Inspection on 25/02/09 for St Michael`s Lodge

This inspection was carried out on 25th February 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Michael`s Lodge 28/02/07

St Michael`s Lodge 28/02/06

St Michael`s Lodge 02/03/05

St Michael`s Lodge 19/04/04

St Michael`s Lodge 09/01/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: St Michael`s Lodge 6-8 St Michael`s Avenue Northampton Northants NN1 4JQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ansuya Chudasama     Date: 2 5 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: St Michael`s Lodge 6-8 St Michael`s Avenue Northampton Northants NN1 4JQ 01604250355 01604638496 a.gowing@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Anne Going,Mr Kenneth Going,Mr Raymond Galbraith,Mrs Marian Galbriath care home 13 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The home may continue to provide care for 2 existing named service users under 45 years of age The Home provides care for Service Users in the Age category of 45yrs to 65yrs and 65yrs and over. Date of last inspection Brief description of the care home St Michaels Lodge is a care home providing care and accommodation for 13 service users with Mental Disorders excluding Learning Disabilities and Dementia. Mr K. and Mrs A. Going and Mr R. and Mrs M. Galbraith own the home. Mr R. Galbraith is the Registered Manager. The home is situated within easy access to the Tying Centre and adjacent to a local Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 13 Brief description of the care home shopping centre. The home was opened in 1989 and consists of a large Victorian three-storey building providing three double bedrooms and seven single rooms. The home has a stair lift to the basement floor. There are two lounges and a dining room and service users have access to the rear garden Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This home has 1star rating and this means that the people using the service receive an adequate service. We inspected the home on the 25th of February 09 and spoke to the staff, and the manager/proprietor of the sister home assisted with the inspection. The manager of the home was not working on the day of the inspection. We looked at information about some of the people in the home to find out how their needs are being met by the staff. This is called case tracking. We spoke to some of the people and watched how they got along with the staff. Staff training records and information about policies and procedures were looked at in detail. This tells the staff how to do things in the home. We were also given a tour of the home. Care Homes for Adults (18-65 years) Page 6 of 30 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 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 9 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. The people and their representatives are given information about the home so therefore they know that the services provided will met their needs. Evidence: The home has a Statement of Purpose and a Service User Guide. These documents are given to people who are interested in coming to the home. The people also sign to say that they were given a copy of the guide. People spoken to say that they had visited the home with their social worker and wanted to stay. We were also told that the manager of the other home had visited some of the people in their own environment. The manager discussed the assessment process including getting information about the person from the funding authority. The home completes a pre-assessment form, but the information needs to be more detailed and the names of the people involved in the process needs to be recorded. The manager said that this would be done. Care Homes for Adults (18-65 years) Page 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All the people have care plans but they are not involved in drawing them up so therefore they are not always aware how the home is meeting their goals and aspirations. Evidence: The home had care plans for all the people in the home. The people spoken to say that they had not been involved with drawing up their care plans. Some of the people also did not know what a care plan was. We were told that the manager/proprietor wrote the plans and also reviewed them. The plans seen had information about the peoples personal and health care needs. Some times information seen in the file was not recorded in the care plan. One person said that they wanted to go to day care but there was nothing recorded in their plan to state how this was going to be achieved. The staff told us that they write in the daily notes. The care plans were being stored in the staff toilet/cleaning cupboard. The funding authority were carrying out yearly reviews for the people in the home. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: Risk assessments were being undertaken for all the people but every thing was recorded in the same risk assessment. The risk assessments needed to be individualised to a specific activity. The five steps to assessing risk need to be recorded. The manager told us that all the risk assessments for the home were being reviewed soon. Care Homes for Adults (18-65 years) Page 12 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some activities provided by the home but this could be further developed to increase the peoples independent living skills Evidence: One person said that they used to have a community psychiatric nurse visit them. It was said that they took them out but this has now stopped. We were told that the staff were running low and they were not able to take the person out to day service. The information recorded on the board in the kitchen needs to in the communication book. The board also had personal information about the people. This is not good practice and does not maintain the persons dignity. We were told that the manager discussed the menu for the week on Mondays with the people. Those spoken to said that they were not aware of this. One person said that they wanted to get involved with cooking with staff and wanted to become more Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: independent. They did cooking at the last place they came from and enjoyed this. Some people said that the food is ok and others said its nice. One person said if they did not like what was on the menu, they would tell the staff. We were told that the people did not cook or get involved with laundry work. The staff did this and the cleaning. This was observed on the day of the inspection. Most of the people shared the bedding and towels in the home. The people spoken to welcomed the idea of having their own bedding and towels. The home did not have house meetings but staff told that this would start soon. We were told that the manager was ok, supportive, and they could have a joke with him. Some of the people told us that they go out for walks, go to town, do shopping and attend day care. They also watch television and listen to music. We were told that in April 08 they went to Wicksteed Park and at Christmas they went to see a pantomime, which they enjoyed. The people say that they would like to go out on more day activities. The people spoken to said that they were left to