Inspection on 17/04/09 for Sheridan House

This inspection was carried out on 17th April 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sheridan House 30/05/08

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 10/07/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Sheridan House Sheridan House 8 Bedford Road Sandy Bedfordshire SG19 1EL     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: 1 7 0 4 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 30 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 30 Information about the care home Name of care home: Address: Sheridan House 8 Bedford Road Sheridan House Sandy Bedfordshire SG19 1EL 01707332244 01707332255 ngrauwiler@brookdalecare.co.uk 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) : Brookdale Healthcare Limited care home 9 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 9 The maximum number of service users who can be accommodated is 9 The registered person may provide the following categories of service only: Care Home only - Code 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 - Code LD Date of last inspection Brief description of the care home The home is situated in the village of Sandy and is in close proximity to local community amenities. The service is owned by Brookdale and was registered on the 20th of March 2008. The home currently has 6 people using the service but can accommodate a maximum of 9 people. The fee structure averages at about £2800 per week. This information was provided from records on the day of the inspection. Care Homes for Adults (18-65 years) Page 4 of 30 Care Homes for Adults (18-65 years) Page 5 of 30 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 key inspection undertaken on the 20th of April 2009 by Andrea James. The acting manager was present for the duration of the visit which lasted for 6.5 hours. This was the second inspection undertaken since the service was opened in 2008. The purpose of the inspection was to undertake a key inspection and to follow up on the requirements made at the last key inspection. The inspection followed a case tracking methodology where a sample of people were randomly selected. These peoples files were inspected in detail and their key workers interviewed where possible. The AQAA ( Annual Quality Assurance Assessment) tool was also used in assessing the standard of care people receive in the service. Care Homes for Adults (18-65 years) Page 6 of 30 Observation of care practices and communication between the people who use the service and the staff team was also undertaken in this inspection. What the care home does well: What has improved since the last inspection? What they could do better: The service should ensure that people have Health Action Plans that accurately reflects their medical needs. The Health and Safety within the home should be reviewed to ensure all areas of the environment protects people from trips and falls or the potential of burns. Fire risk assessments should also be reviewed to ensure it reflects the needs of people in the event of a fire. Controlled drugs facilities should be implemented in line with the homes own policies and procedures for administering and storage of controlled drugs. The providers should submit an application to the Commission for the acting manager to be registered. Care Homes for Adults (18-65 years) Page 8 of 30 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 30 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 30 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. Systems were in place to ensure prospective people have the information they needed to make informed choices about the service and assessments were undertaken to ensure peoples needs were identified. Evidence: People who use the service received sufficient information in order to make informed choices. This information was contained in their Statement of Purpose and Service User Guides. The information provided suggested people were encouraged to be integrated within the community by accessing local facilities. We were told that all potential users undergo a full pre-admission assessment which was carried out by psychologists, psychiatrists and speech and language therapist as well as the manager of the home. On inspecting these documents The service had an overarching care plan which identified the needs of people, detailed the care intervention required and showed that people and or their relatives were consulted in putting the information together.Areas identified included strengths and weaknesses, Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: mental health etc. The documents seen were very clear in identifying the intervention of the staff team. The service ensured all people who use the service received a Mental Health Capacity Assessment and where needed a Deprivation Assessment was also undertaken. We were told from the Annual Quality Assurance Assessment (AQAA) tool that transition programs for all potential people who use the service was actively encouraged. During these visits the potential person and their families were permitted to meet at the start and encouraged to ask questions. All people who use the service have other contractual agreements in place which was signed and dated appropriately. Care Homes for Adults (18-65 years) Page 12 of 30 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. People who use the service are empowered to make decisions about their lives and as a result their personal goals are reflected in the way that they live. Evidence: Peoples individual needs and choices were identified and reflected in peoples care plans. On the day of the inspection we case tracked three people who uses the service. The care plans detailed personal information such as guidelines, triggers of behaviour, anxiety, diagnosis etc. A Person Centered approach was also implemented and presented in a pictorial format. The overarching care plan identified the strengths and needs of the person with the support