Inspection on 25/09/08 for The Willows

This inspection was carried out on 25th September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Willows 22/09/09

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Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: The Willows 30a The Finches Bexhill-On-Sea East Sussex TN40 1UF     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: Caroline Johnson     Date: 2 5 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 32 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 32 Information about the care home Name of care home: Address: The Willows Bexhill-On-Sea 30a The Finches East Sussex TN40 1UF 01424732935 01424751641 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Iswaraj Sunassee Type of registration: Number of places registered: Hastings and Rother Primary Care Trust care home 6 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 6. 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 Willows is a purpose built bungalow situated in a quiet residential area of Bexhillon-Sea, with nearby access to local amenities, bus and rail routes. The home is registered to accommodate six adults with learning disabilities, some of whom also have physical disabilities and a visual impairment. Accommodation is provided in six single bedrooms that are decorated and furnished to reflect individual tastes and interests. Communal space is provided by way of a lounge and kitchen/dining room. There is also a large conservatory that has been furnished as a sensory room. Care Homes for Adults (18-65 years) Page 4 of 32 Over 65 0 6 Brief description of the care home Bathroom and toilets offer the appropriate adjustments and facilities to meet the needs of the people who live there. The home has an attractive garden to the side of the property and off road parking is available at the front of the home. In April 2008 Hastings and Rother PCT became the registered providers for this service taking over from the Kent & Medway NHS and Social Care Partnership Trust. The Trust manages nine other homes within the Hastings, St Leonards and Rother area. See summary section for information regarding fees. Care Homes for Adults (18-65 years) Page 5 of 32 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: For the purpose of this report the people living at the Willows will be referred to as residents. As part of the inspection process a site visit was carried out on 25 September 2008 and it lasted from 9.55am until 4.30pm. The registered manager facilitated the inspection. Over the course of the inspection there was an opportunity to meet with and to spend time in the lounge with all of the residents. In addition time was spent with two members of staff in private. A full tour of the home was undertaken. Two care plans were examined in detail. In addition records seen included; staff rotas, training, medication, menus, health and safety, quality assurance and leisure activities. Care Homes for Adults (18-65 years) Page 6 of 32 Care Homes for Adults (18-65 years) Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: The arrangements in place for formal day care need to be reviewed to ensure that residents receive a regular and consistent day care package. The arrangements in place for the management of residents DLA (disability living allowances) need to be clarified with their relatives and/or representatives. Monthly visits carried out by the senior management team need to be more detailed, need to identify shortfalls observed, how they are being managed and any impact the Care Homes for Adults (18-65 years) Page 8 of 32 shortfalls have on the quality of care received by the residents. One of the shower facilities has been broken for some time and needs to be repaired. Action also needs to be taken to address the recommendations made as part of the homes fire risk assessment. The home needs to keep a record of all correspondence made on behalf of residents. 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 32 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 32 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. Work is underway to ensure that prospective residents receive information about the services on offer in a format that can be easily understood. Evidence: Since the last inspection the statement of purpose and the service user guide has been updated. However, since then the care provider has changed. Within the organisation a working party was set up to develop a new generic statement of purpose. A copy of the document has been received by the home and the manager advised that he needed to make alterations to the document to add specific information about the Willows. Following the inspection, the Commission has received an updated statement of purpose. Each resident has a service user guide, which is located in their individual bedroom. Work is underway to ensure that each guide is in a format that is appropriate for each resident. For some this means having a guide in a pictorial format and for others this will mean having an audio guide. Work has started on this. Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: The property is owned by Hastings and Rother PCT and leased to Kelsey Housing Association who are the registered social landlords, RSL, and responsible for cyclical maintenance and decoration of the home. There is a licence agreement between the housing association and the PCT as the care provider and in addition there is a terms and conditions of residence which is a contract between the PCT and the residents. Both these documents have yet to be updated to reflect the changes in the care provider. There were no vacancies in the home at the time of inspection. There is a detailed assessment in place of each residents abilities and needs and this is updated at regular intervals. In each of the care plans seen there was detailed information about the residents ability to communicate. As residents have limited communication skills the form included detailed information about the gestures or vocal sounds made by residents, what it is thought they mean and how staff should respond. Care Homes for Adults (18-65 years) Page 12 of 32 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. The progress made to date to improve the quality of care plans is good. However, improved record keeping demonstrating work undertaken would enhance the quality of the care plans even further. Evidence: Two care plans were examined in detail. Since the last inspection extensive work has been carried out to improve care planning and to use the PCP (person centred planning) approach. Support plans have been compiled using this