Care Home: Bourne Hill

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What the care home does well This was the first key inspection of the service. Assessments are completed before people move into the home. The service User Guide was provided to the Care Quality Commission before the report was completed the services response to this request was prompt. Action is being taken by the service to improve the activities and opportunities provided to the two people living in the home. Residents have contact with their relatives which promotes their emotional welbeing. What has improved since the last inspection? A number of enviromental improvements had been completed as requested at the last random inspection. Improvements had been made with regard to the rota. What the care home could do better: The service needs to update one identified care plan. Develop behaviour guidelines linked to the care plan. The service also needs to update the risk assessments that are in place to ensure that all current risks are minimised. The service is in the process of developing health action plans to ensure that residents health care needs are fully met. The complaints procedure requires minor amendments to be made with regard to information contained within the document to ensure that all information recorded is up to date. A number of environmental improvements need to be undertaken to continue to ensure the home is well maintained. Improvements need to be made with regard to the staff rota. Some staff training needs to be undertaken to ensure that staff have the knowledge and skills to fully meet the needs of the residents living in the home. Some action needs to be undertaken with regard to the recruitment process and obtaining staff references to ensure that people living in the home are fully protected from potential abuse. Advice needs to be sought via the fire service with regard to fire procedures to be followed within the home. Key inspection report Care homes for adults (18-65 years) Name: Address: Bourne Hill 26 Bourne Hill London London N13 4LH     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: Wendy Heal     Date: 2 9 0 6 2 0 1 0 This is a review of 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 2 1 0 stars - excellent stars - good star - adequate 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. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 30 Information about the care home Name of care home: Address: Bourne Hill 26 Bourne Hill London London N13 4LH 07901846945 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Clo Clo Limited The registered provider is responsible for running the service care home 5 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number service users who can be accommodated is 5 The registered person may provide the following categories of service only: Care Home only (PC)To service users of the following gender: Either whose primary care needs on admission to the home are within the following categories Learning Disabilty (LD) Date of last inspection Brief description of the care home Bourne Hill, provides care and support for up to 5 people who have a learning disability.The home is located in southgate, North London. The home is owned by Mr K Ramjaugee. At the time of the inspection there were two people living at Bourne Hill. Bourne Hill is situated on a busy trunk road, a short distance from southgate. It is a semi-detached three-storey building, which has parking space at the front and a garden at the rear of the premises. Fees are available on request. Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 5 0 2 1 1 2 0 0 9 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection that took place as part of the inspection process. Compliance was checked against key standards and took place over approximately 9 hours. We undertook a tour of the home and spoke with people that live in the home and members of the staff team. We gained further information from an inspection of the documents kept in the home. This included care plans and health and safety documentation. We would like to thank the people that use the service and the staff for their participation. Care Homes for Adults (18-65 years) Page 5 of 30 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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 6 of 30 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 7 of 30 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 is information informing people about the service to enable them to decide if their individual needs can be met. There are some amendments that need to be made to the documents to ensure that they are fully accurate and up to date with regard to the people that view them. Service users do not move into the home without having their needs assessed. Evidence: At the time of the inspection one new person had moved into the home. We looked at the Statement of Purpose and noted that details within the document needed updating with regard to areas such as staffing arrangements and organisational structure for example. This is to ensure that accurate information is available to the people that need to use the document to obtain the information they require. The Service User Guide was made available after the inspection in a draft format. The Care Homes for Adults (18-65 years) Page 8 of 30 Evidence: current document is in the process of being updated and the provider was advised to review the guide to ensure it complies with the regulations. The home has a brochure which the home are also in the process of updating as some documented information such as the address of the Care Quality Commission, information regarding accomodation, and identified manager are no longer accurate. We looked at one case file of the two residents living in the home. The provider had completed their own assessment of the identified person in conjunction with other professionals working with the identified person at the place were they were previously living. The care home does not provide an intermediate care service. Care Homes for Adults (18-65 years) Page 9 of 30 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. There are care plans in place. One needs to be updated to ensure that the resident can be fully supported. The service does support residents to take risks as part of an independent lifestyle but further improvements need to be made to ensure that all current risks are minimised. Behaviour guidelines need to be developed to ensure that residents and staff