required, their mental health , social, physical, educational, leisure and financial needs. The interventions were clear which would suggest the staff team would be able to provide a consistent standard of care. Individual timetables were also implemented and kept under review as peoples mental state at times would deteriorate. There was also evidence to suggest people were consulted about the interventions to be undertaken on a daily basis. Staff spoken to Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: were able to demonstrate how people were given the opportunity to make decisions about their lives. There were several pictorial information throughout the home that ensured the staff would be able to communicate with the people who use the service effectively. The home had undertaken detailed risk assessments for all the people case tracked and a list of these were in place on the day of the inspection. We counted 31 areas that were risk assessed for people who use the service. The home also carried out mental capacity assessments to ensure people can express all choices in regards to treatment, finance and accommodation. Where capacity was assessed as limited further assessments using the Deprivation of Liberty Safeguards were carried out in consultation with families and care managers. Care Homes for Adults (18-65 years) Page 14 of 30 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. By speaking to people, observing the daily practices of the service and viewing records we found that people received very good opportunities for personal development and their lifestyles maximised their independence. Evidence: People who use the service had opportunities for personal development that was meaningful and balanced for both recreational and educational activities. We were told that people are supported by the staff team to access chosen activities. People were able to access local community resources and undertake a varied range of in-house activities such as drawing, cooking, arts and crafts and painting. People were also encouraged to attend colleges and visit relatives and families on a regular basis. Peoples timetables were used in an active away throughout the day. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The home informed us that they promote the health and well-being of people who use the service in a variety of ways and one of these was the plan and nutritious and varied balanced diets. We observed the weekly menu being displayed in a pictorial format that would ensure people knew what they wanted to eat. It was very commendable to see how the service helps to promote independence and choice by offering alternatives at meal times. The staff who implemented this procedure explained that as well as having the menu displayed pictorially a second copy of the menu was kept in the kitchen and on a daily basis people were shown these in order to make choices. This form of communication was also used for people who had obsessive behaviours of wanting to enter the kitchen at inappropriate times. People were also encouraged to prepare meals and purchase the ingredients. On the day of the inspection one person was preparing to make rock cakes as his cooking activity. Care Homes for Adults (18-65 years) Page 16 of 30 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 health-care support provided to people was of a satisfactory standard, but further development was needed to ensure medication procedures are reflected in the service and Health Action plans are implemented in order to meet the medical needs of people who use the service. Evidence: The personal and health care support needs for people were recorded in care plan documentation. The people using the service require a lot of support and assistance in order to meet their personal and hygienic needs. In most cases people require one-toone assistance and verbal prompts. Staff spoken to said they were aware of peoples privacy and dignity and independence while undertaking personal care. This was demonstrated in the way the staff communicated with people throughout the day. However for two people this was not maintained. One person was seen walking around the home with nothing on but a dressing gown that was held together with a clothes peg. We were informed that this persons mental health had deteriorated and she had refused to wear any clothes at all until recently she agreed to the dressing gown. The home was keen to work with her through her illness and was confident that she was Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: getting better. We were told that external professional meetings were held in ensuring this persons best interests are maintained. Another person had repeatedly removed curtains and other forms of window protection and as a result was opened to having his dignity compromised as he could be seen by neighbours when using his bedroom. We were told that people were supported to access all health-care resources as and when required, there was evidence that people had access to general practitioners, chiropodist, opticians, hairdressers, therapists, psychologists etc. The home had made efforts in recording the health-care needs of people but further development was needed as Health Action Plans were not yet implemented for people being case tracked. This was a requirement made in the last inspection report. The service had implemented new policies and procedures for the safe receiving, recording and administration of medication to include PRN. They had made improvements since the last visit where some discrepancies were identified in regards to the original instructions written on Medication Administration Records (MARS). On the day of the inspection we found that medication stocks and records are satisfactorily maintained. The home needs to provide satisfactory control drug storage facilities, in line with their medication policies, although at the time they did not have any person on controlled drug medication. We were told that all