Inspection on 17/03/09 for Victoria Cottage

This inspection was carried out on 17th March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria Cottage 15/03/07

Victoria Cottage 23/11/05

Victoria Cottage 17/05/05

Victoria Cottage 14/12/04

Victoria Cottage 22/06/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 07/08/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Victoria Cottage Victoria Cottage 37 St Andrews Road Bedford Beds MK40 2LW     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: Andrea James     Date: 1 7 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Victoria Cottage Victoria Cottage 37 St Andrews Road Bedford Beds MK40 2LW 01234271225 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Victoria Cottage Limited care home 14 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Any service users who have physical disabilities in addition to their learning disabilities must be provided with a bedroom on the ground floor. The home is permitted to accommodate one named service user over the age of 65 years. The home may also admit up to 2 service users who have a physical disability in addition to their learning disability. The home shall only admit service users between the ages of 18 and 65 years. Date of last inspection Brief description of the care home Victoria Cottage is located in a pleasant residential area of Bedford within walking distance of the local park and the town centre. The home is registered to provide for Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 0 14 14 Brief description of the care home fourteen younger people who have a learning disability, two of whom may also have physical disabilities. Most people go out from the home during the day to various day care activities, although the home also provides day care for two people. The accommodation is arranged over two floors with single bedrooms on each floor and a double room on the ground floor. Each bedroom has a washbasin facility and a call bell. Eight of the bedrooms have ensuite shower facilities. Two of the bedrooms share the ensuite facility. A combined shower toilet room is located on the lower floor and a separate toilet is located on the upper floor. The communal facilities of a large lounge, an all weather conservatory and a dining room are all located on the ground floor. To the rear of the property is a well-maintained garden with an enclosed pond. The fees for this home vary from £405.00 to £1000.00 per week. 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 was an unannounced inspection undertaken on the 17th of March 2009 by Andrea James. The manager was present throughout the inspection process which lasted for eight hours. The inspection followed a case tracking methodology where a sample of people were chosen randomly. These peoples files were inspected in detail, their key workers spoken to and where possible these people were interviewed. The report also consists of information received from people not being case tracked and other staff members. The case tracking methodology was used in order to identify what it was like for people living at this service. The methodology explores in detail all aspects of peoples lives. Observations of care practice and communication between the people who use the service and the staff was also undertaken in this inspection. The focus of the inspection Care Homes for Adults (18-65 years) Page 6 of 30 was to undertake a key inspection by looking at the key standards and follow up previous requirements made at the last inspection. What the care home does well: What has improved since the last inspection? What they could do better: The service should ensure that all records necessary to promote the welfare of people are audited and in place at all times this includes satisfactory information for recruiting staff members. 5 staff members failed to have satisfactory evidence on the day of the inspection that their immigration status was satisfactory. Since the inspection evidence for 4 people was produced but one staff member had to be suspended. Effective Manual Handling assessments should be made available for identified people to avoid unnecessary risk to their health or safety and risk assessments should be implemented for people where the activities undertaken could result in possible harm. The service should also ensure Health Action plans are made available for all people who use the service in ensuring their medical needs are assessed. The care plans Care Homes for Adults (18-65 years) Page 8 of 30 should reflect accurate and measurable interventions that ensures care staff are able to offer a consistent service delivery to people who use the service. The health and safety within the home should be reviewed to ensure all areas protect people from trips and falls. The environmental standards should be improved to ensure satisfactory furnishings such as settees and curtains are replaced to provide a comfortable home for people who use the service. Appropriate assessments should be undertaken to ensure peoples liberty is not compromised where they are expected to share bedrooms. Homely remedies should be clearly identified and evidence of medication reviews should be made available. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service received information about the facilities provided by the home and were assured that comprehensive assessments would be undertaken but further development was needed to ensure these documents are updated and reviewed on a regular basis. Evidence: The home had a Statement of Purpose that detailed the aims and objectives of the service. We saw information such as the qualifications of the manager which was updated on 17/03/09. The rest of the information in the document had not been updated since 2006, for example the complaints procedure still had the address for the Commission which had changed two years ago. The Service User Guide was also available for inspection and this document showed pictures of the home and the key facilities available for people who use the service but again some information was outdated and needed to be updated. Information seen on the care plans suggested people received a comprehensive Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: assessment of need which was updated in the plans inspected. The assessments were detailed and covered areas such as accommodation, communication,personal support, oral health, eating, weight, physical/ mental health, behavioral and sexual needs. We inspected three peoples files and found in all cases that contractual agreements were in place and were signed and dated accordingly. 