Inspection on 18/12/08 for Springfield Care Home

This inspection was carried out on 18th December 2008.

CSCI found this care home to be providing an Good 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Springfield Care Home 05/07/06

Springfield Care Home 28/02/06

Springfield Care Home 28/07/05

Springfield Care Home 07/03/05

Springfield Care Home 11/11/04

Springfield Care Home 04/03/04

Similar services:

Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Springfield Care Home 45 Grove Road Walthamstow London E17 9BL     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: Robert Cole     Date: 1 8 1 2 2 0 0 8 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 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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 28 Information about the care home Name of care home: Address: Springfield Care Home 45 Grove Road Walthamstow London E17 9BL 02085207429 02085209131 springfieldgroveroad@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Mahendra Pratap Rambojun care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 3 The registered person may provide the following category 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 Springfield Care Home is a residential home providing care and support to three adults with learning disabilities. The home is situated in a residential area of Walthamstow in the London Borough of Waltham Forest, and is close to shops, transport networks and other local amenities. The home is in keeping with other homes in the area. The home is privately run. 3 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 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 took place on the 18/12/08 and was unannounced. The inspector had the opportunity of speaking with both of the service users who currently live at the home. The inspector was also able to have discussions with staff from the home, and the homes manager was present throughout the course of the inspection. The homes proprietor was present at the end of the inspection, when feedback was given and the inspector was able to discuss the requirements made within this report with both the proprietor and manager. The inspection included an examination of records and other documents, and a tour of the premises. Prior to the inspection, the CSCI sent surveys to service users to gain their feedback on the running of the home. Two of these were completed and returned Care Homes for Adults (18-65 years) Page 5 of 28 to the CSCI. The home completed an Annual Quality Assurance Assessment (AQAA) prior to this inspection at the request of the CSCI. All of this has contributed to the overall inspection process, and helped to form judgments made within this report. For part of this inspection an Expert by Experience was used to help gain an insight and understanding of the experiences of people who use this service. As a result of the inspection by the Expert by Experience, they have produced their own report. Some sections from that report have been incorporated in to this report, where this is the case, it is clearly stated. 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.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 7 of 28 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 8 of 28 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. It is the judgment of the inspector that prospective service users are provided with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through written documentation, and the opportunity of visiting the home. Evidence: The home has a Statement of Purpose in place. This states Our overall aim is to provide every service user with the highest possible standards of individualized care within a friendly, homely and supportive environment. Quality of life is paramount and service users rights are safeguarded and respected. The Statement also includes details of the staff team and of the facilities and services provided. The home also as a Service Users Guide. This includes details of the complaints procedure and of the aims and objectives of the home. Both the Guide and the Statement of Purpose have been produced n plain English, and also in audio form to help make them more accessible to service users, helping to meet needs around Care Homes for Adults (18-65 years) Page 9 of 28 Evidence: equality and diversity issues. All new service users are provided with their own copy of these documents. At the last inspection of the service, pre admission assessments were assessed and found to be of a satisfactory standard. As there have been no further new admissions to the home since then, pre admission assessments were not tested as part of this inspection, but will be assessed at the next key inspection of the home. The home has an admissions procedure. This has been reviewed since the last inspection, and is now in line with National Minimum Standards (NMS). This states that service users will have the opportunity of visiting the home before making a decision as to move in or not, and that they will initially move in on a six week trial basis. All service users are provided with an individual written contract/statement of terms and conditions. These have been signed by the service user and the homes manager. Contracts include details of fees payable, and the rights and responsibilities of both parties. Care Homes for Adults (18-65 years) Page 10 of 28 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. It is the inspectors judgment that service users are supported to have as much control over their daily lives as possible, and that they are involved in the day to day running of the home. Evidence: Individual care plans are in place for all service users. These are drawn up with the involvement of the manager, the service user and their keyworker. Service users sign their care plans to indicate their agreement with them and their inclusion in the care planning process. Care plans are subject to regular review, and service users have an annual review meeting in conjunction with their placing authority which feeds in to the care planning process. Plans cover needs around personal care, medication, social and leisure needs and equality and diversity issues for example on relationships. Risk assessments are in place for all service users, and as with care plans these are of a satisfactory standard. Assessments identify any given risks, and include strategies to Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: manage and reduce those risks. There was evidence to indicate that service users are able to take reasonable risks, for instance one service user wanted to attend the Notting Hill carnival with their boyfriend. A risk assessment was drawn up, and the activity took place. Other assessments are in place, for example around healthy eating, and clear individual guidelines are in place on managing any challenging behaviours that service users present. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. As mentioned, one service user is able to access the community independently, while the other requires staff support. On the day of inspection this service user indicated that they wished to visit a local cafe, and this was seen to be facilitated by the staff. Service users informed the inspector that they are able to get up and go to bed as they choose, and choose their own mealtimes etc. The home has taken steps to enable service users to be involved in the day to day running of the home. For example, service users have the opportunity of been involved in the recruitment and selection process for new staff, and monthly service user meetings are held. The inspector examined the minutes of these meetings, which evidenced discussions around menus, activities, and the most recent meetings included discussions on plans for Christmas. The AQAA supplied by the home states that since the previous inspection new flooring has been fitted in some communal areas of the home, and that one bedroom has been decorated. The service user informed the inspector that they were happy with the way their room had been decorated, and were able to choose the colour themselves. The home has a confidentiality policy, which makes clear under what circumstances a confidence may be broken in the health, safety and welfare interests of service users and others. Staff spoken to demonstrated a good understanding of the issues involved around confidentiality. It was noted during the inspection that confidential records relating to one of the service users were stored on a shelf in the homes sitting room. This was brought to the attention of the homes manager, who arranged for this information to be stored securely during the course of the inspection. The report from the Expert by Experience states Regular meetings are held in the home between staff and service users to talk about how they are getting on. The service users also have weekly key-worker sessions, but are free to talk to staff about any issues as and when they need to. Care Homes for Adults (18-65 years) Page 12 of 28 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. It is the inspectors judgment that service users are supported to live valued and fulfilling lives. Service users have regular access to the community, and food was of a satisfactory standard. Evidence: One service user recently had employment working as an office administrator, and achieved an NVQ in office administration. They are actively looking for further employment through the MENCAP job service program. One service user attends college where they study art. On the day of inspection they were visiting an art gallery through this course. They also plan to study computers in the new year, and have their own computer in their bedroom. Service users are involved in various day services. One is a member of Eastsiders, run Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: by MENCAP. This provides the opportunity of various activities, including bowling and a regular Friday night disco. The service user also goes on holidays trough this group, and is planning on going to Butlins in the near future. Another service user attends a music therapy group. Service users have routine access to local community facilities, including cafes, shops, markets, banks and parks. Service users have access to public transport, including trains and buses. One service user visits church weekly, thus helping to meet needs around equality and diversity issues. Service users have access to a variety of activities, both in house and in the community. In house service users have access to satellite television, DVDs, music, puzzles and card games. On the day of inspection the home was preparing for a Christmas party to take place that evening. One service user informed the inspector We are having a Christmas party tonight, I am looking forward to it. In the community the home supports service users to take part in various social and leisure activities, including visits to restaurants, the cinema, swimming and occasional day trips. Service users are supported to go on holidays, one service user said I went on holiday to Majorca with my boyfriend, it was really good. Service users are able to maintain contact with family and friends, and can visit their family for overnight stays. Service users can see visitors at any reasonable time, and can see them in private if they so wish. Service users have access to a telephone, and one service user has their own telephone. Service users are given their own mail to open. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Traditional Jamaican and English dishes feature on the menu, helping to meet needs around equality and diversity issues. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures. The report by the Expert by Experience states Service users have many activities outside the home. The service users are offered food choices to cater for their specific ethnic diets. Care Homes for Adults (18-65 years) Page 14 of 28 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. It is the inspectors judgment that the home is generally meeting the health and personal care needs of service users. Service users have access to health care professionals, and medications are administered and recorded as appropriate. Evidence: Care plans indicated that service users are supported to manage their own personal care as much as possible. Service users are able to choose their own clothes to wear, and all were appropriately dressed on the day of inspection. Health Action Plans are in place for all service users. In the areas that they cover, these are detailed documents clearly setting out how the home can meet the health needs of service users. For example, it has been highlighted that there are concerns around a service users weight, and the action plans details what action needs to be taken, including regular weight checks, monitoring of food intake and referral to GP. There was evidence that all of this has been done. However, the Health Action Plans do not cover all the health needs of service users. For example, one service user has a diagnosis of bi-polar disorder and schizophrenia, yet the Plan makes no reference to Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: this or how the home is able to meet needs around this. In order to help ensure that the health needs of service users are being met in a comprehensive and consistent manner, Health Action Plans must be in place that set out how the home is meeting all the health needs of service users. Service users are registered with a GP, dentists and optician. Records are maintained of medical appointments, including details of any follow up action necessary. These records indicated that service users have access to health care professionals as appropriate, including psychiatrists, chiropodists and dentists. The home has a comprehensive medication policy in place, and all staff undertake training before they are able to administer medications. Medications are stored in a locked cabinet inside the office. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home and of those that are returned to the pharmacist. Medication Administration Record charts are maintained, those examined by the inspector were accurate and up to date. The AQAA supplied by the home states that they have a monthly audit of their medication carried out by their supplying pharmacist. Care Homes for Adults (18-65 years) Page 16 of 28 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. It is the inspectors judgment that the home has taken reasonable steps to help ensure that service users are safeguarded from the risk of abuse. Appropriate policies and procedures are in place, and all staff have undertaken training in adult protection issues. Evidence: The home has a complaints procedure in place. This was on display within the home, and service users have been given their own copy. The procedure includes timescales for responding to any complaints received. Surveys returned to the CSCI from service users indicated that they have a good understanding of whom they could complain to if they so wished. The home maintains a complaints log, although the manager informed the inspector that no complaints have been received since the previous inspection of the home. The home has a policy in place on adult protection. This has been revised since the last inspection, and now makes clear the homes responsibility to refer any allegations of abuse to the local authority. The home also has a copy of the local authorities adult protection procedures. All staff have recently undertaken training around adult protection issues. All service users have their own bank accounts, and only they are able to access these Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: accounts. The home holds money on behalf of service users, with their agreement, in a locked cabinet inside the office. Records and receipts are maintained of financial transactions involving service users monies, those checked by the inspector were found to be satisfactory. Care Homes for Adults (18-65 years) Page 18 of 28 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. It is the judgment of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users have access to adequate private and communal space. Evidence: The home is situated in a residential area of Walthamstow, in the London Borough of Waltham Forest. The home is in keeping with other homes in the area. The home is close to shops, transport networks and other local amenities. The homes communal areas consist of a sitting room, dining room, kitchen and rear garden, which includes garden furniture. The AQAA supplied by the home states that there are plans to buy a new table and set of chairs for the dining room in the next twelve months. Service users were observed to move freely around communal areas of the home. The home was generally well maintained, both internally and externally. Furniture and fittings were well maintained, and domestic in character. New flooring has been fitted in communal areas of the home which the service users were able to help choose, and the AQAA states that there are plans to buy a new carpet for the stairs in the next twelve months. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: The home has one bathroom/toilet and one bathroom shower. The inspector was pleased to note that both of these have been fitted with a working lock which includes an emergency override device since the previous inspection. Bathrooms were found to be clean, tidy and free from offensive odours. However, the taps on the sink in the downstairs shower room were found to be extremely loose, and staff informed the inspector this often caused water to be splashed over whoever was using the taps. It is required that these taps are repaired. All service users have their own bedroom, and are offered a key to their room. One service user showed the inspector their bedroom. This was found to be recently decorated, and the service user said they liked the new decor. The service user has been able to personalize their room, for instance with family photographs and personal possessions such as televisions. Bedrooms were seen to contain adequate furniture, including chest of draws, wardrobe, table and chair. Curtains, bedding and carpets were well maintained and domestic in character. Bedrooms meet National Minimum Standards on size requirements. Bedrooms were all centrally heated, and had adequate natural light and ventilation. The home has taken steps to help prevent the spread of infection. There is a small laundry room which is appropriate in sale to the size of the home, and is separate from the kitchen. Hand washing facilities are situated around the home, and protective clothing such as gloves and aprons are available to staff. COSHH products were stored securely. The home is not suitable for service users with physical disabilities, and this is made clear in its Statement of Purpose. The report by the Expert by Experience states The home is clean and tidy. Service users choose colours and decorations of their bedrooms. The bedroom I looked into was decorated in her colours and flowers as that is what she likes. There were cracks in the bathroom. Care Homes for Adults (18-65 years) Page 20 of 28 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. It is the judgment of the inspector that the home is staffed in sufficient numbers to meet the needs of service users, and that the staff team are suitably qualified and experienced to carry out their duties. Evidence: The home provides 24-hour support, including an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. Staffing levels are currently reduced due to one of the three service users been in hospital on a long term basis. The inspector believes that staffing levels are adequate to meet the needs of service users, but that they would need to be reviewed if the home begins to operate with three service users residing there. Through observation and discussion there was evidence that