Inspection on 08/01/09 for Spion Kop Care Home

This inspection was carried out on 8th January 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

Spion Kop Care Home 14/01/08

Spion Kop Care Home 24/09/07

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Spion Kop Care Home 72 - 74 Park Lane Pinxton Nottinghamshire NG16 6PS     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: Bridgette Hill     Date: 0 8 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 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.csci.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: Spion Kop Care Home 72 - 74 Park Lane Pinxton Nottinghamshire NG16 6PS 01773862813 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs June Thorpe Type of registration: Number of places registered: Pauline Waddoups care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 6 The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Male Whose primary care needs on admission to the home are within the following category: Mental disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Spion Kop is large converted house situated on the outskirts of Pinxton. It is registered to accept 6 service users aged 18 – 65. The service has chosen to accept only male service users as detailed in the Statement of Purpose. The home is not registered to give nursing care. Service users are accommodated in single bedrooms, three of which have an en suite bathroom. The home is of a domestic style and has a large lounge with a snooker table in it and a separate dining area. The fees charged at the home are 6 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home £760.00 - £982.00 per week, this does not include hairdressing and chiropody. An information pack is made available to each service user in their bedroom. 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: 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: This inspection was an unannounced one. The purpose of this inspection was to assess all key standards and compliance to previously listed requirements. The Inspector was accompanied for part of the Inspection by an Expert by experience Rebecca Shaw. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Various records including care planning records were examined the findings are recorded in the body of this report. Discussions were held with residents, relatives, staff and visiting professionals during the visit. Care Homes for Adults (18-65 years) Page 6 of 30 An Annual Quality Assurance Assessment was completed by the Manager of the home prior to the visit and where relevant the content has been included in the body of this report. Surveys were also sent to service users. Relatives and staff. Where these were returned these have also been considered and included as part of the evidence when assessing the home. The Manager June Thorpe was on duty during the inspection and the owner Pauline Waddoups was available throughout the day. What the care home does well: What has improved since the last inspection? What they could do better: There is scope to improve the recording of identified needs in care plans. General terms such as schizophrenia are used however the care plans do not define how this affects the residents as individuals. All prescribed medications should be recorded on the medication administration records even if they are administered by external healthcare professionals. There are parts of the building such as the lounge which needs redecorating and the bathroom carpet requires replacement to ensure the home is maintained to a comfortable standard. Residents were not happy with the smoking lounge so consideration should be given to Care Homes for Adults (18-65 years) Page 8 of 30 look at if this can be improved. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 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. There are arrangements in place prior to admission to ensure that people are assessed and the home has information to ensure peoples needs will be met. Evidence: The Annual Quality Assurance Assessment told us that prospective residents were invited to spend a day at the home and that trial visits were offered with each prospective resident being fully assessed prior to admission to ensure their needs could be met at the home. The surveys from residents also confirmed that residents told us they had enough information on the home before moving in. One care record for a recently admitted resident confirmed to us that an assessment had been completed at the place where the resident was prior to being admitted to the home. The assessments we looked at also considered any risk factors evident and information from previous placements and other professionals were held on file. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: The expert by experience talked to some residents about when they moved into the home. This confirmed that residents had visited the home before moving in and had contracts in place to tell what to expect of their stay. The terms and conditions contracts were viewed in residents files. Residents all commented that they had no choice on moving to the home in the first place or where they moved onto if they needed to. I had no choice in coming here and No choice on where I move on to. This appeared to be due the lack of appropriate residential homes in the area which restricted choice. All the residents said it would be worth having more similar homes to this one and that they all told us they felt lucky to be residents here rather than anywhere else. Residents told us I have been in 6 or 7 care homes and this is the best. Another comment summed up all the residents views as the home being a much wanted place to be. 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. There are sufficient care plans and risk assessments in place with scope for improved personalisation to ensure the care delivered to residents is person centred. Evidence: We looked at 2 care files to assess how staff were recording peoples care needs and where possible the Expert by Experience spoke to people to ask residents their views on the home. The Annual Quality Assurance Assessment told us that all service users are involved in care planning and service users are encouraged to make their own decisions. Residents told the Expert by Experience that they had been involved in deciding their own care plan although some did not want a copy. Residents commented how their care plans were discussed jointly with them and how plans were finally agreed giving them the final choice. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: Residents told us about their care Anything I want I ask for I get it. Never been refused anything yet. I keep my requests within reason and I dont want a copy of my care plan as I get everything I need, anything I dont have or need I just ask. One relative survey told us that that they feel the care home meets the residents needs with no improvements needed. The care plans we looked at appeared to cover all the residents assessed needs however the description of areas of needs were not always individualised to how they affected residents. An example of this is that general terms such as schizophrenia was used as an assessed needs but there was not sufficient detail of how this condition affected the residents or what was the indicators to look for to tell staff that the residents mental health was potentially worsening. Risk assessments were documented in care plans and supported by plans of care. Where restrictions were in place for example the banning of alcohol in the home residents had signed that they had understood this. A key worker system was in place with staff have particular responsibility for some residents although all staff worked at different times with every resident equally. There were reviews held of care plans but the dates varied for each care plan and there did not appear to be a regular time frequency for this although all had been reviewed within acceptable timescales. One care plan included that the chiropodist was seen 6 weekly but this was not arranged and on discussion with the Manager was not actually required. Staff recorded progress logs each shifts. These were well completed and gave an overview of how the residents spent their time and how they had been on that particular day. Some residents fully managed their own finances and for other residents there ad been help given to establish some budgetary control with residents having an agreed amount of money each day to ensure the money was well managed. There appeared to flexible and individual routines in the home which allowed residents to choose how they lived their life. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents in the home enjoy varied lifestyles with flexible routines and are regarded as individuals to ensure their needs are met Evidence: The Annual Quality Assurance Assessment told us that a local community group are used by 1 service user and all service users use local buses or trains. We were told some service users go out with their families, there is open visiting, service users have the key to their bedrooms, service users have been on 2 holidays and meals are discussed at the monthly meetings. The expert by experience found that outings had been enjoyed including bonfire night, Matlock and a planned trip to Chesterfield not so many outings in winter, too cold. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The choice of outings are down to what the residents would like to do and even if only one resident would like to go the outing still goes ahead e.g. a trip to a folk music event. The home produced quarterly newsletters to inform residents about birthdays, events or anything else of significane. Residents told us I like playing dominoes, got a bit of a competition going, I would go to church but cant have the wine, Dont tend to go out prefer to stay in and warm as my feet hurt a lot. Residents told us they feel comfortable in their home that they dont feel the need to go out too much. There is a pool table, piano, sky television and feeding the local horses carrots and apples. Everyone told us they felt able to come and go as they wanted to. Some residents had contact with families either by them visiting the home, phone or by visits to families. Forms had been completed to consult residents about the level of involvement their families had in their care. The Expert by Experience considered that the staff was also promoting independence and where residents can easily manage everyday tasks they are encouraged to do so e.g. making a cup of tea/lunch. We were told by resident that staff will support residents when they go out if they want. The residents told us they dont want to access any education or go to college at present but if they did they know they could ask for support in doing so. One resident told us that Staff encouraged us to go to college if wanted. The home is small and because staff and residents get to know each other really well all needs are individually tailored including food. Staff knew how individual residents like their toast cooking for example and their personal likes and dislikes. One resident told us I dont like the chicken, theyll do a separate meal for me. I can get to know what we are eating but I prefer a surprise, its all good. Independence was also being promoted by the staff and where residents can easily manage everyday tasks they are encouraged to do so e.g. making a cup of tea/lunch. The care records we looked at contained some domestic skill assessments of residents. Care Homes for Adults (18-65 years) Page 16 of 30 Care Homes for Adults (18-65 years) Page 17 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were regarded with respect and their healthcare needs were being met. Medicines are competently handled to ensure residents receive prescribed treatment. Evidence: During the visit the Expert by Experience met 5 of the residents as one had gone out and discussed with them what life was like in the home. The Expert by experience considered that in general privacy is respected by all. We observed staff to knock on residents doors before entering bedrooms. All residents held the key to their bedroom to allow them privacy when in or out of their room. One resident told us the linen cupboard is inside my bedroom which means staff have to come in but staff will always knock before coming in and respect my privacy. This