approach. Each resident has a PCP meeting every six months and as part of this process opportunistic goals are discussed. This often includes ensuring that residents have opportunities to go to the theatre, to go on holiday, to use restaurants or regular cafe trips. The home has yet to draw up any skill development goals. The manager advised that the placing authority is always invited to reviews held but Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: that they rarely attend. A record is not currently kept of the invitation or whether minutes of the meeting are sent to the placing authority. In each of the care plans seen there were detailed risk assessments in place, which had been reviewed and updated regularly. However, risk assessments have yet to be transferred to the PCP system. Each of the residents has a support record where staff record information about the support they have provided over the course of the day and there is space to record whether the resident enjoyed the activity, what worked well and what didnt work so well. Records seen provided limited information and generally related to the mood of the resident saying they were happy. If a resident had one to one reading it doesnt say what was read to them. If they were involved in food preparation it doesnt say how they actually participated. There was however, an example in each folder showing how the form should be completed. Staff spoken with confirmed that residents make simple choices throughout the day such as a choice of drink or choosing clothes. Some residents are more able to make choices than others. Where possible staff use photos and for some it would be giving a tactile choice. Record keeping does not current demonstrate the choices made by residents. Care Homes for Adults (18-65 years) Page 14 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff work hard to ensure that residents are offered a variety of activities on a daily basis. A further review of the formal day care arrangements would enhance this further. Evidence: The PCT have a contract with MCCH to provide day care for the residents. It was reported that the contract is still under review. Since April the understanding was that MCCH would provide a worker three days a week and that activities would either be based at the Willows or in the community. This worked well initially and a two-week timetable was provided in advance, but as a result of staffing problems at MCCH, this is currently not working so well. Staff reported that the designated worker for the Willows knows the residents well and the residents all respond well to them. However, as there is such a shortage of staff at MCCH, the frequency of sessions available to the Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: home has greatly reduced and there is often no notice given of whether activities are going ahead as planned or not. In addition the home often has to take residents to their MCCH activities so this can have an impact on arranging activities for other residents. In addition to the planned MCCH activities, the home also has a plan of activities throughout the week. The plan is a guide and will often change depending on what is going on in the home on a particular day. Records show whether the activity has taken place and if not what alternative was provided. Records rarely show the reason why an activity has not taken place. Records show that residents make use of the community regularly and have opportunities to be involved in both leisure and sensory activities. However, the purpose of the activities is not always recorded, so it is therefore difficult to make a judgement about the quality of the activities provided. During a tour of the premises it was noted that one resident was in their bedroom listening to a talking book, two were in the conservatory having hand massages and the remainder were listening to music in the lounge whilst a staff member was reading 1:1 with one of the residents. A staff member advised that they had recently been on holiday with one of the residents and that the resident had opportunities to do rock climbing, canoeing, archery, abseiling, and zip wire. Visitors are welcome to the home at any reasonable time. Staff support residents to keep in touch with their friends from other services and to maintain contact with their families. Staff support residents to be involved in as many tasks around the home as possible. This could include actual involvement in meal preparation, observation of meal preparation or being in the room for sensory stimulation. There is a four-week menu in place, which is varied and well balanced. If there are any changes to the menu these are recorded. Staff advised that if a resident refuses a particular meal they are given a suitable alternative. It was reported that a staff member is due to attend a nutrition course so it is hoped that on completion this staff member will be able to use her new knowledge to improve the menus even further. Care Homes for Adults (18-65 years) Page 16 of 32 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. There are good arrangements in place to ensure that the healthcare needs of the residents are met. Evidence: The arrangements in place for the storage and handling of medication were in order. However, in relation to the administering of invasive medication it was noted that the instructions on the Mar chart had been crossed out and staff were advised to refer to individual guidelines within care plans. This needs to be raised with the pharmacy and if the individual guidelines are to be used then the MAR chart should be amended and a copy of the guidelines should be kept in the Mar chart. Some of the residents receive specialist advice and support in relation to their health care needs. Guidelines draw up by professionals are included in individual support plans. Each of the residents has a health action plan in place and it is reviewed regularly to ensure that individual needs continue to be met. It was noted that there were particular concerns relating to one residents health. The Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: home had taken appropriate action and was working closely with other professionals to ensure appropriate treatment was being provided. In addition they had obtained detailed information about the residents condition and what to expect and had also obtained audiotapes so that the condition could be more easily explained to the resident. Residents are supported to attend healthcare appointments such as chiropody, dental and opticians on a regular basis. A monthly check is also kept of each residents weight. The wishes of residents