Care Home: Coppice House

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What the care home does well Some people have access to a wide range of activities including college, shopping, horse riding and day trips. People were observed playing football and flying a kite in the garden.Relatives were visiting one person and said they were made to feel welcome.People are involved in the choice of menu and have access to a range of healthy nutritional meals.Staff have access to a comprehensive training programme which includes internal training, NVQ Awards, open learning and college based courses.A quality assurance system is in place which involves feedback from people. What has improved since the last inspection? The home had met the four requirements issued at the last inspection. The fire risk assessment had been reviewed.Where people have epilepsy there is personal care guidance and a risk assessment in place.Stock levels of `as necessary` medication were being recorded. Staff were having access to communication training. What the care home could do better: The trampoline must be safe to use.The number of hours lone working staff spend in the bungalow should be monitored.The manager had sent an application to us and he was waiting to be interviewed. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Coppice House Main Road Huntley Glos GL19 3DZ 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: 0 7 0 5 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: Coppice House Main Road Huntley Glos GL19 3DZ 01452831196 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) : Orchard End Limited care home 11 Number of places (if applicable): Under 65 Over 65 11 0 Learning disability Additional conditions: Date of last inspection 1 1 0 5 2 0 0 7 A bit about the care home Coppice House is a residential care home for eleven adults with learning disabilities who may also have autism and challenging behaviours. People living at the home have complex needs particularly in relation to communication. The home consists of the main building and an adjacent bungalow that is a few yards from the main house. Coppice House is one of six registered homes that are part of Orchard End Limited, a subsidiary of C.H.O.I.C.E Ltd. The home has a Statement of Purpose and Service User Guide that are available from the office or head office of the organisation upon request. Fee levels are available from the home on request. 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 May 2009 and included two visits to the home by one inspector. The manager was present throughout. The 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 received surveys from staff and healthcare professionals prior to our visits. We looked at a range of records including staff files, health and safety records and quality assurance systems. 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 Some people have access to a wide range of activities including college, shopping, horse riding and day trips. People were observed playing football and flying a kite in the garden. Relatives were visiting one person and said they were made to feel welcome. People are involved in the choice of menu and have access to a range of healthy nutritional meals. Staff have access to a comprehensive training programme which includes internal training, NVQ Awards, open learning and college based courses. A quality assurance system is in place which involves feedback from people. What has got better from the last inspection The home had met the four requirements issued at the last inspection. The fire risk assessment had been reviewed. Where people have epilepsy there is personal care guidance and a risk assessment in place. Stock levels of as necessary medication were being recorded. Staff were having access to communication training. What the care home could do better The trampoline must be safe to use. The number of hours lone working staff spend in the bungalow should be monitored. The manager had sent an application to us and he was waiting to be interviewed. 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 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 updated their Statement of Purpose and Service User Guide to reflect changes in the service being provided. The latter document was available in a format using photographs and pictures as well as an audio version. Each person had a current copy of the statement of terms and conditions on their file. The admission information for two people who had recently been admitted to the home were examined. One person had been transferred from another CHOICE service and whilst an assessment of need had been completed by CHOICE there was no evidence that a current assessment of need or care plan had been provided during the admission process from the placing authority. There were copies of reports supplied from health care professionals previously involved in their care dating back to 1999. Care plans and other related documentation had been transferred with them from their previous home when they moved into Coppice House. For the other person there was evidence of an assessment completed by CHOICE and an assessment and care plan from the placing authority. Records indicated that transition meetings had been held to plan the move into the home including visits and overnight stays. Assessments had been completed in advance of environmental changes to the home which would be needed. Both people had three monthly reviews to assess their move to the home and confirm that the home could meet their needs. Evidence: Another person was being assessed at the time of this inspection and was making visits to the home. The homes Development Plan indicated that people living in the home should be involved in transition visits to assess compatibility. Feedback from staff indicated that this had not been happening due to other people being out at times of visits. 