Care Home: Brook Lodge

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What the care home does well Each person is involved in their Individual Support Plan. People said that they have a key worker and that they have reviews with healthcare professionals and parents.People said that they enjoyedregular activities such as horse riding, swimming and going to the pub.People enjoy helping to prepare meals and enjoy the range of food provided.Each person has an en suite bedroom and access to comfortable and homely accommodation that they have been involved in redecorating.The quality assurance processinvolves people living in the home. What has improved since the last inspection? Thirteen requirements issued at the last inspection had been complied with. Staff were having access to a robust training programme including specialist training in mental health and autism. There had been a decrease in the use of physical intervention and `as necessary` medication. People were being supported to manage their anxieties and anger. Staffing levels were beingmaintained at a minimum of 4 per shift. When people make a complaint they are given feedback about any concerns raised. What the care home could do better: Water damage to baths must be investigated and bath sides replaced.A full employment history must be obtained for new staff. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Brook Lodge Brook Lodge Latchen Longhope Glos GL17 0QA Two star good service The quality rating for this care home is: 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: Lynne Bennett Date: 1 5 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. 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 Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.cqc.org.uk Information about the care home Name of care home: Address: Brook Lodge Brook Lodge Latchen Longhope Glos GL17 0QA 01452830614 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) : sherwoodj3@aol.com Voyage Ltd care home 11 Number of places (if applicable): Under 65 Over 65 11 0 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) The maximum number of service users who can be accommodated is 11 Date of last inspection 2 3 0 4 2 0 0 8 A bit about the care home Brook House consists of two semi-detached cottages,which have been joined to form one care home. The property was completely refurbished in 2005. The care home is one of several residential homes in the area managed by Voyage Homes. Brook House is in a rural location in the village of Longhope in the Forest of Dean. People living at the home have an identified learning disability and may present with challenges to the service. People have en suite accommodation and access to a range of comfortable and homely spaces. An additional self-contained flat is attached to the property, which has its own entrance and this provides accommodation for the eleventh resident. Each person has a copy of a service user guide and a statement of terms and conditions. A copy of the Statement of Purpose and last inspection report is available in the entrance hall. The fee levels for the home range from 793 to 2,200 pounds per week. Some people contribute 50 per cent of their mobility allowance to Voyage for costs for transport. 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 How we did our inspection: This is what the inspector did when they were at the care home This inspection took place in April 2009 and included two visits to the home. The registered manager was not present for our visits but the deputy manager was present throughout. An additional visit was made to give her feedback. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). We talked to 3 people using the service, and asked staff about those peoples needs. We also looked at the care plans, medical records and daily notes for these 3 people. This is called case tracking. We also talked to other people living in the home and observed the support and care they received. Four members of staff were interviewed. We sampled a range of records including medication sytems, staff files, quality assurance information and health and safety records. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well Each person is involved in their Individual Support Plan. People said that they have a key worker and that they have reviews with healthcare professionals and parents. People said that they enjoyed regular activities such as horse riding, swimming and going to the pub. People enjoy helping to prepare meals and enjoy the range of food provided. Each person has an en suite bedroom and access to comfortable and homely accommodation that they have been involved in redecorating. The quality assurance process involves people living in the home. What has got better from the last inspection Thirteen requirements issued at the last inspection had been complied with. Staff were having access to a robust training programme including specialist training in mental health and autism. There had been a decrease in the use of physical intervention and as necessary medication. People were being supported to manage their anxieties and anger. Staffing levels were being maintained at a minimum of 4 per shift. When people make a complaint they are given feedback about any concerns raised. What the care home could do better Water damage to baths must be investigated and bath sides replaced. A full employment history must be obtained for new staff. 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 Lynne Bennett Colston 33 Bristol BS1 4UA Tel: 0117 930 7110 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535 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 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the persons wishes and needs are taken into consideration before offering them a place. Evidence: The home had a Statement of Purpose and Service User Guide which had been reviewed and contained current information about the home and Voyage. Each person had a copy on their personal file. These documents were produced in a format using pictures and large text. They were written in plain English. The home had admitted one person to the service since the last inspection and another person was visiting with a view to moving into the home. The admission information for the person who had moved into the home was inspected. They had a full assessment of need that had been completed by Voyage which was supported by an assessment and care plan supplied by the placing authority. An updated version of this had been requested by the home after admission. Other supporting information had been supplied by health care professionals involved in their care. They had an initial placement review which confirmed that the home was able to meet their needs. The person said they had visits to the home and had settled in well. They had the opportunity to meet with other people living in the home. A person was visiting the home during our inspection and stayed overnight. Each person had a current statement of terms and conditions on their files which provided information about the service they receive, the fees and any additional costs. 