Inspection on 11/02/09 for Sevenoaks

This inspection was carried out on 11th February 2009.

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

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

Other inspections for this house

Sevenoaks 22/02/07

Sevenoaks 22/03/06

Sevenoaks 16/08/05

Sevenoaks 15/02/05

Sevenoaks 01/12/04

Sevenoaks 16/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Sevenoaks Sevenoaks Lords Hill Coleford Glos GL16 8BG Two star good service The quality rating for this care home is: 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: Lynne Bennett Date: 1 1 0 2 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. They reflect the things that people have said are important to them: 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. 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. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Sevenoaks Sevenoaks Lords Hill Coleford Glos GL16 8BG 01594832679 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): sevenoaks@orchard-trust.org.uk The Orchard Trust Name of registered manager (if applicable) Mr Stephen John Thomas Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 11 5 0 0 Care home 11 Learning disability sensory impairment Additional conditions: The registered paerson may provide the following category of service only: Care Home only - (Code PC) to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning Disability - (Code LD) Sensory Impairment (Code SI) - maximum of 5 places The maximum number of service users who can be accommodated is 11. Date of last inspection 2 2 0 2 2 0 0 7 A bit about the care home Sevenoaks is a modern detached split-level bungalow situated within half a mile of Coleford Town Centre in the Forest of Dean. The home accommodates up to eleven people with learning disabilities. The accommodation comprises of 11 single bedrooms, seven of which have en-suite facilities. The home currently has a vacancy. The house is separated into two wings, known as Phase 1 and Phase 2. Each has its own separate dining and lounge areas, kitchen, offices and communal bathrooms. The original home retains sleeping-in facilities for staff and a small laundry. The newer home has a larger laundry. At the rear of the property there is a parking area and landscaped garden. Residents have access to three vehicles. The home is part of the Orchard Trust group. Prospective service users and others involved in their care are offered information about the home including copies of the Statement of Purpose and Service Users Guide. This has just been updated and will be produced in symbol format in due course. Fees for individuals are negotiated with placing authorities using the Fair Pricing Tool and start from around 750 pounds per week. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: Two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This inspection took place in February 2009 and included a visit to the home on 11th February by one inspector. The registered manager was present throughout. He had completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). Surveys had been returned to us prior to the visit from two people living in the home and four members of staff. Time was spent with people during the visit, talking to them and observing the care being provided. Five members of staff were spoken with. A selection of records were examined including staff files, health and safety documents and quality assurance systems. We talked to people using the service, and asked staff about those peoples needs. We also looked at the care plans, medical records and daily notes for these people. This is called case tracking. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well The home provides accommodation of the highest standards which is homely, clean and pleasantly decorated. People have rooms with en suites and are provided with the equipment they need such as overhead hoists and assisted baths. One person said they like the home and their room. They also said they can choose what activities they want to do. People are supported to go to day centres, college and work in a studio. They have holidays and trips out to the theatre. People help around the home with the cleaning, laundry and cooking. Staff have access to a comprehensive training programme. What has got better from the last inspection Information obtained for new staff is in place before they are appointed. The deputy manager had completed training in a positive approach to supporting challenging behaviour. There was less use of physical intervention and people were being supported to manage their anxieties. Fire checks are in place and being recorded. What the care home could do better Changes to person centred plans should be finished and records for monthly checks which review these should be completed. Plans to replace carpets in Phase 1 and refurbish a bathroom should be followed through. Records need to be put in place to show that when medication is given to people in their food this is being done in their best interests. This should be discussed with other people involved in their care. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Lynne Bennett Colston 33 Bristol BS1 4UA 0117 930 7110 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 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 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 have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the persons wishes and needs are taken into consideration before offering them a place. Evidence: The home has a Statement of Purpose and Service User Guide which were reviewed in 2008. These had been produced in a text, picture and symbol format. The registered manager said that the Service User Guide was being produced in a format appropriate to peoples needs using photographs of the home. Since the last inspection one person had been admitted to the home. Comprehensive admission information had been collated prior to their admission. A transition meeting had been held with relatives and other healthcare professionals to ensure a smooth move to the home. At each stage there were records to evidence what had taken place. An initial assessment had been completed by the home which was supported by an assessment and care plan provided by the placing authority. Records confirmed that staff from the home had worked closely with the persons day centre and respite unit spending time in both places with the person. Visits to the home had been supported by staff from the respite unit including an overnight stay. Other people living in the home had been included in this process having a chance to meet the person and also to express their feelings in a meeting. A photograph of the person was used as a prompt to remind people who would be moving into the home. There was evidence that assessments had been requested from other healthcare professionals prior to the move to assess communication and bathing. Evidence: An admission checklist indicated that the person had been shown around the home, given a copy of the Service Users Guide and Information Pack and provided with a general induction when they moved into the home. 