Inspection on 11/12/08 for Swanage Lodge

This inspection was carried out on 11th December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Swanage Lodge 22-24 Swanage Waye Hayes Middlesex UB4 0NY     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: Sarah Middleton     Date: 1 1 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 31 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 31 Information about the care home Name of care home: Address: Swanage Lodge 22-24 Swanage Waye Hayes Middlesex UB4 0NY 02088484599 02085730129 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Poucarshing Luchmun Type of registration: Number of places registered: Parvy Homes Limited care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 5 Date of last inspection Brief description of the care home Swanage Lodge was registered in 2008 for five adults with Mental Health needs. The Owner and Manager also own and manage another small mental health care home in the next road. The home is near to local ammenties such as shops and public transport. there is a main road with good bus routes to local towns and a mainline railway station is a bus ride away. The home maintains good links with health professionals and looks to support those people who are able to move on to more independant accomodation. There is a Manager, Deputy Manager and care staff to Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 5 Brief description of the care home support the people living in the home. The home is staffed twenty four hours a day. The current fees start from £997.88 upwards. This fee can depend on the type of support each person needs to live in the home. Care Homes for Adults (18-65 years) Page 5 of 31 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: An unannounced inspection was made on 11th December 2008. Before the visit we looked at: The Registration report. Information we received since the registration of the new home. The Annual Quality Assurance Assessment, (known as the AQAA). The AQAA gives us evidence to support what the home says it does well and gives them an opportunity to say what they feel they could do better and any future plans. During the visit we: Talked with the two people living in the home, one new member of staff, the Deputy Manager and the Registered Manager (who will be referred to in this report as the Manager). The Manager is the Owner of the home. Looked at information Care Homes for Adults (18-65 years) Page 6 of 31 about the people who live in the home and how well their needs are being met. Looked at other records which must be kept; such as training records, checks carried out on staff and health and safety checks. Looked around parts of the home to make sure it was clean, safe and comfortable. Five requirements were made at this inspection visit. We told the Manager what we found. 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 8 of 31 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 31 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. People looking to move into the home need to be assessed to ensure the home can meet their individual needs. Evidence: The home had recently admitted two people over the past three or four weeks. New people are encouraged to visit the home and spend time meeting staff and any other people. One new person had stayed overnight and both people are on a trial stay in the home. Staff are currently assessing the needs of each person to ensure the home can meet the longer term needs of each person. We looked at the file of one person to assess how the home carries out their preadmission assessments. The Manager explained that he had not been able to complete the homes pre-admission assessment but had met with the person before they moved into the home. Various reports from professionals were seen relating to this person, but most were several years old. We discussed with the Manager the expectation that the professional referring a new person to the home should provide the home with an Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: up to date assessment of the persons needs along with any known risks. We did see information completed by the Manager about the circumstances surrounding the persons admission into the home and this recorded certain characteristics of the person and general background about them. The self-assessment the Manager had completed (known as the AQAA) stated that all relevant assessments are obtained prior to a person moving into the home and that there are pre-admission assessments available to evidence people are fully assessed before they move into the home. Although we recognise that the Manager had met with this person before they moved into the home, there was a lack of written evidence to support information the Manager might have obtained during the pre-admission process. In addition, we discussed with the Manager the need to clearly record any visits made to the home so that there is a record of how visits or overnight stays went and then any useful information noticed could be recorded onto an initial care plan and/or risk assessments. Due to the findings noted above, we discussed with the Manager the need for whoever is involved in assessing a person, to record information gathered from the person, their relatives or professionals. This information is crucial in deciding if the person should move into the home on a trial basis. We had viewed the blank pre-admission assessment that would usually be used. This covered areas such as psychiatric history and any behaviours that were identified. We noted there were no questions relating to a persons preference for the gender of staff that might need to assist the person with personal care tasks. Cultural and dietary needs should also be included into this assessment. This was brought to the attention of the Manager. A requirement was made that any new people being considered to move into the home should be throughly assessed and evidence of this assessment be available for inspection. Care Homes for Adults (18-65 years) Page 11 of 31 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. The lack of detail in the care plan could place a person at risk. People are supported to make decisions about their daily lives. People are supported to take assessed risks. Evidence: We viewed one persons file. This contained some of the necessary information needed, such as their diagnosis, and brief outline of their history. An initial care plan was seen, this noted actions to take to settle in the person, ways to monitor their mental health and other particular health needs were recorded. However the person is known to have particular needs that had not been clearly recorded onto the care plan. This needs to be included along with noting how to