staff received training before being allowed to administer medication. On the day of the inspection 11 staff have been deemed as competent to administer medication. Medication records suggested monthly audits were undertaken in order to ensure satisfactory stocks are in the home at all times. The people who use the service were unable to self- Medicate due to their diagnosis and therefore have had Mental Capacity Assessments completed to identify and support this fact. Care Homes for Adults (18-65 years) Page 18 of 30 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 complaints and protection procedures in place ensured people were safeguarded and their views would be acted upon. Evidence: People who use the service had satisfactory policies and procedures in place to be able to make a complaint if the were not happy. The complaints procedure was also displayed in the communal areas around the home. They were displayed in a pictorial and suitable format to meet the needs of people. Since the last inspection the home received three complements from relatives and visitors and one complaint. We were made aware of this one complaint and recorded evidence suggested the home followed their policies and procedures to ensure people were protected. The service told us in their Annual Quality Assurance Assessment that they also listen to people through the use of augmented questionnaires, one-to-one sessions and discovery groups as they found this was the best way of assessing and reviewing anything that people were not happy with. Since the last inspection the home made one safeguarding referral which was satisfactory in protecting the people who use the service. They told us that all staff are trained in safeguarding adults procedure. This was confirmed by speaking to some members of the staff team and on inspection of the training records. Care Homes for Adults (18-65 years) Page 19 of 30 Care Homes for Adults (18-65 years) Page 20 of 30 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 who use the service live in a comfortable environment that was clean and hygienic and promoted their independence. Evidence: The home was warm and welcoming and people appeared happy and comfortable in their environment. It was bright with modern fixtures and the walls were decorated with craft undertaken by people using the service. All the bedrooms were decorated to meet individual peoples needs and people were seen accessing their bedrooms at different intervals throughout the day. Some peoples bedrooms appeared basic in nature but this was again the choice of the individual. The manager explained for example that one person would remove all furnishings pictures and other items from his room which clearly shows how he liked his room to be. This person would remove any curtains or protection from the window and so the home found it difficult to ensure his privacy could be maintained. We were informed that the home had a cleaning schedule that ensured peoples rooms and communal areas were kept clean at all times. One person took pride in mopping the communal flooring. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: On the day of the inspection we identified areas in the home namely the kitchen and bathrooms dispensed water that was in excess of 43 degrees which could cause harm to people using the service. The manager reported this to the maintenance department in an attempt to prevent harm to people. We were also concerned that the side door leading to the back garden failed to have any stability in regards to hand rails for people accessing the garden. This was highlighted in the previous inspection report and remains a concern as some people are unstable on their legs. Care Homes for Adults (18-65 years) Page 22 of 30 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. People who use the service benefits from a competent, experienced and trained staff team that provides a good standard of service delivery. Evidence: The staff team appeared competent and experienced in meeting the needs of the people who use the service. We were told that all the staff team have experience of working with people who have Autistic Spectrum Disorders and Learning Disabilities. On the day of the inspection each person had a one to one staffing ratio. The staff spoken to appeared knowledgeable about the needs of the people who use the service. We were able to sit in on a staff handover and the staff showed that they had the ability to communicate the needs of people in a positive and effective way. We were told in the AQAA tool that the home employed 19 staff members. From the information we saw staff received extensive specialist training in areas such as ASD (Autistic Spectrum Disorder), Communication, interventions to manage challenging behaviour etc. Training and development files inspected were able to confirm this information and suggested staff also received training in prevention and control of infection, food safety and nutrition, health and safety at work, management of money, privacy and dignity to name a few. The information we received showed that all 19 Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: staff completed their induction training which was recommended by TOPSS. 