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 . A person centred approach to care planning ensures that peoples identified needs reflect their wishes and dreams . Peoples needs are being assessed and they are being supported to makes decisions about their lifestyles. Risks are being managed safeguarding them from possible harm. Evidence: The home was introducing a new format for their person centred plans after discussion with staff to make plans clearer and provide step by step guidance about each persons needs. Of the three people case tracked one person had plans in the new format. All plans were person centred and indicated, What we need to know to successfully support me. A range of holistic needs were then identified providing care plans for peoples physical, intellectual, social and emotional needs. Most plans had been reviewed in 2008 and there was evidence that systems were in place for the monthly review of plans encouraging staff to identify, What worked well and What did not work well. These latter forms had been filled in inconsistently with some not being completed since January 2008. The deputy manager said new forms had been provided for staff to complete for 2009. On these forms staff were invited to give feedback but on the ones examined there was little evidence of any changes to peoples needs or whether the plan had been followed through successfully. Staff had been booked for Person Centred Planning training in 2009. The deputy manager stated that the review for one person had included a pictorial representation of their wishes and aspirations, using diagrams, pictures and photographs which were displayed around the room. Supervision notes for their key worker confirmed that they had been involved in the preparation of this meeting, Evidence: deciding who to invite and what to discuss. Plans examined were comprehensive, person centred and provided staff with clear guidance about how to meet peoples needs. Staff were observed putting this into practice during the visit, such as directing a person to recognise peoples personal space by prompting them to put their hands down when they were trying to have close contact with people. Each person had a communication profile or passport in place which provided guidance about how to interpret their verbal and non verbal behaviour. These also indicated whether people used makaton sign language, or objects of reference and photographs. On one file there were photographs indicating how the person used makaton to express themselves. Staff were observed using makaton and objects of reference with people. For instance one person was visiting the dentist and staff supported them to clean their teeth and showed them the toothbrush prior to the visit. There were some restrictions in the home such as access to the kitchen and access to the front door. The reasons and rationale for these had been recorded in risk assessments. The home needs to consider what documentation needs to be provided in respect of access to the front door in light of the Deprivation of Liberty Act to be implemented in April 2009. The AQAA stated, Service users are supported to take risks to participate in preferred activities and are given verbal information by the staff to guard their personal safety. A range of risk assessments were in place which reflected hazards identified in care plans. Some care plans referred to these documents, which is good practice. Risk assessments were being regularly monitored and reviewed. There was some inconsistency in relation to risk assessments for people who have epilepsy. All care plans examined clearly identified where people had epilepsy and provided guidelines for staff although not all people had the necessary risk assessments in place. 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 . People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. Evidence: Each person had a list of activities on their files which they liked to participate in, as well as an activity schedule for the week. Records were being kept indicating for some how they spent each hour of the day or for others how they spent the morning, afternoon or evening. An activities co-ordinator had been appointed and had produced an outline plan of activities which could be offered to people spending time at home. This included pamper sessions, trips out, sensory sessions, story time, crafts, cooking and music. During the visits people were observed listening to music, singing, having foot massage, listening to a story, playing a game of ball and watching television. Some people had gone to day care at The Barn which was run jointly by The Orchard Trust and Gloucestershire County Council. One person attended a day centre in Monmouthshire and people also went to a local college. Staff said that one person was working in a Studio one day a week. The registered manager confirmed that holidays had taken place last year to a variety of places including Centre Parcs and Tunisia and that holidays were being planned for this year. People had also taken day trips, gone to the theatre and cinema. One person loved watching rugby and the home were researching purchasing a season ticket to Evidence: support a local team. During the visit people went out for walks locally and also used local facilities. People were able to walk to local shops and the library. Records were being kept of contact with family and friends. People were supported to visit relatives and key workers kept in touch by telephone. Staff said people met friends each week at a local social club. People were observed helping around the home, with the laundry and planning to bake a cake. Staff described how people were supported to help out with the evening meal whether this was laying the table, cooking or washing up. Menus were planned for a six week period providing a range of freshly produced meals using fresh vegetables. Fruit was provided in the kitchen. People were observed being supported to have regular drinks throughout the visit. Special diets were being catered for. Where people had a Gluten and Diary Free diet they had a separate menu and shopping list indicating what needed to be purchased each week. Individual meal records were being kept for each person. 