Inspection on 13/03/09 for Southernwood

This inspection was carried out on 13th March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southernwood 20/02/08

Southernwood 04/12/06

Southernwood 20/06/05

Southernwood 12/04/05

Southernwood 30/09/04

Southernwood 20/04/04

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Hillview Farm

Dalewood Respite Care

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Fairways

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Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Southernwood 148 Plantation Road Amersham Bucks HP6 6JG     The quality rating for this care home is:   two star good 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: Suzanne Magnier     Date: 1 3 0 3 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 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Southernwood 148 Plantation Road Amersham Bucks HP6 6JG 01494721607 01494721607 h3m069stringer@mencap.org.uk www.mencap.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Royal Mencap Society care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximumnumber of service users who can be accommodated is: 6 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 Southernwood is a purpose built home, registered to provide accommodation for up to six adults with learning and physical disabilities. Each person living at the home has considerable care needs. The home is staffed by Mencap and is within a mile or so of local shops, and the towns of Amersham and High Wycombe are a few miles away. The home is not directly accessible by public transport. The home provides single bedroom accommodation with rooms of a good size, personalised and decorated to individual tastes and interests. There are lounge and conservatory areas and a combined kitchen Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 6 Brief description of the care home dining room. The home has two bathrooms with all necessary adaptations and lifting equipment. There is an enclosed garden that can be accessed through patio doors leading from the conservatory. All of the facilities are on the ground floor with just the office and staff bathroom on the first floor. There is parking at the side of the building. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This inspection of the care home was an unannounced Key Inspection and some additional standards were assessed and have been included within the report. Following the previous key inspection on the 20th February 2008 and the 3rd March 2008 the service has met all the requirements made. Ms S Magnier Regulation Inspector carried out this inspection and the registered manager represented the service. For the purpose of the report the individuals using the service are referred to as individuals or people. Care Homes for Adults (18-65 years) Page 6 of 29 The home had submitted the Annual Quality Assurance Assessment AQAA prior to the inspection, which was well written to inform the commission about the service and some details of document have been added to the report. The inspector arrived at the service at 07.30 and was in the home for eight hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. During the site visit the inspector gave the registered manager pictorial comment cards for the individuals living at the home which could be completed with them by family members, friends or staff. Written comments were received by the commission all of which were favourable and stated that individuals living at Southernwood were well cared for and staff support people well. The inspector spent time talking and observing the staff members and individuals in order to gain their views and opinions about the service. The inspector looked at how well the service was meeting standards and has in this report made judgments about the standard of the service. Documents sampled prior and during the inspection included the homes Annual Quality Assurance Assessment AQAA, care and person centred plans, risk assessments, medication procedures, staff files, a variety of training records, health and safety records and several of the organisations policies and procedures including the complaints and safeguarding procedures. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, it is considered that the home continues to be able to provide a service that meets the needs of people who have diverse religious, racial or cultural needs. The final part of the inspection was spent giving feedback to the registered manager about the findings of the visit. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 8 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission and assessment procedures ensure that peoples needs are appropriately identified. Evidence: The registered manager said that no individuals had been admitted to the home since the last inspection. The AQAA states that the homes policies are good and that robust assessments would be documented by a qualified person to ensure that the needs of the individual could be met by the homes staff before they are admitted to the home. In order to promote peoples rights of choice the person would be supported to visit the home, meet with other individuals living at the home, share a meal time and have an overnight stay if they chose to prior to moving into the home. Care Homes for Adults (18-65 years) Page 10 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The support and personal care that people receive is based on their individual needs set out in their care plans. Monitoring of risk assessments is not currently well managed to ensure the safety of individuals. Peoples rights to dignity and confidentiality must be maintained at all times. Evidence: Following the previous site visit the homes staff have improved the standard of the care plans and have met the requirement made. Two care plans were sampled and it was evident that the plans were well written to allow the reader to gain an overview of the persons medical, emotional, sensory, social and lifestyle preferences. The homes staff had commenced to introduce person centred plans which evidenced that individuals were involved in the content of the plans and had been encouraged to maintain an interest and where possible sign the plans. Within peoples rooms it was observed that the staff had developed with each resident interesting and stimulating circles of life collages which included family and friends involvement. Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: The care plans indicated that people have a keyworker and there was evidence that the persons keyworker had ongoing inviolvement in the persons plan of care and their welfare. The homes staff promote peoples rights to have their opinions and concerns listenned to and work hard to promote advocacy both within and outside of the home, with the inclusion of peoples family, friends and other health care professionals. The care plans included risk assessments. The assessments were discussed with the registered manager and it was agreed that those sampled did not reflect fully the hazards in an individuals life, the actions that staff or the individuals representative should take in order to minimise the risk. Some were not current and had not been monitored to consistently promote the individuals safety and wellbeing. The registered manager had identified the shortfall was a priority. It has been required that all risk assessments must be reviewed, monitored and updated when necessary in order to promote the safety and wellbeing of the individual. It was observed that individuals were able to have choice and independence in their lives through staying in bed to have a lie in and being offered choices at the breakfast time in order to promote their rights to autonomy, independence and choice. The daily records maintained by staff were well documented and professionally written to detail the twenty four hour period in the persons life. Whilst touring the premises it was observed that there was awareness of peoples rights to confidentiality of their information as documentation was stored either in peoples bedrooms or within the office however it was noted that some information regarding individuals support at meal times, fluid charts and dietary needs were displayed on the kitchen notice boards. It has been recommended that this practice be reviewed in order to further promote peoples rights to privacy and confidentiality. Care Homes for Adults (18-65 years) Page 12 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are able to exercise choice in their daily lives, maintain bonds with family and friends and take part in social, cultural, religious and recreational activities. Individuals are encouraged to be involved in the running of the home and maintaining their daily living skills. A choice of a healthy diet is provided. Evidence: Throughout the inspection it was observed that individuals were comfortable and settled in their surroundings and the staff on duty were attentive to the needs of each individual. There was evidence in the home that people are encouraged to take part in meaningful and purposeful engagements which include aromatherapy, going on holidays, visits to London and Blackpool, going to the pub, staying with relatives, Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: taking part in day service activities, supporting staff with the homes recruitment and continuing to be present within the local community. The homes staff are engaged in working alongside the local day centres in order to promote the safety and well being of the individuals attending the centres and it was evident that any issues arising are promptly dealt with by staff in order to ensure the well being of the individual attending the centres. It was observed that individuals can have choice about their lives as one individual had decided to rest on the sofa from the early hours of the morning, objects of reference and security were seen with individuals and music that was meaningfull to individuals was played during breakfast. The AQAA advises that one person has requested to move closer to their family and to live more independantly and during the inspection it was observed that one individual went with a member of staff to the local town centre to do shopping for a special familiy occassion. Individuals culture and ethnicity is promoted and it was observed that individuals were supported by staff to wear clothes, have hair styles and foot wear which was in fashion and supported the individual to have a good sense about their own individuality and esteem. It was noted that peoples rooms were locked when they were not at home and all reisdents have keys to their rooms in order to protect their belongings and promote their right to privacy. There was evidence that family and friends are involved in the lives of residents and staff work alongside peoples friends and family for the best interest of the residents. Peoples bedrooms contained family photos and personal items which involved their inclusion in family life. Records confirmed that regular one to one support is provided by the individuals keyworker in order to seek the persons views about their home and to listen and act upon the feedback given. Although people supported at Southernwood have complex communication staff were observed to understand and have knowledge of the individuals way of communicating and to respond accordingly. Within the kitchen it was noted was a large perpex covered picture which contained pictures of a variety of foods and sweets. The registered manager said that the picture Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: is used as a prompt for people to point to the picture of what they would like to eat. It was observed that individuals were given choice at the breakfast meal time and residents sat in the kitchen at the large dining table. The staff promote individuals choice so that meals can be taken by individuals at different times and in different places within the home. The home promotes healthy eating and it was evident through looking at documents that dieticians and speech and language therapists were involved in the dietary and special needs of individuals to promote their safety and welfare at meal times. Nutritional, eating and drinking risk assessments and a nutritional screening tools with regualr body weight charts were kept within the persons care plans in order to ensure the well being and safety of individuals and which were sampled by the