in order to ensure the smooth running of the service. The mental health needs of people should be highlighted more effectively and strategies should be implemented to deal with relapses as they occur or in some cases proactive procedures implemented to prevent relapses. Policies and procedures should be reviewed to ensure they reflect the most recent legislations. Care Homes for Adults (18-65 years) Page 7 of 29 Peoples care plans should be reviewed to ensure they reflect the current needs of people who use the service. A comprehensive needs assessment should be in place for all people who use the service in order to establish whether or not the holistic needs of people are being addressed. The medication procedures should be reviewed to ensure safe recording and administration can be maintained at all times. 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 health-care 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people using the service had sufficient information to be able to make informed choices and were able to visit the service prior to admission, but further development was needed to ensure a comprehensive needs assessment is undertaken for people who use the service, as a result peoples needs could be unmet. Evidence: The service had up to date Statement of Purpose and Service User Guides. They also had a welcome pack available for visitors to the service. The packs had details of leaflets for What we are about,Working together wellbeing approach, a pictorial view of the service detailing the decorations of all bedrooms and communal areas and an annual review pack. This ensured people were provided with sufficient information to be able to make a choice of whether or not they wanted to use the service. Surveys recieved from people using the service suggested that they felt they recieved enough information about the service before they moved in. One person said, I was able to visit the service before I moved in. In another survey one person commented Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: by saying I was brought to look around the home first. This information was also confirmed by people using the service on the days of the inspection. During the inspection we looked at three peoples documentation one being the most recent admission. We found that the service did not have enough evidence to show that individual needs assessments were undertaken prior to admission, with one exception of an assessment undertaken by an external agency for one person before he moved to the service. This resulted in us being unable to know if the holistic needs of people were being addressed in the care plan documentations. All documents inspected suggested people were issued with a contractual agreement that detailed the cost of the placement and a license agreement. Both documents were signed and dated by the person using the service and the service manager. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people using the service were empowered to make decisions about their lives but further development was needed to ensure clear and consistent information is recorded for people in their care plans, as a result inconsistent service delivery could be provided by the staff team. Evidence: All people using the service had a care plan document on file that detailed information for staff about their required needs. We inspected a sample of 3 care plans to include a new admission to the service. The care plan for people using the service for a long time appeared to be very detailed but inconsistent in places. Some staff spoken to said they felt the care plans were too detailed with information that was not always needed.The plans covered aspects of mental health, daily life, personal care, budgeting, medication and some had triggers for mental relapses. The information in these files suggested the service tried to Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: ensure the information was current to meeting peoples needs. This was reflected in one persons whose needs had changed and she needed more staffing input. The care plan and risk assessment was reviewed to reflect this. However for some files seen the information presented were inconsistent with the current needs of people for example one person who decided to stop smoking his details said he was a smoker and on the same page said he did not smoke. The service had identified triggers that would suggest people were in mental relapse but had failed to implement satisfactory interventions for what to do in the event these triggers were identified. For the newest admission to the home his care plan had details about his behaviours but failed to show any intervention as to how the staff were expected to care for him despite being in the service for 14 months. This care plan had not been reviewed since 24.05.08. Staff spoken to were knowledgeable about the changing needs of people using the service. The service had very good risk assessments in place and these were reviewed on a regular basis. Staff spoken to were aware of the information recorded in the risk assessments. Information seen and people spoken to suggested people were enabled to make decisions about their lives. We spoke to two couples in the home who were enabled to have a relationship. Other people spoken to said they were enabled to access community resources, attend colleges and visit family members when they wanted. One person said I help with the shopping. People were observed to prepare midday lunch with the support of the staff team. The service enables people to take informed risks in order to maximize their independence.The records seen suggested monthly key worker meetings were held and people were empowered to meet their goals and aspirations. People were observed to leave the home and return during both days of the inspections. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Those living at the home had opportunities for personal development and their nutritional needs were met. People were also able to form personal and family relationships inside and outside of the home. Evidence: The people using the service were given sufficient opportunities for personal development. Those spoken to said they were able to embark on community activities such as college courses. We observed however on both days of the inspection that some people stayed in their bedrooms or spent most of the day watching television or pottering around the home. Several of the people using the service appeared contented with a slower pace of life which could be as a result of their age. Some people had reached the age of 65 and did not want to do much activities. Others were observed accessing the community without the support of the staff team. The staffing Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: ratios of 2 to 10 did not appear to give enough opportunities for staff to embark on individual activities with people if they wanted to. We saw evidence that three structured activities were arranged by the staff team for people to include relaxation and beauty evenings. Staff said some people helped with the preparation of meals and we observed one person cleaning her room and doing her laundry with the support of a staff member. This person said I go to MIND where I do Art and Craft. The nutritional needs of people were in accordance with maintaining a healthy and balanced diet. People spoken to said they did menu planning on a weekly basis all made a contribution to the menu. The menus seen suggested people were able to have a choice of meal. We were also informed that people sat together to have their meals on a daily basis but the choice was given to those who wished to eat on their own or with visitors. The home also kept a record of what people consumed on a daily basis. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and health-care 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Procedures were in place to ensure people received personal support in areas of their health care needs but further development was needed to ensure all procedures are in place for safe storage and administration of medication, as a result some peoples health care needs could be compromised. Evidence: Staff spoken to were knowledgeable about the needs of people who use the service and the support they required. We were informed of one person whose needs had changed so significantly that an alternative placement was being sought. Staff explained how they supported this person in various ways to include personal care. External professionals who visited this person said the staff were very good at reporting concerns at the early stages. We were informed that the first onset of pressure area was reported and as a result prevented an outbreak. Peoples emotional needs constantly changed due to their mental state, as a result staff could not always predict the behavior of some of the people. It was for this reason that the absence of satisfactory relapse indicator interventions mentioned Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: earlier on in the report was needed to be improved, as the records failed to show how the service was able to meet the emotional health needs of people. One person was observed to stay in his bedroom all day. We observed very little staff intervention with this person who appeared to lack motivation. The service had satisfactory policies and procedures in place for the safe administration of medication. The storage, recording , administration and disposal of medication was satisfactorily maintained but for one person the home had changed the instructions for the administration from having 40mg of Methadone once per day to staggering the dose and have 30mg am and 10 mg at night, when asked they said this was following the instructions of an external medical professional but the evidence of this was not recorded and as a result it would appear that the home have failed to follow the instructions of the prescriber for administering a controlled drug. The receipt of medication was not recorded for the month of January on any of the peoples Medication Administration Record Sheets (MARS) although this was done for records seen in previous months. Staff records seen suggested staff received training before they were allowed to administer medication although the staff training records could not clearly show how many staff had this training. Some certificates seen were also dated back to 2003. The service failed to keep a record of the temperature of the medication room which could affect the effects of medication administered especially in hot weathers. Care Homes for Adults (18-65 years) Page 17 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. There were satisfactory systems in place to ensure peoples concerns could be dealt with effectively and they were safeguarded from abuse. Evidence: The service provided sufficient information to ensure people knew how to make a complaint should they wish to do so. We saw effective recording of all complaints received along with the investigative and outcome processes. Since the last inspection one complaint was received and the information recorded suggested it was dealt with and satisfactory outcomes were obtained. The service had a safeguarding procedure but this needed to be reviewed to ensure it reflects the current procedures implemented by social services. We were informed that the home have not had the need to make any referrals since the last inspection. Some staff spoken to said they knew what to do if they felt people were being abused. People using the service were safeguarded from abuse and evidence suggested they were protected from financial abuse. Three peoples finances were checked and all found to be satisfactorily maintained. Care Homes for Adults (18-65 years) Page 18 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home presented a welcoming and warm environment that was clean in most parts and free from offensive odours, however the safety of the environment was compromised due to people being exposed to excessively hot water or risk of accidental fires. Evidence: The service consisted of a two storey building that was spread across two homes joined together by a conservatory. On the day of the inspection both units were inspected. The environment appeared homely and comfortable and people spoken to said they were happy at the home. Peoples bedrooms are furnished to reflect individuality, one person said they had chosen the colour that they wanted in their bedroom. The lounge and dining rooms were welcoming and they were decorated to ensure a homely environment could be maintained. One persons bedroom failed to reflect a good hygiene standards and staff spoken to said they regularly encourage this person to clean their room but with little success. We were informed that staff have also taken it unto themselves to clean this room but it soon reverts back to an unkempt state. We were also concerned that this person was a heavy smoker and did this in his bedroom. Some furnitures appeared to be Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: black with scars of burns, on entering the room it was thick with smoke and we were concerned that this could become a potential fire hazard to people using the service. In view of this the environmental risk assessment was inspected and as a result found that it needed to be updated to ensure other people are safeguarded in the event this could occur. The environmental risk that assessment was last updated on the 2/12/03. The service had sufficient bathing and toilet facilities to meet the needs of people using the services. Some bathroom facilities appeared stained and detracted from the homeliness the service was trying to maintain. We identified that the hot water temperatures dispensed from all hand basins bathrooms and communal facilities were in excess of 50 degrees and as a result could cause burns or scalds to people using the service. The home had implemented immediate measures to protect people from burns on the day of the inspection. These measures included supervising people while using hot water and taking hourly checks after reducing the temperature in the main boiler system. These measures however were not satisfactory and as a result on day two of the inspection and immediate requirement was issued to the home. Since the inspection we were informed that temperature controlled valves were to be fitted on the 15th and 16th of January 2009 to ensure safe water temperatures are dispensed at all times. On the 19th of January 2009 an email was received by the Commission to say that the valves had been fitted and the temperatures being dispensed are able to safeguard the people using the service. The service employed a domestic cleaner and as a result the home was kept clean and free from offensive odours. People using the service and