Care Home: 24 Flambard Avenue

What the care home does well People who are considering using the service have the information they need to make an informed choice. People who use the service are now playing an active role in the care they receive. People who use the service are able to make choices about theactivities they participate in. People who use the service receive the health care support they need to be well. People who use the service have their dignity and privacy respected. People know how to complain if they are unhappy. The home is safe, comfortable and well maintained. What has improved since the last inspection? At the end of the inspection in April 2009 there were ninerequirements. Eight of the nine requirements have been addressed in full. Care plans are more detailed and accurately reflect the needs of the person.The complaints procedure is available in a format that each person can understand.There is now training in place for staff and it is relevant to the work they do.Improvements have been made to the number of staff on duty so that people are supported individually to participate in activities of their choice.A senior manager is visiting the service on a monthly basis and completing a report with action points. The manager tells us whenever an incident occurs in the home. What the care home could do better: At the end of this inspection there are no requirements and two recommendations. It is important that staff who work in the home are working towards nationally recognised qualifications such as NVQ.The quality assurance process needs to be developed to ensure that people living in the home have a voice in its development. Key inspection report Care homes for adults (18-65 years) Name: Address: 24 Flambard Avenue 24 Flambard Avenue Fairmile Christchurch Dorset BH23 2NF The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Tracey Cockburn Date: 1 4 0 4 2 0 1 0 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. They reflect the things that people have said are important to them: 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 Care Homes for Adults (18-65 years) Page 2 of 38 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 mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 38 Information about the care home Name of care home: Address: 24 Flambard Avenue 24 Flambard Avenue Fairmile Christchurch Dorset BH23 2NF 01202474848 01202474803 Flambard@robinia.co.uk 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) : Solor Care Group Limited care home 4 Number of places (if applicable): Under 65 Over 65 4 0 learning disability Additional conditions: The maximum number of service users who can be accommodated is 4 The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection 1 5 0 4 2 0 0 9 Care Homes for Adults (18-65 years) Page 4 of 38 A bit about the care home Flambard Avenue is registered to support up to four people with a learning disability. Everyone has their own bedroom and bathroom. Local shops, cinema, restaurants, churches and a library are all within walking distance or by using a car or bus. Care Homes for Adults (18-65 years) Page 5 of 38 We can do lots of different activities. Care Homes for Adults (18-65 years) Page 6 of 38 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 Care Homes for Adults (18-65 years) Page 7 of 38 How we did our inspection: This is what the inspector did when they were at the care home We visited the service without telling them we were coming. We spoke to people who live in the home and observed staff at work. We spoke to the manager and were shown round the home by someone who lives there. We looked at a variety of records such as individual support plans, staff records, training, health and safety records and medication. Care Homes for Adults (18-65 years) Page 8 of 38 In preparing for our visit we looked at information the home had sent to us such as notifications and the annual quality assurance assessment. What the care home does well People who are considering using the service have the information they need to make an informed choice. People who use the service are now playing an active role in the care they receive. People who use the service are able to make choices about the Care Homes for Adults (18-65 years) Page 9 of 38 activities they participate in. People who use the service receive the health care support they need to be well. People who use the service have their dignity and privacy respected. People know how to complain if they are unhappy. The home is safe, comfortable and well maintained. What has got better from the last inspection At the end of the inspection in April 2009 there were nine Care Homes for Adults (18-65 years) Page 10 of 38 requirements. Eight of the nine requirements have been addressed in full. Care plans are more detailed and accurately reflect the needs of the person. The complaints procedure is available in a format that each person can understand. Care Homes for Adults (18-65 years) Page 11 of 38 There is now training in place for staff and it is relevant to the work they do. Improvements have been made to the number of staff on duty so that people are supported individually to participate in activities of their choice. Care Homes for Adults (18-65 years) Page 12 of 38 A senior manager is visiting the service on a monthly basis and completing a report with action points. The manager tells us whenever an incident occurs in the home. What the care home could do better At the end of this inspection there are no requirements and two recommendations. It is important that staff who work in the home are working towards nationally recognised qualifications such as NVQ. Care Homes for Adults (18-65 years) Page 13 of 38 The quality assurance process needs to be developed to ensure that people living in the home have a voice in its development. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Tracey Cockburn CQC South West Citygate Gallowgate Newcastle upon Tyne NE1 4PA Care Homes for Adults (18-65 years) Page 14 of 38 03000 61 61 61 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Care Homes for Adults (18-65 years) Page 15 of 38 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 16 of 38 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. People who are considering moving into the home only do so after an assessment and the manager is clear the home has the skills and experience to support them. Evidence: The annual quality assurance assessment says they plan to do the following over the next 12 months to improve further: Update the Service User Guide and Statement of Purpose to reflect staff and management changes Set up user friendly service user guides and statement of purpose Set up a brochure for the service to ensure we include people already living with in the home are included in the assessment process. to ensure we plan transitional periods in place that are person centred and relevant to the individual. To have regular Makaton training for the staff as we have 2 service users that communicate using Makaton To have contact with Advocacy groups that we can link in with to support service users when looking at our Home. (Standard 3.7) Care Homes for Adults (18-65 years) Page 17 of 38 Evidence: Care Homes for Adults (18-65 years) Page 18 of 38 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. Improvements to care planning ensure that people who use the service are being involved in the development of their own person centred plans. Evidence: The annual quality assurance assessment says under the heading what has improved in the last 12 months: Support Plans and guidelines have been re written and improved to clearly state how individuals prefer to be supported. staff are now following guidelines and are more consistent in their approach Routines are written and followed by the staff which ensure a more consistent and stable approach In the next 12 months they plan to : To complete Person Centred Plans which would state how the service user prefers to be supported to enable the service users to choose who supports them and record this. They also told us: To set up plans that include positive interventions ( Standard 6.5) the staff need to give more choice regarding evening meals and plan weekly rather than having a rolling menu that doesnt t change. We need to ensure we are reviewing risk assessments regularly and amending as necessary to write Person Centred Plans and involve service users more regarding support planning To document evidence that service users are able to choose the staff that support them. Write support plans in service user Care Homes for Adults (18-65 years) Page 19 of 38 Evidence: friendly format We looked at the support plans for two people who use the service we found that the support plans were clear and contained information to enable staff to support people effectively. One person has very complex needs and the support plan has been developed to be clear about why the structure needs to be in place, the service has involved an occupational therapist in helping staff understand how to meet the persons sensory needs. We could see that support plans had considered individual restrictions on choice and freedom and in one case a best interests assessment had been completed and was due to be reviewed after three months. There are very individualised procedures to support one person who can cause harm to themselves or others and the guidance focuses on positive behaviour and is written from the perspective of the individualconcerned. we could see that support plans had been signed by both the individual concerned and the person who wrote the plan. Support plans have been developed in a person centred way and are available in a format which the individual can follow, the manager acknowledged that further work is needed to these plans, however when we spoke to one person they were very aware of what was written about them. We observed how people make choices in their every day life, one person was due to go out for activities at 11am however they were not ready as they take time to build themselves up to going out, staff respect this process and followed the very clear guidance in the person plan about how to support them. We spoke to one person about how they look after their money, they told us that they go to the bank to take money out and it is kept in the safe and when they need to buy anything they can but they must always get a receipt and bring it back to go in the safe. We looked at risk assessments for one person they were titled my risk assessments they were clear and focused, identifying the risk and strategies to minimise them. We looked at one persons book all about them and noticed that some of the pictures being used were not of the person themselves but of different people both men and women and of different cultures, when we pointed this out to the manager she immediately said that this culd be updated and pictures of the individual concerned put in their place. She told us this was a template form provided by a healthcare professional. Care Homes for Adults (18-65 years) Page 20 of 38 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their life style and are supported to develop their life skills. Evidence: The annual quality assurance assessment says under the heading what has improved in the last 12 months: better recording of activities and 1-1 hours, consistent staff team has enabled a consistent activity timetable the weekly food budget has been increased which enables more choices Service users are supported to prepare meals. One Service user is supported to see their family more as requested by them in meetings. Service users are supported to use alternative transport if the minibus is in use therefore not limiting them from activities Staff supervision is now regular and in depth and is used to discuss more effective ways of supporting the service users We spoke to all three people who use the service, two briefly and one other person spoke to us about life in the home and what he likes doing. Care Homes for Adults (18-65 years) Page 21 of 38 Evidence: One person works two afternoons a week locally and told us they really enjoy it. One person was going out for the day and was laughing and joking with staff, staff gently but firmly reminded the person they had to focus on the tasks they were doing in order to go out for the day. Each person has a structured timetable of activities which easily identifies the one to one hours that people have. People using the service are involved in menu planning and the menu on the fridge clearly shows who chose what meal. The manager told us that they are involved in choosing from a photo album of meals and food. The manager told us that they are planning to use a camera with each person so they can take pictures while they are out on activities one person writes a journal of what she did each day and they are planning to print the picture of the activity with space below it so they can write about what they did and then this will form the basis of her history in the home. This person also has a photo album of her family, friends and her life int he home. We looked at one persons album with them and they told us what they had done this with the support of staff. The manager is introducing talking albums for people. One person is going on a day trip to somewhere they have always wanted to go as they were born their, we could see that this had been identified as a goal and the work done to make it happen. They were very excited about the trip. We could see that people who live in the home are able to decide when they want to be alone and when they want to have company. People