in relation to dying and death have not yet been assessed. Care Homes for Adults (18-65 years) Page 18 of 32 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. There are procedures in place to ensure that anyone wishing to make a complaint can do so. The management of residents allowances needs further clarification. Evidence: There is a detailed complaint procedure in place. In addition a simplified version of the procedure is on display in the home and a copy of this is also included in the service user guide. The manager advised that the guide would also be put onto an audiotape in the near future. A record is not currently kept that the procedure has been explained to individual residents. Records showed that the last recorded complaint was made in 2004. There is a procedure in place on the protection of vulnerable adults. A copy of the Sussex multiagency guidelines on the protection of vulnerable adults is also available in the office for staff to refer to. Staff spoken with were clear about the action that should be taken should they suspect abuse. Residents finances were not examined in detail. Records seen in relation to daily expenditure were in order. The arrangements in relation to the management of DLA (disability living allowances) monies need to be clarified. Care Homes for Adults (18-65 years) Page 19 of 32 Care Homes for Adults (18-65 years) Page 20 of 32 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 generally well maintained and provides a good standard of accommodation for the residents. Having full use of all shower facilities would enhance this further. Evidence: Communal areas consist of a large lounge area and a separate large dining room/kitchen area. The large kitchen enables residents to spend time in this area either observing meal preparation or assisting with these tasks. In addition there is a conservatory, which is used as a sensory room. There is a large garden to the side and front of the property. A gazebo was purchased this summer but due to the poor weather it had very little use. Each of the residents has their own chair for relaxing in, which is stored in the conservatory. Staff advised that as some of the residents have had the chairs a long time they are now being reassessed to ensure that they continue to meet their needs. Bedrooms are well decorated and are homely in design. Some of the residents have sensory equipment in their rooms. A number of the bedrooms have been redecorated since the last inspection. Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: There is a large bathroom with a spa bath and a shower facility. In addition there are a further two shower rooms. One of the showers is broken and has been broken for some time. Records showed that this issue has been raised with the housing association on a number of occasions and that a formal complaint has also recently been logged. With the exception of one new member of staff all of the staff team have had training on infection control. Arrangements have already been made for the one staff member to attend this training. All areas of the home seen during the inspection were clean. Care Homes for Adults (18-65 years) Page 22 of 32 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. Staff are provided with regular opportunities to update their knowledge and skills to meet the needs of the residents. Evidence: Since the last inspection two new staff have been recruited to work in the home. The manager advised that he was not part of the interview panel as he was on leave but that he did have an opportunity to meet with both staff prior to appointment and he looked at all the recruitment records. The manager advised that following the first interview a second stage interview was held at the home and this included an opportunity for the applicants to visit the home and to spend time with the residents. A record was kept of how well applicants interacted with the residents and how residents responded to the applicants and this feedback formed part of the decision making process. Recruitment records are stored at the head office so an examination will be carried out of record keeping in relation to this separate to this inspection. It was reported that generally there are always three care staff on duty on each shift and that the managers hours are now supernumerary. Where there is staff sickness Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: the home are now able to use agency cover and they will always try to ensure that there are three carers. On very rare occasions they work with two carers. The rotas seen showed that there was always a minimum of three care staff on duty. A training matrix is on display in the office. This shows that the majority of the staff team are completely up to date with mandatory training. There is a system in place to show when refresher training is due and this ensures that there is time to arrange further training. There was evidence that where there were gaps in training a refresher course had been booked. A staff member spoken with stated that this new system is a great asset to the home as staff training is now rarely out of date. In addition to mandatory training there are a number of courses that are regarded as essential for working at the Willows. These courses include epilepsy, communication, eating and drinking and visual impairment. Staff have received training in all areas except working with people with a visual impairment. However, the manager demonstrated that he had looked at a number of courses to determine the most appropriate and it is hoped that this training will be arranged in the near future. New staff complete the organisations induction to the service and following this they then go on to complete the Learning Disability Qualification, LDQ. It was reported that six of the staff team have completed NVQ at level two or above and a further three staff are currently studying for NVQ level three. Staff spoken with confirmed that they receive regular supervision. Dates for supervision are recorded throughout the diary so it was not possible to determine at a glace if staff were receiving regular supervision. A staff member spoken with stated that their supervision was overdue but that a date had been booked. Another staff member advised that they are receiving regular supervision and that they value this support. Care Homes for Adults (18-65 years) Page 24 of 32 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 home is run well in the interest of the residents accommodated. More thorough Regulation 26 reports would demonstrate that the provider is being kept informed of all shortfalls and what is being