Inspection on 08/09/08 for The Bungalow

This inspection was carried out on 8th September 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Bungalow 14/11/08

The Bungalow 26/09/06

The Bungalow 07/03/06

The Bungalow 22/08/05

The Bungalow 12/11/04

The Bungalow 24/05/04

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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: The Bungalow Dennes Lane Lydd Kent TN29 9PU     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: Kim Rogers     Date: 0 8 0 9 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 © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: The Bungalow Dennes Lane Lydd Kent TN29 9PU 01797321612 Telephone number: Fax number: Email address: Provider web address: bangalow.lydd@craegmoor.co.uk Name of registered provider(s): Name of registered manager (if applicable) Ms Janet Clayton Type of registration: Number of places registered: Parkcare Homes (No2) Ltd care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 5. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home The Bungalow is registered to provide accommodation and personal care support for up to 5 adults with a learning disability. The property is a detached colt bungalow with five single bedrooms one of which has an ensuite shower and two have a wash hand basin fitted. All rooms have a television point. The clients also have the use of a kitchen, utility, lounge/diner, shower room and bathroom. The bungalow has a well-maintained garden with patio and lawn. There is a parking area to the front of the home. The Bungalow is situated in a quiet lane on the outskirts of Lydd. The Home has transport available for clients. Within Lydd there is a regular Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 5 Brief description of the care home bus service, golf club, pubs and club and a selection of shops. For more information about the fees and services please contact the Provider. 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: 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: The last key inspection of this home was 26/09/06. This site visit formed part of the Key inspection for the service. The Key inspection for the service was brought forward following the Annual Service Review carried out by the Commission on 17/12/07. The site visit took about 6 hours. We spoke to all of the people who use the service, staff and the new manager and made observations. People who use the service showed the inspector around the home. Records were sampled including care plans, medication records and staff records. We looked at information we have received about the home including the Annual Quality Assurance Assessment (AQAA) that homes are now required to complete. This should give information about what the service does well, how it has improved and how it intends to improve further. The AQAA was not received on time but was received after this site visit. The AQAA has very limited information Care Homes for Adults (18-65 years) Page 6 of 31 and does not tell us much about what they do well and how the service has improved. Some requirements and recommendations made at the last inspection have not been met. Although the manager said he is working towards meeting the requirements and recommendations we may now take enforcement action. The fee for this home is about 1700 pounds per week. For more information please contact the Provider. This report shows Janet Clayton as the registered manager. This is because the Provider failed to notify us that the registered manager has left. 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. Care Homes for Adults (18-65 years) Page 8 of 31 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 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 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective and current service users do not have up to date information about the home and services. Needs are assessed before a person moves in to ensure the home can meet the persons needs. Evidence: There is some written information about the home that is displayed in the hallway. Some of the information also has symbols. The information is not up to date. For example the names of previous managers are given as being the current manager. This means that prospective residents do not have up to date information about the home to help them make an informed choice about moving in. The manager said he is aware that the information needs updating and plans to do this. We sampled service user plans and found that assessments of needs are carried out before a person moves in. This enables the manager to ensure that the home can meet the persons needs. A service user told us about the trial visits and stays they had. They said that this helped them to get a taste of what it is like to live at The Bungalow and helped them to make a decision about moving in. Care Homes for Adults (18-65 years) Page 11 of 31 Care Homes for Adults (18-65 years) Page 12 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs and aspirations are recorded but without recorded plans people may not have the support they need. Communication must be better supported so people have the support they need to make choices and decisions. Evidence: We found that each person has a service user plan that they have been involved in writing. All plans look the same. Some people spoke about their aspirations and hopes for the future. We found that needs and some aspirations are recorded but there are no written plans to support individual aspirations and personal goals. This means that people may not get the right support to achieve their aspirations and goals. The manager said he plans to review and update service user plans involving each person. We found that some review and evaluation sheets in care plans are not completed. Without regular effective review peoples changing needs may not be recognised, recorded and supported. Risk assessments are completed when a risk is identified. Service users said they were Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: aware of these risk assessments and agree with them. Risk assessments sampled have a focus on keeping people safe and relate to the persons needs. Some people have communication needs. We found that information about how people communicate needs to be more detailed so staff can give the right support. For example one plan said uses some signs but there was no record of what these signs are and what they mean. Staff talked about how a person communicates but this was not recorded in their plan. The manager said that communication needs have lead to people becoming anxious and frustrated when they cannot be understood. The manager said he has made a referral for speech and language support. A requirement from the last inspection was that staff must have the training and skills they need to communicate with people who use the service. This is because staff must have the skills to support people to be heard and make choices and decisions. The manager said he has arranged this training. 