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. The service helps to promote peoples choices and decision making but further development was needed to ensure the care interventions are measurable and effective manual handling assessments are in place. Evidence: All the people who use the service have a support plan available. We inspected in detail three of these plans. For one person the support plan followed a Person Centered Approach but this had not been developed for the other plans inspected. The support plans showed that reviews were undertaken annually. Guidelines were in place for staff to know how to deal with peoples behaviors and some information was graphically illustrated in order to meet the needs of people with limited understanding of their needs. There were also behavioral management plans that were tailored to deal with verbal or physical aggression. The interventions were not clearly recorded in these plans but instead the service produced objectives where areas of need were identified. There was therefore a need Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: for the support plans to have clear interventions that could be measurable and specific in what staff needed to undertake in meeting the needs of people who use the service. We identified that several people had in place risk assessments these included risk assessments for epilepsy, dressing, choking, drinking, healthy weight, bed rails, accessing transport and evacuating the building. We were concerned that despite the service having people who were totally reliant on being moved by the care staff they failed to have a manual handling assessment in place. Staff spoken to were able to demonstrate how they transferred people and confirmed that they had some guidelines to follow but their was a lack of assessments for effective handling in place. One person case tracked also failed to have risk assessments for violent outbursts despite the staff team being able to confirm that she regularly threw objects at staff and other users. There was evidence to suggest people were able to make decisions about their lives with assistance as required. One person had informed the manager that he felt that he needed to move onto a more independent accommodation as the environment was too noisy. The home had shown that they were listening to this person and had put in place effective measures to ensure this persons needs will be met in the future. Other people spoken to were able to confirm that they were able to access community resources such as day centers and shops. People were seen to be able to participate in aspects of home life. One person was proud to show us his bedroom where he said he cleaned on a weekly basis. The staff team informed us that some people were also supported to undertake their own laundering of their clothes and we observed some people preparing snacks and assisting with the preparation of the evening meal. 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. People who use the service have good links with the community and opportunities for personal development was evident in the way people were encouraged to enjoy their lives. Evidence: We were able to see recorded evidence that people were given opportunities for personal development. In several cases people were encouraged to access day centers, attend therapeutic sessions and visit families and friends. People spoken to said they were given opportunities to develop. We saw evidence where one person made a written contribution to asking for what he wanted within his review process.On the day of the site visit 6 of the 13 people were at various day centers. For other people the opportunities were more limited and staff commented that some people failed to have enough structured activities. We failed to see any activities Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: offered to some people on the day of the site visit. Several people were seen watching television or just walking around the home. Entries made within the records suggested people were offered some activities but this was more evident for some people than others. We saw evidence to suggest one person who needed one to one care was offered a structured activity and was enabled to engage in community activities. The meals offered to people appeared health and well balanced. On the day of the site visit we saw several freezers , cupboards and store rooms that had sufficient food to be able to meet the needs of people who use the service. On the day of the visit people were observed helping to prepare the evening meal, while others were supported to make their pack lunches in preparation for the following day. People spoken to at the dinner table the meal they were eating tasted very nice. 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. The personal health support given to people who use the service was satisfactory, but further development was needed to ensure procedures are implemented in regards to the safe administration of PRN medication and homely remedies for people using the service. Evidence: The personal and health care support provided by the service ensured peoples emotional and physical health was met. Records inspected showed that the service enlisted the support of external professionals to ensure peoples best interests were being maintained. Case records inspected showed that peoples needs were being met in regards to their current placement where assessments were being made to determine if the placement is still appropriate to meeting their needs. The home had satisfactory policies and procedures in place for the safe receipt, recording and administration of medication. Records inspected showed that 9 staff were trained to be able to administer medication. Training was being offered by Boots pharmacist and one staff member spoken to was able to confirm that he was due to embark on the training in the week following the inspection. This member of Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: staff also confirmed that he had to do in- house medication training and shadowing before he would be allowed to administer medication to people who use the service. Other members of staff spoken to said they had to do annual refresher training on medication. Records inspected confirmed that 12 staff members had received the training. The procedures for administering medication showed that two members of staff had to administer the medication to people at all times. The medications were stored in colour coded