Inspection on 19/11/08 for Tennyson Road, 104

This inspection was carried out on 19th November 2008.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tennyson Road, 104 28/12/07

Tennyson Road, 104 20/04/07

Tennyson Road, 104 27/11/06

Tennyson Road, 104 28/10/05

Tennyson Road, 104 17/06/05

Tennyson Road, 104 12/03/05

Tennyson Road, 104 14/09/04

Tennyson Road, 104 06/03/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Tennyson Road, 104 Tennyson Road, 104 Luton LU1 3RP     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: Sally Snelson     Date: 1 9 1 1 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 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Tennyson Road, 104 Tennyson Road, 104 Luton LU1 3RP 01582418858 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Geoffrey Plane,Miss Deborah Newman Type of registration: Number of places registered: care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 8 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 Date of last inspection Brief description of the care home 104 Tennyson Road is a care home, which is registered for a maximum of eight adults with mental health needs. The accommodation is a three-storey house with eight single bedrooms. The office is on the ground floor. It also has sleeping in facilities for staff (including en suite facilities). The lounge, dining room, and the kitchen are also located on the ground floor. The laundry room is located at the back of the house and accessed via the dining room or from outside. There is a small parking space at the front and a garden at the back. The rear garden is secluded and has some shrubs, Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 8 Brief description of the care home trees, flowerbeds, and a small patio area with a barbeque. The home is situated approximately one kilometre from the shopping centre of Luton. A bus stop is located within walking distance of the home. There is a regular bus service to the town centre. The fees for this home vary from 500 pounds to 886 pounds per week according to needs. 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 inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for younger people that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Sally Snelson undertook this inspection. It was a key inspection, was unannounced, and took place from 11.00am on 19th November 2008. Care Homes for Adults (18-65 years) Page 6 of 30 Feedback was given throughout the inspection to the acting manager and to the owner after the inspection. During the inspection the care of two people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. We sent out questionnaires prior to the inspection and received back three from residents and two from staff. The information from the questionnaires was also used to inform judgements about this inspection. The inspector would like to thank all those involved in the inspection for their input What the care home does well: What has improved since the last inspection? What they could do better: There remain some areas that need to be improved. These include the need to:Keep the Statement of Purpose under review and ensure that the Service Users Guide is in a suitable format to be meaningful, and useful, to those using the service. Provide the evidence as to how identified risks are to be dealt with as part of the risk assessment documentation. Show that people using the service make decisions for themselves. Provide the evidence to show that activities offered reflect the residents past interests. Ensure that people using the service are supported to understand and make healthy choices. Care Homes for Adults (18-65 years) Page 8 of 30 Appoint a person to become the registered manager as soon as possible. Ensure staff files include all the information set out in the National Minimum Standards. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service was aware of the need to fully assess and offer pre-admission visits before an admission decision was made. This ensured that the service could provide the necessary support and care, and the potential resident would mix positively with others using the service. Evidence: We were shown two documents that provided information about the home. The Statement of Purpose had been reviewed in January 2008 and included all the information required by the National Minimum Standards, but continued to refer to the previous acting manager as the manager. The Service Users Guide was detailed and included some line pictures, but it was not totally suitable for the clients living at the home to use as a reference guide as to what the home offered and what they could expect from the service. It was too detailed and had some jargon that could be confusing. The Service Users Guide needed to be condensed and made simple. It was not possible to fully assess how the home managed the assessments of new Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: admissions as there had been no new admissions to the home since the last inspection. There was one new person using the service but he had moved from the sister home to 104 Tennyson Rd. He was able to tell us that he had made visits to the home before moving in permanently. The current acting manager also explained that the homes policy had altered and a referral would not be accepted without sufficient details of the persons past history, from the person making the placement. Each of the people using the service had a contract that had been signed by them and the management of the service. The contract included the required information. Since the last inspection we had issued a new registration certificate and the service was now correctly registered to provide care for people of any age with mental health problems. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans had been written in detail and were being reviewed, but in order to ensure that people using the service received consistent support from all staff the details as to how risks should be managed should be included with any assessment of risk documentation. Evidence: It was apparent that the plans introduced, to met the requirement made before the last inspection, were being kept under review and were being altered as situations changed. Residents, and in some cases the residents care manager were agreeing care plans. The people using the service confirmed that they had the right to make decisions, and were only supported with issues such as finances or medication administration, if they had previously agreed this with the staff team. However, on the day of the inspection at about 11.20am, a member of staff asked the residents who were in the home at the Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: time what they fancied for lunch. They all had the option to choose from items that were in the stock cupboard. At 11.45am people were told lunch was ready and one person was back in the lounge, having eaten his lunch by 11.50am. He told us he was not particularly hungry as he had four slices of toast at 9am. This same person was complaining of being hungry by 1.30pm so would have benefited from being asked when he would like to eat. As stated in the last section of this report documents were not produced in a style that would be suitable for all the residents, so they would not necessarily contribute to the development of these. However residents were made aware of what was happening in the home and did appear to be consulted over some issues. Risks to individuals had been considered but still needed more detail to provide the evidence that thorough risk assessments had been carried out. For example in one plan for a person using the service was this statement, At risk of ill health, at risk of not taking regular baths, at risk of high cholesterol. Other than a comment about him needing support with his diet we did not see how the risks were to be managed. Later in the file was further information about risks and risk management, but the reader had to be prepared to read through the file to get the complete picture. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were encouraged to plan how they spent their time. Evidence: At the lat inspection it was noted that there had been a big change in the lifestyle of some of the residents and they were more active and would join in some activities. This trend had continued. However there was little evidence that people were engaging more than they were at the last inspection. None of the residents had been on holiday, but some had been on a day trip to Folkestone, and one resident told us he would like to go and stay there. On the day of the inspection one of the residents went to church and another was at a day centre. One resident had been with a member of staff to pick up something from a DIY store, although he had remained in the car. Another resident suggested to his key Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: worker that they should go to a near-by discovery museum for a cup of tea. In the AQAA we were told some service users refuse to engage with activities provided. More detail in the care plans about what had been offered would support this statement and encourage staff to try different methods of persuasion. Residents were known in the area and one would use a local public house and the local bus service. As described in the staffing section of the report the shortage of staff on duty in the evening did not make it possible to support people to go out in the evening, unless they went out alone. Residents were able to have contact with the family and we were told by one resident that they could have friends into the house but they should not stay overnight and staff should be made aware of their presence. As at the last inspection there was more staff resident interaction and staff did not confine themselves to the office, but interacted with the people using the service. The staff are aware that external day care services have been cut back and must therefore investigate how this can be provided in-house or elsewhere in order to meet residents needs The residents met together and planned the weeks menu. At the time of the inspection none of the residents were working towards independent living skills but some sometimes offered to help with the cooking, the shopping or the laundry. A diary was kept of what was eaten at mealtimes by the residents. Care Homes for Adults (18-65 years) Page 16 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home had built good links with community health staff, but did not always fully support people to make healthy choices. Medications procedures were adhered to and provided good outcomes for people. Evidence: The people living at 104 Tennyson Road were supported by a staff team of both genders. A key working system was in place and residents were aware of who their key worker was, and looked to them in the first instance for support. The residents were able to decide how they dressed and wore their hair, and what time they got up and went to bed etc. Few of the people living at 104 Tennyson Road needed assistance with care, but many needed prompting and intermittent support with care. At the time of the inspection none of the people using the service had nursing needs. Community Psychiatric Nurses (CPN) were frequent visitors to the home and staff had good relationships with them as they did with the GP’s and consultants involved in residents care. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: We would have expected to have seen more evidence that health needs were supported. For example one of the people case tracked had a high cholesterol level and had been advised to reduce his fat intake and loose weight. He requested a cheese omelette at lunch time and was to have fish and chips for his supper. We were told after the inspection that the fish and chips were to be baked in the oven. A staff member did suggest he may like some salad with his omelette but when he refused this bread and butter was offered. Staff also bought him a cake to have after his lunch. This did not demonstrate a good understanding of his health needs. He was however encouraged to go with a staff member for a walk, although this had no purpose. He told us he was walking to help with weight loss and he had lost half a stone. His file suggested that he had initially lost weight but he had not been weighed for more than six months. A resident spoke about wanting to give up smoking. Again an opportunity for seizing the moment was missed, and it was suggested he should see the doctor about this, rather than offering some constructive support. Following the inspection we were advised that the butter referred to a part of the bread and butter would have been a low-fat spread. However eggs, cheese and fried food all have a fat content and would not be advised for someone trying to reduce their cholesterol levels. There had been a huge improvement in the management of medication within the home. A new cabinet had been installed in the home. At the time of the inspection a controlled drug (CD) cabinet was not in place meaning it would not be possible for a resident requiring CDs to remain in the home. We were told that the home had an agreement with the pharmacy that a CD cabinet would be provided if the need arose. Sampling of the Medication Administration Charts (MAR) indicated that charts were signed correctly and that omission codes were also used correctly. Staff also recorded on the back of MAR charts the actions that they took, and why they took a particular action. The medications were regularly audited and there was a running total of the medications held in the home, so that although the amounts of ‘as prescribed’ medication was not carried forward on the MAR chart it was possible to reconcile the medications by checking the stock total. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents had been made aware of how to make a complaint and staff were aware of their responsibility to protect the residents from any form of abuse. Evidence: There had been no complaints made about, or to, the home since the last inspection. All of the residents had been given a copy of the complaints procedure and those residents we spoke to were aware of how to complain. We were concerned that throughout the inspection we saw different documentation that was referred to as the complaints procedure; some of these documents had obviously been superseded as they did not detail how long a complainant would need to wait for a response. It is important that old information is archived. There had been an improvement in the staff teams understanding of safeguarding vulnerable adults (SOVA). All the staff had received training and the home had built up good relationships with the SOVA team and felt supported. Any allegations of abuse, including service user on service user, were now being correctly reported to us via Regulation 37, and to the safeguarding team at the Local Authority. Residents monies were now being appropriately held on their behalf and they were aware of how there money came to them and how much they paid as their contribution to their care. Staff were checking the balances of service users monies at every handover. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: The management of the home were still awaiting the final outcome of an investigation by the Health and Safety Executive into an incident involving a resident jumping from a window in June 2007. Care Homes for Adults (18-65 years) Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was kept clean and tidy and was suitable for the residents needs. Evidence: In the last inspection report it was recorded that, there had been a number of changes to the home, for example the lounge had been cleared of clutter, it had been painted and new curtains hung. The home continued to look clean and there was no obvious smell. However because of the number of residents that smoked the communal rooms had began to look tired and in need of redecoration despite recent redecoration and the addition of an external venting extractor. The home had been inspected by Health and Safety and staff had worked to meet the requirements and recommendations made by them. All windows were restricted, which some of the residents found frustrating during the summer (the manager had advised them about the need for the restriction), and all water was delivered below 43 degrees as recommended by the health and safety inspector. People using the service were now more involved in keeping the home clean and tidy and as a result were proud of their home. Individuals were supported and encouraged to personalise their bedrooms to suit them. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: The long-term plans for the environment that had been discussed with us at the last inspection had not been actioned so the office that doubled up as a sleep-in room remained small and there was a poor distribution of bathing and showering facilities. The residents had been given access to a ground floor shower which was off the office, so they now had a bath, a shower and three toilets, but some still had to move between floors for bathing. The laundry area was separate to the kitchen but access was via the dining room or the outside. Care Homes for Adults (18-65 years) Page 22 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. The staff team were continually sourcing training in order to gain the skills and the experience needed to support and care for the people living at 104 Tennyson Road Evidence: Once again there had been some changes to the staff team since the last inspection. The team had a variety of qualifications and training and the acting manager provided us with a training matrix for the next year, that covered a range of training both mandatory and that that was needed to meet the needs of the client group. We were pleased to see that the proposed staff training included anger management, managing violence and aggression and other areas associated with mental health, as a number of the new staff had not worked in the field before, and consequently did not have the experience. On the day of the inspection four members of staff were doing an external training course. At the time the AQAA was completed there were nine staff employed as care workers, four had a qualification to NVQ level 2 or above and two were