Inspection on 15/12/08 for Westfield Road (1)

This inspection was carried out on 15th December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westfield Road (1) 19/12/06

Westfield Road (1) 16/01/06

Westfield Road (1) 01/08/05

Westfield Road (1) 02/02/05

Westfield Road (1) 09/11/04

Westfield Road (1) 01/03/04

Similar services:

Flint House

The Cotswold Home

Fairways

Treloar College

Rush Court

The Maypole Nursing Centre

Fir Tree Lodge

Chilmington House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Westfield Road (1) 1 Westfield Road Bletchley Milton Keynes Bucks MK2 2RR     The quality rating for this care home is:   two star good 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: Jane Handscombe     Date: 1 5 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Westfield Road (1) 1 Westfield Road Bletchley Milton Keynes Bucks MK2 2RR 01908366168 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): The Disabilities Trust The registered provider is responsible for running the service Name of registered manager (if applicable) Sandra Stevens Type of registration: Number of places registered: care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: The maximum number of service users who can be accommodated is: 3 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: Physical disability - PD Date of last inspection Brief description of the care home Westfield Road is a care home for three people with a physical disability. The aim of the home is to provide rehabilitation for people with brain injury into more independent living. The Brain Injury Rehabilitation Trust owns the home. The day-to-day support and external management of the home is provided by Thomas Edward Mitton House, Care Homes for Adults (18-65 years) Page 4 of 31 3 Over 65 0 Brief description of the care home which is based in Milton Keynes. The home consists of a two-storey building. All of the bedrooms are single, and one of the bedrooms has an en -suite shower. The home is situated in Bletchley, close to local shops, leisure facilities and other amenities. It is easily accessible for public transport. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good 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 key inspection, which took place over 1 day and was carried out by one inspector. The visit took place on the 15th December 2008. The purpose of the visit was to see how the service is meeting the National Minimum Standards. Prior to the visit we sent out two surveys to people using the service, four staff members surveys and six health and social care professionals to gain feedback on the service, however, we have not yet received any completed surveys and therefore results were not available at the time of writing this report. They will however, be considered as part of CSCIs ongoing regulatory responsibilities for registered services. Results of this inspection report are derived from feedback gained from speaking with users of the service, staff, discussions with the manager, viewing service users records held within the service, viewing policies and procedures, staff personnel files, general observation Care Homes for Adults (18-65 years) Page 6 of 31 throughout the day, along with information provided to us within the AQAA, an annual quality assurance assessment which is a self assessment which focuses on how well outcomes are being met for people using the service and gives us some numerical information about the service; we ask providers to complete and return these to us on an annual basis and any other information that CSCI has received about the service in order to gain an understanding of how the service meets the service users needs, and impacts upon their lives. Records required by regulations were examined, including staff files and the services policies and procedures We looked at how well the service was meeting the key standards set by the government and have in this report made judgements about the standard of the service. We would like to thank all those who gave their time during the inspection process. Fees for this service range from 1,849 pounds to 2,635 pounds per week. What the care home does well: What has improved since the last inspection? What they could do better: Whilst the service provides good outcomes for those using the service, a number of requirements and recommendations have been made within this report to address shortcomings found on the day of inspection, which are as follows: Ensure that detailed logs of food provided to service users is kept to evidence that appropriate nutritionally balanced meals are provided which meet their health needs appropriately and to allow for tracking purposes. Care Homes for Adults (18-65 years) Page 8 of 31 Ensure that medication entering or leaving the premises is recorded appropriately and accounted for at the time of delivery. Mandatory staff training is to be brought up to date to ensure staff have the right skills and knowledge to meet peoples needs. It is reccommended that whilst awaiting a paper towel dispenser, paper towels be provided in the in the meantime so as to avoid the risk of cross contamination and thereby protecting service users health and welfare. 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 31 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective and current users of the service are provided with sufficient information about the home and services that they offer and are provided with a comprehensive assessment of need prior to admission to ensure their health, personal and social care needs can be met appropriately. Evidence: Since there have been no new admissions to the home, we discussed the admission procedure and it was ascertained that a full assessment needs would be undertaken prior to a place being offered. In addition to a full assessment of needs, the person is invited to visit the home and meet with fellow users of the service and staff members to enable them to gain a feel of the home and to ensure that all parties are confident their needs would be met appropriately at Westfield Road. Information about the home and the services it can offer are provided in the form of a Satement of Purpose and a Service Users Guide. The service have recognised that improvements could be made in developing these in improved formats, which they Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: plan to do and they now provide a copy of the service users guide to prospective users of the service prior to their admission to the home. From