inspector. Care Homes for Adults (18-65 years) Page 15 of 29 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. Peoples care plans were up to date and the provision of personal care and support were well documented. Peoples health care needs are well met. Medication is administered in way that protects the individual and promotes their safety and well being. Evidence: The staff team consist of a multi racial mixed gender staff group. Gender specfic care and support is provided and staff demonstrated awareness of peoples individual preferences. It was observed that staff supported individuals in a sensitive way ensuring their privacy is respected when providing assistance with personal care and individuals responded favourably to staff. Individual care plans documented how the individual liked to receive care and support from staff and it was noted that staff were sensetive and aware with regard to peoples sensory impairments for example specfic areosols aromas were used to support an individual in their daily lives with each differing aroma meaning a specfic activity. The inspector was told that this way of communicating with the individual had helped them Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: to have more control over their life and had decreased their level of anxiety and helps to make their daily life more predictable. The care plans and health care reports have been well maintained and included records of attended health care appointments which included visits to the individuals general practitioner, appointments with the dietcian, continence advisors, mobility specialists, speech and language therapists, occupational therapists, dentists, visits by care managers and other specialist health care personnel. The daily records completed by staff were well written and contained good evidence of the care and emotional support provided by staff over a twenty four hour period and the monitoring of any health related concerns. Through sampling care plans and observation it was evident that the home maintains good working partnerships with health care professionals. Medication cupboards are located in a safe and secure area within the individuals bedroom and a monitored dosage system remains in place. Procedures regarding the safe handling, administration and disposal of medicines have been maintained. In discussion with the registered manager it was agreed that the procedures could be improved to support the residents and staff to save time in the busy periods of the day with regard to the administration of medicines. The homes medication policy and procedure was robust and medication administration charts were well recorded and demonstrated the way the person preferred to take their medicines, the side effects, purpose of the medicine and the individuals photo and any known allergies were available within the records sampled. No controlled medicines are currently prescribed or stored within the home. Staff confirmed that individuals have the right to refuse to take their medicines and the procedures for reporting of the event, they also confirmed that where possible, and following the completion of a robust risk assessment, individuals rights to independence regarding taking their own medication would be promoted. The inspector observed a staff member administering medicines. The procedures were unrushed and methodical to ensure the safety of the individuals receiving their prescribed medicines. Care Homes for Adults (18-65 years) Page 17 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes complaints procedure is an accurate document for individuals to express any concerns or complaints. Individuals are protected from abuse and harm by the homes policies and procedures and all staff have received safeguarding vulnerable adults training to ensure that all persons are safeguarded from abuse or harm. Evidence: The home has a clear complaints policy and procedure which is available within the home for individuals or any person associated to the home to see in order that their views, opinions and complaints are recognised and acted upon. It was evident during the site visit that the best interests of individuals is strongly promoted by the staff in order that ensure that people being supported have a voice and that their views and opinions are considered. The registered manager confirmed that no complaints have been received by the home and no complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. The registered manager demonstrated that they were aware of the local authorities multi agency procedures for safeguarding adults and confirmed that no referrals had been made to the local authority safeguarding team. The home has a whistle blowing policy and procedure, which is available to staff in order to safeguard individuals in their care. The home have the current multi agency safeguarding procedures within Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: the home. Records confirmed that all care staff had received safeguarding vulnerable adults training to ensure that individuals living at the home are proteceted from harm and abuse. Care Homes for Adults (18-65 years) Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All areas of the home are clean yet improvements need to be made regarding the control of infection in the home and the improved services with regard to repairs and maintenance to promote the safety and well being of all people in the home. Evidence: During the tour of the premises the inspector observed that the home was fairly well maintained and following the previous inspection the organisation have secured the service of a cleaning company who visit the home every two weeks to undertake a cleaning programme. It was noted that there was no malodour in the home during the site vist. There were various areas in the home that were considered below the expected standard which included two broken toilet seats, tiles missing in the bathroom, the windows in some bedrooms were not secure and require a better standard of locks and double glazing, areas in the home were poorly decorated and trailing electric flexes were not secured in the lounge. These shortfalls were brought to the registered managers attention and he assured that improvements had been made since the previous inspection with the staff incorporating some cleaning activities within their shift. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: It was observed that staff did not observe safe methods of the control of infection in the home for example not wearing protective clothing in the kitchen when preparing meals, lack of robust procedures for the clinical waste, soiled laundry left on the floor in the bathroom and not consistently wearing protective clothing when supporting people with personal care. It has been required that arrangements be made to ensure that the control of infection in the home is improved and the maintainence of the home is consistent in order to ensure the wellbeing and safety of all persons in the home. Care Homes for Adults (18-65 years) Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes staff provide twenty four hour support to the individuals living at the home. The homes recruitment practices, induction, mandatory training and supervision of staff is consistent to ensure that peoples needs are appropriately and safely met and staff have equal opportunities with regard to their own professional development. Evidence: The homes staff are currently supporting 6 people and have a stable staff team. The level of staffing was observed to meet the needs of the individuals on the day of the site visit however it was noted that the morning routine appeared rushed as the transport for the day services had arrived earlier than anticipated. As previously documented the homes staff were observed as skilled in supporting individuals in their care and were knowledgeable regarding the specific needs of individuals to ensure their safety, well being and offer reassurance. The home has a recruitment and selection policy, which incorporates equal opportunities. The inspector sampled two care staff files which were well recorded and contained application forms, with two references, evidence that face to face interviews Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: had taken place and the job description in order that the staff member was clear about their roles and responsibilities. There was documented evidence that a CRB clearance had been obtained. The care staff mandatory and induction training records evidenced that staff had received updated training and had also undertaken specialised training in order to support the needs of the individuals in their care. The AQAA identifies that over 50 per cent of staff have achieved their National Vocational Qualification in Care awards in level 2 or 3. The care staff records evidenced that they are formally supervised by the registerd manager and staff confirmed that they felt supported by the manager on a day to day basis. Care Homes for Adults (18-65 years) Page 23 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is robust and the home continues to be run in the best interests of the individuals and their views and opinions and those of others associated with the home are sought. Individuals welfare is generally promoted through monitoring of health and safety in the home. Evidence: As documented within the report it was evident through observation that the pace of the home continues to be designed to meet the needs of the individuals and the care staff present during the site visit demonstrated a good knowledge about individuals in the home to ensure their safety and well being. The home has a registered manager who has been in post for several years. Staff confirmed that the manager conducted the home in the best interests of the individulas and offered an open and inclusive style of management. The registered Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: manager undertook their duties in a professional and calm manner and was very knowledgeable about the running of the home to benefit the people being supported and the staff. The management of files and related documents were well established and orderly. Accident and incident records were sampled. The registered manager was reminded of the homes responsibility in giving notice to the commission without delay regarding any event, which affects the safety and welfare of the supported people. Hand washing facilities remain available throughout the home. Records indicated that servicing of fire equipment had taken place and health and safety checks had been undertaken and recorded. A current insurance indemnity, gas and electric certification was sampled and the current certificate of registration of the home displayed. Confirmation was seen that the home continues to seek residents and their representatives views and opinions about the service through the Quality Assurance procedures. All substances which are hazardous were stored in compliance with the control of substances hazardous to health COSHH legislation in order to ensure the safety and welfare of residents. Care Homes for Adults (18-65 years) Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 13 Arrangements must be made to ensure that the control of infection in the home is improved and the maintainence of the home is consistent. In order to ensure the wellbeing and safety of all persons in the home. Arrangements must be made to ensure that individuals risk assessments are updated to reflect the hazard being assessed, detail the measures in place to reduce the hazard and are monitored and updated when necessary. In order to promote and ensure the safety and well being of the individual. 08/06/2009 2 9 13 11/05/2009 3 30 13 Arrangements must be made to ensure that the control of infection in the home is improved and the 08/06/2009 Care Homes for Adults (18-65 years) Page 27 of 29 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 maintainence of the home is consistent. In order to ensure the wellbeing and safety of all persons in the home. 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 10 It is recommended that individuals information in the kitchen area of the home be reviewed in order to further promote peoples rights to privacy and confidentiality. Care Homes for Adults (18-65 years) Page 28 of 29 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 29 of 29 - 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!