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Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 56 Monks Dyke Road 56 Monks Dyke Road Louth Lincolnshire LN11 0NY 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: Sue Hayward Date: 1 6 0 9 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. 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 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. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 33 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2008) 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 33 Information about the care home Name of care home: Address: 56 Monks Dyke Road 56 Monks Dyke Road Louth Lincolnshire LN11 0NY 01507610877 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): andrew.kennedy@sense.org.uk Sense, The National Deafblind and Rubella Association Name of registered manager (if applicable) Mrs Fiona Kennedy Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 7 7 0 0 care home 7 learning disability sensory impairment Additional conditions: The home is registered to admit a maximum of 7 service users in the categories Learning Disability (LD) or Sensory Impairment (SI). Date of last inspection 2 0 0 9 2 0 0 6 Care Homes for Adults (18-65 years) Page 4 of 33 A bit about the care home 56 Monks Dyke Road is one of a number of care homes within the county operated by SENSE East and is located in a residential area in the market town of Louth. The building is owned by a housing association, which has some maintenance responsibilities. It was originally a family home. It provides personal care and support in single rooms for up to seven service users over the age of eighteen. Three bedrooms have en-suite facilities. The home has a safe, enclosed garden at the rear of the property and car parking spaces at the front and rear of the house. Transport is provided through the use of a minibus and staff cars. The manager confirmed during the visit that the current range of fees is from £81,977:43 to £104,305:10 per year. There are no additional charges. Information about the day-to-day operation of the home, including a copy of the last inspection report, can be found in the entrance hall. Care Homes for Adults (18-65 years) Page 5 of 33 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 6 of 33 How we did our inspection: This is what the inspector did when they were at the care home Throughout this report the terms we and us refer to The Commission for Social Care Inspection (CSCI). This was an unannounced visit and it formed part of an inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. The main method used to do this was through a process we call case tracking. This included following the care of a sample of two people through their records and assessing their care. We met all people who use the service and saw the rooms of the two people whose care we followed. In addition we spoke to three staff who were on duty. Care Homes for Adults (18-65 years) Page 7 of 33 We took into account information we already hold on our files, which was used to plan the visit and produce this report. Prior to the visit the manager had completed a questionnaire. This gave us some important information about their own assessment of how well they are meeting standards and how they plan to improve the service. As people have very individual ways of communicating we did not send out surveys to them. Instead, time was spent during the visit observing staff working with people. We also undertook an annual review of the service on 24th January 2008, which indicated that the service was providing positive outcomes for the people using the service. What the care home does well The home is, clean, tidy and well Care Homes for Adults (18-65 years) Page 8 of 33 maintained and is furnished according to peoples needs and preferences. People’s independence is encouraged within the home and community and they can participate in a range of social and leisure activities if they wish. People’s health care and well-being is checked through regular appointments with a range of health professionals. There is a consistent and committed staff team who are well trained. Staffing levels ensure people’s needs are met. Care Homes for Adults (18-65 years) Page 9 of 33 What has got better from the last inspection Staff have participated in a range of training to ensure they know how to provide people with a good standard of care. Reviews are being held on days when people who use the service are at home so that they can attend them if they wish. Some bedrooms have been redecorated and new furniture purchased to ensure that people who use the service live in a pleasant, comfortable and well-maintained environment. Care Homes for Adults (18-65 years) Page 10 of 33 What the care home could do better Care plans need to show more clearly that people’s capacity to make decisions has been considered and staff would benefit from some training to ensure they fully understand how the Mental Capacity Act affects the work they do. Action needs to be taken to ensure that any potential health and safety risks, which have been identified, have received attention. For example, ensuring that handrails are provided on the ramped entrance to the property. This will promote people’s independence as well as their health and safety. Some information on display in the entrance hall, which is available to any visitors, needs to be reviewed to ensure it does not contain any personal details so that people’s privacy is respected. Care Homes for Adults (18-65 years) Page 11 of 33 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 Sue Hayward Eastern Regional Office CPC1 Capital Business Park Fulbourn Cambridge CB21 5XE 01223 771300 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 12 of 33 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 13 of 33 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. There are good systems in place to introduce and assess people who use the service to ensure their individual needs are identified and can be met prior to admission. This process ensures as far as possible that people are well informed about the home. Evidence: There have been no new admissions to the service in the past twelve months. In view of this the care records of the most recently admitted person and