9 care staff also received their NVQ level 2 or above in care or Health and Social Care. One staff spoken to said the training is good another said the training here is second to none. Some staff said they were also able to submit proposals for future training needs. The recruitment procedures inspected suggested people were protected. we inspected 5 care staff files in detail and found that they had satisfactory clearances, application forms and references in place. Staff spoken to were able to confirm that they undergo a full recruitment procedure before being employed in the home. Staff spoken to said they received regular supervision and appraisals. we were able to confirm this by seeing evidence of the supervision records inspected on file. we also saw evidence that the staff team had regular staff meetings and the communication between the manager and staff was effective in meeting the needs of people who use the service. Members of the team interviewed to include new staff members explained that they felt people were getting a very good standard of care. Care Homes for Adults (18-65 years) Page 24 of 30 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 was well managed but further development was needed to ensure procedures are reviewed people are not at risk of scalds, trips or falls as a result peoples safety could be compromised. Evidence: The acting manager of the service appeared knowledgeable about the needs of people who use the service, she had a clear vision for the future of the service and was able to ensure the staff team is empowered to deliver good care to the people who uses the service. We have been informed that the registered manager was not returning to work after a long maternity leave and as a result the acting manager was due to submit an application to the Commission to be registered for this service. The acting manager is qualified to manage the service and was already registered to manager another service in the past. She was also due to embarked on an NVQ level 3/4 in Autism which is being piloted for England and has plans to undertake a NCFE (National Certificate for Further Education) in Learning Disabilities. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: Staff spoken to said the manager is approachable and communicates well with the team. This was evidenced on the day of the site visit, as care staff often spoke with the manager to make decisions throughout the day. The home had several policies and procedures that were generated corporately and at times did not accurately reflect the service or the needs of people who uses the service. Some of the policies were also dated 2007 and did not show how or when they would be reviewed. The home had procedures in place to ensure all staff signed to say that they had read these policies. The service had developed their Quality Assurance policy and procedures. In April 2009 questionnaires were issued to people who use the service and these were completed with the support from the staff team. Response to questionnaires were also received from relatives but the results had not yet been anaylsed and we discussed with the manager how this could be done. The homes health and safety policy was in place and staff members knew the principles that ensures peoples safety is maintained. The fire records seen needed further development to ensure they are clear and coherent. The records seen suggested tests for fire were undertaken,weekly fire audits recorded but the information was not presented in a measurable way. The home also failed to have a fire risk assessment that was up to date and reflected the needs of the service. We saw evidence that one was undertaken in 2007 prior to the home being open and nothing has been done since. We also found that some areas of the home accessible by people who use the service had excessively hot water being dispensed from the hot water taps. The manager had informed the engineer on the day of the inspection. Records of all hot water were kept in the home and the water temperatures in people rooms were checked and found to be of a satisfactory level. ( See the environmental section of this report). We were also concerned about the door leading to the back garden that the steps were too steep and failed to have hand rails for people to hold on to which could put people at risk when accessing the garden from this door. This was identified in the last inspection undertaken in 2008 and a requirement was made but had not been met. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 (4) (b) All activities undertaken by 30/07/2008 the people who live at the home and that pose a risk to health or safety must have a risk assessment. Current accurate health action plans must be implemented as an active part of the users care plans. 30/07/2008 2 19 12 (1) (a) 3 24 13 (4) (a) Environmental risk 30/07/2008 assessments must be undertaken to ensure the safety of the users when accessing areas of the home. The privacy and dignity of people must be maintained by ensuring suitable coverings are placed at people?s windows. 30/08/2008 4 27 12 (4) (a) Care Homes for Adults (18-65 years) Page 27 of 30 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 18 12 Arrangements must be made to ensure the staff team are able to provide flexible personal support that maximises peoples privacy and dignity. To ensure people receive care and support in the way that they require. 30/05/2009 2 19 13 Arrangements must be made to ensure a Health Action plan is in place for people using the service. To promote the health and welfare of people who use the service. 30/05/2009 3 42 13 Arrangements must be made to ensure the hot water being used in the home are at a safe temperature. To protect people from scalds and burns. 30/05/2009 Care Homes for Adults (18-65 years) Page 28 of 30 4 43 8 The registered provider must appoint an individual to manager the care home by submitting an application to the Commission. To ensure the smooth running of the home. 30/05/2009 5 43 13 Arrangements must be made to ensure an up to date fire risk assessment is in place that identifies the potential risk of fire throughout the home. To protect people who use the service from potential risk of death by fire. 30/05/2009 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 2 3 20 39 40 You should ensure that facilities for locking controlled drugs are available. The views of people should be collated and published as a form of quality assurance procedures. A review of all policies and procedures should be undertaken to ensure they reflect the service provided and are up to date. Care Homes for Adults (18-65 years) Page 29 of 30 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. 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