was discussed with the Manager and possible options for relocation are to be considered. The Expert by experience talked to residents about their healthcare and was told All Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: residents are registered with a dentist and the local GP and go to the surgery when they need too, I have my blood tests at the GP I am registered with they are gentle with us. I am registered with a dentist, keep going. He keeps telling me of for not brushing my teeth. I now have a mouthwash. Residents were weighed regularly and records kept to monitor changes. The Annual Quality Assurance Assessment told us that nutritional assessments were completed but none were found in residents files. This was discussed with the Manager who told us that they were completed only if there was felt to be a potential problem with nutrition. The care records we looked at told us that residents healthcare needs were recorded. Residents typically used community-based services and had chosen different opticians or dentists they wished to use. There was some support given to residents by visiting care managers and Community Psychiatric Nurses visited some residents to administer medications. There were clearly documented systems for recording medication received in and staff told us that medications no longer needed were returned to pharmacy and recorded in a book. The records we saw indicated that residents were receiving their medication on a regular basis. Some residents were self medicating and appropriate risk assessments had been completed. There was one medication administration record we looked at which did not detail all medications prescribed as a Community Psychiatric nurse administered one medication. At present the home did not have a dedicated controlled drug storage area however we were informed that a new drug cabinet was on order. The bottom of the drugs cabinet was found to require cleaning. Some care files we looked at had information recorded where people had made decisions about their post death wishes. Care Homes for Adults (18-65 years) Page 19 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. Arrangements are in place to safeguard residents welfare and ensure that their concerns are listened to and acted upon. Evidence: The surveys we received were ticked yes that service users knew who to talk and complaint to if needed. There was a copy of the complaints procedure in the kitchen of the home which was readily accessible for residents and visitors. This gave appropriate timescales for the resolution of complaints. We also looked at the minutes of residents meetings where residents had opportunity to discuss any concerns and the complaints procedure was discussed if residents wanted to raise issues privately. The Annual Quality Assurance Assessment told us that there had not been any complaints received at the home. Since this had been completed there was one complaint recorded in the records at the home. This was regarding the temperature of a residents room and was rectified immediately with a blanket as it was too hot with the heating on and too cold without. The staff records we looked told us that all staff had received Safeguarding Adults training. A whistle blowing policy was also in place to tell staff they could raise concerns if they had any. The home had a range of information available on Safeguarding Adults which included a copy of Derbyshire County Councils procedures Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: should an allegation be made. There had not been any Safeguarding Adults allegations or referrals made in the past according to the Annual Quality Assurance Assessment completed by the home. For some residents small amounts of money was held safely by the manager. A sample check of balances indicated that the records and amounts of money held were the same. Some items of value were also kept but a log of these was not recorded. Care Homes for Adults (18-65 years) Page 21 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. The home is generally well presented and maintained and offers a clean and comfortable environment for the people who live there. Evidence: The home is a converted former domestic house in a quiet village location. There is a bus stop and church nearby with some local shops a short walk into the nearby village. Since our last inspection the home has increased the number of places registered and now offers 6 places. The additional rooms are spacious and have en suite toilets and showers. The Expert by Experience told us that all the residents told us they thought the home was homely. It appeared clean, well decorated, tidy, homely and friendly. Posters were kept to a minimum to maintain a homely atmosphere and avoid it becoming clinical. The residents treated it as their home during the visit coming and going freely. Residents feel can they can do what they wish with their room. One staff survey told us that through conversations with service users they considered residents are happy with the cleanliness of the home. All service users surveys were Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: ticked positively that the home is fresh and clean. We looked at the fire log which told us regular checks were being completed of the fire alarm, drills had been held and extinguishers had been serviced. The fire officer had visited the home in November 2007 where no requirements were made. There was a book in place to record the maintenance of the home and an ongoing redecoration programme was in place. We undertook a general tour of the home and with residents permission looked at some bedrooms. The home was clean and generally well maintained the only deficits which we found were the paper in the lounge was peeling a little and in the bathroom a carpet was fitted which was stained. There was also an odour in the bathroom possibly from the carpet. The only comments were residents wanted improvement was the smoking room. The smoking room is at the rear of the building and was very cold, filled with stale smoke with a painted concrete floor and a few chairs. There is a wall heater but this takes time to heat up and must be turned of each time the room is