their own devises and did what they wanted to do. Friends and families are welcome at the home and the people are able to use the privacy of their room to have private time with their visitors. Some of the people in the home maintain contact with their families and friends. The people say that the staff are very nice but some staff accent was difficult to understand. Care Homes for Adults (18-65 years) Page 14 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. The peoples personal and health care needs are met by the home. Evidence: The care plans seen had information about how the peoples personal care needs were being met. The people spoken to said that they did their own personal care. One person said that they come downstairs to have a shower and the room gets hot however the staff help wash my hair. Another person said if I was not feeling well, I would tell the staff. The staff told us that the people are helped to do their personal care and they make sure they have clean clothes in the mornings. We observed staff interaction and noticed that they talked to people in a respectful manner. There is evidence in the care plans that the people are offered support for their physical and emotional health needs. There are records of doctors, dental, medication appointments, and people have access to the district nurse, opticians, and other health care professionals. There was information on medication reviews and mental health reviews being carried out. The people had signed the medication consent form for staff to give them their medication. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: Two staff gave out medication but the staff on duty had not received the accredited medication training. Medication administration records (MAR) showed that there were gaps when staff had not signed the MAR sheet when giving out medication. We were therefore not able to ascertain if the medication had been given out. A Photograph of the person is needed on the medication record. A record needs to be made of the date when medication is stopped. Care Homes for Adults (18-65 years) Page 16 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints policy and the people in the home know how to make a complaint if they are not happy. Evidence: The people that we spoke to told us that they knew how to make a complaint to the manager. One person said that they would tell the manager of the other home and said no one will push me around. The home had a complaints procedure and the proprietor told us that they had not received any complaints and had not made any safe guarding referrals to social services. The two staff on duty had not had training on safeguarding of vulnerable adults training and did not know what this was. Care Homes for Adults (18-65 years) Page 17 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The proprietor is aware that the decoration within the home need improving to meet the needs of the people. Evidence: The home is situated in a residential area within easy walking distance to the shops and the local communal services. A tour of the home showed that the main lounge was used as a smoking area. The lounge was smoky and the door is kept open and the smoke spreads into the communal areas of the home. The home had some people and staff who did not smoke. The furniture in the room was shabby and some of the chairs were ripped, stained and not appropriate for some of the people to use. We were told that new chairs had been purchased and the people had been consulted and these were arriving at the home soon. The room needed to be arranged so every one was able to see the TV. At present this was situated in the middle of the room, near the wall. The people sitting at the far end could not see the TV. The home had a stair lift but this could not be used for people who were large build because the stairs were very narrow. A buffer and a heater were stored in the Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: gangway. These items needed storing in a safer place. One person told us that the bathroom got very hot when they had a bath. This room has a tiny window, and a small extractor fan but this was not working. The bath chair stand was very wobbly and needed repairing. The water was also very hot. The laundry room is small and to get access to this room, the people and staff have to go through the bathroom and toilet. The ceiling was coming off in the laundry room. We were told that this was due to the heat and steam coming from the dryer that was on top of the washing machine. We were told that this was being sorted. The floor in the room needed replacing as it was worn out. We were told that the door to the bathroom was a fire door. This door was kept open by wedging a chair to let the steam out from the bathroom. One bedroom looked at had old furniture. The person in the room asked for a lino and a rug to replace the old carpet they had. They also asked for a small table for putting their drinks on. Some of the peoples carpets needed replacing due to some people having accidents and the carpets were also worn out. Most of the rooms needed new light shades, curtain nets and curtains. Extractor fans were needed for people who smoked in their bedrooms to get rid of the smoke. Some peoples bedrooms were being kept open and these were fire doors. There was discussion about putting fireguards on these doors. The people in these rooms also smoked and the smoke spread through out the building. Over exposure to cigarette smoke may pose a risk to passive smoking for non smoking staff and residents. The needs of these people are not being met. Two people shared a double room and the room only had one sink. The room also had a big radiator next to a bed and this was very hot when we touched it. A risk assessment needs to be undertaken to ensure that the person is kept safe. One persons en-suite was not fixed to the ceiling and had a big gap. The ventilation fan was also not working properly. The proprietor was aware of this and stated that this was being sorted out. The manager told us that each room is being done individually to meet the persons needs. The bedrooms seen were personalised with the peoples hobbies that they enjoyed doing. The staff and the people told us that the front room upstairs was used for visitors. At present this room was used for storing personal items, a wheel chair and a few crates. The room also needed decorating. The manager told us that this room was being decorated and it would be used as a no smoking lounge for any one to use. The room was also to have a television. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: The patio needs cleaning from the back to make it pleasant for the people to use in the summer months. The curtains were coming down and needed putting up properly. The garden at the back has an old washing machine and the furniture needed attention as it was worn out. The staff told us that the toilet down stairs is used as a staff room. This room has a toilet, a small sink, staff coats, and the peoples files. The toilet seat was broken. The cleaning materials and bucket and mops were also stored in this room. The manager needs to get advice from the environmental health officer to find out if this practice meets the regulations The light in the kitchen needed cleaning. The tablecloth on the dining table need to be properly cleaned because it had dried food stuck on it and felt sticky. Most of the dinning chairs were wobbly and were not suitable for most of the people in the home. The proprietor told us that these chairs were being replaced with new ones. Care Homes for Adults (18-65 years) Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management recognises the importance of training, and is aware that there are gaps in the training provided and is dealing with this. Evidence: The home has staff training certificates displayed on the wall. The dates on the certificate had 2000, 2002,2003 and 2005. The certificates were out of date. We discussed with the proprietor that these did not have to be displayed on the wall but needed to be kept in the staff files. The certificates were also out of date. New staff receive the homes induction when they start work. The staff needed to sign and date the document where the manager has signed. This is to confirm that they have received the training. One of the staff on duty had not done the homes induction. None of the staff had started the skills in care induction training. The manager told us that they would start this soon. Evidence showed that the two staff on duty had not done any statutory training. One of the staff said that they had done health and safety training before they started work. One staff told us that they had worked at the home before and decided to come back because they enjoyed the work. The staff said that they had team meetings and these were held with the other sister home. The minutes from the meeting are kept at Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: the other sister home; however a copy should be kept at this home for the staff to read. We were told by staff that the manager was supportive. The staff working rota was inspected and showed that there were times when only one care staff was on duty. The manager needs to review the staffing rota to ensure that there are enough staff on duty to meet the needs of the people. The staff recruitment files for staff were looked at in detail. Evidence showed that the home was obtaining all the relevant information required to safe guard the people in the home. We were told that not all the staff were receiving supervision on a regular basis. This needs to happen at least six times a year and needs to be recorded. Care Homes for Adults (18-65 years) Page 22 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management is aware of the work that needs doing to meet the needs of the people in the home. Evidence: The manager was not on duty on the day of the inspection. The statement of purpose states that the manager has 20 years experience of working with people with mental health needs. It also stated that the manager was currently undertaking NVQ level 3 in promoting independence. The manager needs to complete NVQ level 4 in care and management and needs to undertake the managers award as stated in the standard. The staff told us that they found the manager supportive. The home had not sent us the completed annual quality assurance assessment (AQAA). The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also gives us numerical information about the service. The manager told us that this was being completed. The home did not have a quality assurance system that met the standard. No Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: questionnaires had been sent out to people living at the home or their relatives as required under the regulations. We were told that the Fire Officer visited on the 25/2/09 and this was satisfactory. We were told that a fire drill was done last week. Needs to record the point and time taken. One staff spoken to had not completed a fire safety training, other staff had not done first aide, food hygiene, and manual handling training. The accident and incident forms looked at were being completed properly. (Risk assessments: see section on individual needs and choices) The fire doors in the home must be kept closed to protect the people from any risks. The smoking policy says that one of the no smoking areas is the lounge on the ground floor. However we observed that the smoking area is on the ground floor. The manager stated that the policies and procedures were being reviewed and updated. Care Homes for Adults (18-65 years) Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 24 23 (2)(b) (d) All areas of the home must be kept in a good state of repair and reasonably decorated. 30/06/2007 Care Homes for Adults (18-65 years) Page 25 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 6 15 The people must be involved 17/06/2009 in drawing up their care plans and when they are being reviewed This is to ensure that the people are aware how their goals and aspirations will be met 2 16 12 Personal information about the person must not be recorded on the kitchen board This does not maintain the persons dignity and privacy 17/05/2009 3 24 23 All areas of the home must be kept in a good state of repair and reasonably decorated. This is to ensure people live in a homely enviroment 30/09/2009 Care Homes for Adults (18-65 years) Page 26 of 30 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 4 33 18 The staffing rota must be 30/05/2009 reviewed to ensure that there are adequate numbers of staff on duty. This is to ensure that the needs of the people are met and they are not put at a risk. 5 35 18 Staff must be provided with the training as stated in the report. This is so they have the skills to look after the people that they care for. 30/06/2009 6 39 24 The AQAA must be completed by management when asked for by CSCI. This is so that we are aware of how the home is managing the needs of the people and information that we need is obtained for monitoring purpose. 30/04/2009 7 39 24 There must be systems in place including the seeking of the views of the people that live in the home, that management then act upon and subsequently change the delivery of care. This is so that the people influence the running of the home. 18/06/2009 Care Homes for Adults (18-65 years) Page 27 of 30 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 8 42 13 The fire doors must be kept closed at all times unless there are fireguards put on. This is to ensure that the people are protected from any risks to their health and safety. 30/04/2009 9 42 13 The no smoking areas in the 30/04/2009 house must be kept odour free from the odours of tobacco smoke. This is to ensure that the people and staff are protected from passive smoking. 10 42 13 A risk assessment must be undertaken for a radiator that is next to a persons bed This is to ensure that the person is kept safe from any risks. 20/05/2009 11 42 13 The tap in one of the 30/05/2009 bathrooms must be repaired and the water temperatures must be monitored and maintained and be set This is to ensure the people are kept safe from any risks. Care Homes for Adults (18-65 years) Page 28 of 30 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 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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