a person who had lived in the home for a number of years was chosen and their care followed. Both care records checked on this occasion contained information demonstrating what assessments had taken place and included information about a range of different matters form which care plans had been developed. Discussion with the manager and staff confirmed that in view of the communication needs and level of understanding of the current people the service supports all would have great difficulty in being directly involved in the development of their care plan. However, the assessment process includes opportunities for people who wish to use the service to visit along with their relatives, carers or other representatives such as Care Homes for Adults (18-65 years) Page 14 of 33 Evidence: social workers. Staff told us people were encouraged to visit the home and this could include overnight or longer stays, this gives staff the opportunity to ensure that they can meet the needs of any new person before agreeing their admission and it also gives the person who is using the service the opportunity of experiencing the home. The records of both people checked contained much information about their needs such as communication, health and physical needs. Assessment information had also been obtained from other health professionals. It was noticed that records also contained information to show whether people had any specific religious or cultural needs, which is important information for staff to know. Where identified any risks were incorporated into personal records including any action needed to minimize them. Staff had a good knowledge of the needs of people who use the service and were observed to communicate with them in differing ways. There is information on display in the hall, which tells people about the service and the terms and conditions it is offered under. The management arrangements changed in July 2007 but the information has not yet been reviewed to reflect this, which could be misleading. It was also noticed that some information that was available in the hall included some personal details about staff and people who use the service. The manager agreed to act to ensure both matters received attention. People who use the service looked relaxed and well cared for. Care Homes for Adults (18-65 years) Page 15 of 33 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. People who use the service are supported to be independent and make choices and decisions about their lives. Staff have a good knowledge of peoples needs and how to meet them, which contributes to ensuring peoples health and wellbeing. People’s capacity to make decisions is not clearly reflected in care plans. Evidence: Two peoples records were checked and they gave clear information for staff to follow about their needs and how to meet them. They contained information to show where risks had been identified and any action needed to minimize them. They also contained some general information to demonstrate how staff would include people in decision making but limited reference as to whether peoples capacity to make specific decisions had been considered. This is important information for staff to know to ensure people are not deprived of their rights. Staff also told us that they had not had any specific training relating to this legislation and did not feel totally clear about it. It was understood from discussion with the manager that this is being planned by the organisation. Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: Reviews are held a minimum of twice yearly and records and discussion confirmed that relatives and other professionals such as funding authorities are invited to attend and contribute to them as are people who use the service if they wish and are able. Staff discussion and observations indicated that they were aware of the needs of people who live at the home and of their different needs in relation to communicating with them. For example one staff member showed us a diary containing photographs showing aspects of a person’s life at the home, which was being, compiled with the person themselves. Staff also gave us examples of how they offer people who use the service choices such as in the case of a person who lives at the home, ensuring that the range of choices offered is limited to a couple of options as the person concerned would be unable to make a choice if too many options were offered. People looked well cared for and staff were noticed to be attentive to their needs during the visit. Care Homes for Adults (18-65 years) Page 17 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are encouraged and supported to have control over their daily lives and their independence is promoted within their capabilities. People have opportunities to participate in a wide range of activities to enable them to pursue social and leisure activities within the home and community. Visitors are made welcome. Evidence: Staff told us about the various activities and leisure interests that are arranged for people and records checked showed what activities people who use the service had participated in. For example, archery, sailing, reflexology and visiting local pubs and community events are regularly arranged for people who use the service. People are also able to take part in activities in the home such as baking, and craft activities if they wish and some of the latter were seen on display. Staff provide support for them to do so. Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: SENSE East have a resource centre that people who use the service attend and there are additional vocational and occupational opportunities offered there. Transport is provided in the form of a mini-bus to enable people who use the service to get out and about. On the evening of the visit people were due to go out to an archery session. People also have opportunities to go on holidays and staff told us that people’s particular preferences are taken into consideration when arranging them. For example, a horse riding holiday had been arranged as well as a barge holiday to suit the particular interests of the people living at the home. Some relatives were visiting during the inspection and it was noticed that staff were polite and welcoming to them. Staff told us and records confirmed, that people who use the service are able to keep in contact through visits to or from friends and relatives. Records of meals were checked, they showed that there were healthy and varied meals provided. There is a rotating menu, which although set has been based on the known likes and preferences of people who live at the home. Care Homes for Adults (18-65 years) Page 19 of 33 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. People who use the service receive individual care that promotes their health and welfare. They are protected by the medication procedures in place and any errors are appropriately dealt with to ensure the safety of people who use the service. Evidence: Staff were observed for short periods assisting and supporting people who use the service. They were seen to be kind and caring when communicating with people. For example, when asking someone whether they would like to go to their room. People were observed to be able to move around the home as they wished and were supported by staff to do so. Records showed that if needed other professionals such as psychologists are consulted and that people who use the service have regular health checks such as visits to the doctor, dentist and opticians. Staff told us that if people who use the service need to stay in hospital, they stay with them, which helps with communication. We observed how medication was administered in the home and a safe process was followed. Two staff were present one who administers and one who double checks. Care Homes for Adults (18-65 years) Page 20 of 33 Evidence: This helps to ensure people who use the service have their medication administered appropriately. Medication records checked were well maintained and up to date and storage arrangements were satisfactory. A community pharmacist visits periodically to offer advice about the systems in place. The report of the most recent visit, which occurred on 10/09/08 was checked and no issues were raised. Records and a staff members comments confirmed that staff have training in administration of medication. They also knew the correct procedures to follow in relation to what to do if an error occurred and how to dispose of medication safely. Care Homes for Adults (18-65 years) Page 21 of 33 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 using this service are protected by satisfactory procedures in place for handling complaints and allegations of abuse. Evidence: Information, which we were sent prior to the visit told us that the organisation has policies and procedures relating to ensuring the protection of people who use the service. For example, complaints and raising concerns, safeguarding adults, whistleblowing, restraint and handling of money in safekeeping procedures. Staff told us that they receive training about safeguarding adults, which is updated periodically and annual training about dealing with challenging behaviour. They gave us a good account of the action they would take should they become aware of anyone who may have a concern or complaint and of what to do to protect people who use the service if they became aware of any allegations of abuse. Records showed that family and other professionals are invited to attend formal reviews, which provide another opportunity for any matters to be raised should anyone have any concerns about the service. Staff said that in view of the communication needs of people who use the service they may not be able to make their concerns easily known however, staff rely on their own observations and knowledge of ways in which service users communicate, as well as any changes in behaviour to determine their well being. We were told that no complaints have been made in the past 12 months. There is a record in place to record such events if needed and this showed us Care Homes for Adults (18-65 years) Page 22 of 33 Evidence: that three compliments had been made about the service in the past year. There has been one safeguarding adults investigation in the past year. This related to a medication error. It was concluded that this was a practice issue and staff at the home had taken appropriate and swift action to address the issue. There are satisfactory arrangements in place for people who wish to have their money or valuables kept safely in the home and appropriate records are kept of any transactions, which were accurate and up to date. People who use the service looked comfortable and relaxed and were responsive to staff. Care Homes for Adults (18-65 years) Page 23 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a generally safe and comfortable environment that is suitable for their needs. However, the lack of action taken to address issues raised from environment audits has the potential that people who use the service may be put at risk. Evidence: Equipment is provided to assist service users with mobility problems including a passenger lift, handrails in bathrooms and a ramp to the front door. We were told at the time of the last site visit in 2006 that the services own health and safety audit had identified that hand rails were needed outside the main entrance. We were also told this was planned to be addressed, however no action has yet been taken to do so. Furthermore the health and safety audit which was conducted on 31st July 2008 again made reference to identifying the same risk, and it needed action before the winter. This matter has the potential to pose a risk to people particularly as some people who use the service are not able to walk without some assistance. People’s rooms were noticed to be comfortably and individually furnished according to their interests and personal preferences. The home is spacious and all areas checked on this occasion looked clean and tidy. The service was last visited by an Environmental Health Officer in 2006 when a recommendation was made about the times refrigerator temperatures are recorded and it was confirmed these are now done Care Homes for Adults (18-65 years) Page 24 of 33 Evidence: during the night to ensure accurate readings. The manager provided us with information before the visit confirming that in the last 12 months bedrooms have been redecorated and some new furniture has been purchased. We were told that one of the ways they wish to improve the environment for people over the next year is