done to address them. Evidence: The registered manager is a qualified nurse holding the RNMH. In addition, along with a number of other qualifications he has also completed the Registered Managers Award. The deputy manager is also a qualified nurse holding the RNLD qualification. The manager and staff spoke about the number of positive changes that have happened since the change in the care provider. One very positive change is that the home now has their own computer, which means that all administrative tasks can be carried out at the home rather than at the head office. The handover system between shifts was discussed and it was noted that a daily record is maintained of the location of particular medication and that residents finances have been checked. Staff also advised that they check the diary and Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: communication book. Discussion was had about how the handover system could be improved particularly for the benefit of staff that have been on leave and for agency staff. As part of the homes quality assurance system satisfaction questionnaires are sent to the relatives of the residents. Records showed that two had been sent out and two returned. There was no indication of the outcome. The manager advised that if there had been issues raised he would have been asked to respond. The PCT have also introduced a new tool to assess the views of the residents on a range of topics. To date three different questionnaires have been completed, one with three residents and the other two with one resident each. The manager advised that they are building up a bank of photos to assist in developing this further. However, as only two of the residents would be able to respond to questions using photos they need to find other ways of demonstrating that residents are satisfied with the quality of the care provided in the home. A member of the senior management team visits the home once a month unannounced to report on the conduct of the home. Records showed that visits last from forty minutes to one hour and fifteen minutes. A number of maintenance tasks that are outstanding had been highlighted along with the action taken by the manager to try to address them. However, the views of the staff team that were met with are not recorded, equally the problems with inconsistency of the day activities are not highlighted. During the last visit there was a record of a possible adult protection issue but no reference to what it was about or how it was being managed. In advance of the inspection process service user surveys and health care professional surveys were sent to the home to distribute. Staff completed the service user surveys with the service users but as the majority of the residents are unable to communicate, the comments provided were that of the care staff rather than of the residents. No professional surveys were returned. Fire drills are currently held twice a year and a detailed evaluation is kept of the outcome. It was reported that staff generally know when a drill is to be held. In addition to the drills there are regular staff briefings on fire safety. A fire risk assessment was carried out in July 2008. The manager advised that three recommendations were made as a result of this but that they have yet to be acted upon. He has advised the housing association of the recommendations and is awaiting a response from them. On reading through residents notes it was noted that the house minibus was involved Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: in a minor collision in August. Two residents were in the car at the time. The manager advised that an incident form was completed and that residents were checked over and there were no apparent injuries. This incident was not reported to the Commission. Two other incidents that occurred in the home, since the last inspection, had been reported. The manager advised that the PCT are in the process of updating the policies and procedures manual and that as new procedures are updated they are sent to the homes to include in their house manuals. Care Homes for Adults (18-65 years) Page 27 of 32 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 32 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 10 17 The registered person must 30/01/2009 ensure that a copy be kept of all correspondence entered into and received on behalf of a resident. Residents need to know that information about them is handled appropriately. 2 12 16 The registered person must ensure that a further review of the day care arrangements be carried out. Residents need to be able to take part in a range of age, peer and culturally appropriate activities. 27/02/2009 3 21 12 The registered person must 28/02/2009 ensure that an assessment is carried out in relation to the needs/wishes of residents in relation to dying and death. If necessary relatives and/or representatives should be consulted on this subject. Care Homes for Adults (18-65 years) Page 29 of 32 The ageing, illness and death of residents must be handled with respect and as individuals would wish. 4 23 17 The registered person must 27/02/2009 clarify the arrangements in place for the management of (disability living allowance) payments. Residents must be protected from abuse. 5 24 23 The registered provider 31/01/2009 must ensure that the broken shower be repaired. In addition all areas identified in the homes fire risk assessment must be addressed. Residents must have a comfortable and safe environment. 6 39 26 The registered provider 30/01/2009 must ensure that more effective monitoring is achieved through Regulation 26 conduct visits of the home. The provider must be kept informed of all improvements/shortfalls in order to gain an informed opinion of the conduct of the home. 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 32 1 7 Support records should provide more detailed information about the support given to residents and the outcome. The home should find ways of demonstrating more clearly how residents are making choices and decisions. If an activity has not been carried out as planned the reason should be documented. The registered person should clarify with their pharmacist and gp the advice given on the MAR chart in relation to the management of invasive medication and if the home are to use the in-house guidelines this should be stated in the MAR chart and a copy kept with the MAR chart for reference. The home should review the handover system between each shift. 2 3 13 20 4 38 Care Homes for Adults (18-65 years) Page 31 of 32 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). 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