Care Home: Ash Villa Care Home

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What the care home does well People who want to move to the service are assessed prior to moving in and know that the staff can meet their needs. People have person centered plans and they provide enough detail to help staff understand how to support someone safely. People`s health care needs are met by staff who understand what support is needed and when to refer on to specialists. Complaints are handled well and staff receive training to ensure people are safe.The home provides people with a safe, pleasant and homely environment. People who use the service are supported by sufficient well trained competent staff. What has improved since the last inspection? People who use the service have their support plans reviewed regularly to ensure they remain up to date. Medication is administered after a risk assessment has take place to ensure that people are supported to self medicate if they are able to. The home is currently undergoing refurbishment to ensure people live in a safe pleasant environment. Confidential records are now stored securely ensuring that information regarding people who use the service remains confidential. What the care home could do better: All the key standards were found to be met on this occasion. Key inspection report Care homes for adults (18-65 years) Name: Address: Ash Villa Care Home 159 Musters Road West Bridgford Nottingham NG2 7AF 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: Susan Lewis Date: 1 8 0 8 2 0 0 9 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 32 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) Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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: Ash Villa Care Home 159 Musters Road West Bridgford Nottingham NG2 7AF 01159826644 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) : mgbcareservices@btconnect.com MGB Care Services Limited care home 10 Number of places (if applicable): Under 65 Over 65 10 10 learning disability Additional conditions: MGB Care Services Limited is registered to provide accommodation and personal care at Ash Villa Care Home, 159 Musters Road, West Bridgford, Nottingham for people whose primary care needs fall within the following categories and numbers: Learning disability (LD) 10 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 32 A bit about the care home Ash Villa is large detached purpose built house owned by MGB Care services Limited. The house is situated in West Bridgeford within walking distance of the town centre with good access to a variety of local amenities. The home, which is owned by MGB CARE SERVICES LIMITED, is large and spacious with a walk through dining room and lounge. There is parking space for several cars at the front and there is a private and well maintained garden. The premises has three floors, which are all occupied by residents, access to the ground is by stairs and passenger lift. The home has nine bedrooms which all have en-suite facilities available to residents. The fees are calculated on the level of dependency. This does not cover items such as holidays, Care Homes for Adults (18-65 years) Page 5 of 32 weekend socialising, clothing, or personal equipment. This information is made available to prospective residents upon request. Care Homes for Adults (18-65 years) Page 6 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 Care Homes for Adults (18-65 years) Page 7 of 32 How we did our inspection: This is what the inspector did when they were at the care home The focus of the inspection undertaken by the Care Quality Commission is upon outcomes for people who use the service and their views on the service provided. The process considers the providers capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that needs further development. One inspector conducted the unannounced visit. The main method of inspection used is called case tracking which involves selecting people who use the service and looking at the quality of care they receive by speaking to them, observation, reading their records and asking staff about their needs. The acting manager, two members of staff and one person who uses the service were spoken with as part of the visit, records relating to medication management was also inspected to form an opinion about the quality of care provided. Care Homes for Adults (18-65 years) Page 8 of 32 A partial tour of the building was undertaken which included peoples bedrooms and communal areas they frequent to make sure that the environment is homely and safe. A review of all the information we have received about the home since the last key inspection on 14/05/07 was considered in planning this visit which included the Annual Quality Assurance Assessment which was provided by the acting manager. In addition we also had five responses from the Have your Say pre inspection service users questionnaires and three Have your Say relative surveys What the care home does well People who want to move to the service are assessed prior to moving in and know that the staff can meet their needs. People have person centered plans and they provide enough detail to help staff understand how to support someone safely. Peoples health care needs are met by staff who understand what support is needed and when to refer on to specialists. Complaints are handled well and staff receive training to ensure people are safe. Care Homes for Adults (18-65 years) Page 9 of 32 The home provides people with a safe, pleasant and homely environment. People who use the service are supported by sufficient well trained competent staff. What has got better from the last inspection People who use the service have their support plans reviewed