Inspection on 18/05/09 for Sea View Lodge

This inspection was carried out on 18th May 2009.

CQC 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

Sea View Lodge 04/08/09

Sea View Lodge 19/06/08

Sea View Lodge 26/06/07

Sea View Lodge 22/11/06

Sea View Lodge 23/06/06

Sea View Lodge 02/03/06

Sea View Lodge 31/05/05

Sea View Lodge 14/12/04

Sea View Lodge 30/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Sea View Lodge 116 Central Parade Herne Bay Kent CT6 5JN     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: Joseph Harris     Date: 1 8 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 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 31 Information about the care home Name of care home: Address: Sea View Lodge 116 Central Parade Herne Bay Kent CT6 5JN 01227375253 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : seaviewlodge@aol.com Mr Shahid Sheikh,Mrs Nelofar Sheikh care home 10 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 10 The maximum number of service users to be accommodated is 10. The registered person may provide the following category/ies of service only: Care home only ? (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) Date of last inspection Brief description of the care home Sea View Lodge is a 10-bedded home for people with learning disabilities in the town of Herne Bay. The house is located on the seafront close to the pier and a short distance from the centre of town with a good range of amenities and facilities. There are reasonable public transport from the town including bus routes and a train station. The home is set out over two floors. The ground floor mainly comprising of communal space with two bedrooms there are no communal toilet or bathing facilities on this floor. The first floor consists of bedrooms and toilets/bathing facilities. There is adequate communal space throughout the home. There is a small, enclosed courtyard to the rear of the home and a larger paved area with parking space to the front of the home. Care Homes for Adults (18-65 years) Page 4 of 31 Brief description of the care home The current fees for the service at the time of the visit range from 475 to 860 pounds per week. Information on the home services and the CSCI reports for prospective service users will be detailed in the statement of purpose and service user guide. Care Homes for Adults (18-65 years) Page 5 of 31 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 unannounced inspection process culminated in a site visit to the service on 18th May 2009. The site visit inspection lasted for approximately 7 hours commencing at 09:30 hours and concluding at 16:30 hours. Prior to the visit a range of documents received about the home were examined and reviewed including the Annual Quality Assurance Assessment, information received in relation to the home, past inspection reports and other relevant documentation. During the course of the visit a tour of the premises was undertaken. Discussion were held with service users, staff, the manager and the owner as well as a visiting healthcare professional. Records and documentation was examined covering a wide range of aspects including information relating to service users, staff, health and safety, medication and the day Care Homes for Adults (18-65 years) Page 6 of 31 to day running of the home amongst other things. What the care home does well: What has improved since the last inspection? What they could do better: 4 requirements and 13 recommendations have been issued under the Care Home Regulations 2001 as a result of this inspection process. The requirements relate to information and facilities available to ensure that the changing needs of service users are met. The individual service user plan and risk management plan examined for one service user had not been sufficiently updated and reviewed. This was discussed in detail with the manager and the provider and needs to fully reflect the changing needs and provide clear and unambiguous guidance for staff to meet those needs. Additionally, due to changing needs, a Safeguarding Vulnerable Adults alert has been raised. The home has received support from a range of healthcare professionals as a result of this and have highlighted the need for equipment and adaptations to meet the individuals need. Therefore requirements have been made to produce an action plan leading to these improvements being addressed. Recommendations for best practice have also been made covering a number of issues. These include continuing efforts to update staff training including mandatory topics and issues relating to adult protection and the Mental Capacity Act and some further amendments to the recruitment process. It is advised that the service user guide and Care Homes for Adults (18-65 years) Page 8 of 31 contract covering terms and conditions of residency are reviewed and updated. A new manager has been appointed and it is recommended that he continues the process of registration with the Commission. As a result of managerial changes the provider should further develop the quality assurance processes that are in place. Due to the changing needs of service users the home is advised to review staffing levels to ensure that individuals needs can be met at all times. The home should also ensure that all records relating to the health, safety and welfare of service users are in place and up to date. 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 9 of 31 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 10 of 31 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. Service users have access to information about the service and their needs are assessed prior to admission. Evidence: The home has a statement of purpose and service users guide and it is reported that these are made available to prospective residents of the home. The service users guide would benefit from being updated and reviewed. It is advised that the guide is developed in a format that is more accessible to prospective service users introducing pictures and symbols to aid understanding for people with learning disabilities. Refer to recommendation 1. No new service users have been admitted to the home since the last inspection. Two pre-admission assessments were examined relating to people who have moved into the service over recent years. In both cases the assessment of needs had been completed in good detail covering a range of needs including physical, social and emotional issues. The homes own assessment was supported by information obtained from care managers including recent care management reviews and risk assessments. Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: Contracts covering the terms and conditions of residency were examined for three service users. It is recommended that these documents are updated to include information relating to specific fees, rooms occupied and details of the Commission and the complaints process. Refer to recommendation 2. Care Homes for Adults (18-65 years) Page 12 of 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs and risks of all service users are not adequately assessed and planned for. Service users are able to make decisions affecting their day to day lives. Evidence: Three individual service user plans were examined, which were of differing quality. Two plans had been developed in good detail providing guidance for staff to adequately meet the needs of the service users in question. Recent care management reviews were on file and mirrored the information developed by the home. There is evidence that the plans have been reviewed. The individual service user plan for one person did not address the current needs of the resident in question. The plan was handwritten and quite difficult to decipher. There was evidence that the plan had been reviewed in February 2008. However, since this time the needs of the individual have significantly changed with particular reference to mobility, personal care and social activity. These changing needs were not reflected in the plan of care or risk assessments. It was evident, through discussion Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: with staff, that the needs and requirements of the individual are understood, but clear and consistent guidance relating to the management of current care needs was not present. The provider acknowledged that the plan had not been updated and agreed to ensure that this was completed as a matter of urgency. A pen portrait has also been developed, but the information contained within this is similarly out of date. Refer to requirement 1. Risk assessments were also variable in quality. In two circumstances these had been developed addressing a range of perceived risks and providing guidance on how to minimise these. However, in one case the current risks had not been suitably addressed and updated to reflect changing needs. The risk assessments covered issues such as burns and scalds in the bath and slips, trips and falls none of which are significant risk factors at the present time. However issues such as the use of a hoist, pressure area care and fire safety amongst other things were not addressed. Refer to requirement 2. Following discussion with service users and staff members it was evident that residents are able to choose how they wish to spend their time and that they are enable to do so. Residents stated that they have choices regarding their daily activities, menus and access to finances. The provider is currently financial appointee for a number of service users, but stated that he has requested that this role is now taken on by someone independent of the service such as a care manager or family member. Records are retained of incoming and outgoing transactions. The acting manager stated his intention to review and update financial processes in the home. Records were not examined during the course of this inspection in relation to resident finances. Care Homes for Adults (18-65 years) Page 14 of 31 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. Service users have a lifestyle that suits their needs. Evidence: A number of service users regularly attend outside day centres and clubs through out the week, ranging from 1-4 times per week. Some residents are now of an older age and do not wish to or cannot go out of the home, but activities afternoons have reportedly been introduced so people have the opportunity to engage in arts and crafts, bingo and gentle exercises. Residents were observed to be engaging in activities of their choice throughout the day, such as playing games, knitting, colouring, playing the piano and watching TV amongst other things. Among the comments made by service users were, Im happy here, theres enough to do. Its a happy home and I like it here, we all get on, its my house. Residents stated that they are able to go out with staff into the Herne Bay and along the seafront with staff Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: support. One person was looking forward to their birthday and said that a party was arranged and family and friends had been invited. No visitors were present at the time of the site visit, but residents confirmed that their visitors are welcomed into the home and that they are able to meet in private should they wish to do so. Menu records are kept on a daily basis and meals are planned depending on individual choices. The records showed evidence that a range of choices are available and that a healthy and balanced diet is provided. Diabetic diets are provided and the cultural dietary wishes for another person met. One person said I like the food, its nice. I like it when we have fish and chips. Care Homes for Adults (18-65 years) Page 16 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and healthcare needs of the service users are met. Evidence: The personal care needs of service users are met. The majority of residents are relatively self-caring requiring prompting and encouragement only. Three service users have greater needs in this area and all of these individuals had been supported to meet their personal care needs. One person said the staff are very good, they help me when i need it and are very caring. After reviewing the care plan for one individual it was apparent that information relating to personal care needs requires updating, but staff demonstrated a good awareness of needs and the individual concerned stated that they feel their needs are met in this regard. Refer to recommendation 3 and requirement 1. The home maintains healthcare records for all of the service users and there is evidence that in most cases health issues are referred to the appropriate professional. Outcomes of these visits are recorded. An adult protection alert has been raised in connection with the health care needs for one resident. As a result of this, input has been received from relevant professionals and equipment has been acquired to ensure Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: that their needs can be appropriately met. The visiting Occupational Therapist stated that the staff team have been responsive to advice and have implemented his recommendations and treatment plan. Records are being maintained demonstrating that care staff are providing necessary support for this individual. The service user in question stated that I dont want to move, this is my home, the staff do everything to help me. The individual service user plan requires updating to ensure