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 . A person centred approach is in place which reflects the wishes and aspirations of people living in the home, as far as is practicable. Risks are being managed which should safeguard them from possible harm. Evidence: A person centred approach to care planning was in place and each person had support plans which had been developed from their assessment of need. Each person had a personal profile which for two had been completed in full. The other persons profile had gaps in sections such as likes and dislikes and Psychology. Read and sign lists were being replaced with questionnaires for key workers to explore their understanding and knowledge of peoples needs. The manager also stated that key workers were being supported to understand their responsibilities and to develop their roles. This was being done at handover meetings during our visits. Staff spoken with had a good understanding of peoples needs. Each person had a range of support plans covering their physical, intellectual, social and emotional needs. These had been reviewed in February 2009 and entries on some plans indicated that where changes were occurring these were being noted and plans amended if necessary. Annual reviews were being scheduled and placing authorities invited. A selection of goals had been identified for each person but it was difficult to ascertain progress towards meeting these. For instance one person had comprehensive guidelines in place to supplement their goal to wear their shoes each day. Edible reinforcers and a drive out were part of this process. They were observed achieving this during our visits but daily records did not make reference to this. Evidence: Communication support plans were in place which indicated peoples verbal and non verbal expression. Some people had communication passports or boards in place. Staff have key fobs with pictures commonly used by people. Some people also use makaton sign language, although staff were not observed using this during our visits. There was a significant improvement in the use of photographs around the home both to illustrate records and to pass on information to people such as which staff were on duty and what was for lunch. Draws in one bedroom were labelled to indicate their contents labels used the written word rather than pictures. The manager said that he had identified this and had questioned why these were in place. Where there were restrictions in place these were clearly noted with the rationale for these identified. Restrictions included locking of the kitchen door and access out of the garden. The reasons for these were to safeguard people from possible harm. Risk management plans were in place which had been reviewed in April 2009. The summary of hazards were identified and classified as red, amber, green or blue. Individual risk assessments were developed from these to minimise the risk of harm. Risk assessments were seen to be enabling rather than preventing people from participating in activities. Staff lone work in the bungalow with people and a walkie talkie system was in place should they need additional support from staff in the house. Risks identified with one person living in the house had resulted in additional funding being provided to make sure they had one to one support for 15 hours each day. 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 have the opportunity to take part in a variety of social, recreational and educational opportunities which reflect their interests. They are supported to maintain relationships with family and friends. They have a healthy and nutritional diet and their diverse needs are catered for. Evidence: Activity schedules had been put in place for each person and those displayed in the hall used a mixture of text and photographs to illustrate what people would be doing. Daily records had been redesigned since the last inspection and provided the opportunity for staff to indicate whether people had been involved in activities. Some staff were recording where activities had been offered and refused. This provided a clear picture of what was available to people and how their decisions were respected. Daily notes for the period between 19th April and 6th May were sampled for the three people being case tracked. One person was being supported to access a wide range of activities both inside and outside of the home including swimming, horse riding, college, jacuzzi, drives, bowling, cinema and social clubs. Another person had not participated in daily activities but had been out for drives, used a sensory room, played football in the garden and used the trampoline. Support plans for this person indicated they liked to use the computer. Communication entries showed that there had been discussion within the team about how they could maintain access to a computer after changes to the use of the computer room into an office. At the time of our visits the computer had been set up in an activities shed and their key worker said they would Evidence: resume using this. The third person had been offered activities and their daily notes evidenced times when they had refused them. Over the past week changes in their behaviour had been noted and staff were monitoring them on an hourly basis and maintaining a record for health care professionals. The AQAA stated that Service Users have a choice of entertainment that is brought into the home including pottery, literacy and numeracy tutor and vital therapy which is regularly participated in within the home. A room was being used to listen to music and there were plans to develop this into a sensory area. People were being supported to maintain contact with family and friends either by visiting or over the telephone. A visiting relative said they were always made to feel welcome. They said staff supported their son to visit them on occasions. People were observed choosing where to spend their time and with whom. Their routines were flexible according to their schedule of activities and commitments. People had the opportunity to help prepare meals and snacks for themselves. There were plans to develop the facilities in the bungalow to enable people to be more independent. People were being involved in the choice of menu for the home. Alternatives to the main meal were observed being offered and full records of each individual persons diet were recorded. Where people had specific dietary needs these were catered for. The home employed a cook who prepared freshly made meals. Fruit and fresh vegetables were available. 