are clear with regard to guidance to be followed. This will assist to ensure residents individual needs are fully met. Evidence: We looked at two case files in respect of the residents whose care we case tracked. Each file contained a care plan one of which needed to be updated. The care plan covered areas such as service user rights, health, mobility, behaviour, mental health, psychological needs, interaction communication, daily living, activities, dressing personal care and bathing. One resident also has a seperate personal care support plan in a pictorial format. This assists the resident to be communicated with to ensure Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: their needs are met. The service needs to develop clear behaviour guidelines for each individual resident to ensure that the residents needs are met and staff are clear with regard to actions and agreed practices they need to follow. This will ensure they support residents in a consistent way. The files contained risk assessments that covered medication including buying own medication, absconding, ironing, bathing, preparing meals and challenging behaviour. A discussion took place with the provider and deputy manager and it was agreed that the assessments would be reviewed updated and signed and dated. This will ensure that all risks are minimised for the residents living in the home. Minutes of review meetings were on file for one identified resident. One other persons review had taken place but the record of the meeting had not been received and the service were advised to request this document and ensure that it was available on the file for inspection. Care Homes for Adults (18-65 years) Page 11 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents at the home have some opportunities to access the community and undertake appropriate activities. Contact with families is encouraged. Residents rights are respected and a varied diet is offered. Evidence: There are currently two residents living in the home. One identified resident has just undertaken an assessment and has registered at a centre were they will be undertaking activities twice a week. The assessment the deputy manager has confirmed will be ongoing to make a decision in relation to whether staff from the home will be required to attend the day centre with the identified resident. One other resident living at the home attends a service when they wish to. I was informed this particular resident particularly enjoys attending an Asian group which they are next going to attend in two weeks time. This resident is also currently being Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: supported to try to undertake voluntary work. Residents living in the home do undertake activities in the community such as shopping and bowling. One the day of the inspection one resident went to the park and went out for lunch and another resident went shopping. On the day of the inspection I was informed that on a Tuesday this was the day that the mains shop was undertaken. A shopping trip was undertaken on this day. All of the food stored was in its use by date and properly labelled. This ensures that people are not eating food that is harmful to their health. one resident that was spoken with confirmed they were looking forward to the curry they were having that evening which we saw being prepared. The current deputy manager is in the process of developing activity plans for each individual resident. One identified resident assists to complete their laundry. This also assists to develop their individual skills. Both of the residents living in the home are in contact with their relatives. One resident stays with their family members once a week. Another resident has contact with their relatives twice a month. This benefits their emotional welbeing. The deputy manager is in the process of developing a contact sheet to indicate when relatives visit. This will ensure that a clear record of contact is maintained. The kitchen was inspected on the day of the inspection. The kitchen was clean. Care Homes for Adults (18-65 years) Page 13 of 30 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 physical and emotional health care needs are met. To ensure consistency of care health action plans need to be developed for each resident. The process for recording and administering medication is effective. Evidence: Residents receive personal support in a way they prefer and require. There was evidence in the case files of access to health care services in the community. There was a record of appointments with the dentist, GP and psychiatrist who was visiting on the day of the inspection to complete a medication review for an identified resident living in the home. Health action plans need to be developed for the two identified residents living in the home. This will ensure that all health care needs can be effectively met. We checked the storage of medication and it was safe and secure. The service confirmed that staff are currently undertaking medication training. This will assist to ensure that they are provided with up to date training and knowledge with regard to Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: the administration of medication. The medication administration record was inspected and found to be in order. Care Homes for Adults (18-65 years) Page 15 of 30 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 have access to a complaints procedure but changes in relation to the contact details of the Regulatory Authority and managers details need to be made. Complaints are being addressed and recorded but a decision is needed with regard to the use of a book or form to ensure that complaints are recorded and documented in line with the complaints policy. Evidence: A discussion took place with the provider and deputy manager with regard to the fact that the complaints procedure needs to be displayed and available for people to view. A copy of the document is available in the staff office. This was the first key inspection at the home since it had been bought by the current provider. The Complaints Procedure includes the stages of the process, with timescales attached. Sections of the document had incorrect details recorded for the Regulatory Authority and the managers details. This document needs to be updated to ensure that all information is accurate and up to date with regard to people that may wish to contact the Regulatory Authority if they wish to. The home has recorded two complaints and we studied the detail of these. The two complaints were both made with regard to an identified persons challenging behaviour. We were satisfied that each complaint had been appropriately investigated. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: A safeguarding policy is in place. There is also a whistle blowing procedure which includes information to ensure that if a person uses the policy they will be protected from victimisation. There has been one safeguarding investigation at the home which has been investigated. Staff files contained a record of safeguarding. This assists staff to have the knowledge and skills to protect people from potential abuse. Care Homes for Adults (18-65 years) Page 17 of 30 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 using the service are provided with a home that requires some maintenance tasks to be undertaken. The home was clean and free from offensive odours. Evidence: During the visit we conducted a site visit accompanied by the owner of the home and one identified resident. Having sought the residents permission we inspected their bedrooms. One identified person has a bed, chest of drawers and a wardrobe but due to their specific needs has no personal items in their bedroom. This identified person will not tolerate heavy curtains being in place at the window. During a discussion with the provider it was confirmed that the home is going to place a film on the window to ensure that the identified persons privacy and dignity is protected. This will make them feel valued. The only other person living in the home will also not tolerate a heavy curtain at their bedroom window a discussion is going to take place with them with regard to film being placed on their bedroom window to protect their privacy and dignity. It was noted by the inspector that this residents bedroom had some form of liquid that had been thrown onto the wall above their wardrobe. A discussion took place with the provider regarding this and it was agreed that the walls needed to be washed down. Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: This would ensure that the persons room was maintained to an appropriate standard and ensure that they were provided with a pleasent bedroom to sleep in. There are five single bedrooms, in the home one with en-suite facilities. Each bedroom has a bedside cabinet, wardrobe and bed. There is a ground floor cloakroom and first floor bathroom. The window in the bathroom is locked and cannot be opened due to the behaviour of an identified resident. (Please refer to risk assessment section of the report.) There is a kitchen which has a fire exit door which is locked with a key which is held by the senior staff member on duty. (Please refer to the management section of the report.) The provider confirmed that all appliances in the kitchen were working effectively on the day of the inspection. There is a lounge - dining room were there is a sofa, television and table and chairs were people can eat their meal. There is also a conservatory that is used as an office and overlooks the rear garden of the property. When walking around the home we noted that it was clean and free from any offensive odours. This promotes peoples health and wellbeing. Care Homes for Adults (18-65 years) Page 19 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff require further training to ensure they can fully met the needs of the residents living in the home. People living in the home are not fully protected by the homes recruitment procedures. People living in the home need to receive regular supervision so that a consistent approach to work can be maintained. Evidence: We discussed staffing levels in the home and a copy of the rota was provided. A discussion took place with the provider and deputy manager and and it was agreed that staff that are no longer employed at the home must be removed from the staff rota. Staff need to be identified on the rota using their full names. The rota needs to indicate the permanent staff and the bank staff and their shift times. The rota also needs to indicate the responsible person that is on call in the event that support is required. I was informed by the provider that the deputy manager is going to make an application for registration to become the Registered Manager at the home. It was recognised that he currently has very little time to undertake administrative tasks. The majority of the working day is spent working with the residents. The provider agreed to review the current shift pattern and staffing arrangements. This was to ensure that Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: the necessary administrative duties can be completed effectively. During the time of completing the report the provider confirmed that the deputy managers hours have been changed to ensure that administrative tasks can be completed effectively. We discussed the National Vocational Qualification training with regard to members of staff one member of staff has their NVQ 2 another member of staff has NVQ 3 and 4 and is a qualified assesor and the provider has started their NVQ 4. We noted that when we examined staff files that there was evidence that a number of staff had completed health and safety awarness, first aid, food hygiene, manual handling, COSHH, protection of vulnerable adults training. However staff needed to undertake training in infection control, epilepsy challenging behaviour, and The Mental Capacity Act. One staff member that has returned from maternity leave needs to undertake refresher training in all identified areas. We looked at staff recruitment practices. We noted that each file contained the necessary recruitment checks apart from three files that did not cotain adequate references. One file had only one reference a second reference had been requested but was not available on file. Two other files had references that were not on headed paper and the references were personal references and were not professional references. Not all references had been verified. Staff supervision records were inspected and the deputy manager had not received any formal supervision . This does not assist to ensure that staff are supported to work with people living in the home in a consistent way. A discussion took place with the provider and deputy manager and it was confirmed that staffing levels would need to be reviewed when any further residents move into the home other than the current two people that live there. This is to ensure that peoples needs can be fully