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 . Personal care support is offered in a way that responds to peoples needs and references, promoting peoples dignity. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. Evidence: Pen pictures had been developed as part of each persons care plan providing a record of their likes and dislikes and way in which they wished to be supported with their personal care needs. These guidelines were clear and succinct providing step by step information for staff about how people wanted their care to be delivered. Staff spoken with had a good understanding of peoples needs. Equipment and specialist adaptations had been provided throughout the home for those people requiring technical aids. Overhead tracking was fitted to bedrooms and bathrooms, personal chairs and assisted baths were provided. There was evidence that the home was working closely with the local Community Learning Disability Team. Action agreed forms provided after each consultation were being monitored by the Team and the home appeared to be actioning these. A range of monitoring forms were being used to provide information as requested. Appointments with health care professionals were being recorded and indicated that people had regular access to their Doctor, Dentist, Optician and an Incontinence Nurse. Two people were being supported sensitively by staff to attend Dentist appointments. The Dentist had visited the person at the home and the person was Evidence: gradually developing the confidence to have treatment . Health action plans were in place providing information about each persons health care needs and providing a summary and pen picture should they need to go into hospital. The AQAA stated, The Health Action Plans outline their preferred routines and approaches to personal care. Integral to the plan is the need to promote and maintain the persons privacy, dignity and choices while at the same time encouraging their independence. The registered manager said that they had tried to arrange annual health checks for each person with the local surgery but these had not been forthcoming. Some people had frequent contact with their Psychiatrist and had their medication reviewed at these meetings. Systems for the administration of medication were examined and found to be mostly satisfactory. Staff said they had completed training in the safe handling of medication. One member of staff talked through the process for giving medication to people and the safeguards which were in place to make sure this was done correctly. The home had an old copy of a British National Formula and the registered manager said that updates would be downloaded from the internet if needed. Patient information sheets were kept on the medication file. Protocols were in place for the administration of as necessary medication. Some people were observed having their medication given with their food. This was noted on a care plan for one person but not another. There was no evidence that protocols or a best interests meeting had been held to discuss this. Guidance was given to the deputy manager about what needs to be in place. She started to arrange this during the visit. A signature list of staff dispensing medication was not seen at the time of the inspection. Although the temperature of the medication fridge was being monitored and recorded, the temperature of the medication cabinet did not appear to be checked. Medication should be stored below 25 degrees centigrade. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The service has an accessible complaints procedure which enables concerns to be raised by people using the service or on their behalf. Systems are in place which should safeguard people from possible abuse. Evidence: The home has a complaints policy and procedure which was available in symbol format. The registered manager confirmed that no complaints had been received, he said any concerns from parents were dealt with as they arose. Keeping a record of these would evidence how responsive the home was to expressions of concern. Staff were aware of the whistle blowing policy and procedure and one said they were confident that management would challenge poor practice and deal with it appropriately. Staff confirmed they had attended training in the safeguarding of adults and had a good understanding of abuse. A copy of the local procedures was in the office. Management had attended training in the Mental Capacity Act and information was available. The deputy manager had just completed training as a trainer of PRICE - Protecting rights in a caring environment utilising a positive approach to supporting challenging behaviour. She said she would be cascading training to new staff. Most staff had also completed this training. People living in the home had Behaviour Management Plans in place which clearly indicated triggers, behaviours and response strategies for staff. The use of physical intervention was as a last resort. Techniques which could be used with people were described and photographs showed how these were to be carried out. Records were completed when physical intervention was used and incident records described peoples behaviour. The use of physical intervention had been discussed in a multi disciplinary forum and an assessment of capacity to consent had been completed. These indicated that the use of physical intervention was in peoples best interests to minimise risk of injury to themselves, staff and others. The registered manager confirmed that he had been informing us of the use of physical intervention. Evidence: He was advised to inform us when two staff were involved in the use of physical intervention. He confirmed that there had been no use of physical intervention this year. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People live in a home that is safe,clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. Evidence: Accommodation of the highest standards was being provided to people. Communal areas were pleasantly decorated with good quality fixtures and fittings. The home looked fresh and clean, was well lit and light. Peoples rooms were individualised with some having a sensory environment and all having rooms which reflected their lifestyles and interests. Specialist equipment and adaptations were provided where needed. Some rooms had overhead hoists. The new ground floor extension provided a room with en suite with an assisted bath and overhead tracking. The grounds around the home were well kept and all people had access to a patio area. A survey from a person living in the home said,I like my room, the home is always clean and fresh. The registered manager confirmed that carpets in Phase 1 would be replaced and that a bathroom would also be refurbished. Kitchens were clean and infection control procedures were seen to be in place and good food hygiene practice appeared to be followed. The home had the Better food safer business pack which was being used by staff to monitor procedures and reflect on practice. Personal protective equipment was provided around the home. Liquid soap and paper towels were provided in communal toilets. Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Peoples needs are met by a competent staff team,who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Robust recruitment and selection procedures should safeguard people from possible harm. Evidence: Surveys were returned from four staff and five staff were spoken with during the visit. There had been some changes to the staff team with new inexperienced staff working in the home. Consensus about this was mixed with some staff feeling this put additional pressure on existing staff taking on alot of responsibilities and other staff saying that team morale and support for each other was good. Some surveys had expressed concerns about communication in the home and it appeared that management were attempting to address this introducing new ways of using the communication book between the two Phases and having regular staff meetings. Staff confirmed that staffing levels were being maintained and were sufficient to meet the needs of the people they support. New staff confirmed that they had completed an induction programme and copies of this were on their personal files. Staff also had access to the Learning Disability Qualification and a NVQ programme. The DataSet indicated that 38 per cent of the team had a NVQ Award in Health and Social Care. Files for four new members of staff were examined and found to be satisfactory. Application forms provided a full employment history and where there had been gaps this was explored fully during the interview and recorded. People had been appointed upon receipt of two references and a satisfactory Criminal Records Bureau (CRB) check. One person had been appointed before the CRB check had been received and had evidence that a povafirst check had been obtained prior to starting work. A copy of the risk assessment was not on file but a sample was forwarded from head office Evidence: during the visit. The registered manager explained what would be put in place when employing staff without a CRB check which complied with the Care Homes Regulations. Evidence of identity was in place with a current photograph. The registered manager was advised not to take copies of birth certificates. A checklist on the front of each file indicated when information had been received or seen. This is good practice. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People benefit from a well run home. Effective quality assurance systems are being developed which will involve people who live there. Satisfactory health and safety systems are in place providing a safe environment. Evidence: The manager has considerable experience working with people with a learning disability. Since the last inspection he had been registered with us as the registered manager. He has the Registered Managers Award and a NVQ Level 4 in Health and Social Care. The management team have ensured that the requirements issued at the last inspection were complied with. The AQAA was sent to us on time and was a comprehensive document providing information about improvements in the home and plans for the future. The Orchard Trust were introducing a new Quality Management System in accordance with ISO 9001 which it stated would provide a periodic and systematic review of quality assurance procedures. The registered manager said that he was reviewing the survey forms for relatives and people living in the home and looking at ways of obtaining meaningful feedback from people. Monthly unannounced visits to the home take place each month in accordance with the Regulation 26 visits required by us. The Orchard Trust was awarded the ISO 14001 - Environmental and ISO 9001 - Quality Assurance in 2008. Systems monitoring health and safety around the home were in place. There was evidence that staff were regularly monitoring and recording temperatures of fridges, freezers, hot food temperatures and labeling food in fridges. Fire risk assessments were in place which needed amending to remove the reference to people staying put in Evidence: their rooms in the case of fire. The registered manager confirmed that this would not be the case. Fire drills were taking place regularly and the registered manager was aware of the need for night time fire drills/practice. Fire equipment was being regularly checked and serviced. The AQAA confirmed servicing of other equipment and utilities around the home. Are there any outstanding requirements from the last inspection? Yes  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 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 Description 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 Description Timescale for action 1 20 13 Where medication is 31/03/2009 administered with food, evidence must be provided of discussion and agreement by a multi disciplinary team that this is in the best interests of people. This is make sure that medication is administered safely and in the best interests of the person. 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 6 6 Systems for review of care plans should be monitored to check that this is being done regularly. Monthly review forms should indicate whether there are any changes to needs and/or progress towards meeting the goals identified. Review documentation in relation to locking or access to front and rear doors of home in respect of the Deprivation 3 7 of Liberty Act, and hold best interests meetings if appropriate. 4 5 6 7 8 9 20 20 22 22 All people who experience epilepsy should have risk assessments in place. A signature list of staff administering medication should be kept in the medication cabinet. The temperature of the medication cabinet should be monitored and recorded. A record should be kept of any concerns expressed to the home and action taken as a result. When two staff are involved in the use of physical intervention, we should be informed. Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. - 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!