Inspection on 31/03/09 for Woodham House 3

This inspection was carried out on 31st March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodham House 3 13/05/08

Woodham House 3 16/05/07

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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: Woodham House 3 5 Daneswood Avenue Catford London SE6 2RG     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: David Lacey     Date: 3 1 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 32 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 32 Information about the care home Name of care home: Address: Woodham House 3 5 Daneswood Avenue Catford London SE6 2RG 02084612706 F/P02084612706 woodhamhousewoodhamltd@aol.com 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) : Woodham ENT Ltd care home 8 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 8 The maximum number of service users who can be accommodated is: 8 The registered person may provide the following category of service only: Care home not providing medicines or medical treatment (CRH - NM) 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 Date of last inspection Brief description of the care home Woodham House 3 is situated in a residential area of Catford. It provides care and rehabilitation for up to eight people with mental illness and forensic histories, who have been discharged from psychiatric in-patient facilities, medium-secure units or special hospitals. Residents are encouraged towards independent living in the community. All bedrooms in the house are for single occupancy and have en-suite facilities. There are public transport links and shopping facilities close to the home. The provider told us in March 2009 that the fees for Woodham House 3 start from 1,000 pounds per week. Care Homes for Adults (18-65 years) Page 4 of 32 Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 key inspection included an unannounced visit to the home. During the visit, the inspector spoke with three of the four people in residence, the acting manager and the deputy manager. All communal areas of the premises and three bedrooms were inspected. Documentation was sampled, which included care plans and records of care provided, staff recruitment files, and policies and procedures. As part of the inspection, we carried out a survey by questionnaire of a sample of residents. The responses received by the time of writing this report have contributed to the evidence underpinning our judgements. At our request, the care home provided us with its annual quality assurance Care Homes for Adults (18-65 years) Page 6 of 32 assessment (AQAA), which also informed the inspection. This self-assessment document focuses on how outcomes are being met for residents and also gives us some numerical information. The acting manager/responsible individual confirmed there had not been changes in the ownership, management or service registration details for Woodham House 3 in the 12 months before this inspection. The last inspection on this service was completed on 13/05/08. 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 printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 Care Homes for Adults (18-65 years) Page 8 of 32 7535. Care Homes for Adults (18-65 years) Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed and they are encouraged to have trial visits before they move into the home. People are told whether the home can meet their needs. Each resident has a contract setting out the terms and conditions for their stay. Evidence: Since the last key inspection, three people had been admitted to the home. From files sampled, it was evident residents needs had been assessed before admission. There was evidence of detailed reports and assessments, including risk assessment and management plans from the referring authorities. It was also evident that the home had carried out its own assessments and that these include consideration of diversity. Residents who responded to our survey stated they had been asked if they wanted to move to Woodham 3 and that they had received enough information about the home before they moved in so they could decide if it was the right place for them. From discussions and examination of relevant documentation, it was evident people thinking of moving into the home are encouraged to make visits to the home, including Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: overnight stays if they wish. There were copies of letters on residents files sent to them by the provider confirming the home could meet their assessed needs. Residents files sampled for inspection included copies of contracts detailing the terms and conditions of their stay in the home. Care Homes for Adults (18-65 years) Page 12 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can make decisions about their lives in the home and are supported to maintain their independence. Care plans have enough detail to guide staff on how to meet residents needs, and residents are involved in reviewing their care. Evidence: The three care plans seen identified the residents needs and the actions required to meet them. Risk assessment and risk management plans were in place that covered each residents mental health needs. These plans gave information and guidance about signs and symptoms that are likely to indicate recurrence or deterioration of their mental health problems. They also underpin activities that promote rehabilitation for residents. The home aims to support residents to follow their chosen lifestyle, to give them more confidence in moving towards independent living. On the day before the inspection visit, a resident had moved out of the home into a more independent living situation. Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: From the documentation sampled and from discussions, it was evident residents had been involved in reviewing their care. Care plans had been reviewed regularly, both by the homes staff and by care coordinators, and residents had been invited to sign, confirming their involvement in planning their care and their agreement with the plans. Each resident has an allocated key worker, and residents plans had monthly key worker summaries on file. From these key work summaries and from notes of residents forum meetings, it was evident residents had been supported to make decisions about how they spend their time and could give their views and ideas about the running of the home. Residents who responded to our survey stated they always make decisions about what they do each day. Residents are able to come and go from the home as they please, though they tell staff where they are going and return by the agreed curfew time. Residents are made aware of this restriction before they move into the home, and it is included in the statement of terms and conditions that they sign. Care Homes for Adults (18-65 years) Page 14 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are encouraged and supported to maintain links with the community, including with their families and friends. They are supported to take part in meaningful, culturally appropriate activities. Residents have a varied diet, and contribute to decisions about the food provided. Evidence: Discussions and examination of relevant documentation showed that learning and leisure opportunities are explored and encouraged. For example, some of the homes residents attend a local facility offering culturally appropriate activities and counselling. It was evident that the homes senior staff are aware of their role in supporting residents to develop their independent living skills. Residents said they make use of local facilities such as the gym, library and local Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: shops. Compared to our last inspection, there was also more evidence of activities carried within the home. It was evident that residents had been supported to maintain links with family and friends. The family of one resident was due to visit him on the day of inspection. It is apparent that the daily routines and house rules aim to promote residents independence, choice and freedom of movement. Residents who responded to our survey stated they could do as they wish during the day, in the evening and at weekends. Individuals are expected to take responsibility for house keeping tasks such as doing their own laundry and tidying their rooms. On the day of the inspection, residents were coming and going from the house freely. Residents have freedom passes so they can use public transport without charge and make use of this for local travel and also for travel further into London. A mainline rail station is close by the home. Discussions and examination of daily records of food provided showed residents are offered a varied and nutritious diet. Residents said the food is good and that they are able to ask that their preferences are taken into account when buying food and planning menus. Residents arrange breakfast and lunch, and can make snacks and drinks as they wish. Each resident has a cooking day when they are expected with staff assistance to take responsibility for helping to plan and prepare the evening meal. Care Homes for Adults (18-65 years) Page 16 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and social care is made available to residents as needed. Staff members offer support to meet individual needs and preferences. Medicine administration is generally satisfactory. The home was not storing any controlled drugs but would have to upgrade its medicines cupboard if it needs to do so in the future. Evidence: The home makes sure that residents have access to the health and social care they need. Residents whose care was looked at in detail were continuing to receive treatment and support, in line with their present status under mental health legislation. For example, some people living in the home were being encouraged to address their substance misuse by supportive discussion, risk assessment and management, random screening and room searches, and attendance at a specialist drug rehabilitation project. There is regular contact with the relevant community mental health teams, and Care Programme Approach (CPA) reviews of their mental health needs and risk factors had been held. There were positive reports from the psychiatrist of one of the residents Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: whose care was looked at in detail, stating the residents mental state has improved since moving into Woodham 3 and that he had stopped misusing substances. Residents are registered with a local GP, through whom they can access other primary health care services. On the day of inspection, a resident visited the GP surgery to have a planned treatment. The home operates a key worker system to ensure consistency of support. It was evident from discussions and from records that key worker sessions had been held regularly. None of the current residents need support with their personal care but staff members offer prompting and encouragement as needed. Residents privacy and dignity is respected, for example, through staff knocking on bedroom doors before entering. There was friendly and informal interaction between staff and residents observed during the visit. Residents who responded to our survey stated that staff members always listen and act on what they say. The homes arrangements for medication administration were generally satisfactory. Residents said they receive the right medication at the correct times. There were no residents managing their own medication at the time of this inspection, although each bedroom has a lockable cupboard for storing medicines when the occupant is selfadministering. Three residents medication administration records (MAR) were selected for inspection and were up to date, with no unexplained gaps in recording. The home had a staff members signature and initial list, to assist medication auditing, and it was evident the homes senior permanent staff had undertaken training in the administration of medicines. The home was not storing any controlled drugs (CDs) at the time of this inspection but the manager was advised that because the law has changed the home must obtain an appropriate cupboard should it need to store any CDs in the future. Since