working towards this qualification. The level of staffing had been a major concern at the last inspection. There was now a Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: minimum of two staff on duty during the day until 7pm and then one from 7pm to 9pm when that member of staff became a sleep-in. As mentioned in past reports it is expected that younger adults may want to engage in evening activities and this staffing level would not be able to support this. This must be kept under review. When staff were working alone there was an on call system for the senior carers or management to provide support if needed. Staff recruitment files had been tidied and it was much easier to find the information. On the whole the files included all the required information although none had a photograph of the staff member. The acting manager told us that there were photographs of all the staff and the residents displayed in the dining room. We were concerned that in one file we looked at a member of staff working on a student visa (allowing 20 hours of work per week) had ticked on the application form that he/she would continue with other employment. There was no evidence in the interview notes that this had been explored. The acting manager was asked to look into this, and, why a member of staff had started work prior to CRB clearance. The acting manager had the information the next day and it appeared that a pova first had been secured (allowing the staff member to start work with supervision prior to their CRB check), but the pova first documentation was not a file. Also it was discovered that the staff member had not meant to tick the box stating that he /she would continue with their current employment. It was therefore acceptable for this person to be working. However it would be expected that the manager, or the senior staff, interviewing prospective staff would have ensured that they had checked this and recorded the error. We expect to see complete and accurate recruitment files to indicate that recruitment practises are safe and robust. Staff files provided the evidence that staff were having regular supervision. Care Homes for Adults (18-65 years) Page 24 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. There is a need to appoint a registered manager to the service to meet the Care Homes Regulations and to provide consistency to the people using the service and the staff team. Evidence: The manager who had been in post at the last inspection had made many changes to the way the home was run. She had been moved to support a sister home. This had left a gap that was filled by a senior from the sister home acting as deputy and the previous registered manager of the sister home acting as manager (this was a temporary post as he was moving into management of the two homes). The home has been operating without a registered manager for almost three years. The owner had yet to officially inform us that the registered manager for the Beeches was no longer working in that position. The owner told us that it was hoped that a manager could be recruited in the new year and that he /she will be ready to become the registered manager in April 2009. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: Last year the quality of the care provided had been monitored and reported on by sending out questionnaires to a variety of stakeholders. This process was currently be repeated. Staff met regularly for staff meetings and the owner visited regularly and made a report of the visit to met Regulation 26. While there was no registered manager in post the managers from the two homes in the company and the owner met weekly. We looked at health and safety documentation, including the fire log and maintenance book. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis, and that fire drills were carried out periodically. On the whole records were kept well and updated. However we were aware that the record keeping policy had not been reviewed since 2005. Policies and procedures were not in format that would be of any interest to the people living at the home so they were not involved with them. Care Homes for Adults (18-65 years) Page 26 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 34 19Schedule2 Staff files must include all the documents listed in schedule 2 of the National Minimum standards. 01/04/2008 Care Homes for Adults (18-65 years) Page 27 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 9 12 It must be apparent how risks that have been identified are to be dealt with. This will provide consistency in care and support and ensure that the person using the service understands why staff are taking certain actions. 01/01/2009 2 12 12 The service must provide the evidence to show that activities are those which reflect the residents past interests. So residents can continue to take part in activities they engaged in prior to entering the home. 01/04/2009 3 19 13 Staff must ensure that 12/12/2008 people using the service are supported to understand and make healthy choices. Care Homes for Adults (18-65 years) Page 28 of 30 To ensure that people using the service have been offered the best possible outcomes 4 37 8 The service must appoint a person to become the registered manager as soon as possible. To ensure consistency for staff and people using the service. 01/04/2009 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 1 The Statement of Purpose should be kept up-to-date and the Service Users Guide should be in a suitable format to be meaningful, and useful, to those using the service. It should be apparent that people using the service have had more involvement in the service and make decisions for themselves. Consideration should be given to staff providing those day Care activities that are no longer externally provided. Staff must ensure that only one complaints policy is available in order to avoid confusion. Consideration should be given to improving the office/ sleep-in facility. Staffing levels should be kept under review. 2 7 3 4 5 6 14 22 24 33 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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