regularly to ensure they remain up to date. Medication is administered after a risk assessment has take place to ensure that people are supported to self medicate if they are able to. The home is currently undergoing refurbishment to ensure people live in a safe pleasant environment. Confidential records are now stored securely ensuring that information regarding people who use the service remains confidential. Care Homes for Adults (18-65 years) Page 10 of 32 What the care home could do better 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 Susan Lewis CQC Citygate Gallowgate Newcastle Upon Tyne NE1 4PA Tel: 03000616161 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 Care Homes for Adults (18-65 years) Page 11 of 32 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 12 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 13 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. Effective needs assessments are performed prior to people being admitted to the home to ensure peoples needs can be identified and met. Evidence: The Annual Quality Assurance Assessment (AQAA) states We have assessments from referring agency but also do own assessment undertaken based on the Activities of Daily Living model by Roper, Logan & Tierney to ensure the Home can meet the needs of the prospective Service User. We looked at information people receive if they are interested in moving to the service this included the Service User Guide and the Statement of Purpose. Both these gave good information about the service and what people could expect if they moved in. We looked at support plans of people who used the service and these showed that they had been assessed prior to them moving to the home and that information was obtained to support staff in being able to meet their needs. Staff spoken with said they felt they received good information about people but they never stopped learning about someone once they moved in. Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: The pre inspection questionnaires asked service users Did you receive enough information about this home before you moved in so you could decide if it was the right place for you, all five respondents stated yes. A requirement was made at the last inspection to ensure that a letter confirming that the service can meet the needs of the person is kept on file. Although this has not been done the evidence from discussion with staff and the senior managers of MGB care shows that they only admit people to the home they are able to support. We will therefore change this from a requirement to a recommendation At the last inspection a requirement was made to provide a copy of the terms and conditions of the placement on each persons file. This was seen on the plans viewed and so the requirement is met. Care Homes for Adults (18-65 years) Page 15 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. People who use the service are assured that their changing needs and aspirations are reflected in their individual risk assessments and care plans. People are are supported to make their own choices, take risks, and have an active independent lifestyle. Evidence: The AQAA states Support plans are person centred and staff at the home have received training in person centred planning. Support plans encompass all aspects of personal and social support including behaviour, communication, eating and drinking, general health, safety, mobility, bathing and dressing, finance, family, environment, sexuality and medication. The Have your Say surveys asked service users Do you make decisions about what you do each day, four people stated Always and person stated Sometimes. People spoken with on the day of the inspection confirmed that can take control of their lives and are encouraged to be as independent as possible whilst being supported by the care staff. People commented I can do what I want. Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: We looked at support plans these were well presented, person centred and stored securely to promote peoples confidentiality. The plans also included effective risk assessments to promote peoples safety in the home and in the community. The care planning and risk assessment documentation had been reviewed regularly to ensure peoples needs and aspirations can be identified and met. Staff spoken with confirmed that the support plans and risk assessments are always available for reference and guidance and they find them useful. A requirement was made at the last inspection to ensure support plans were reviewed and kept up to date. We saw that the manager is carrying out reviews and the requirement is now met. A requirement was made at the last inspection to identify where restrictions on liberty and rights of people and the people who use the service or their representative must sign to say to say they consent. All staff are currently undergoing Deprivation of Liberty training and the provider told us where restrictions are in place assessments either have taken place or are the process of taking place. The requirement is now met. Care Homes for Adults (18-65 years) Page 17 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. People can participate in a comprehensive range of social activities. Peoples rights and responsibilities are upheld and they can maintain contact with their family and friends as they wish. A well-balanced menu is provided which promotes peoples choice and preferences. Evidence: The AQAA states Residents are involved in planning their day and any activities they wish to participate both within the Home and in the community. We saw evidence in support plans and photographs of people involved in a variety of activities of their choosing. Service users also confirmed that they are provided with annual holidays to destinations of their choice. People also benefit from a secure garden area which can be used in the summer months for social activities. Relatives who responded to the surveys said that residents are frequently taken out and they take my relative out where they want to go. Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: People spoken with stated that they were very satisfied with the meals at the home. A set menu is not provided as service users are encouraged to choose what they want eat on a daily basis. People also said that the can have a drink or snack whenever they wish. The kitchen has recently been refurbished as part of the homes wider refurbishment plan, it was also inspected by the Environmental Health Officer who found it to have an excellent standard of cleanliness and hygiene. Care Homes for Adults (18-65 years) Page 19 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. Peoples health and personal care support is of a good standard. Medicine management promotes peoples safety and independence. Evidence: The AQAA states Staff ensure that personal and health care needs are maintained with privacy and dignity. Individual care plans detail any support they need to maintain their personal hygiene and health. We saw staff treat people with respect and staff spoken with understood how to maintain peoples privacy and dignity whilst providing care. We looked at support plans and these showed that people who needed to be referred to specialist healthcare support got that support. We also saw in diary notes that if people felt unwell staff took them to see the GP. People we spoke with confirmed that saw a doctor if they felt ill. Three relatives who responded to the pre inspection surveys told us that the care service always gives the care to their relative that is expected or needed. One replied usually and one replied sometimes. Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: A requirement was made at the last inspection to ensure that people were supported to manage their own medication in a risk assessment framework. We looked at support plans and they showed that assessments took place to look at whether someone was able to self medicate. This requirement is now met. We looked at the medication for people who used the service and we found that it was stored safely and the records were well maintained. Staff told us that only staff who have received training are allowed to administer medication. Care Homes for Adults (18-65 years) Page 21 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. People who use the service are supplied with a complaints procedure that they can understand and it is available in a variety of formats. People feel safe and staff listen to them. Evidence: The AQAA states The Home has a complaints procedure that is up to date and documents the stages of the process. The complaints procedure is presented in a clear and simple format using a sign and symbol format with photos. The complaints procedure is clearly displayed in the entrance to the home and is also contained within the policies and procedures of the Home. To ensure people are safeguarded from abuse, prior to commencing employment at the Home, staff have a CRB and POVA check. All staff at the Home have completed a Safeguarding Adults training course. We saw the complaints procedure in the hallway of the home and it was in a suitable format for people who use the service it was also available on a CD in audio format to support people who would be unable to use any other format. People who use the service told us that they knew who to speak to if they were unhappy and wanted to make a complaint. We looked at the complaints records and these showed that people who used the service were supported to complain. It also showed that the manager followed the procedures and complaints were investigated thoroughly. Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: Staff spoken with understood how to support people to make a complaint. We saw in some paperwork that people had been asked to put their complaint in writing. The provider told us that complaints would be investigated no matter how they were made. We looked at staff training records and they showed that they had attended safeguarding adults training and understood how to ensure people were protected from abuse. Staff knew where copies of the policies were to ensure that they supported people safely. We looked at financial records and saw that people were protected from abuse. We also saw evidence that the provider audited the finances regularly to check they were correct and people were protected from financial abuse. Care Homes for Adults (18-65 years) Page 23 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. People live in a homely well maintained environment which is clean, pleasant and hygienic throughout. Evidence: The AQAA states that The home is well decorated, very clean, safe, comfortable, homely and all staff and residents take pride in the home. The home benefits from having a variety of communal space and a large well maintained garden. The home employs a full time house keeper and residents contribute to keeping the house clean on a daily basis supported by staff and the home smells clean and fresh. We looked at the communal areas and we saw that they were will decorated and the furniture was of good quality. It had been commented on in the Councils contract inspection that the home lacked a homely feel as there were no ornaments. The manager said this was because some people who used the service could potentially hurt themselves or others when throwing them. People who use the service told us that the home is always clean and fresh. The home is safe, bright