blister packs and locked away in appropriate metal cabinets fixed to the office wall. Some people were encouraged to self- medicate with the support of the staff team. The home had some homely remedies such as olive oils to be administered to people but one bottle inspected failed to show who the oil was for and when it was opened. We also saw paracetamol tablets that were two years old still being administered to two people who use the service as a homely remedy. The manager said the people who use the service receives regular reviews but this could not be evidenced. The returns procedure seen needed to be reviewed as the home did not return medication on a regular basis. The records seen suggested staff would store medications to be returned for more that two months. The home regularly administered PRN medication to people who at times can challenge the service but we failed to see guidelines for when these medications should be administered. The staff member said they did not have these in place but the manager later said this was in place for some people as they worked with external professionals such ad psychiatrists to ensure consistency for the staff team. The procedures for dealing with ageing and the death of people who use the service was in place for people. 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. The complaints and safeguarding procedure in place ensured people were listened to and protected. Evidence: The home had complaints procedures in place that ensured people would know how to complain. Since the last inspection the service received 7 complaints and the records inspected suggested most people received a response to their complaints and investigations were undertaken by the manager to satisfactorily resolve each complaint. One safeguarding referral was made since the last inspection. The Commission was made aware of this which was investigated within the procedures of the safeguarding board and resolved satisfactorily. Staff spoken to said they were aware of the safeguarding procedures and confirmed that they have had training on this in the past. Training records seen suggested staff received the training and further training was being provided in March 2009. Care Homes for Adults (18-65 years) Page 19 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. People live in a clean and welcoming home but several aspects of improvements are needed to ensure people are safe and comfortable in their home. Evidence: On entering the home it appeared warm and welcoming. All areas of the home had individual touches to ensure it was made homely, such as pictures and plants. I person showed me his bedroom which was decorated to his own personal taste. This bedroom had an en suite facility which was reflective of most of the bedrooms seen on the day of the inspection. One bedroom seen was recently decorated and reflected the persons choices very well. In general most bedrooms appeared satisfactory but several aspects of the bedrooms needed to be addressed for example some carpets needed replacing as they were either lifting up from the floor, worn very thin or very dirty, chest of drawers needed to be replaced or re varnished, curtains in several areas of the home to include bedrooms and lounge were torn and discolored and failed to hang properly on their rails. In the lounge the leather settees that were made available to people were old and outdated and on sitting on one the spring was making it an uncomfortable experience. The leather was also cracking and as a result detracted from the homeliness created in other areas of the home. staff members spoken to commented Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: that people who use the service regularly reported being bruised by a spring from the settee. Staff also commented that the seats are very low as the cushions had gone flat and people struggles to get up and down out of these seats. The manager said the lounge was due to be refurbished in the near future Their were sufficient bathroom and toileting facilities but we identified that for one bathroom their was no lock fitted and as a result privacy could not be maintained when people where using this facility. In this same bathroom the cover for the hot water tap was missing. Another toilet inspected on the second floor had strong urine odours which was offensive to people accessing this facility. The manager said she have implemented several measures in order to rectify the situation but have not been successful. It was suggested that the flooring be changed. The home had sufficient equipments in place to be able to meet the needs of people who use the service. We saw evidence that some people were provided with Hi/low beds,changing tables, wheelchairs and hoists. The usable space for some people was very limited and as a result failed to comply with the current regulations. Two people who shared the same bedroom did not appear to have the ability to consent to this arrangement. The home manager said this arrangement had been in place for several years and they had ensured that individuality can be maintained. A curtain was also placed in the middle of the bedroom to ensure privacy and dignity could be maintained. It was suggested that an assessment was undertaken under the new legislations to make sure this was consenting as neither of the people who used the room appeared to have the ability to consent to this arrangement. We were informed that plans are in place to identify how better use of bedroom space can be made by possible making two bedrooms into one for those rooms where people have very limited space. The home had sufficient communal space that was utilised by the people who use the service. People were seen sitting in the lounge, dining area and the conservatory throughout the day.People also had free access to the outdoor facilities and the kitchen. Care Homes for Adults (18-65 years) Page 21 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. People who use the service benefits from a competent and qualified staff team but their safety was compromised by the recruitment policy and procedures in place. Evidence: The home was fully staffed on the day of the inspection we were told that in general 4 staff are rostered on for each shift and sometimes 5 to ensure people are able to access their community activities.The shifts are covered from 7 to 2:30 pm, from 2 pm to 8 pm and then a sleep in and a waking night staff covered the night shifts. On the day of the inspection we found evidence to suggest staff were competent and qualified to meet the needs