staff have built up good relations with service users, and that they have a good understanding of their roles and responsibilities. Staff were seen to interact with service users in a friendly and respectful manner, and examples of positive staff interactions with service users were seen throughout the day, for example one service user became distressed over a bereavement, and staff were seen to react in an appropriate and sensitive manner to this. At times service users made it clear that they wished to be left alone, and staff Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: were seen to respect this. The AQAA supplied by the home indicates that the home has all necessary employment related policies and procedures in place, including on equal opportunities and recruitment and selection. The inspector was pleased to note that service users have the opportunity of been involved in the recruitment process for new staff. The inspector checked four staff employment files at random. These were found to contain all required documentation, including proof of ID, references and CRB checks. As no new staff have been recruited to the home since the previous inspection, staff induction processes were not checked as part of this inspection, but will be tested at the next key inspection of the home. Staff have access to training, and recent training has included health and safety, infection control, first aid and POVA. The AQAA supplied by the home states that it is planned to arrange training around learning disabilities and mental health issues, and the manager confirmed that they are hoping to arrange this in the near future. Six of the seven care staff employed at the home have achieved a relevant care qualification, and the inspector was informed that the remaining staff member was currently working towards such a qualification. The care staff and deputy manager in the home all receive regular formal supervision. Minutes are maintained, these evidenced discussions around performance, training needs and service user issues. It was noted that the manager has not had any formal supervision at all since they took over as the manager. This issue was raised with the homes proprietor during the course of the inspection, who said that they would make arrangements for the manager to have regular formal supervision, and this is required. The report by the Expert by Experience states The staff are friendly and keep the service users safe. Service users are involved in the recruitment of staff and are supported to sit at interviews. Care Homes for Adults (18-65 years) Page 22 of 28 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. It is the inspectors judgment that this is a generally well run home. Appropriate systems are in place around quality assurance, and health and safety is well managed. However, the home must appoint a manager who is registered with the CSCI. Evidence: The home has appointed a new manager since the previous inspection. It was noted that the previous manager never applied for registration with the CSCI, and it is now over two years since the home has had a registered manager in place. The inspector spoke with the proprietor on the day of inspection, who said that they intended that the current manager would apply for registration with the CSCI in the near future, and it is required that the home appoints a manager who is registered with the CSCI. It was noted that staff and service users informed the inspector that they found the manager to be approachable and accessible. The manager has eight years experience of working in social care. The manager informed the inspector that they have achieved an NVQ Level 4 in Care, and that they are currently working towards the Registered Care Homes for Adults (18-65 years) Page 23 of 28 Evidence: Managers Award. The AQAA supplied by the home indicated that the home has all policies and procedures in place required by the National Minimum Standards. Those checked by the inspector, including complaints, admissions and adult protection were all found to be satisfactory. Record keeping was of a generally good standard, and staff and service users have access to their records as appropriate. Care plan reviews, service user meetings and staff meetings all contribute to the quality assurance processes within the home. Copies of previous inspection reports were available to view, and there was evidence that monthly unannounced Regulation 26 visits have taken place. Surveys are issued to service users and their relatives to help gain their feedback on the running of the home. Completed surveys seen by the inspector contained generally positive feedback. One relative wrote X is looked after very well. Fire exits were clearly signed and free from obstruction. Fire extinguishers were situated around the home. The home has a fire risk assessment in place. The home had in date safety certificates for PAT testing, gas safety and electrical installation. The home has in date employers liability insurance cover in place. Care Homes for Adults (18-65 years) Page 24 of 28 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 37 8 The registered person must appoint a suitably qualified and experienced permanent manager to the home, and submit them for registration with the CSCI. 31/10/2006 Care Homes for Adults (18-65 years) Page 25 of 28 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 19 13 The registered person must 28/02/2009 ensure that comprehensive Health Action Plans are in place for all service users, which set out how the home is able to meet all the health needs of service users. To help ensure that service users health needs are being met in a comprehensive and consistent manner. 2 27 23 The registered person must ensure that the taps on the sink in the downstairs bathroom are repaired. To ensure the taps are not loose and that they are working properly. 28/02/2009 3 36 18 The registered person must 31/01/2009 ensure that all staff employed at the home, including the homes manager, receive regular formal one to one supervision at least six times a year. Care Homes for Adults (18-65 years) Page 26 of 28 To help ensure that staff are able to carry out their duties effectively and to promote professional development. 4 37 8 The home must appoint a permanent manager who is registered with the Commission for Social Care Inspection. To help ensure that the home is managed effectively in the best interests of service users. 31/03/2009 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 Care Homes for Adults (18-65 years) Page 27 of 28 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. 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