evidence gained through discussions with the registered manager, the team leader and viewing service users files there is a commitment to ensure that all those using the service, however diverse their needs may be, receive a person-centred package of care and support taking into account their individual preferences and goals to meet their needs appropriately. Care Homes for Adults (18-65 years) Page 12 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Every resident has an individual plan in which their assessed needs are identified and the action required to meet them. Residents can make decisions about their lives and what assistance they need. Evidence: At the time of this inspection, there was one user of the service and this individual had a detailed care and support plan in place, which gave a good picture of the users individual needs, preferences and goals and how these were to be met. The service users file contained evidence of current specialist requirements and planned interventions, rehabilitation plans, therapeutic programmes and risk assessments. There was evidence of regular reviews of the care and support plan with the involvement of the service user together with family/representative/other relevant health and social care professionals.Risk assessments were contained within the care and support plans detailing any risks present and how these risks are to be minimised whilst promoting the service users choices and independence.People using the service Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: are encouraged and supported to make decisions about their lives, both within and outside of the home. Care Homes for Adults (18-65 years) Page 14 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users live a full and varied lifestyle according to their wishes and preferences and are encouraged to maintain contact with their families, friends, representatives and the local community as they wish with support being given as required. Evidence: The service has a strong commitment to enabling users of the service to develop or maintain their skills, including social, emotional, communication and independent living skills and supports individuals to identify their goals and work to achieve them. Part of the rational for a placement in this home is to improve opportunities to integrate into the local community life. The home is very well placed for this as it is very close to the centre of the town and the variety of facilities available offer the residents the opportunity to broaden their experiences. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: The care plans include information about each persons choice of recreational and leisure pursuits and their individual goals and a weekly plan of individual activities undertaken is contained within service users care plans. It was noted that the weekly plan viewed failed to note the month to which it related, which the manager assured us would be attended to appropriately. The activities people attend depend upon their individual choice and what they want to do. The service actively supports those using the service back into work placements or college. The current service user has a work placement which he/she attends two evenings a week, attends the gymnasium on a daily basis, attends a brain injury awareness group and is being supported to arrange and view properties in readiness to living independently within the community, all of which are undertaken within a risk management framework. Service users are actively involved in the domestic routines of the home and responsibility for housekeeping tasks is included on their individual weekly planner. Service users choose individually what they wish to eat and when and are assisted by staff to shop, prepare and cook the meals. Whilst viewing the current service users file, it was noted that whilst food intake was logged this was not in sufficient detail making it impossible to establish if the user of the service was receiving appropriate well balanced, nutritious meals which meets their needs appropriately. A requirement has been made within this report to ensure that detailed logs of food provided to service users is kept to evidence that appropriate nutritionally balanced meals are provided which meet their health needs appropriately and to allow for tracking purposes. Arrangements for service users to meet with friends and family members are flexible and support is given to maintain personal relationships where required. People are involved in making decisions about the way the home they live in is run, and the manager and staff make sure their views are central to any decisions. Care Homes for Adults (18-65 years) Page 16 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each resident has personal support in the way they prefer and require, and their physical and emotional health needs are met. Whilst there are policies and procedures around the recording of medication coming into the home these are not always put into practice. Evidence: Each service user has an individualised plan of care detailing their individual needs, preferences and goals and how these needs are to be met. Service Users records viewed during the inspection indicated evidence that their views, preferences and needs are taken into account when providing care and support.The healthcare records were in good order and included separate records of contact with various healthcare professionals. The records indicated appropriate regularity of appointments and appropriate one-off consultations where necessary.Since the last inspection , the home is using a new care plan format, which has resulted in service users care plans being more person centred. Each service user has an individualised plan of care detailing their individual needs, preferences and goals and how these needs are to be met. Each person has an allocated key worker and a primary support worker who work with him Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: or her on a one to one basis and whom they are able to discuss any issues or concerns that they may have. People using the service are supported and facilitated to take control of and manage their own healthcare including accessing NHS healthcare facilities in the community such as dentists, opticians, audiologists, chiropody etc and any medical appointments that service users have attended are documented in their individual files.The service has good working relationships with health and social care professionals and accesses