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 wellbeing are being met helping them to stay well. Medication processes should safeguard people from possible harm. Evidence: Most peoples likes and dislikes were identified in their personal profile and support plans. Staff had a good understanding of how people liked to be supported with their personal care and the importance of routines. Concerns were expressed to the manager about how the dignity and privacy of all people living in the house could be promoted when all toilet paper and paper towels from communal toilets and bathrooms were removed due to the behaviour of one person living in the home. They should explore whether alternative secure methods of storing these items can be provided or whether additional work can be done with the person to change the habit of posting these items down the toilet. Health action plans had been put in place for most people. People had access to annual health checks in February this year and were also having medication reviews. They were receiving support from the local Community Learning Disability Team and reviews under the Care Programme Approach where appropriate. A record was being maintained for all appointments with health care professionals. A quarterly summary sheet was in place which provided an at a glance summary of when future appointments were due. Support was being provided with people who experienced stress when visiting dentists and alternative ways of receiving treatment were being explored. The home has a medication system which used blister packs and some medication packed in boxes. Stock controls were kept on the medication administration record with any stock at the end of the month being transferred onto the new record. Creams Evidence: were labelled with the date of opening and external and internal treatments were stored separately. Staff confirmed they had training in the safe handling of medication. Training records indicated most had completed this in 2007. Competency audits were in place which were being conducted by registered managers from other homes. Protocols were in place for the administration of medication and where homely remedies were used the General Practitioner had authorised their use. The AQAA stated that, Self medication was being explored with one person. The home needs to obtain an up to date copy of the British National Formula. 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 . Systems are in place that enable complaints and concerns to be raised by people using the service or on their behalf. People should be safeguarded from possible harm or abuse. Evidence: The homes complaints procedure was displayed in the dining room. It had been produced in a format using text and symbol. The DataSet indicated that 7 complaints had been received by the home. The complaints file contained copies of these complaints and evidence of the outcome of the complaint and any action taken as a result. A relative said they would talk to staff if they had any concerns. People have monthly house meetings providing an opportunity to highlight any concerns they may have. Staff confirmed they had attended training in the protection of vulnerable adults and those spoken with were aware of the signs of abuse and of their responsibilities in reporting abuse. The home had an intensive training session in January 2009 to refresh staff knowledge and understanding of abuse and the whistle blowng procedure. The manager was not from the local area and information was given to him about training for managers by the Adult Protection Team to provide guidance about local procedures. Staff had access to training in the Mental Capacity Act and Deprivation of Liberty safeguards. Placement assessments and support plans made reference to whether people were likely to lack capacity to make decisions in any areas of their life. One person was meeting with an Independent Mental Capacity Advocate (IMCA). Staff had recently completed training in Strategies for Crisis Intervention and Prevention(SCIP) which promotes a non aversive approach to interactions with people who may challenge the service. Management confirmed that risk management strategies would be reviewed in line with this training. Staff indicated that physical intervention was rarely used and that any incidents could be managed by diversion or Evidence: distraction. Behaviour observation charts (BOC) confirmed a reduction in incidents and the use of PRN medication. The home has the support of a Psychology team who monitor incidents and work closely with staff to respond appropriately to people in distress. Staff were observed checking peoples personal finances. Receipts were being kept for purchases and could be cross referenced with financial records. Regular audits were 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 . Ongoing redecoration and refurbishment of the home will provide a safe and homely environment for people which meets their needs. Evidence: Since the last inspection communal areas around the home had been redecorated, an unused shower room had been changed into a toilet and new furnishings had been purchased. A new contract had been put in place with a maintenance firm to provide repairs for day to day issues and staff reported that this was working well. People living in the bungalow were being supported to access their facilities throughout the day rather than using facilities in the house. There were plans to facilitate people to use the kitchen to prepare their meals. Greater use was being made of the conservatory for arts and crafts and other activities. A summerhouse in the garden was also being used for activities. The grounds around the home were well kept. A trampoline in the garden had been damaged and a make shift repair had been made to the safety netting. This needs to be attended to. At the time of the visit the home was clean and tidy. The AQAA stated, more detailed cleaning schedules have been introduced and a quarterly deep cleaning schedule has also been implemented. The laundry facilities were satisfactory although this has been earmarked for refurbishment along with the replacement of the boiler. Staff had attended infection control training. Personal protective equipment was provided and communication notes indicated that staff were monitoring the disposal of clinical waste. 