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 opportunities to take part in leisure activities, but more support is needed for life long learning, skills development and employment opportunities. Service users are involved in most aspects of the day to day running of the home. Relationships are supported. Evidence: We found that people have the opportunity to take part in a range of leisure activities held locally. For example some people went to an art and craft session followed by Karaoke during the visit. Some people said they were going to a local disco that night. Others said it was not their thing and stayed at home to do other things. Service users said they go to the local shops and further afield for the food shopping. There is a car for staff to use to access the community. Service users said although they do not choose to attend a local centre there are other opportunities for example going to local Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: markets, charity shops and boot fairs. We found that there are generally enough staff to support activities. Service users said they enjoy camera club held on site one day a week. We found that some people want to get jobs and develop their skills but there are no plans in place to support this. This was also found at a recent internal audit and means that people will not get jobs or increase and develop new and existing skills. The manager said he plans to review service user plans to ensure that personal goals are supported and opportunities increased. The AQAA says they plan to develop opportunities for learning and employment. We found that for some relationships are supported with support needs recorded. Others need more support and this needs to be planned for and supported so people can keep in touch with family and friends and make new friends. Some people meet their friends at local clubs. We found that people are involved in day to day home life like cooking and cleaning. There is a house cat and fish that service users all look after. The manager said there are plans to involve service users further including having more of a say in staff selection. Service users take part in planning and preparing meals and have access to the kitchen for drinks and snacks. The manager said that staff encourage healthy eating. Special diets are supported with information about this recorded in individual plans. Everyone has a key to their bedroom but not all have a key to the front door so have to wait for staff to let them in. A staff member from another home let themselves in without knocking first and this practice should be reviewed. Service users said that staff knock on their doors before coming in. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Facilities and information need to improve to ensure that people have the right support with personal care. People need the right information and support to lead healthier lives. Medication practice is safe. Evidence: We found that basic information about peoples personal care needs is recorded in individual plans. For example one said needs no help From observations and talking to people it was clear some people need more support in this area.Without detailed plans and regular review people may not get the support they need in the way they prefer. Service users said they are all sharing one bathroom as feel the separate shower room is not suitable. The manager agreed and said he plans to improve the shower room and will update information about personal care needs in service user plans. We found that people cannot always have a bath when they choose due a lack of hot water. We found that health needs are recorded in individual plans. Weight is monitored and individual health needs are generally well supported. We found that people need more support about healthier lifestyles. This was a requirement at the last inspection. For Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: example information in a suitable format about giving up smoking and healthy lifestyle choices. The manager said staff try to encourage people to be more healthy and agreed more support may be needed. The manager agreed to ensure that people have the right information and support about more healthier lifestyles.This means that people will have the support they need to remain well and healthy and will enable staff to be more proactive rather than reactive in their support to health matters. We found that medicines are stored safely. We sampled medication administration records (MAR). Most were in order but one record had no staff signature for a medication that should have been administered. This means that it is not clear if the medication had been administered or not. The manager said he is looking in to this. Some guidelines for when needed medication need review. One seen was dated 19/01/04 and talked of the person being unmanageable and for staff to withdraw their support. The manager agreed to review this and said the opposite is necessary in that the person needs more support not less. Some information in service user plans about medication is out of date. For example one plan sampled said the person was taking one medication when in fact they are taking more. Any special instructions about medicines should be recorded in service user plans so people take their medication in the right way. We found that allergies are not recorded on MAR as they should be. Currently staff control medication at the home. Individual assessments have been carried out that require people to be able to open bottles, read, know about side effects of medication and routes of administration. In practice most of these skills are not necessary for people to have more control of their medication. Some assessments showed that people were capable in all 9 areas of the assessment but still have none or little control of their medicines. Service users said they have self medicated in the past and feel they have the skills. No plans are in place to increase these skills at present although the manager said he is in the process of talking to service users about