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 are being involved in developing their care plans that reflect their aspirations and needs. Peoples needs are being assessed and they are being supported to make decisions about their lifestyles. Risks are being managed safeguarding them from possible harm. Evidence: The care of three people was case tracked and other files were sampled. A new system of person centred planning had been introduced. Each person had an Individual Support Plan in place providing an assessment of need for peoples physical, intellectual, emotional and social needs. Their strengths and support needs were noted. From this short term and long term goals were identified with corresponding support plans. These documents provided clear guidance about how people should be supported. Staff said that people had been involved in this process and several people had signed records on their files. People said they had monthly meetings with key workers when they talked about what they had done and anything they would like to try or change. Records for these were seen to be in place. Staff said they had mixed feelings about the new plans, with some finding them useful and others stating that they did not provide a clear pen picture of the individual for new staff. The plans were comprehensive and each support plan indicated to the reader other supporting records such as risk assessments and violence and aggression assessments. These documents were kept in the same section as the support plans making cross referencing of documents relatively simple. Plans were being monitored regularly and any changes identified. There was evidence that changing needs had been addressed with new care plans and risk assessments. Daily records were being kept evidencing any changes in needs and indicating use of incident forms or other monitoring records. This was good Evidence: practice. There was evidence in staff supervision notes that report writing and practice was being monitored by management and staff supported to develop their skills. There were very few restrictions in the home. Where there were any, such as the removal of taps in an en-suite, these were recorded with the rationale for these identified. The key pad on the front gate had been removed since the last inspection and each person had been offered a key to their room. Some people living in the home used Makaton sign language. There could be greater use of photographs and symbols around the home to enable people without verbal communication to express themselves. Each person had an Individual Support plan for Decision Making which indicated how people were being supported to make choices and decisions about their lifestyles and activities of daily living. These records also indicated where people might need support from family or health care professionals to make decisions in their best interests. Areas identified were health, their placement or finances. This was in line with the Mental Capacity Act guidelines. The appropriate assessments and records would be completed where needed in a multi disciplinary forum. Risk assessments identified hazards and how they were to be minimised. It appeared that people were being supported in a proactive way which supported them to safely try out a range of activities or opportunities. Each person had a written description in place and a current photograph. A missing persons procedure was in place and had been followed appropriately when people had not returned home at the agreed time. We had been notified of these incidents. Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. Evidence: Each person had an Individual Support Plan in place identifying their spiritual needs and how they would like to be supported to meet these. One person was going to church with their family and with others visited a church in the village as well as going to Gloucester Cathedral, Tewkesbury Abbey and other churches in neighbouring towns. People living in the home were being involved in training in the home such as fire training. Where identified they also had access to support from counsellors or therapists. Each person had an activity schedule in place with comprehensive supporting documents evidencing whether they had participated in, refused or been unable to attend scheduled activities. People were observed going out on day trips, horse riding, shopping and to the pub. They said they were planning holidays for this summer and had enjoyed trips away last year. Whilst at home they were observed helping around the home, cooking, watching old movies, listening to music and doing arts and crafts. Regular activities also included going to college, bowling and swimming. Daily diaries were examined for a two week period and indicated that at times people were very Evidence: busy followed by periods spent at home. Staffing levels appeared to be maintained at a level of 4 per shift. Staff indicated that one team had struggled with drivers but with new recruitment it was hoped to alleviate this. People were also using public transport. Relationships with families and friends were being supported. Contact sheets evidenced when people had visited or been visited and any telephone contact. One person was observed being supported to write a letter. People went to a social club one evening a week as well as parties at other homes enabling them to keep in touch with friends. There had been increased opportunities for people to develop skills in activities of daily living such as cooking, doing laundry and cleaning. People were also helping to grow vegetables and herbs. People were observed deciding where to spend their time and with whom. Several people smoke and rules about smoking were clearly displayed around the home. People were observed smoking in the garden. A shelter had been provided to the front of the home. At the last inspection the home had employed a cook to plan, shop and cook meals. This role had been taken over by care staff and people living in the home were being involved in this process. Each week they were helping to plan the menu for the following week which provided freshly prepared meals at tea-time and a snack for lunch. An alternative choice was being offered. Every other week a theme was being chosen for the Wednesday meal promoting food, music and the culture of different countries. During our visit they were preparing food from Iceland. Comprehensive meal records were being kept. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The health and personal care which people receive is based on their individual needs that are reflected in their care plan. Systems for the administration of medication should safeguard people from possible error or harm. Evidence: The way in which people would like to be supported was clearly identified in their Individual Support Plans. Their likes and dislikes were also noted. Daily diaries indicated that they had flexible times for going to bed and getting up. Each person had a Personal Care Individual Support Plan in place providing staff with guidelines about how people wished to be supported. The gender of staff providing care was also identified where a preference had been identified. Health action plans were being developed with input from health care professionals for each person. There was evidence that people were having regular access to Doctors, Dentists, Opticians and consultants. Records of appointments were being kept with a note of the outcome of each appointment. Staff confirmed people were being receiving support from the local Community Learning Disability Team. Action agreed forms left by the teams were examined and other records confirmed that the home were working towards completing these actions. One person had just been discharged from hospital and there were records evidencing the support they had received from staff during their stay. Staff and health care professionals were continuing to monitor their health and wellbeing. Systems for the administration of medication were found to be satisfactory. Staff confirmed they completed training in the safe handling of medication. Medication administration records were completed correctly. Each person had an Individual Support Plan in place for medication and there was evidence that they had given their Evidence: consent to have medication administered. Protocols were in place for as necessary medication and stock records maintained. There was evidence that the home were proactively trying to reduce the use of as necessary medication for some people. Some homely remedies were found in the medication cabinet. Staff said that people had purchased these and given them to staff. By the time of the second visit to the home, a homely remedy protocol had been produced and authorised by the Doctor. A copy of a 2006 British National Formula was in place. 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 are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. Evidence: The home had a complaints procedure, Letting us know what you think. This was accessible to people and had been produced in a version using text and pictures. In their surveys people said they knew how to make a complaint. There was evidence that one person living in the home had made a complaint and that this was recorded and responded to. Four other complaints had been received since the last inspection. Records confirmed the outcome of these complaints. Staff were completing training in Non Violent Crisis Intervention (NVCI) to replace their former training and new systems were being put in place to complement NVCI procedures. There was evidence that there had again been a significant reduction in the amount of physical intervention and as necessary medication being used in the home. Staff spoke with confidence of the way in which they supported people to manage their anxieties and anger. They were observed calmly diverting people during the visits to manage their anger and to calm down quickly. Records were being maintained to record incidents and we had been informed of the occasional use of physical intervention. Voyage also monitor incidents within the home. We had been informed when physical intervention was used. Financial systems were being audited both by the home and Voyage. One person had been supported to manage their finances after getting into debt. Individual Support Plans indicated the level of support people required. Robust systems appeared to be in place. 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 . The home is well maintained and provides a safe environment which reflects the lifestyles and personalities of the people living there. Evidence: At the time of the visits the home was clean and tidy. Communal areas were pleasantly decorated and had good quality fixtures and fittings. People had been involved in the choice of colour scheme and decor of their rooms. One person had asked for Arsenal memorabilia to be displayed in his room and this had been done. Another room had been developed into a sensory environment. One person chooses to eat their meals in the lounge and they had been provided with a table for this purpose. Greater use was being made of communal areas with the quiet lounge and the conservatory being used in addition to the lounge and dining room. People had more access to the kitchen. Locks had been removed from the front gate and security of the building had been reassessed as a result. The side of the bath in the first floor bathroom and an en suite were water damaged and need to be attended to. The AQAA stated that there were plans to provide appropriate accessible laundry facilities that meet with current requirements. The laundry was on the first floor and concerns expressed by one person about the noise at night had been resolved by asking night staff to not use the laundry after 11.30 pm at night. Liquid soap and hand paper towels were provided in all communal toilets and wash hand basins. The deputy manager stated that COSHH data sheets and individual risk assessments had just been reviewed. Where people had problems with continence this was being dealt with sensitively and with greater dignity than previously noted. New beds had been provided for some with water proof mattresses and pillows where needed. 