to create a sensory garden. The manager told us there are policies and procedures in place about infection control and 22 staff have received training about this subject. Stocks of gloves and aprons were seen around the home and staff were noted to use them. Care Homes for Adults (18-65 years) Page 25 of 33 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. People who use the service are supported by a team of staff who have had relevant training and who are employed in sufficient numbers to meet their current needs. Evidence: The majority of staff are female however there are two male staff employed. This enables people to have some choice as to who undertakes their personal care. We were told that there is generally five staff on duty in the mornings and evenings and at night there is one wakeful staff member and one on the premises who is on-call. The information we were given before the visit showed that no staff have left in the past 12 months indicating there is a consistent staff team. SENSE East has a satisfactory training programme in place, which all new employees attend over a six-week period. This includes a modular training programme covering matters such as manual handling, food hygiene, first aid, challenging behaviour, communication and protection issues. This ensures staff have the appropriate skills and knowledge to care for people who use the service. After staff have gone through the initial induction programme training is updated periodically. Information prior to the inspection confirmed that eighteen staff had achieved a National Vocational Qualification award at level II or above and three were working toward it. Care Homes for Adults (18-65 years) Page 26 of 33 Evidence: Staff told us that staffing levels were sufficient to meet the needs of the people who use the service and to enable some flexibility to meet individual needs. For example, staffing levels are sufficient to enable people who have to stay in hospital to have a staff member with them during that time. They are also sufficient to enable people to pursue different activities. The records for two members of staff checked provided evidence that there is a satisfactory process in place, which includes taking up references, a criminal records bureau and a protection of vulnerable adults check prior to staff working in the home. Staff told us they were well supported and worked well as a team. There is a satisfactory system in place to support and monitor staff, which includes staff meetings and supervision and appraisal meetings . Care Homes for Adults (18-65 years) Page 27 of 33 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 and there are good systems in place to monitor the quality of the service. This helps to ensure the health and welfare of people who live at the home. Evidence: Since the last key inspection there has been a change of registered manager. The current manager has completed a registered managers award and is in the process of working to achieve a nationally recognised vocational award in care at level 4. He is an approved trainer for SENSE East in the area of non-crisis intervention techniques. He has 23 years experience of working in residential and community care settings and has worked for SENSE since 2001. Staff made comments indicating that they felt well supported through, staff and individual supervision and appraisal meetings, which are held regularly and records are kept to show the frequency these occur. There are various ways that the quality of the service is monitored. For example records were in place to show that a representative of the organisation visits the service on a monthly basis at different times of the day and checks various matters Care Homes for Adults (18-65 years) Page 28 of 33 Evidence: such as care records, complaints and concerns and maintenance issues. We were told that people who use the service would have difficulty to formally voice their views due to their needs so people who can advocate on their behalf such as relatives, social workers and staff from SENSE East attend are invited to attend reviews so that any issues can be raised which may affect people who use the service. In addition we were told and records were in place to show that SENSE East conduct their own internal audits such as financial, health and safety and their own self-assessment. All records showed that these had been carried out within the last 12 months. Records showed that the service is working toward achieving a nationally recognised quality award, Investors in people. Information received prior to the inspection indicated there are a range of policies and procedures in place relating to health and safety issues and these were noted to be accessible to staff during the visit. We were also told that equipment such as the lift is serviced regularly. The sample of records checked on this occasion which included the premises fire risk assessments, weekly fire alarm tests and tests of the emergency lighting showed they were regularly checked and reviewed. Care Homes for Adults (18-65 years) Page 29 of 33 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 Care Homes for Adults (18-65 years) Page 30 of 33 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 1 6 15 Care plans must be reviewed 30/11/2008 and clearly show the Mental Capacity Act 2007 has been considered and any outcomes. This will ensure people are not deprived of their rights. 2 24 13 13/12/2008 Action must be taken to address those matters identified which pose a risk to people who use the service e.g. providing handrails to the ramp leading to and from the front entrance. To ensure the health and safety of people who use the service. 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 Care Homes for Adults (18-65 years) Page 31 of 33 improving their service. No Refer to Standard Good Practice Recommendations 1 1 It is recommended that information on display and accessible to the general public is reviewed to ensure that it meets the Data Protection Act 1998 so that people who use the service know any information about them is being stored securely. Care Homes for Adults (18-65 years) Page 32 of 33 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 © (2008) Commission for Social Care Inspection (CSCI). 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