them where appropriate.Medication is securely stored at the home and all required policies and procedures are in place; since the last inspection a new homely remedies has been put in place for those using the service and users of the service are supported and prepared for self administering their own medication within a risk management process. The medication system in the home is provided by a local pharmacist and is a monitored dosage system that is designed for people who administer their own medication. The pharmacist from the provider regularly visits the home and is readily available to the staff should they need advice. All staff are provided with medication training and are assessed on the safe handling of medication via a questionnaire on annual basis and the house leader undertakes regular competency testing every three months.One staff member takes responsibility for the ordering and receipt of the medication into the home, however it was noted that procedures had not been followed following the delivery of medication on the Friday evening prior to our visit. The delivery of medication had not been accounted for in the medication book and we were informed that this had not been entered as the medication had arrived when staff were leaving on the Friday evening and was therefore placed in the refrigerator with a view to documenting it on the Monday morning when staff and service users returned to the home. The registered manager acted upon this immediately to ensure that the medication was immediately logged appropriately. A requirement has been made within this report to ensure that medication entering or leaving the premises is recorded appropriately and accounted for at the time of delivery. Care Homes for Adults (18-65 years) Page 18 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an accessible complaints system in place, which users of the service are aware of and would use if the need arose. People using the service are protected from harm. Evidence: The service has a complaints procedure in place, which is supplied to everyone living at the home. Information within the completed AQAA informs us that the service recognises that they could make some improvements in providing the policy in different formats and plan to introduce different formats over the next twelve months. We spoke to a user of the service who told us that he/she is confident in bringing any concerns or complaints to the attention of staff and would use the complaints procedure if required, that he/she had no concerns and felt safe and well supported. The home has an open culture and encourages people to voice their views and any concerns. It was also explained that there is an advocacy service available for users of the service to access should the need arise, details of which were readily available within the home. Since the last inspection, the complaints procedure has been updated and changes have been made to ensure that it contains the correct up to date contact details and name of the regulatory body. The registered manager informs us that she is presently putting together a computerised presentation around the safeguarding of vulnerable adults, which will be used with users of the service to raise their awareness and encourage them to raise any concerns if the need should arise. Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: All staff are provided with training around the safeguarding of vulnerable adults both in their induction training and regularly thereafter, enabling them to recognise the signs of abuse and how to respond if an allegation or incident is brought to their attention. Staff are all provided with and understand their responsibility to use the agencies whistle blowing policy if the need should arise.The Commission for Social Care Inspection has not received any correspondence from the general public in relation to concerns, complaints or allegations since the last inspection. Care Homes for Adults (18-65 years) Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are provided with a comfortable, clean, safe environment in which to live, which suits their needs and lifestyles. Evidence: The service continues to upgrade the environment to ensure comfort and meet the needs of the people living there. Areas of improvement, since the last inspection undertaken in December 2006, include the fitting of a new bathroom upstairs, redecorating one of the bedrooms, the provision of new flooring in the kitchen and the purchase of a new cooker and a new washing machine, renovating and repaving of the outdoor patio area to facilitate access and provide comfortable surroundings for the service users to use during the warmer summer months. Further areas of improvement have been planned and include renovating the downstairs cloakroom, redecorating bedrooms to include new carpeting, and a security gate is to be installed to enclose the parking area. Discussions with the current service user informed us that he/she is happy with his/her bedroom and the surroundings and that the home is kept to a good standard of cleanliness, which was evident whilst touring the home. Whilst touring the home, it was noted that in the bathroom/shower room there was a Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: shared towel, however we are informed that a paper towel dispenser has been ordered to ensure that the risk of cross contamination is eliminated. It is reccommended that whilst awaiting a dispenser, paper towels be provided in the meantime. Care Homes for Adults (18-65 years) Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides staff cover to meet needs and undertakes thorough recruitment procedures to ensure that there are suitable staff to support people. Some attention is needed to training to ensure that staff have up-to-date skills to meet care needs. Evidence: The homes policy around the recruitment and selection of staff serve to protect service users health and welfare. Application forms are completed, references are collected and a face-to-face interview is undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken prior to appointment to ensure the persons suitability with working with vulnerable people. All newly recruited members of staff receive a structured induction training including shadowing more experienced carers until both parties feel confident and comfortable. Staff are provided with mandatory training in the core subject areas, to ensure that they have the necessary skills and knowledge to undertake their roles competently. Whilst