Inspection on 30/01/09 for Manor Park Care Home

This inspection was carried out on 30th January 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Park Care Home 11/03/08

Manor Park Care Home 13/09/07

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Victoria Road Care Home 52 Victoria Road Keighley West Yorkshire BD21 1JB     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: Stephen Marsh     Date: 3 0 0 1 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 Road Care Home 52 Victoria Road Keighley West Yorkshire BD21 1JB 01535680410 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Olu Femiola care home 22 Number of places (if applicable): Under 65 Over 65 5 mental disorder, excluding learning disability or dementia Additional conditions: 17 The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD and Code MD(E) the maximum number of service users who can be accommodated is: 22 Date of last inspection Brief description of the care home Victoria Road Care Home is in Keighley, close to the town centre and local services such as shops and public houses. It is easily accessible by public transport, being a short walk from the nearest bus stop. The home provides accommodation, personal care and support to people with a history of mental illness. Nursing care is not provided and the home will work with district nurses and community psychiatric nurses if this type of support is needed. The main building is a Victorian house that has had extensions added to it over the years. Accommodation is provided in mainly single rooms over two floors. The entrance is up a short flight of steps; people living at the home need to be mobile and able to manage stairs as there are no lifts or facilities for disabled people. There are two lounges, a separate dining room and adequate Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home provision of toilet and bathing facilities. Information about services provided by the home is available in the Service User Guide. Copies can be provided on request. A copy of the most recent inspection is available in the office. 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: The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This inspection was to see if improvements to the service had been made since the last key inspection in March 2008 and how the improvements had benefited the people living at the home. The inspection process included looking at records, observing staff at work, talking to people living at the home, talking to staff and looking around the property. Before the visit we had provided people living at the home, staff and other health care professionals with survey questionnaires so that they could share their views of the Care Homes for Adults (18-65 years) Page 6 of 30 service with us. We received fifteen questionnaires back from people living at the home, nine from staff and three from health care professionals. The information they provided has been used as evidence in the body of the report. The home had also completed and returned the Annual Quality Assurance Assessment (AQAA) form. The AQAA is a self assessment form that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The registered provider/manager was unavailable on the day of inspection therefore feedback was given to the acting manager at the end of the visit. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get Care Homes for Adults (18-65 years) Page 8 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before admission and they can visit or stay for a trial period to make sure the home is right for them. Evidence: The home has produced a service user guide, which is made available to people considering moving in to the home on a permanent or short stay basis. The guide is currently only available in English although the manager confirmed that it could be translated in to different languages or formats on request. The manager confirmed that pre-admission assessment visits are always made to see people either in their own homes or temporary place of residence. Before admission people are encouraged to visit the home to meet the people who already live there and the staff. This means that staff can get to know the persons needs and the individual can see at first hand the accommodation and facilities provided. People are also able to move into the home for a trial period if they are still undecided about living in a residential setting. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: People offered a place at the home are supported through the admission process and care is taken to make sure they settle into their new environment. The home will take emergency admissions, but only if a full needs assessment has been completed and the manager feels that the home can meet their needs. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care records provide accurate and up to date information, which means that people receive the level of care and support they require to meet their personal, health and social care needs Evidence: Care plans are in place for all people living at the home and records show that where possible individuals are involved in the care planning process and in developing and reviewing their own plan. This means that people are involved in making decisions about how they would like their care and support to be provided. The care and support plans we looked at showed that improvements have been made to the plans since the last inspection visit. The manager has started to involve the staff in the care planning and development process and has established good working relationships with other health care professionals to make sure identified needs and objectives are met. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: Risk assessments have been completed where areas of potential risks to peoples general health or welfare have been identified, such as managing challenging behaviour and they now give clear guidance to staff on how to meet the individuals needs. Our observations during the visit showed that the staff did seem to understand each person and their care and support needs. The interaction between people and staff was relaxed and friendly. 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 are offered the opportunity to take part in a range of social and leisure activities that take account of their preferences and abilities. Evidence: The manager confirmed that no one living at the home is in paid or voluntary employment although three people attend day centres and one person is a member of a social activities group. The manager confirmed that people are encouraged to make choices and decisions about how they spend their time whilst living at the home and wherever possible they are supported by staff to follow their own daily routines. People are encouraged to keep in close contact with their family and friends and visitors are welcome at any reasonable time. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The home does not employ an activities co-ordinator but staff arrange some in-house activities and people benefit from the home having a mini-bus, which is used for regular trips out. The manager confirmed that some people had also expressed an interest in going on a foreign holiday in 2009 and he was currently looking at seeing if this was feasible. On the day of the visit a number of people were looking forward to a meal out at a restaurant in Bradford. Two people that had previously lived in other care homes said that the activities and outings arranged at Victoria Road were a lot better than they had experienced in the other places they had lived. They went on to say that staff always listened to them when they made suggestions about the day-to-day running of the home and supported them to live a full and active life. The manager confirmed that staff support people to maintain and meet their cultural and religious needs by encouraging them to attend religious services and by following their beliefs both within the home and the wider community. Mealtimes at the home are unhurried and people said they like the meals and thought they were very good. The meals are planned to include the wishes of the people who live at the home and to meet any special dietary needs. Drinks are available throughout the day. At present some of the people living at the home go into the main kitchen to make themselves drinks. It would however be far better if the home established a skills kitchen in another part of the building so that they could develop their daily living skill without compromising the standards of hygiene and cleanliness in the main kitchen. One possible solution would be to relocate the existing laundry room situated at the back of the dining room and install a domestic kitchen, which people could use to make drinks and light snacks. Following a Food Hygiene Inspection in June 2008 by the Environmental Health Department the home was awarded a five star rating. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are met in a way that maintains their dignity and independence. Evidence: The manager confirmed that the daily routines of the home are flexible and based around the needs of the people living at the home. People spoken with said that they could generally plan their own day and restrictions were not placed on them unless they formed part of their agreed care and support plan. All people living at the home are registered with a general practitioner and are supported in having access to the full range of NHS services. The input of other health care professionals is clearly recorded in the documentation available, which shows that staff are seeking advice if they have any concerns about an individuals health care. We received feedback from three health care professionals who confirmed that the home is pro-active in seeking advice and that the staff generally do a good job in caring for a difficult client group who can at times be reluctant to comply with requests Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: that affect their health care. Comments included staff I have had dealings with seem committed to their role and competent in their duties. and I have no concerns about the standard of care and support provided by staff. Through discussion with staff it was clear that they continue to have a good knowledge and understanding of peoples needs and encouraged them to take control of their own health care if possible. On reviewing the medication system we found that overall medicines are safely managed and minor discrepancies found were addressed by the manager immediately. However, any controlled drugs prescribed for people living at the home would currently be stored in a unlocked metal cabinet within a locked wooden cupboard. The legislation relating to the storage of controlled drugs changed in 2007 and the present arrangement does not meet the new standard. At the present time only one person manages their own medication but the manager confirmed that risk assessments are carried out for all new admissions and people would be encouraged to manage their own medication if they had the capability. 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. Staff have now attended safeguarding training and there are are suitable systems in place to make sure that complaints are dealt with appropriately and people are protected from abuse. Evidence: There is a complaints procedure in place and feedback from people living at the home shows that they would have no problems in approaching the manager and staff if they had any concerns. We have received no complaints about the service since the last inspection visit. Adult protection (safeguarding) policies and procedures are in place and training has been planned for all staff in February 2009. As the lack of appropriate staff training in the recognition and reporting of abuse was highlighted in the last inspection report we asked the manager to confirm when the training as taken place. Following the inspection we received confirmation from the manager that with one exception all staff had attended the above training. At the time of the inspection seven people living at the home were having their Disability Living Allowance paid in to a joint account. The previous homeowners had operated this system and the present provider has continued with the systems. However, concerns were raised at the last inspection about the lack of information Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: about how the fund was managed and the manager was advised that clear policies and procedures must be put in place. It was therefore disappointing on this visit to find that no action had been taken to address this matter and there was still no clear policies on how this fund was being managed. Following the visit the provider contacted us and confirmed that immediate action would be taken to make sure peoples Disability Living Allowance was paid directly in to their own bank accounts and the remaining funds would be distributed equitably between the people that had contributed to it. While this appears to be a satisfactory solution to the matter we still have concerns that the provider should have been more pro-active in resolving this issue without it again being brought to his attention through the inspection process. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Both internally and externally work is still required to make the home a safe, comfortable and pleasant place for people to live. Evidence: Internally some parts of the home are still in need of upgrading and there is an ongoing programme of refurbishment and renewal in place. We asked the provider to provide us with an updated copy of the refurbishment plan. All the communal areas including lounges and the dining room are situated on the ground floor of the home conveniently close to toilet facilities. Laundry facilities are currently located in a room at the rear of the dining room, which is not a satisfactory arrangement as both dirty personal laundry and bedding has to be transported through the dining room. We recommended to the manager that he should contact the Environmental Health Department and seek advice on this matter. Until a permanent solution is found risk assessments must be completed and infection control procedures followed to minimise the risk of cross contamination. Bedrooms are located on both floors of the home and consist of twenty single and one double room, which is currently being used as an exercise room for people living at the Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: home. The bedrooms we looked at were furnished to a satisfactory standard although many would benefit from decorating. The manager said that on admission people are encouraged to bring personal possessions into the home to personalise their room and it was evident during the tour of the building that many people had done so. People living at the home said that they were generally satisfied with the standard of accommodation, and were pleased that they had been able to furnish their rooms with personal possessions. Externally the grounds are in a very poor state especially to the rear of the property where a stone wall has been taken down to allow a fence to be erected. Piles of stone and some old discarded furniture have just be left making the area look unsightly and a potential hazard to people living at the home. This area must therefore be cleared as soon as possible and made safe for people to use. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. As the home is running on minimum staffing levels at the weekend and recruitment and selection procedures are not always being followed people might be put at risk. Evidence: The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two written references and a Criminal Record Bureau (CRB) before new staff start work. This should make sure only people suitable to work in the caring profession are employed. However on reviewing the recruitment files we found that the recruitment policy was not always being followed as in one instance the home had accepted references handed in by the prospective employee, addressed to whom it may concern. This is unsafe practice, which might put people living at the home at risk. The staff rota showed that the home is currently running on minimum staffing levels at the weekend and concerns were raised that care staff were expected to undertake cleaning and laundry duties in addition to their main role as support workers. As this matter as been raised at the last two inspections it is very disappointing to find that no action has been taken to address the matter and make sure the home is adequately Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: staffed at all times. The manager confirmed that the home is in the process of introducing the Skills for Care Common Induction Standards. These are nationally agreed induction standards designed to help new staff get the skills and knowledge they need to care for people. Following induction there is an expectation that staff will study for a National Vocational Qualification (NVQ) at level two or three depending on the post they hold. The manager confirmed that to the best of his knowledge the majority of staff had achieved a NVQ. Feedback from staff indicates that they are generally happy with the standard of training provided although questionnaires returned by two staff clearly shows that training courses have only recently become available and very little training was provided in 2008. On the day of the visit the manager was unable to produce staff training records and therefore we were unable to evidence the level or quality of training provided. We did see evidence to show that protection of vulnerable adult and fire training was booked for February 2009 and four people had been booked on a falls prevention course. Following the inspection we received confirmation from the manager that staff had attended the above training courses and had also attended a course on the Mental Capacity Act. The manager also confirmed that the home had carried out a training audit and were now maintaining accurate and up to date training records. Feedback from staff show that they have now started to have one-to-one supervision with the manager and that they feel generally well supported by the senior staff team. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made to the management structure at the home, however the lack of effective quality assurance monitoring systems means that shortfalls in the service are not always being identified without them being raised through the inspection process. Evidence: We have had concerns in the past regarding the management of the home as the registered provider/manager Mr Femiola lives in London and owns two other care homes based in Wales and Bridlington. In July 2008 Mr Femiola appointed a manager to run the home on a day to day basis and following this inspection he confirmed that he had now appointed a permanent manager who would be going through the registration process. Concerns raised in the last inspection report about the management of the service have therefore in many respects been addressed although a great deal more work needs to be done before the home is managed effectively. It is important that the Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: registered provider works with the new manager to improve standards and makes sure the home is being run in the best interest of the people living there. Effective quality assurance monitoring systems have still to be introduced at the home although the manager confirmed that surveys will be sent out to people who live at the home and their relatives early in 2009. The questionnaires will give people the opportunity to express their views and opinions of the service and should provide valuable information on what improvements they would like to see. It was recommended to the manager that survey questionnaires are also sent out to other health care professionals to enable them to comment on how they feel the home is meeting stated aims and objectives. We asked the manager to forward us a summary of the survey results indicating what action the home is taking to address any concerns raised. The manager confirmed that policies and procedures are in place to make sure staff follow safe working practices and all equipment is serviced in line with manufacturers guidelines. However, no fire risk assessment for the building could be found and the last recorded fire alarm test was on the 3 November 2008. The manager also confirmed that following a recent inspection of fire fighting equipment it was found that eight extinguishers required replacing. These matters must be addressd so that people can be confident that their health and safety is not being compromised. Care Homes for Adults (18-65 years) Page 26 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 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 A new controlled drug cabinet must be installed. So that if people are prescribed controlled drugs they can be stored safely and in line with current legislation. 29/05/2009 2 24 23 The home must provide us 24/04/2009 with an updated programme of refurbishment. So we can be sure that people are living in a safe and comfortable environment. 3 33 18 The home must review staffing levels at the weekend. To make sure that peoples physical, personal and social needs are met and staff are not spending long periods of time doing domestic and laundry duties. 24/04/2009 Care Homes for Adults (18-65 years) Page 28 of 30 4 34 19 Recruitment and selection procedures must be followed. So that people can be confident that they are being cared for by staff suitable to work in the caring profession. 24/04/2009 5 39 24 Effective quality assurance 24/04/2009 monitoring systems must be put in place. So that shortfalls in the service can be identified sooner and people can be confident that the home is run in their best interest. 6 42 23 A fire risk assessment must be completed for the home and the fire alarm tested on a regular basis. So that people can be confident that their health and safety is not being compromised. 24/04/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 30 Advise should be sought from the Environmental Health Department about the implications of transporting dirty laundry through the dining room area. Survey questionnaires should be sent out to other health care professionals to enable them to comment on how they feel the home is meeting stated aims and objectives. 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. If you would like a summary in a different format or language please contact our helpline or go to our website. 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