respond to this person. This was raised with the Manager, as we acknowledge the person had only very recently moved into the home, however as soon as needs or issues are identified they should be Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: recorded and reviewed on an ongoing basis. We recognise that during the trial stay for new people, the staff team are getting to know each person and this can take time. However this persons needs were made known to the Manager therefore the staff team need to be able to read a care plan that informs them and tells them what to do in certain situations. It was noted that some of this behaviour had been noted in a risk assessment, (See Standard nine). The Manager was advised to discuss this person with the relevant professionals to ensure everyone knows how to support and care for this person. The person also goes out of the home alone to the local shops. This had not been recorded on their care plan or risk assessment. This needs to be, so that staff are aware of potential risks and action to take if the person goes missing. The selfassessment the Manager had completed stated that the home encourages risk taking. This is not an issue in itself, but there needs to be a record of the risk and the assessment of that identified risk. A requirement was made for care plans to record in detail a persons identified needs and how these needs are to be met. We saw evidence that a review had taken place shortly after the person had moved into the home. A management plan was seen that recorded the activities that would be offered to the person and how to monitor the person to minimise a relapse. We discussed with the Manager ensuring that this plan is accurate and records what the home offers. A sample of daily records were read. These outlined what the person had done each day and their mood. We were informed that staff encourage the two residents to be as independent as possible. One person spoken with said they would like to gain more cooking skills but have not had the opportunity to make some meals. This was fed-back to the Manager. One person manages their money, whilst the other needs support from the staff team. Neither person has an independent advocate but both have input from relatives and other professionals, such as the community outreach team and community drugs team. We looked at one persons risk assessments. As noted earlier, this did not include the persons known needs or the decisions the staff team have made about how this person leads their lives. For example there needs to be evidence of how the staff team decide that a person is able to go out into the community without staff. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: We were pleased to see there were records regarding some of the identified risks, such as deterioration of the persons mental health needs and their potential threatening behaviour. The person had signed both their care plan and risk assessment and we spoke with the Manager about the different ways staff can seek the views of the person. A person might see their needs and risks very differently from the staff team and this could be recorded and looked at with each person. Care Homes for Adults (18-65 years) Page 14 of 31 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. People have the opportunity to engage in social activities. People are supported to maintain social contact with family and friends. Peoples rights are respected. The meal provision offers people a healthy balanced diet that includes individuals preferences. Evidence: The home is still getting to know what each person wants to do with their time. One person goes out to visit the local community teams for support and advice and then usually sees friends. We spoke with this person who confirmed they are out every day. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: They are also considering College courses and joining the library. The other person spends more time in the home and staff are looking to provide various activities such as art, cooking and spending time getting to know the person. The Manager informed us, both in the written self-assessment (AQAA) and at the inspection visit, that he is considering employing a member of staff who would focus on providing activities. This person would work at this home and his other small care home which is nearby. This is seen as good practice as this person could look at providing regular activities on an ongoing basis. The Manager keeps in regular contact with relatives and the people living in the home are supported to see relatives or friends as much as they want to. As the Manager lives on the same road as this care home, staff can get hold of the Manager or his wife, who is the Deputy Manager, should any relatives wish to speak directly with them. One person sees their friends outside of the home. Due to the background of this admission into the home it was felt by all concerned that this is the best arrangement for the time being. This will be reviewed on an ongoing basis. The two people asked confirmed they can lock their bedrooms for privacy. The Manager informed us people can also receive their own post. Staff were seen to interact with one of the people living in the home and not just between themselves. The home provides a four week rolling menu but alternatives are also available. The two people asked said they enjoyed the food provided. Staff confirmed they encourage people to assist in the preparation of the meals and that cooking, as mentioned earlier, will be offered to those people interested in learning how to make meals. Food that had been opened was covered appropriately in the fridge. To protect the safety of those living and working in the home we were informed that kitchen knives are locked in a secure cupboard. Care Homes for Adults (18-65 years) Page 16 of 31 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. People can receive personal care support in their preferred way. Health needs are recorded and were being met. The peoples health and welfare could be at risk due to the medication shortfalls identified. Evidence: The personal care needs of the people living in the home need to be assessed and recorded onto a care plan. We were informed that the two people living in the home need prompting and encouraging to maintain their personal hygiene. However they are both independent and do not need direct support in this task. It should be made clear on care plans as to whether the person is happy to receive personal care support from a female or male member of staff. This is important as at some stage the person might need assistance with a personal care task. Currently the only male member of staff is the Manager and he would not assist with personal care tasks in this home as there are female members of staff available. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: One person has registered with a local GP, whilst the other person is still under the hospital and cannot be registered yet with a GP. All other health professionals would be accessed, such as dentist or optician. As stated earlier the care plan viewed had recorded a particular health need the person had and how this would be managed by the home. We discussed with the Manager the possible development of a health appointments form. This could clearly record each time a person sees a health professional along with the outcome of the visit. We looked at the medication systems in the home. Staff observe medication being administered and attend training on this subject. The Manager is also looking at staff signing up for a long distance learning on medication. We viewed one persons medication. Currently no-one self medicates and the home does not have any controlled drugs in the home. Medication is locked in a safe and secure cabinet. We counted and checked medication with the Manager. Six different types of tablets were counted. Three of these were counted correctly against the Medication Administration Records. However there were discrepancies with the three other medications. One medication, Metformin had not been accurately recorded on the Medication record. Fifty-six should have been recorded on the 3.12.08 but only 28 had been recorded. This error in recording can lead to confusion when trying to carry out a count on the remaining medication. We then checked Amisulpride and found that the amount prescribed had altered on the 25.11.08, but on one Medication record, dated 4.12.08 this change had not been accurately noted. Due to this error it was difficult to count and confirm the right amount of medication had been administered by all members of staff. Finally we counted Zopiclone and found that there should not have been any left but there was three left in the box. At the time of the inspection the Manager could not explain why there were these three left over. Subsequent to the inspection the Manager informed us that there had been a box of the Amisulpride dropped on the floor whilst we had been checking the medication. We had not been aware of this at the time of the inspection. However there had still been an error on the Medication record dated the 4.12.08, which meant that it was difficult to confirm exactly what medication the person had actually received. The shortfalls were discussed with the Manager, as it was concerning to find such noted errors. The Manager and the Deputy Manager need to ensure that all Medication records are accurate documents and the amount delivered or carried over are clearly recorded. The Manager must also provide evidence that there have been regular counts and checks on all the medication. Carrying out regular checks ensures any errors are noted quickly and can be investigated and action taken can be swift. Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: Requirements were made in relation to the above shortfalls. Care Homes for Adults (18-65 years) Page 19 of 31 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. People can make a complaint and this will be listened to and acted on. Overall there are systems in place to protect people from abuse and harm. Evidence: The home has only recently opened and has not received any complaints. Those people asked said they knew they could talk to staff or the Manager if they were unhappy. The Manager informed us that staff receive training on adult abuse. This is sometimes provided by the Local Authoritys Safeguarding co-ordinator. We discussed with the Manager the No Secrets document that is currently being reviewed and updated. This should be obtained in 2009 for the staff team. Due to some of the needs of the people living in the home, the Manager should ensure there are guidelines in place so that all members of staff know how to deal and manage particular situations that might arise in the home. We counted one persons personal money. This is locked away in the office. This was correct at the time of the inspection. Care Homes for Adults (18-65 years) Page 20 of 31 Care Homes for Adults (18-65 years) Page 21 of 31 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 clean and welcoming for the people living in it. Evidence: We had taken a full tour of the home earlier in the year at the registration visit. Therefore we only viewed the downstairs at this inspection visit. The Manager showed us the new covered smoking area in the back garden. Overall the home was clean and welcoming. The front room is used as a meeting room and the living/dining area was spacious. Care Homes for Adults (18-65 years) Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a competent staff team. The recruitment checks protect the welfare of the people living in the home. Overall the training offered to staff enables them to care and support the people living in the home effectively. Evidence: The staff team comprises of some new members of staff, who are working through their induction to the home and some staff who also work at the other small care home owned by the Manager. The Manager is aware of the need to have a balance of staff, so that they can meet the diverse needs of the people living in the home. Staff can speak a variety of languages, such as French and Punjabi. We viewed the rota. The amount of staff working each shift varies depending on the time of day and what is going on in the home. There are only two people currently living in the home, therefore often there is one member of staff working with either the Deputy Manager or Manager. Currently one member of staff sleeps in at night. The Manager will monitor the staffing levels as and when new people move into the home. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: We discussed management arrangements for when the Manager and the Deputy Manager, his wife, go on holiday. This does not occur often but when it does the Manager would arrange for the Senior member of staff to manage both care homes. The senior has worked in the home for a few years and is familiar with the general running of the home. The Manager will inform us whenever he plans to take a holiday. The Manager confirmed there will be staff meetings held. Staff have the opportunity to study for an NVQ qualification. Two staff have an NVQ level 3 and one will be studying for the new Management qualification in care. We viewed two staff files to look at the homes recruitment checks and processes. The Manager had gone through the necessary checks with the member of staff who also works at his other local care home. This staff member had a new Police Check carried out. This is important as currently the other care home is registered as a different provider/owner to the home we were inspecting, which is a Limited Company. The other files seen had all the necessary checks although the Manager informed us that one reference had been lost. The Manager was asked to obtain this reference again as soon as possible and forward to us a copy of this second reference. Subsequent to the inspection the Manager forwarded on a copy of this second reference. The Manager showed us the induction new staff work through. This covers a wide range of areas, such as principles of care, health and safety and abuse. This is slowly worked through and signed by the new member of staff and their line manager. The Manager described how staff receive training in different ways. Some of this is using a DVD on a topic and then there are tests for staff to complete before they are issued with a certificate. The Local Authority also offers training and the Manager looks for places where possible. We discussed the Mental Capacity Act and the Manager was aware that the staff team need to have information on this new legislation and how this might have an impact on how the home supports the people living in it. We viewed one member of staffs file to see the training they had attended. Individual training records need to be updated so that they accurately reflect the training staff have attended. In addition, we spoke with the Manager about having an overall training record of the whole staff team which would show at a glance what training the whole team, including the Manager, had attended. Overall the file viewed showed that the member of staff was up to date with the main Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: topics relating to working in a care home. We advised the Manager to also focus on obtaining further training on mental health subjects, as there are new staff joining the staff team in the home. Care Homes for Adults (18-65 years) Page 25 of 31 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 people living in the home would benefit from having a Manager who is able to spend sufficient time managing the home. Systems are in place to obtain the views of the people living in the home. The health and safety of the people living in the home is protected. Evidence: The Manager is a qualified nurse and has a Diploma in Management. He has owned another care home since 2002. The Manager informed us that he is still working as a nurse full time along with being the Registered Manager for the two care homes. This issue had been raised with the Manager during inspections for the other established care home. The understanding during the registration of this home would be that the Manager would resign from his post as a nurse. We were informed that this is still the plan but Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: that until the home has been re-mortgaged the Manager cannot leave his post as a nurse. The home needs a Manager to settle in new people and to manage the day to day running of the home and a requirement was made for this issue to be addressed. The Deputy Manager has an NVQ level 4 and has enrolled to start the new Management qualification in care in December 2008. We discussed how the Manager would carry out reviews of how well the home is running and how he would obtain the views of the people living in the home. The Manager informed us that he would use surveys as a way to seek the views of those who live in the home, their relatives and other professionals. We also discussed the importance of the Manager to produce a short report each year demonstrating the work the home has been doing to improve outcomes for people living in the home. The report should also reflect areas that still need attention and future aims and objectives. Regularly reviewing the home can improve standards of care and practice and identify any shortfalls. This report should then be made available for the people living in the home and for inspection. We viewed samples of the health and safety checks. Those viewed such as the Gas safety Record, Portable Appliance Test and Fire equipment were all up to date. Regular fire drills are held and we suggested it would be good practice for risk assessments to be completed on each person regarding their ability and willingness to respond to the fire drills and practices. The fire risk assessment dated May 2007 was seen which had been completed by an external person. The Manager had then reviewed it in April 2008. The Manager was advised to check with the Local Fire Authority to see if there were any guidelines on fire safety and completing fire risk assessments. This document should be reviewed each year to ensure it is detailed and informative. Other safety checks are carried out such as checking the water temperatures in the home. Care Homes for Adults (18-65 years) Page 27 of 31 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 31 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 2 14 To ensure a persons needs can be met, the home must fully assess a new person and provide evidence of this assessment. This ensures a prospective persons needs are identified and can be met by the home. 30/01/2009 2 6 15 In order for a persons needs 08/01/2009 to be supported and met, the care plan must record all identified known needs. A detailed care plan can inform staff regarding how to support a person. 3 20 13 Regular counts and checks of all the medication in the home needs to occur to ensure people are receiving their prescribed medication. Regular checks can identify medication errors and rectify these quickly. 07/01/2009 Care Homes for Adults (18-65 years) Page 29 of 31 4 20 13 To protect the welfare of the 07/01/2009 people living in the home, the Medication Administration Records need to be an accurate record of the medication in the home, the amount that needs to be administered to people and clearly show any other information relating to the medication a person has been prescribed. These records need to be accurate so that it is clear what a person has been prescribed and has been given. 5 37 8 For the benefit of the home, the Manager must be available and able to give his full attention to managing the home. This ensures the new home has the full attention of a Manager who can settle in the new people living in the home and support the staff team. 30/04/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 23 To protect the welfare of the person and others, guidelines should be in place, so that staff know how to manage and deal with particular vulnerable situations. Care Homes for Adults (18-65 years) Page 30 of 31 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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