viewing staff personnell files, it was noted that some mandatory training was due for updating; one file viewed highlighted that the staff member was due update training in manual handling, first aid, and food hygiene and training for COSSH and Safeguarding were booked and the staff member would be attending two weeks after this inspection. Likewise a second staff members personnell file highlighted that Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: COSSH and safeguarding were due for updating and is also booked onto the relevant training. Within the same staff members file was evidence to suggest that an update in manual handling was due, however we were informed that the training had been provided in April 2008, although there was no certificate on file to evidence this. A requirement has been made within this report to ensure that mandatory staff training is brought up to date to ensure staff have the right skills and knowledge to meet peoples needs. Information provided to us in the AQAA highlighted that the service were aware of the deficit, which was due to the inhouse trainer leaving the organisation, however we are informed that the post has been filled and a training plan is in place to ensure that all staff receive their mandatory training/updates in a timely manner. Information provided in the AQAA informs us that of the four permanent staff, two havegained the National Vocational Qualification in Health and Social Care and plans are in place to offer the training to the two remaining members of staff as soon as practicable. There was evidence seen in both staff personnel files viewed to highlight that staff are supervised and supported on a regular basis and receive an annual appraisal of their work. Care Homes for Adults (18-65 years) Page 24 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home aims to promote continuity and good overall care and support for the people who live there. Improvements to staff training are needed to ensure that safe practice is in place to reduce the likelihood of injury or harm. Evidence: The registered manager is experienced, knowledgeable, and is competent to manage the home although she has other responsibilities within the trust and is not in the home on a daily basis. The home has a House Leader who is responsible for the day to day running of the service and is able to contact the manager by telephone. The team leader displays a good sound knowledge of matters related to the running of the care home and clear lines of accountability and responsibility are in place. Service users and members of staff reported that the manager runs the home in an open, positive, inclusive way and they would have no worries approaching her if they had any concerns and were confident that they would be listened to and dealt with Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: appropriately. We discussed health and safety issues and saw appropriate maintenance records relating to maintaining a safe environment for users of the service. Regular safety checks are undertaken relating to fire safety and regular servicing and maintenance of equipment, all of which were seen to be documented appropriately. The home does not act as agent or manage monies on behalf of residents. The Quality assurance system includes regular regulation 26 visits, a report of which is kept in the home, and the home engages regularly with users of the service to gain feedback on various aspects of the service it provides; this is undertaken on both an informal and formal basis through feedback and questionnaires, noting any comments or concerns when undertaking residents care reviews. The annual quality questionnaires are sent to users of the service, their family members and/or representatives, health and social care professionals and any other stakeholders involved with the service, the results of which are collated and published annually. The home deals with a number of diverse care needs and always ensures to offer a personalised service to meet the individual needs of their service users. There is a commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care, which meets their needs appropriately. The registered manager sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. The AQAA contains clear, relevant information that is supported by a wide range of evidence and informed us of where improvements need to be made and how they are going to attend to these. Care Homes for Adults (18-65 years) Page 26 of 31 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 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 17 17 Ensure that detailed logs of 28/02/2009 food provided to service users is kept to evidence that appropriate nutritionally balanced meals are provided which meet their health needs appropriately and to allow for tracking purposes Regulation 17(2) of the Care Home Regulations 2001 requires: (2) The registered person shall maintain in the care home the records specified in Schedule 4. Schedule 4 number 13 of the Care Home Regulations 2001 includes: 13) Records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared Care Homes for Adults (18-65 years) Page 28 of 31 for individual service users. 2 20 13 Ensure that medication 28/02/2009 entering or leaving the premises is recorded appropriately and accounted for at the time of delivery. Regulation 13(2) of the Care Home Regulations 2001 requires that: The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. Mandatory staff training is to 31/03/2009 be brought up to date to ensure staff have the right skills and knowledge to meet peoples needs. Regulation 18(1)(c) of the Care Homes Regulations 2001 requires that: The registered manager shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users (c) ensure that the persons employed by the registered person to work at the care home recieve: (i) training appropriate to to the work that they are to perform including structured induction training; and (ii) suitable assistance, including time off, for the 3 35 17 Care Homes for Adults (18-65 years) Page 29 of 31 purpose of obtaining further qualifications appropriate to such work. 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 27 It is reccommended that whilst awaiting a paper towel dispenser, paper towels be provided in the in the meantime so as to avoid the risk of cross contamination and thereby protecting service users health and welfare. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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