and cheerful, most areas are free from offensive odour. However one room was noted as having a string odour and this was discussed with the acting manager. he told us they are aware of the problem and are currently looking at Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: alternative flooring to support the person. Peoples bedrooms were homely, safe and personalised with family pictures, small items of furniture, a television and family pictures. There is a planned maintenance programme and the kitchen has recently been refurbished. The acting manager told us other parts of the home will follow and that the bathrooms are in need of refurbishment as one in particular has been flooded in the past. This bathroom was seen during the tour of those areas. A requirement was made at the last inspection to replace the bulbs on the stairs to the first floor landing. This requirement had beeen met. The laundry facilities are currently in the basement of the home and has limited access to people who use the home. The acting manager told us that they are currently looking at alternative sites but have yet to find one that is suitable. We saw that there is an infection control policy and we saw staff using appropriate equipment when providing personal care to maintain peoples health and safety. Care Homes for Adults (18-65 years) Page 25 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. People are supported by competent and qualified staff and staff recruitment practices promotes service users safety. Evidence: The AQAA states The recruitment of all staff including volunteers, work placements are confirmed in post only following receipt of two written references and completion of a satisfactory police and POVA check prior to commencement of employment. Staff have a thorough induction at Ash Villa and all staff are issued with an Induction Book. We looked at staff files and saw that staff were recruited following the homes policy and procedures. each person had references and Criminal Record Bureau checks before starting work to protect the people who use the service. Information provided by the manager, within the Annual Quality Assurance Assessment showed that over 60 of staff have a National Vocational Qualification (NVQ) level two and above in care to ensure a suitably qualified workforce is employed at the home. The provider also told us that it is the companys aim to ensure that at least 95 of staff have this qualification. We looked at staff training records and they showed, and staff spoken with confirmed that a comprehensive staff training programme is also provided. People spoken with said Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: they felt staff knew what they were doing. Care Homes for Adults (18-65 years) Page 27 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. People who use the service benefit from a well run home, which takes into account their views. The health, safety and welfare of people who live and work there is promoted and protected. Evidence: The AQAA states All staff adhere to the homes policies and procedures of the Home and undertake regular training. The Home has clear documentation of all safety checks to ensure compliance with current legislation as well as the health and safety of residents and staff. The acting manager is currently applying to be registered as fit person and evidence was seen that he has completed the Criminal Records Bureau check and is in the process of applying for his medical check. We looked at records of staff supervision and staff confirmed that the acting manager provides effective staff supervision sessions on a regular basis to encourage a supportive, focused approach to staff performance and development. Care Homes for Adults (18-65 years) Page 28 of 32 Evidence: We looked at the records that show that an effective quality auditing process is carried out by the acting manager and the provider to ensure the service is meeting its aims and objectives and those of the people who live there. We also saw records of residents meetings these provide people with a forum for open discussion in relation to service they receive. Policies and procedures are available at all times and information provided by the acting manager within the Annual Quality Assurance Assessment showed they have been reviewed appropriately to ensure they remain up to date. Staff spoken with said that they could access the policies at any time for reference and guidance. A requirement was made at the last inspection to ensure staff training records were available for inspection. These were seen during the visit and the requirement has now been met. We looked at records to show that peoples health, safety and well being is promoted by the provision of effective routine maintenance. A requirement was made at the last inspection to ensure that accident records are stored according to the Data Protection Act 1998. We saw that records are locked securely and so the requirement is met. Care Homes for Adults (18-65 years) Page 29 of 32 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 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 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 2 3 4 2 22 24 37 People should have letters confirming that the service can meet their needs and copies kept on their files. Reference to putting complaints in writing should be removed to ensure that people are not put off complaining. Include in the Service User Guide why there are no ornaments around the home. Ensure the acting manager applies for registration as fit person as soon as possible. Care Homes for Adults (18-65 years) Page 31 of 32 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. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!