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 . Peoples needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Improvements in recruitment and selection procedures will ensure that people are being safeguarded from possible harm. Evidence: The AQAA confirmed that all staff were completing an induction programme which was equivalent to the Skills for Care Foundation programme. Copies of these were on the files for new staff. A new member of staff verified that they were going through an induction programme, shadowing staff and completing mandatory training. The DataSet stated that over 60 per cent of staff have a National Vocational Qualification (NVQ) Award in Health and Social Care. Staff were completing the Learning Disability Qualification before commencing an NVQ Award. Staff spoken with had a good understanding of the needs of the people they support and observations of them during the visits confirmed their knowledge and positive relationship with people. New staff had recently been appointed and further recruitment was taking place to appoint to two vacancies. Staff rotas for the last four months indicated that a minimum of 4 staff per shift had been maintained rising to 5,6 or 7 on occasions. The deputy manager stated that if the shift fell below 4 and they were unable to fill this through bank staff or staff from other homes the management team would cover. Staff said that staffing ratios were satisfactory although there were concerns that at times the team could be stretched with 4 staff on shift. A number of people living in the home had 1:1 support. The deputy manager was hopeful that increased staffing ratios would be maintained when a new person moved into the home. Five staff files were examined for staff appointed during 2008 and 2009. A checklist had been completed for each person indicating when documents had been received. All Evidence: had been appointed after their Criminal Records Bureau (CRB) check had been received. We have an agreement with Voyage that CRB checks could be kept centrally. On two application forms there were gaps in employment history. (This information was made available to us after the inspection.) For two other people there was evidence that gaps in employment history had been questioned and evidence supplied for missing employment. Evidence of identity had been provided. Copies of birth certificates and Criminal Record Bureau checks should not be kept, in line with Data Protection requirements. Two references had been obtained prior to employment. Voyage had introduced Electronic learning for a number of mandatory courses and have been increasing this to provide specialist learning. Some training was being sourced from alternative providers. Staff had individual training profiles in place and copies of training certificates on file. Refresher training was being provided where appropriate. Staff were having access to mental health and autism training. 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 benefit from a well run home. Effective quality assurance systems are in place involving people who live there. Satisfactory health and safety systems are in place providing a safe environment. Evidence: The registered manager had the Registered Managers Award at Level 4 and was completing a Management Professional Development programme. She has considerable experience in the field of learning disability. The registered manager completed an AQAA and supplied it to us before the deadline. This provided comprehensive information about the home and improvments which had taken place since the last inspection. Staff confirmed that the management team provided support and direction to them and were confident that they would challenge and deal with poor practice. There were no restrictions in place which would involve the home in making assessments under the Deprivation of Liberty safeguards. There was evidence that peoples ability to make decisions under the Mental Capacity Act were considered and would be dealt with appropriately. Voyage had a robust quality assurance system in place which included unannounced visits (Regulation 26) to the home by the Operations Manager. Copies of reports were seen to be in place which had taken place most months. Between January to March 2009 the Operations Manager had completed an Annual Service Review which we had agreed would take the place of Regulation 26 visits to the home. This included feedback from people living in the home and a report was being produced. Actions from this review would be monitored at monthly visits throughout the year. Audits Evidence: being conducted by the home included health and safety and medication. Systems for the monitoring of health and safety were in place with records being maintained for weekly and monthly checks. The AQAA indicated that servicing of equipment and utilities was in place alongside these checks. Sampling of records confirmed these were being done. A fire risk assessment and individual fire risk assessments were seen supported by records for fire checks. Portable appliance testing had been completed last year and was due to be done. 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 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 30 23 The registered person must make sure that damage to the side of baths is made good. 17/06/2009 This is to make sure that there is no further water damage and minimise the risk of infection control. 2 34 19 The registered person must 15/05/2009 make sure that they obtain a full employment history for new staff. This is to safeguard people from possible harm. 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 6 A pen picture should be put in place providing a summary of the support each person requires. 2 3 20 34 The most recent information supplied by the British National Formula should be obtained. Copies of birth certificates and Criminal Records Bureau checks should not be kept in line with Data Protection requirements. Helpline: Telephone: 03000 616161 or Textphone : or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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