that these needs are consistently met, but care staff were able to demonstrate an understanding of the care needs. Refer to recommendation 4 and requirement 1. Medication records are well managed and there are policies and procedures in place relating to the storage, administration and receipt of medication. The newly appointed manager is a qualified pharmacist and stated his intention to review all processes in relation to medication. Storage facilities are adequate for the purposes of the home. Staff have received necessary training relating to the management of medication. Two service users are insulin controlled diabetics and it was reported that staff have received instruction in the use of the administration pens from the diabetic nurse. All of the service users are registered with local GPs and receive support from the Community Learning Disability Teams. Complimentary healthcare needs such as Chiropody and dentistry are routinely arranged and recorded. Care Homes for Adults (18-65 years) Page 18 of 31 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 views of service users are listened to and acted upon. Processes are in place to protect service users from abuse. Evidence: The home has a complaints process in place and it was reported that no complaints have been received since the last inspection. The complaints procedure should be updated to include current details of the Commission. Refer to recommendation 5. There have been two Safeguarding Vulnerable Adult alerts since the last inspection. One has been fully resolved and closed and another is currently on-going. Discussions were held with a visiting professional involved in providing support following this alert who stated that the care staff have been following guidance provided and the outcomes for the individual involved have improved as a result. Equipment has been acquired to assist in the meeting of needs and regular input from healthcare professionals is being received. The service user concerned stated that they are happy with the care and support that they are receiving and that they wish to remain in the home. The home has policies and procedures in place relating to adult protection and abuse awareness and staff have received training in these topics. It is advised that policies and procedures are reviewed and consideration given to further training covering the Mental Capacity Act and Deprivation of Liberty Safeguards. Refer to recommendations 6 and 7. Care Homes for Adults (18-65 years) Page 19 of 31 Care Homes for Adults (18-65 years) Page 20 of 31 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 premises would benefit from some adaptation to promote the health, safety and well-being of all service users. Evidence: Sea View Lodge provides accommodation for up to 10 people with learning disabilities. The home is situated overlooking the sea front in Herne Bay and a short walk from the town centre. There is parking space at the front of the home for 2 cars. There is a small paved area to the rear of the house with access to a back road. The home is arranged over 2 floors. The first floor is on split levels with a few steps leading up to the upper area. There are three communal areas on the ground floor comprising of a large lounge/dining room, a utility area with a piano and a quiet area/office to the rear of the building. There is also a conservatory-type area beyond this that is not equipped to be used as a communal area. There are no communal toilets on the ground floor with all toilet and bathing facilities located on the first floor. One of the ground floor bedrooms has a small en-suite facility, which, with the agreement of the service user, is shared by her close friend and neighbour. Due to healthcare needs the occupants of these rooms have recently swapped. Discussions were held with both residents who stated that they were happy with this arrangement. There is a need to address the toilet and bathing facilities on the ground floor and access issues for one service user. Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: These were discussed with the provider and acting manager who stated their intentions to address these concerns. Refer to requirement 3. The home is reasonably well furnished, although a new chair needs to be purchased following assessment by an Occupational Therapist, for one individual in order that healthcare needs can be met. Refer to requirement 4. The provider has decorated and refurbished much of the home and service users stated that they are comfortable in the environment and like the homely feel. There is a good sized kitchen with equipment in good working order. Following a recent inspection by the Environmental Health Department the home was awarded 4 stars out of 5 for cleanliness and hygiene. It is reported that the home meets the requirements of the fire safety department. The laundry area can only be accessed through the kitchen and risk assessments have been completed to ensure that dirty laundry is carried through in sealed containers at times when food is not being prepared to minimise cross-infection. It was stated by staff that the laundry facilities are in good working order and fit for purpose. Care Homes for Adults (18-65 years) Page 22 of 31 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. There are adequate numbers of staff who are competent in their roles and have access to training. There are suitable recruitment practices. Evidence: The home operates with a small staff team and have two staff on shift throughout the day and one sleep-in staff member at night. The provider stated that there is an oncall system at night time should assistance be required. Staff were observed to be unhurried and relaxed in their work and, in conversation, they stated that they are happy working in the home. Due to the changing needs of the service users it is important that staffing levels are kept under review to ensure that needs can be met and there is flexibility to enable residents to access the community with support if required. Refer to recommendation 8. The home has employed three staff of Chinese origin through an overseas recruitment agency and from other care homes. These staff all have nursing qualifications from China and the provider has documentation stating that their qualifications are equivalent to NVQ level 2 or above. However, it is recommended that all staff are enrolled on NVQs at an appropriate level to their knowledge and experience. Refer to recommendation 9. In conversation staff members demonstrated a good understanding of the needs of the service users and of their roles and responsibilities. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: The staff personnel files contained all required information including CRB checks and two written references. In one case there was an absence of proof of identity. The employment application form should also be reviewed to ensure that a full employment history including any gaps is provided by prospective employees. The home is also advised to request a POVAfirst check for all prospective employees in addition to the CRB check, which contains records of entry on the POVA register. Refer to recommendation 10. The majority of mandatory training for staff has been completed, but it was noted that there are some gaps. Two relatively new staff are still in the first 6 months of employment and there is evidence that they have completed some training including the Common Induction Standards. Another staff member has relatively recent certificated training from previous employment. It is advised that all staff complete manual handling training or refreshers following the Safeguarding Vulnerable Adults alert. Refer to recommendation 11. Staff have also completed other training including Adult Protection, medication and an introduction to Learning Disabilities. Care Homes for Adults (18-65 years) Page 24 of 31 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 home would benefit from consistent management to further ensure the quality of the service and maintain the health, safety and welfare of service users. Evidence: The current provider has recently purchased another home and has become manager of that service. As a result he has now appointed his son as Acting Manager, who has completed all of the relevant management qualifications and is a qualified pharmacist. He has recently applied to become the Registered Manager and is currently working through this process. Refer to recommendation 12. A lengthy discussion was held with him and he demonstrated a commitment to raise the levels of the service and an awareness of his strengths and limitations. He stated that he has only been in post for two weeks and has yet to commence full-time duties in the home, but stated that he will be working in the home for 5 days per week including some weekend work. The service provider was also present during the inspection and he stated his plans to begin to take a more overseeing role of both homes over the coming years. The service users have the opportunity to complete satisfaction surveys annually, Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: which have provided largely positive feedback. The provider was advised to widen the scope of the questionnaires to include relatives and social and healthcare professionals. It is also advised that the provider completes a monthly monitoring report including staff and service user views and audits of key aspects of the home such as care planning, training, finances and medication now he is no longer in day-today control of the service. Refer to recommendation 13. A range of records relating to health and safety issues were examined including fire safety logs, service certificates such as gas and electrical wiring most of which was up to date and in place. However it was noted that the NICEIC electrical wiring certificate had recently expired and needed to be renewed. Care Homes for Adults (18-65 years) Page 26 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 31 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 6 14 2. The registered person shall ensure that the assessment of the service users needs is - a) kept under review. b) revised at any time as is necessary to do so having regard to any change in circumstances. 21/06/2009 Individual service user plans need to reflect current and changing needs providing consistent guidance to ensure that the needs of all service users are met. 2 9 13 4. The registered person 21/06/2009 shall ensure that a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Care Homes for Adults (18-65 years) Page 28 of 31 Individual risk assessments are developed addressing perceived risks and providing clear guidance to minimise these risks for all service users. 3 31 23 The registered person shall 21/07/2009 having regard to the number and needs of the service users ensure that a) the physical design and layout of the premises to be used as the care home meet the needs of the service users. n) suitable adaptations are made, and such support, equipment and facilities, as may be required are provided, for service users who are old, infirm or physically disabled. To develop an action plan ensuring adaptations as recommended following assessment by an suitably qualified professional are carried out in order to meet the needs of the service users. 4 32 23 The registered person shall 21/07/2009 having regard to the number and needs of the service users ensure that j) there are provided at appropriate places in the premises sufficient numbers of lavatories, and of wash basins, baths and showers fitted with a hot and cold water supply. Care Homes for Adults (18-65 years) Page 29 of 31 To develop an action plan addressing the provision of suitable toilet and bathing facilities to meet the needs of the service users. 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 2 3 4 5 6 7 1 5 18 19 22 23 23 To review and update the service users guide providing greater accessibility for people with learning disabilities. To review and update the contract covering terms and conditions of residency. To ensure that the personal care needs for all service users are clearly documented within individual plans. To ensure that the healthcare needs for all service users are clearly documented within individual plans. To review and update the complaints process and procedures. To review and update policies and procedures relating to abuse awareness and ensure staff awareness. To provide instruction and information to staff regarding the Mental Capacity Act and the Deprivation of Liberty Safeguards. To enrol staff on NVQ courses relevant to their knowledge and experience. To update the employment application form to request a full employment history. To provide updated manual handling training for all staff and continue to provide all mandatory training. The acting manager to progress through the registration process and take active day-to-day control of the service. To further develop quality assurance processes including records of provider monthly monitoring visits and action plans. To ensure that all health and safety records are maintained and kept up to date. 8 9 10 11 12 32 34 35 37 39 13 42 Care Homes for Adults (18-65 years) Page 30 of 31 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). 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. Care Homes for Adults (18-65 years) Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!