who use the service have access to all the communal areas of the home. Information is on a noticeboard about which staff are on duty on each shift each day, information on other notice boards relate to the people who use the service. Throughout our visit we observed staff talking to people who use the service and the only time they talked to each other was when they were discussing what strategy they would use next to encourage someone to progress their morning routine. Care Homes for Adults (18-65 years) Page 22 of 38 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. The health and personal care that people receive is based on their individual needs and the principles of respect, dignity and privacy are put into practice. Evidence: We could see in the support plans that people are receiving their personal support in a very person centred way which considers the individual support they need with their daily routines but also takes into account their need to do as much as they can and want to for themselves. We could also see that people are able to make choices about who supports them and changes are made if this is not working well or the person requests a change. We spoke to the manager about the professional support they receive this includes input from the occupational therapist, community nurse and psychologist. We could see through observation on the day that staff are consistently following the guideline in support plans. We could see that that staff are working with each other well and communicating with family and other professionals to support the individual. In the two files we looked at we could see evidence of health care professionals being involved in supporting people, each person has a health action plan. Care Homes for Adults (18-65 years) Page 23 of 38 Evidence: No one in the home manages their own medication, one person is not on any medication and another person is working towards having his medication in a medicine cabinet in his own room but this goal is being worked on slowly at the pace of the individual. There is a clear audit trail in the home with regard to medication and the responsibility has been delegated to a senior member of staff. We looked at the medication file and could see there was a care plan for PRN medication as well as straightforward information on what the medication was for and its effects. All staff have to complete medication training before they are able to dispense medication in the home. Care Homes for Adults (18-65 years) Page 24 of 38 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. People who use the service are supported to express their concerns and worries. Staff receive the training they need to ensure they understand the signs of abuse and can protect people. Evidence: The annual quality assurance assessment says: We have a complaints policy and procedure in place (Standard 22.1) there is also a complaints procedure in a picture format. Complaints are discussed in service user meetings and key worker meetings and service users are supported to make a complaint if required Staff attend SOVA training regularly there is an Assisting People with their finances policy in place. staff record all monetary transactions and receipts are kept. There is Protection of Vulnerable Adults policy in place and Recruitment procedures ensure that an enhanced CRB and 2 references are in place before we recruit our staff. Staff receive Proact-scip training (person specific) to enable them to support service users who display challenging behaviour. The complaints procedure is in easy read and available for each person. Since the last key inspection there has been one safeguarding referral and investigation which related to how the behaviours of one person living in the home were affecting the lives of the other people living there. A multi disciplinary meeting as a result of the safeguarding decided to move one person, who left the home in February 2010 and is now living in supported living. Care Homes for Adults (18-65 years) Page 25 of 38 Care Homes for Adults (18-65 years) Page 26 of 38 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home live in a more homely and comfortable place which reflects it is their own home. Evidence: The environment has changed since the last key inspection, the front garden has been tidied up and there are now flower boxes and planters. People who live in the service were involved in planing flowers in the planters. The quiet room which used to be bare apart from a sofa and some bean bags is now an activity and sensory room, with a touch wall, the manager told us that one person who uses the service finds this very interesting. A great deal of though has gone into this room and how it is used, there are a variety of differents sensory games and a variety of lights to occupy and stimulate. The lounge has a television encased in a secure perspex box for safety. The lounge has the hand and feet prints of both staff and people using the service on the wall. There are also photographs throughout the home of the people living in the service. Two people let us look in their room one person showed us around the home, his room is very personalised and everything is placed where he wants it. He has a desk in the middle of his room and he has recently asked if he can paint the walls a different colour. Care Homes for Adults (18-65 years) Page 27 of 38 Evidence: Another person has recently had changes to her room and has a double bed. There is a vegetable plot in the garden and people who use the service are growing their own veggies. The home was clean and bathrooms had paper towels, liquid soap and lidded foot operated bins. We noted there was a risk assessment in place for one person who may injest toiletries and these are kept in a locked cabinet in their bedroom and only used as part of the persons personal care routine. Staff have received training in infection control. Care Homes for Adults (18-65 years) Page 28 of 38 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. Improvements have been made to support staff and ensure they receive the training they need to be skilled in supporting the people who use the service. Evidence: Since the introduction of clear guidelines for staff from professionals, there has been changes in the provision of care in the home and staff have a better understanding of the needs of one person living in the home, which is affecting the way they work in a positive way and we observed good staff communication on how to support this person with their structured routine. Staff training is taking place and new staff only start work once they have completed the PROACT - SCIPr UK (r) ( Positive Range of Options to Avoid Crisis and use Therapy Strategies for Crisis Intervention and Prevention) training. The annual quality assurance assessment (AQAA) tells us that the last three months prior to submission of the assessment in January; 56 shifts were covered by agency staff. The manager told us that she has turned agency staff away when they have turned up at the home having never worked there before. The manager will only accept agency staff who have completed the relevant training and have skills and experience in working with adults who require intensive support. Four of the 10 permanent staff have NVQ level 2 or above which is less than 50 of the work force. Care Homes for Adults (18-65 years) Page 29 of 38 Evidence: We looked at recruitment, one person has been employed since the last key inspection, the application form had been completed and gaps identified. Proof of identity, photo on passport did not fax well from head office and the manager has raised this with them. The member of staff completed Proact-SCIPr-UK(r) training before starting work in the service and completed person specific training 2 days after starting work. Three day induction which covers abuse, moving and handling, health and safety , first aid and infection control compelted. also completed autism awareness training before starting work in the service. The manager showed us a work book from Scils: social care information and learning service, staff are currently working through the work book on autism and challenging behaviour. We looked at the training matrix for the home, only three staff have not completed Makaton training and the manager told us this is already booked for them, the rest of the staff completed Makaton training on 25/01/10. This is important training as two of the people using the service use makaton, we observed staff using makaton . Three staff have completed person centred planning training on 12/01/10 including the manager, more training is arranged for the rest of the staff. All staff have completed the SCIP training which is yearly and the SCiP person specific training which is also updated yearly, all staff have completed the autism awareness training. All other training was up to date and where there were gaps, the manager was aware and courses were booked. Care Homes for Adults (18-65 years) Page 30 of 38 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 home is well managed with the needs of people using the service at the centre of the service being delivered. Evidence: At the last key inspection there was no manager in post and the service was struggling to support people. We found at this inspection that the manager and staff team have worked together to develop the service and meet peoples needs effectively. We looked at the last three months Regulation 26 reports and could see that they were detailed and had action points for the manager to address. In discussion with the manager it was agreed that she no longer had to send in reg 37s for every incident where one of the people using the service hits a member of staff as we can see from the care plans that there is detailed structure in place and we observed staff following this during our visit. The manager is waiting for her CRB check to be returned and then will submit application to register. We looked at fire records, there is a fire risk assessment in place, all weekly and monthly checks on fire equipment were up to date. There are personal evacuation plans in place Care Homes for Adults (18-65 years) Page 31 of 38 Evidence: for each person living in the home and the fire risk assessment is in place nd due for review in June 2010. Care Homes for Adults (18-65 years) Page 32 of 38 Are there any outstanding requirements from the last inspection? Yes  No  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 1 6 15 (1) The registered provider must 30/06/2009 ensure that in consultation with the individual and their representative a written plan of their needs in relation to their health and welfare are completed fully. 2 22 22 (2) The registered provider must 31/07/2009 ensure that the complaints procedure is appropriate to the needs of the people using the service. 3 32 18(1) (a) The registered person shall, 11/08/2009 having regard to the size of the care home, the statement of purpose and the number and needs of service users - (a) Ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Care Homes for Adults (18-65 years) Page 33 of 38 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 4 32 18 (c) The registered provider must 31/08/2009 ensure that all staff working in the home receive training which is appropriate to the work they do. In this home this would mean ensuring that staff completed training on working with people with autism and the needs of people with learning disabilities as well as challenging behaviour. 5 36 18 (2) The registered person must ensure that all staff are appropriately supervised especially when they are faced with aggressive situations on a daily basis. 31/07/2009 6 39 26 Where the registered 31/08/2009 provider is an organisation or partnership the care home must be visited in accordance with this regulation by the responsible individual or one of the partners, as the case may be Page PAGE of NUMPAGES Care Homes for Adults (18-65 years) 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 another of the directors or other persons responsible for the management of the organisation or an employee of the organisation who is not directly concerned with the conduct of the care home. 7 39 24 The registered provider must 31/08/2009 establish and maintain a system for evaluating the quality of the services provided at the care home. When an annual quality assurance assessment is submitted to the commission it must contain more than one word answers. It must contain details of the measures being taken to improve the quality and delivery of the service based on the system it has developed. 8 42 37 (1)(e) The registered provider must 30/06/2009 inform the commission without delay of any event in the care home which adversely affects the well being or safety of any service user. If people who live in the home are witnessing violence Page PAGE of NUMPAGES Care Homes for Adults (18-65 years) 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 against the staff that support them this could have an adverse affect on their emotional well being. Care Homes for Adults (18-65 years) Page PAGE of NUMPAGES 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 Description 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 Description Timescale for action 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 32 The registered person should ensure that the service works towards 50 of the care staff in the home achieving or working towards an NVQ 2 in care. Care Homes for Adults (18-65 years) Page 37 of 38 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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