vacated. Smoking room has no heating. I have to wrap up warm to go in to have a smoke. We looked at the smoke room and whilst it did have a heater this was not left on and took time to heat up. The home has a separate outbuilding where the smoking room and laundry facilities are situated. There was one washer and one dryer with facilities to line dry clothes. Residents were encouraged to be independent and got involved with the laundering of their own clothing. Care Homes for Adults (18-65 years) Page 23 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. Recruitment practices are robustly followed and regular training is offered to ensure staff have the skills to meet residents needs. Evidence: The home has a small group of 6 staff which includes the manager and owner. Between 9.00 and 5.00 there tended to be two staff on duty according to the rota we looked at. In the evenings 1 staff member was on duty with a sleep in member of staff each night. We looked at a sample of two staff files to examine how recruitment standards were being implemented. The records contained all the required checks including references and Criminal records Bureau checks to evidence staff were being safely recruited. The staff files contained contracts of employment, health screening questionnaires and notes from interviews to tell us that the home was implementing good practices. There were training records available for each staff member and a training matrix of what had been completed. There was a good range of training that had been undertaken including mental capacity act, Safeguarding Adults, Moving and handling, Health and Safety, fire safety, coshh, basic food hygiene and three staff had completed Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: first aid training. Some specialist mental health training had also been completed. A skill-based induction record was available and a completed recent copy was seen to indicate that staff were completing these. However the full workbook was not available in the home. The owner of the home is a registered mental health nurse; the manger has recently achieved an National Vocational Qualification level 3 in mental health. Additionally 2 staff have achieved National Vocational Qualification level 2 in care. One more staff member was in the process of registering on a National Vocational Qualification course and one staff member was part way through completion of their National Vocational Qualification. This shows a commitment of the development of staff to ensuring they have the right skills to care for residents. The Expert by Experience found that residents viewed the staff to be good friends providing high quality tailored support. They observed that during the visit it became obvious that everyone working and living in the home were of equal status, respecting and caring for each others wellbeing. One resident told us they were treated as equals. Another resident told us about the staff they are All great, same consistent type of person, might not be highly qualified but staff dont need to be, treat me as equal and as a human being, they make sure we get all our benefits and keep checking. Care Homes for Adults (18-65 years) Page 25 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well-managed one which has significantly developed with systems in place to assess quality and engage residents in the running of the home. Evidence: There have not been any changes in management since our last visit and the manager has demonstrated a commitment to ongoing development and learning by completing their National Vocational Qualification level 3 in mental health and is currently awaiting verification of their work for the registered managers award. The staff files we looked contained regular records of staff supervision and appraisals of staff had been completed. The Annual Quality Assurance Assessment told us that regular residents meetings were held and this was supported by the records we looked at in the home. The meetings were held to look at a range of issues and decisions such as activities and the menus were discussed with residents. The owner of the home although they worked regular Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: shifts at the home completed monthly visit reports and spoke to residents about the home. Surveys of residents and relatives had also been completed with positive feedback on the home being given. There was a range of audits completed to monitor the quality of the home these included a general audit of the home which covered a wide range of areas, medication audits, care plan audits and Health and Safety audits. These all indicated that the standards at the home seemed consistently good. Where accidents had occurred there were reports completed although there had been few accidents. The records detailed what actions had been taken by staff and examined if additional measures to prevent accidents could be explored or implemented. Since our last inspection risk assessments for radiators in the home and legionella had been written. Bacteriological checks on the water had been completed and were satisfactory. Health and Safety records examined on the day were satisfactory, these included fire safety records, accident, incident, water outlet temperatures, systems in place for prevention of legionella, electrical circuit testing and the gas safety certificate. Care Homes for Adults (18-65 years) Page 27 of 30 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 28 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 24 23 The lounge requires redecoration This will ensure the home is maintained and a comfortable place for residents to live 31/03/2009 2 24 23 The flooring in the bathroom 31/03/2009 requires replacement or cleaning This will ensure the home is kept clean and free from odours 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 6 Care plans should be expanded and describe in detail the areas of need for residents to ensure they are individual and personalised fully The drug storage area should be cleaned regularly 2 20 Care Homes for Adults (18-65 years) Page 29 of 30 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. 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