support staff were also observed undertaking household chores in order to maintain a high standard of hygiene. Care Homes for Adults (18-65 years) Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service received support from staff that were trained, competent and qualified to do so, but further development was needed to ensure satisfactory recruitment procedures are in place to protect people who use the service. Evidence: The service provided sufficient numbers of staff to meet the needs of the people in the home. On the days of the inspection two members of staff were rostered on each shift. We were informed that two staff worked in the morning two in the evening and one waking and one sleep in staff covered the night shifts. The acting manager was supernumerary to the staff rota. Staff spoken to appeared knowledgeable and competent to meet the needs of the people using of the service. External professional spoken to said staff are very pleasant and professional, and we never feel there is a crisis as staff manage people calmly. Another person visiting the home said staff, communicates very well. The service currently employs 7 care staff 3 of which have obtained the National Vocational Qualification (NVQ) 2 and 3 were undertaking the qualification at the time of the inspection. We were informed that several staff had embarked on a specialist training to include Mental Capacity Act and others were due to take several courses in Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: coming months. This was confirmed by training records inspected. The records also confirmed that mandatory training to include Fire and Medication were identified as needing updating for several staff members. Some training had already been booked for 2009 to include Safeguarding, Dementia and Moving and Handling. A sample of four staff files were inspected on day two of the inspection. The records seen suggested the service ensured proof of identity, application forms, references, medical clearance, Criminal Record Bureau checks and relevant certificates were in place for most care staff, however some files failed to show full employment history, references, or proof of identification. It appeared that inconsistent procedures for record-keeping in regards to recruitment resulted in some information been missing. Staff spoken to said they received supervision but this was not as regular as they would have liked due to the change in management. Records seen suggested some staff received regular supervision while others needed to be improved. The acting manager had identified this as an area to be improved in the future. Staff spoken to said they completed application forms and were subjected to a satisfactory reference and Criminal Record Bureau checks prior to employment. Care Homes for Adults (18-65 years) Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a well run home that seeks and monitors their view but further development is needed to ensure the service can benefit from accountable management and the polices and procedures are in place to safeguard people, as a result the welfare of people could be compromised. Evidence: The acting manager have been in post just over a month. She have been acting up in the absence of a manager for several months but said she only just agreed to work in the position until a suitable manager is found. The acting manager appeared competent and knowledgeable about the needs of the people who use the service. She explained that she had embarked on her NVQ level 4 but had to stop due to illness. She has 15 years experience of working in the health care field and have worked in the current service for 10 years. Staff and people spoken to all felt she was capable of running the service and said she was approachable.The leadership of the service was also complimented with senior Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: care workers who assume responsibility when on shift. The service had some quality assurance systems in place that looked at the aims and objectives of the home. The annual review for 2008 looked at the facilities available at the service, to include meals, activities undertaken, fund raising events, the numbers of staff and their qualifications and training. Statistical data presented suggested surveys were evaluated for both staff and people using the service to show that 80 felt peoples wellbeing had been improved, 100 felt they were able to have a say, 80 felt the service had improved. We looked at a sample of policies and procedures in the home and found that in several cases these were outdated. Some were last reviewed in 2003/05 and appeared very basic in nature only covering three paragraphs. Some policies only stated, to be written. The health and safety of people were compromised. See the environmental section of this report. Other aspects of the safety of people were satisfactory and records such as fire records were satisfactorily maintained. The service have not submitted an application for a registered manager. We were informed that adverts have been placed in the local media in an attempt to recruit a suitable candidate for the position. Care Homes for Adults (18-65 years) Page 24 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 25 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 1 2 14 Arrangements must be 28/02/2009 made to ensure all people using the service have a comprehensive assessment undertaken that details their holistic needs. To ensure peoples needs are satisfactorily assessed and they are not left unidentified. 2 6 15 Arrangements must be made to ensure all care plans are reviewed and kept up to date, reflecting the current needs of people. To be sure that people can receive a consistent service delivery. 28/02/2009 3 19 12 Clear interventions must be in place to ensure peoples mental health care needs are identified and strategies are in place to support and prevent relapses. 28/02/2009 Care Homes for Adults (18-65 years) Page 26 of 29 to ensure peoples emotional health care needs are met effectively. 4 20 13 Suitable arrangements must be made for the recording and safe administration of medication. To maintain the health and welfare of people using the service. 5 24 23 Adequate precautions must be taken against the of fire starting in the home. To protect people from coming to harm due to fire. 6 34 19 The recruitment procedures 28/02/2009 in the home must be thorough to reflect the requirements of the National Minimum standards. To protect people who use the service. 7 40 17 Arrangements must be made to ensure the homes policies and procedures and reviewed to reflect current legislations and recognised professional standards. To ensure peoples best interests are safeguarded. 28/02/2009 30/01/2009 20/02/2009 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 12 Arrangements should be made to ensure all people using the service are given the opportunity to engage in age Page 27 of 29 Care Homes for Adults (18-65 years) appropriate activities that will enhance mental stimulation. 2 3 4 20 27 43 Safe temperatures should be maintained for the storage of medication. Arrangements should be made to descale toilet bowls and make them more welcoming. Suitable arrangements should be made to ensure a registered manager is available to effectively manage the service. 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). 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