met. Care Homes for Adults (18-65 years) Page 21 of 30 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 Provider must ensure that Quality assurance is developed within the home to ensure that residents underpin all self-monitoring review and development by the home. The provider must contact the fire service to ensure the safety of the residents living in the home is fully promoted. Evidence: The Deputy Manager is currently in the process of obtaining the necessary documentation to enable him to make an application to become the registered manager of the service. A discussion took place with the provider and deputy manager with regard to the distribution of quality assurance questionnaires. These need to be sent out to relatives and stakeholders. The provider has agreed to send out quality assurance questionaires and people will be asked to express their views on areas such as environment, meals, communication, staffing, activities and complaints. The information and feedback Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: received will then be compiled into a report outlining the action taken by the service with regard to information received. The provider confirmed that no one working for the company is an appointee for any of the residents. One resident needing assistance to manage their financial affairs are supported by a member of the family. One other resident living in the home is in the process of undergoing an assessment the outcome of this assessment will determine if the provider becomes an appointee for this identified person. The provider has been advised to obtain a safe and has agreed to do this. We noted that there was a copy of the Employers Liability Insurance Certificate on display in the office and this was up to date.This means that professional practice is being followed. There were valid certificates with regard to portable electrical appliances, the fire alarm, the gas safety record and the electrical installation. There was a record of regular fire drills being carried out along with the weekly fire alarm testing and emergency lighting. The home does not have a lift. The provider has been requested to contact the fire service regarding a fire exit door in the kitchen which was locked with a key. The key is retained by staff members. At the time of completing the report the provider advised the Care Quality Commission that they had contacted the fire service and the door is to be kept unlocked as advised by the Care Quality Commission and fire service. The fire evacuation plan must also be updated and the deputy manager has agreed to complete this task. Care Homes for Adults (18-65 years) Page 23 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 24 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 The Provider must ensure that behaviour guidelines are developed. This will ensure that residents are fully supported as clear guidance is available to staff. 27/07/2010 2 6 15 The Provider must ensure that the one identified care plan is updated signed and dated. This will ensure that the identified persons needs can be fully met. 26/07/2010 3 9 15 The Provider must ensure that risk assessments are updated. This will ensure that all current risks are minimised. 26/07/2010 Care Homes for Adults (18-65 years) Page 25 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 19 12 The Provider must ensure 02/08/2010 that health action plans are developed for each identified person and are kept up to date. This will ensure that residents health care needs are clearly recorded. This will ensure that their individual needs can be fully met. 5 22 22 The Provider must ensure that the complaints policy is updated and reflects the correct information regarding the Regulatory Authority and managers details. This will ensure that the document contains up to date accurate information for the people that need to use the document. 30/07/2010 6 24 23 The Provider must ensure that the identified resident that has stains on their bedroom walls has the walls of their bedroom cleaned. This will ensure that the resident is living in a homely environment. 29/07/2010 Care Homes for Adults (18-65 years) Page 26 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 24 23 The provider must ensure 29/07/2010 that protective film is placed on the identified windows within the home. This will ensure that the residents dignity and privacy is protected. 8 33 17 The Provider must ensure 28/07/2010 that the rota is updated to ensure that all information is accurate. This will ensure that accurate information is recorded on the document for those people that need to have access to it to undertake their work effectively. 9 34 19 The Provider must ensure that the required professional references are available on the staff file. The references must be on headed paper and must have been validated. This will ensure that the residents living in the home have been protected from potential abuse. 29/07/2010 10 35 18 The Provider must ensure that staff receive training in all of the statutory areas of training staff need to also undertake training in 05/08/2010 Care Homes for Adults (18-65 years) Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action infection control, epilepsy, challenging behaviour, and the Mental Capacity Act. This will ensure that staff have the necessary knowledge and skills to ensure that residents individual needs can be met. 11 36 18 The Provider must ensure that all staff including the current Deputy manager receive supervision at least six times per year. This ensures that all staff can support the residents living in the home in a professional consistent way. 12 42 23 The provider must ensure that the fire evacuation and assessment are updated. This will ensure that accurate up to date information is available to staff and enables them to support the residents living in the home effectively. 13 42 23 The provider must ensure 22/07/2010 that he contacts the Fire Authority to obtain advice with regard to the kitchen fire exit door that is currently unlocked via a key. This will ensure that 28/07/2010 30/07/2010 Care Homes for Adults (18-65 years) Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action professional procedures are being followed and the residents health and safety is being promoted. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 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. © 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. 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