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. Recruitment and selection procedures should safeguard people from possible harm. Evidence: There were no staff vacancies at the time of this inspection. A number of new staff had been appointed and confirmed that they shadowed staff as part of their induction programme. They had completed their induction at the home and copies of completed or partially completed booklets were in their files. Management confirmed that staff would have access to the Learning Disability Qualification as well as the National Vocational Qualification (NVQ) in Health and Social Care. The DataSet indicated that around 40 per cent of the staff team had a NVQ Award. Rotas confirmed that staffing levels were being maintained at a minimum of 7 staff per shift. Staff were observed supporting people in the bungalow and said they lone worked with people occasionally for long periods of time. They had access to a walkie talkie in case of emergency. Management said that staff usually worked half a shift - around 4 hours - when supporting people on a 1 to 1 ratio. Files for new staff were examined. There was some inconsistency in record keeping between appointments made in 2008 and 2009. Staff records for staff appointed in 2008 did not always provide evidence of a full employment history or proof of identity. Files for staff appointed this year had been completed in line with the National Minimum Standards and contained all the information and records required by us. A front sheet provided information about when records had been sent for and when they had been received. Criminal Records Bureau checks were examined and can now be destroyed. Some photographs of staff were unclear. These had been replaced with new photographs by the time of our second visit. Copies of birth certificates should not be kept in line with Data Protection recommendations. The homes development plan Evidence: indicated that two people living in the home had been identified to become involved in the interviewing of new staff. The home had a robust training programme in place. The training matrix confirmed that staff had access to mandatory training during their induction and refresher training when needed. All staff were receiving training in SCIP and Protection of Adults. Additional training in autism, epilepsy and mental health was being provided. Some staff had also completed training in dementia care, activities, sexuality and Learning Disability and loss and bereavement. 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 living at the home are benefiting from a manager who is providing a clear direction and leadership. An effective quality assurance programme is in place involving feedback from people. Systems are in place to maintain and monitor the health, safety and welfare of people. Evidence: A new manager had been appointed to the home since the last key inspection. He had considerable experience working in management and social care. He had a NVQ at Level 4. Staff spoke positively about his management style and his developmental plans for the home. He said that he had submitted his application to us to become the registered manager of the home. The AQAA was provided to us by a registered manager from another home who was seconded to Coppice House prior to his appointment. She had continued to provide management support during his induction. The AQAA was returned to us before the deadline and was completed comprehensively. Staff and management had received training in the Mental Capacity Act and Deprivation of Liberty Safeguards. As mentioned there was evidence that IMCAs were being involved with people where appropriate. No one in the home was subject to a Deprivation of Liberty Safeguards at the time of the inspection. CHOICE had a robust quality assurance system in place which involved feedback from people living in the home, their relatives and other people involved in their care. Copies of their responses were seen and there was evidence that their feedback was reflected in the development plan for the home. The Area Director said that he monitored these actions at Regulation 26 visits to the home. There was evidence that Evidence: the manager was keeping a written record of improvements being made and any actions which had been met. The manager confirmed that the home had been audited by an Area Director from another region as part of CHOICEs ongoing quality assurance programme for homes rated by us with 2 or 3 stars. Systems for the monitoring of health and safety at the home were in place. A current fire risk assessment was supported by individual risk assessments for each person describing the support needed should there be a fire in the home. The evacuation procedure was satisfactory. Fire records indicated that fire alarms had not been tested on a weekly basis in February, March or April but that emergency lighting had been tested each month. Staff were having access to fire training and regular drills. The AQAA indicated that equipment and utilities were being serviced regularly. Records in the home confirmed this. 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 37 9 The registered person must 23/06/2009 ensure that any person managing the home becomes registered with us. This is to make sure that we have assessed their fitness to manage the home. 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 A current copy of the assessment of need and care plan should be obtained for all people wishing to move into the home, including people transferring from other CHOICE services prior to admission. Enable people making visits to the home to meet with all people with whom they will be living. Consider ways in which progress towards meeting goals or identified needs in support plans can be evidenced. Review and finish sections of support plans which have not 2 3 4 6 4 6 been completed. 5 18 Research alternative storage solutions for toilet paper and paper towels or working with the person to change their habits. Consider providing refresher training in the safe handling of medication for staff. An up to date copy of the British National Formula should be obtained. The manager should attend training with the local Adult Protection Team. Consider reviewing the length of shifts staff work with people on a 1 to 1 basis. Copies of birth certificates should not be kept but can be evidenced as having been seen on the front sheet of the staff file. 6 7 8 9 10 19 19 23 33 34 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. 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