our last inspection, the homes medicines cupboard had been moved to a different location. The manager was advised that upgrading the cupboard to allow CD storage would need to include installing it and fitting locks in accordance with the current legislative requirements. As the home was not storing CDs, it was not proportionate to make a requirement on this occasion. The homes format for recording the administration of depot medication by injection needs to be reviewed. A resident has this administered at the GP surgery but the format of the homes chart implies it has been given at the home, rather than making it clear the staff are recording that they have checked it has been given at the surgery (see requirements). Care Homes for Adults (18-65 years) Page 18 of 32 Care Homes for Adults (18-65 years) Page 19 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Any concerns raised by residents are listened to and taken seriously. Training in safeguarding adults has been made available for staff members. Evidence: The commission has not received any complaints or concerns about this home since the previous inspection. The manager confirmed that the home had not received any complaints, and there were no entries in the complaints book. The home has a complaints procedure, which is included in its service user guide and displayed on the notice board in the hallway. A resident said he knows who to speak to if he is not happy about something and residents who responded to our survey stated they know who to speak to if they are not happy and how to make a complaint. Most issues are raised informally during daily contact with staff but it was also evident from records of key worker sessions and notes of house meetings that residents are given regular opportunities to formally raise any concerns they may have. Residents who responded to our survey stated that staff members always treat them well. The AQAA confirmed there had not been any safeguarding alerts raised by the home since our last inspection. Since the previous inspection, the commission received information from the local social services in the form of feedback from discussion between the safeguarding team and the local police when the management of risk in Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: relation to an individual resident had been discussed. At that time, the homes manager confirmed the arrangements in place, which were also evident at the inspection visit. Safeguarding guidance from the local authority is available in the home. As well as a safeguarding policy and procedure and staff training, residents are protected by recruitment checks carried out on applicants for care staff posts at the home. Staff files sampled contained evidence of safeguarding training, either in-house or external courses. Staff members understanding is monitored through supervision. People are supported to know their rights through the homes service user guide, their key worker sessions, and information provided about local advocacy groups. Care Homes for Adults (18-65 years) Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have a comfortable environment to live in, which is generally suitable for its stated purpose. Evidence: The inspector toured the home and saw all the communal areas, which were free from any unpleasant odours and generally clean. Residents who responded to our survey stated the home is always fresh and clean. Three bedrooms were inspected, two occupied and one vacant. One bedroom had evidence of odour. Staff attributed this to the occupants poor personal hygiene, which was an issue they were working with him to improve. Two residents spoken with said they like their rooms, which they said are comfortable and have the things they need. Residents have keys to their rooms, which promotes their rights to privacy and enables them to keep their belongings secure. The laundry has a washing machine and a dryer and is outside in a separate, small building near the back door of the house. The multi purpose building sited at the end of the back garden had a new pool table, which had been requested by residents at one of their meetings. Residents can have visitors in the home but can also use this outside building to meet privately with visitors. This building is also the designated smoking area for the home. Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: The provider owns the adjoining house and has converted this with a view to increasing the number of places at Woodham 3 to fifteen. The manager showed the completed application documents that were about to be sent to the commission for a variation to the homes registration. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team is working well with residents but the staff rota is not always accurate in identifying the staff members who are working on each shift. The homes recruitment procedures are designed to protect residents and are being carried out effectively. Staff members are offered training opportunities relevant to the work they do, and they have either achieved NVQ in care at level 3 or are working towards this. Evidence: When the inspector arrived in the home, the acting manager and the deputy manager were on duty, providing care and support for the three people currently in residence. One resident was an in-patient in hospital and the home had four vacancies. There are four permanent staff members for Woodham House 3, with the remaining staffing needs being met by other staff from within Woodham Enterprises. The staff rotas seen showed that two staff members are on duty throughout the 24hour period. However, there were instances where the staff shown on the rotas did not tally with the names of staff on the homes shift handover sheets, notably on some night shifts. This was raised with the manager who stated clearly that this was an error in that rotas had not been amended to show staff allocation changes and confirmed there are always two staff on duty at night (see requirements). Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: Seven staff members files were sampled for inspection. These included some staff members normally based at other Woodham care homes but who sometimes also provide cover at Woodham 3. The staff files are not kept on the premises but at the companys headquarters (Woodham House 1). The files were brought promptly to Woodham 3 at the inspectors request. They were found to contain the recruitment information required. Four of the staff members whose files were examined had completed a care NVQ at level 3. Other training completed by staff members included: induction programmes; health and safety; medication; safeguarding; mental health and illness; and equality and diversity. Care Homes for Adults (18-65 years) Page 25 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The acting manager is applying to the commission for registration as the manager of Woodham 3. Residents views about the quality of services have been summarised into a report that people can access easily. Regulation 26 reports are now being produced regularly and the home has provided us with its annual quality assurance assessment. Residents health and safety is promoted and the home makes sure required safety checks are carried out within the appropriate timescales. Evidence: It was evident from discussions and examination of documentation during this inspection visit that the acting manager (who is a former registered manager for another of the companys homes) was about to submit an application to the commission for registration as the manager of Woodham 3. She had already obtained a CRB check through our registration team. The home facilitates a monthly residents forum. Minutes are kept and were seen on file during the inspection visit. Residents take it in turn to chair these meetings, which Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: begin with agreeing the previous minutes then proceeding through items on the agenda. It was evident people can raise issues freely, including any concerns about aspects of daily living in the home. Staff meetings are held each month, and the minutes for the previous three months were seen on file. Items discussed included matters regarding care delivery, staff training and policies and procedures. We sent an annual quality assurance assessment (AQAA) document to the home for completion and this was returned promptly, giving most of the information we asked for. We had issued a statutory requirement notice to the provider in June 2008 for non-return of the previous AQAA requested, with which the home had complied. The AQAA was handwritten and the acting manager said this was because of a computer breakdown. It was understood the Woodham homes are to have a new computer system installed, and training to prepare staff for this was being carried out in the home when the inspector arrived. This initiative is to be welcomed. A satisfaction survey had been carried out in December 2008 and the results made available to the residents and their representatives, in the form of a summary report displayed on the homes notice board. Completed questionnaires were seen and it was evident issues raised had been addressed. For example, residents had asked for a pool table and this had been provided. Another action taken as a result of survey findings was the purchase of a new television for the lounge. Regulation 26 visits and reports for Woodham 3 are completed each month and copies of these monthly reports were on file. The content of the reports had been informed by the views of residents and staff members. It was evident that managers of the three Woodham care homes were carrying out the regulation 26 visits on each others homes. Discussion was held with the manager, as she is also the responsible individual nominated by the company and is the companys project coordinator. While undertaking regulation 26 visits may be seen as a learning and development opportunity for managers, it should be evident how there is provider oversight of the process. For example, how a manager from another home visiting to monitor the quality of services at Woodham 3 reports the outcome to the project coordinator, who is also the manager of Woodham 3. The project coordinator undertook to raise this issue with the provider. We have been notified of events that impact on the health and welfare of residents. Reports of such events were on file in the home, together with evidence of the homes liaison with other professionals involved in the care of the individual residents concerned. Care Homes for Adults (18-65 years) Page 27 of 32 Evidence: Inspection of a sample of documentation showed maintenance checks were up to date and within the appropriate timeframes, including a current gas safety certificate, as we had required at our last visit. A food hygiene inspection by the local authority in August 2008 had resulted in the home being given a three-star good rating. Our previous requirement about hand drying facilities in the toilet and kitchen had been addressed, with the provision of paper towels. There would be further benefit from the installation of holders or dispensers for these (see recommendations). Care Homes for Adults (18-65 years) Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 The registered person must ensure the homes format for recording the administration of depot medication by injection is reviewed. This needs to make clear the staff are recording that they have checked the depot has been given at the GP surgery, rather than recording it has been given in the home. 31/05/2009 2 33 18 The registered person must 31/05/2009 ensure staff rotas are always accurate. It is important to amend rotas to show any staff allocation changes. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 30 of 32 1 42 The registered person should install holders or dispensers for the paper towels for hand drying in the kitchen and toilet, to further improve hygiene standards. Care Homes for Adults (18-65 years) Page 31 of 32 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. 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. Care Homes for Adults (18-65 years) Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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