of people who use the service.The staff files were inspected and we found that training records were maintained and future training needs were identified for several staff members. The home employed 14 full time staff and of these 12 had achieved their NVQ level 2/3 in care. One staff had completed her Skills for care training and another 2 had started to do the course. Staff members spoken to all confirmed that they received regular training. One staff said, the home is really good at training. The recruitment procedures for the home failed to safeguard people who use the service of the files inspected their was evidence that satisfactory (CRB) Criminal Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: Record Bureau checks were undertaken and application forms completed but for 5 staff members files inspected their immigration status was questionable at the day of the inspection. These files failed to show work permits that were in date, evidence of eligibility to work, valid passports, or valid entry clearance information that was in date. As a result of this the home was issued with an immediate requirement to produce satisfactory work permits for the 5 staff members identified in the inspection report. We received this information within the timescale requested which suggested 4 of these staff members were eligible to work and the papers were produced to substantiate the information. The fifth staff member was suspended as they failed to produce the required information. Their was also evidence that some staff members failed to have both references available on file. There was evidence to suggest staff received the support and supervision they needed to undertake their jobs. Staff spoken to said they received supervision at least every 2 months. Staff also commented that they received regular staff meetings, records seen suggested these were undertaken every two weeks. Care Homes for Adults (18-65 years) Page 23 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. The management of the home ensured people benefited from a service that promoted effective leadership but further development was needed to ensure peoples welfare is protected and their safety is not compromised. Evidence: The working relationship between the manager and the staff ensured people would benefit from a service that underpins good leadership. The communication between the manager and staff were evident in the home throughout the day and staff members spoken to said, I feel free to speak to the manager. Another staff said the home is run very well, we work as a team. Staff members generally spoke of the way they are motivated by the management team to perform. People who use the service were also seen to interact positively with the management team. One person was observed to explain to the manager that his shower head was broken. Some aspects of quality assurance was in place. We were informed that questionnaires have been collected from people who use the service, their relatives and the staff team for 2009 . These were seen on the day of the inspection and some Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: questionnaires were presented in Makaton symbols in order to ensure people who use the service would be able to understand the questions.These questionnaires had not been collated or analysed. The manager said this would happen in the near future.We saw evidence to suggest past questionnaires were collated and improvements made as a result of information received. The home had several records kept for people who use the service but as reported in the staffing section of this report the records kept for staff in regards to their immigration status was not satisfactory and as a result compromised the welfare and safety of people who uses the service. The safety for people in regards to the environment was also implicated due to the ravelled carpets identified when touring the environment and the potential risk of falling outside the kitchen door which was sloped and had water settled in the middle of the doorway. Care Homes for Adults (18-65 years) Page 25 of 30 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 26 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 1 4 Arrangements must be made to ensure the information provided to people are accurate and reflective of the facilities available. To ensure people are given the correct information. 30/04/2009 2 6 15 Clear interventions must be implemented for all care needs identified for people who use the service. To ensure people receive a consistent and measurable service delivery. 30/04/2009 3 9 13 Effective Manual Handling assessments must be implemented for people needing support to be transferred. To ensure the safety of people and the staff team. 30/04/2009 Care Homes for Adults (18-65 years) Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 20 13 All medications/ homely 30/05/2009 remedies to be administered must have clear instructions to include the name of the person to whom the medication belongs. To safeguard people from medication error. 5 20 13 The home must ensure effective guidelines are available to all staff for the administering of PRN medication. To ensure a consistent service delivery can be maintained. 30/05/2009 6 24 23 Suitable locks must be fitted 30/04/2009 to all bathroom and toilet doors. To ensure peoples privacy can be maintained. 7 24 23 Suitable arrangements must be made to replace curtains and leather settee in the home. To ensure peoples safety and comfort. 30/05/2009 8 24 23 All areas of the home must be made safe and free from trip hazards such as fraying carpets or wet flooring. To ensure peoples safety. 30/05/2009 Care Homes for Adults (18-65 years) Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 9 24 12 Arrangements must be made to undertake satisfactory assessments to ensure the two people sharing a bedroom are consenting. To ensure both peoples views/wishes have been considered. 30/05/2009 10 42 12 The management of the home must ensure satisfactory records are in place at all times for all aspects of the service. To promote the safety and welfare of people who use the service. 30/05/2009 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 14 Efforts should be made to ensure all the people who use the service have a structured activity plan which is undertaken on a daily basis. The information received from the questionnaires should be collated and published in accordance with the standard. 2 39 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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