having more control of their medication with the right support. Care Homes for Adults (18-65 years) Page 18 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Action must be taken to address service users concerns and complaints. Staff need training and support to safeguard people from harm and support challenging behaviors. Evidence: We found that there is a written complaints procedure. We found that not all complaints and concerns raised have been listened to and acted on. This was also found at a recent company internal audit. This means that service users continue to be unhappy about aspects of the service. As previously mentioned, staff need training to give them the skills to communicate with service users so they know when people want to complain or make a disclosure. There is a policy in place to safeguard vulnerable adults who use the service. There has been an adult protection alert since the last inspection. This was investigated by the adult protection team at social services and is now closed. We found that not all staff have had training in how to safeguard vulnerable adults so they may not have the skills to recognise and respond to possible abuse. The manager agreed to address this by organising training. We found that aggressive and challenging behaviors are not well supported. Guidelines are contradictory and speak of people being unmanageable and tell staff to refuse to interact or acknowledge the person This information was dated 19/1/04 and showed no review or agreement from the service user about the withdrawal of staff support. Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: The manager said in fact the opposite is needed in that the person needs more support not less. The manager agreed to update the guidelines with the service user. We found that incidents of aggression are not monitored so support stays the same and incidents continue. Care Homes for Adults (18-65 years) Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are needed to the environment to make the home a welcoming, safe, clean place to live. Evidence: A tour of the home was made with service users. We found that parts of the home are in need of improvement to enhance peoples lives and make the home more comfortable. For example in some parts of the house there are offensive odours, some carpets are worn, faded and stained and parts of the exterior need repair. People smoke outside at the back of the house by the lounge. The doors to the house were left open while people smoked causing smoke to come into the house. Some furnishings and fittings need cleaning or replacing. For example some of the sofas are stained. The home lacks a welcoming feel, for example there are piles of leaves, cobwebs and bird droppings on and around the front door. The manager said he has implemented a cleaning schedule following a recommendation from an internal audit. Service users said they have support to clean their rooms and the house and one person was vacuuming during this site visit. All bedrooms are single and all but one have a wash hand basin, there are no en suite rooms. As mentioned service users said they are all sharing one bathroom and toilet as they feel the shower room is unsuitable. The bathroom being used needs improving. There are stains in the bath Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: and the shower curtain is hanging from some of its hooks. The mirror and some tiles are chipped. Service users said they would like a new lounge carpet and new bathrooms. The AQAA says they plan to improve the environment over the next 12 months. Due to the amount of improvements needed to bring the home to an acceptable standard for service users a requirement was made for the home to produce a time bound development plan to address the environmental issues. Service users said they have keys to their rooms but not to the front door. This means that they have to wait for staff to let them in. People have a safe place to keep their valuables and rooms seen were personalised. During the visit a staff member from another company home let themselves in to The Bungalow without knocking. This disrespectful practice should be reviewed. Part of the garden is currently restricted due to a fallen branch, otherwise there are no environmental restrictions imposed so people can access the kitchen and garden freely. There is a separate laundry room and service users said they have support to do their laundry. To help infection control hand washing facilities should be provided in the laundry. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to meet peoples needs. Recruitment checks are carried out so service users are protected. Staff need mandatory training as well as training related to service users needs so they have the skill sand competencies to provide better support. Evidence: We found that there are usually two members of staff on duty throughout the day and night. The manager said the home is now fully staffed and some staff are longstanding so know service users well. Although there is no rota displayed service users said they know who is on duty as staff work set shifts as part of a rolling rota. Service users said that staff are usually available when they need support. The manager said he has recently recruited a new member of staff. Recruitment checks are carried out to ensure service users are protected. The manager and Human Resources department carry out these checks. The manager said that service users meet prospective staff when they come to look around the home and have an interview. He said there are plans to involve service users more in recruiting staff. This means service users can have a say about who may potentially support them. Staff training records were sampled and we found some shortfalls in mandatory training including fire, first aid and safeguarding vulnerable adults. The manager said Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: this has been identified recently and he plans to organise the required training for staff. A requirement was made at the last inspection that staff have the skills they need to communicate with service users. This requirement has not been met, however the manager said that he has now organised this training. Staff generally have access to mandatory training but training related to service users specific needs including alternative communication, learning disabilities, person centered planning is limited. Less than 50 of staff (the Minimum Standard) have a National Vocational Qualification in care. We found that staff supervisions (one to one meetings) and staff meetings have not been held as often as they should. This means that staff have not had opportunities to discuss work related issues, concerns, make suggestions etc. The new manager has realised this and held a staff meeting on 31/7/08. He has met with most of the staff team individually for their supervisions and plans to have more regular meetings. Care Homes for Adults (18-65 years) Page 24 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of consistent management has meant some support systems, reviews and checks have not been done. Systems are in place to ensure improvements are made based on views of people who use the service. Action must be taken to protect peoples health and safety. Evidence: We found that the management of the home has been inconsistent with no Registered manager for some time. There is now a permanent manager in post who has transferred from another company home. He has several years experience in working with people with a learning disability and has been with the company for eight years and at The Bungalow for two months. The manager has applied to be the Registered manager. This means that he can demonstrate to people who use the service that he is a fit person to manage the home. He has a Registered Managers award qualification which is a combination of the National Vocational Qualifications in care and management. He said he has no formal qualification related to service users needs for example learning disabilities. This means that he may not be up to date with latest Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: research and developments in this area. Homes are required to complete an Annual Quality Assurance Assessment (AQAA) each year. The home failed to return their AQAA by 12/06/08 as required. The manager sent the AQAA to us after the site visit on 10/09/08. The AQAA has very limited information about how the home has improved since the last inspection, suggesting the manager had a limited handover about any improvements. We found that staff meetings and staff supervision is below the Minimum Standard. The manager said he has held a staff meeting and has started to supervise staff. He has identified areas that need to improve. We found that there are quality assurance systems in place. People who use the service are supported to give their views at regular residents meetings. We found that some people have made requests and suggestions in the past that have not been acted on. The new manager is addressing this. For example by improving the cleaning and cooking rota at the request of service users. The manager said that surveys are sent out to service users and their relatives although he is not aware of any responses or feedback as replies go to the company head office. He said that any issues that need action would be sent to him. We found that results from this surveying exercise are not published so service users and other stakeholders do not know the outcomes and any actions. We found that a detailed internal audit was carried out recently. Service users were involved in this audit and some recommendations for improvement were made. These include improvements needed to care planning and supporting people to increase their skills. Recommendations were made to improve the environment, act on all complaints and ensure the home meets fire regulations. The new manager said he is working through the recommendations. The service will soon be reassessed for the Investors in People Award which is an independent quality audit. We found that not all staff are trained in areas relating to health and safety including fire safety and first aid. Some staff have not attended a fire drill and therefore have not had a chance to practice evacuating the building etc. This means that service users may not be in safe hands. We found that a fire risk assessment about the building has some recommendations that have not been met. This means that there are potential risks to service users so a requirement was made to address this. We found that not all incidents have been reported as they should be. Complying with this regulation was a requirement made at the last inspection. We found a serious incident and other events have not been reported. This regulation is important to safeguard residents wellbeing, and so because this requirement has not been met a statutory requirement notice may be issued. The manager said he will ensure incidents are now reported as required. We found that an incident had occurred recently. This had been recorded by staff but Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: there is no action recorded as to what steps will be taken to prevent it happening again. The report was in a file and the manager said incidents are not monitored. This means that any possible pattern may not be seen and support may not be changed accordingly. A service user said he was not happy about this incident. We found that nothing had been done to prevent it from happening again. Current information about the service including the service user guide, statement of purpose and registration certificate have incorrect information and need updating. The manager agreed to do this. We found that information about service users is not held securely. For example care plans and medication records were on a chair in the dining area. This means confidentiality and privacy is not protected. The manager agreed to address this. Care Homes for Adults (18-65 years) Page 27 of 31 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 42 37 Any event affecting the well being of service users or the running of the home should be reported to CSCI in writing within 24 hours 26/10/2006 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 24 16 To ensure that the home is safe, clean and well maintained the manager must develop a time bound improvement plan. To ensure the home is suitable for service users needs and a nice place to live 31/10/2008 2 42 23 The registered provider must ensure that the home meets fire safety legislation and meets requirements of any fire risk assessment. To ensure that service users are kept safe. 31/10/2008 3 42 23 The registered person must ensure that all staff are trained and competent in fire procedures. To ensure that staff know what to do in the event of a fire. To ensure that service users are safe. 31/10/2008 Care Homes for Adults (18-65 years) Page 29 of 31 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 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. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!