Care Home: Crosby Close (1+2)

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What the care home does well Following our inspection in November we reported that the relatives of people living at Crosby Close expressed a high level of satisfaction with the service provided. At that time they said: `The service is exceptional in all aspects of care. the staff are kind, caring and professional`. `The staff are always friendly and make us welcome when we go there`. They look after people `with love and kindness`. `I feel my relative is lucky to have a place at Crosby Close`. `The devotion and care of residents is outstanding`. The staff continue to work closely with the relatives of the people living at Crosby Close and received positive comments and support to plan resident holidays. There are good systems in place for monitoring people`s individual health needs and responding to changes. Great care is taken during the admission process to liaise with families and health care professionals who know the person concerned to make sure people`s needs are clearly understood before they arrive and any specialist equipment, risk assessments or staff training needs are identified and provided to keep people safe. Staff provide support when people are admitted to hospital and work closely with the hospital staff. What has improved since the last inspection? The action MacIntyre Care told us about to improve the management and development of the service has now taken place. Four senior support workers have been appointed and an application to register a manager with the Commission is in progress. The manager has also been able to recruit new support workers and registered nurses to increase the team of permanent staff. This will reduce the need for staff to work additional shifts and use of agency staff who may not be so familiar with the residents and systems in place. Three residents have recently been on holiday. This is a major step forward for residents and staff. The people who live at Crosby Close now have care plans in place that reflect MacIntyre Care`s approach to person centred planning. The manager is introducing systems, through staff training and supervision that will enable the feelings of residents, who may have limited verbal skills, and any concerns they may be expressing, made more explicit and acted upon. A laminated `Hospital Passport` has been introduced for each resident so that hospital staff have clear information available to them about how that person needs to be supported when they visit hospitals or attend appointments. In our last report we referred to a review of how resident finances are managed in relation to expenditure to do with the home and who should incur the costs. This has now taken place and money refunded to residents where it was identified they were not responsible for the costs. The planned refurbishment of each house has continued and a new kitchen has been installed in House 1. Further work is planned. What the care home could do better: The manager is aware of the need to continue to develop a person centred approach to widening the experiences of the people who live at Crosby Close and support them to be able to make decisions about their lives and the things they enjoy. The organisation needs to be more proactive in meeting standards and looking at the experience of the people living at Crosby Close as recent experience indicates action is not taken unless we make legal requirements. In our last report we reported on the poor quality of the lighting. No further action appears to have been taken so we have now made a requirement that the registered provider takes action to improve standards for people who need clear lighting and support staff health & safety. We have previously raised the need to introduce an infection control audit that meets current Department of Health guidelines. This has not been introduced so we are now making a requirement for the registered provider to take further action. Key inspection report Care homes for adults (18-65 years) Name: Address: Crosby Close (1 2) 1 2 Crosby Close Off Hill End Lane St. Albans Hertfordshire AL4 0AT     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: Sheila Knopp     Date: 2 7 0 4 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 29 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 29 Information about the care home Name of care home: Address: Crosby Close (1 2) 1 2 Crosby Close Off Hill End Lane St. Albans Hertfordshire AL4 0AT 01727834139/833142 01727838130 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Macintyre Care Name of registered manager (if applicable) Mr Deborah Helen Ibbetson Type of registration: Number of places registered: care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: First level nurse (RNMH) on duty throughout the 24 hour day supported by additional staff as required by Registering Authority. Records kept in relation to every person containing such details as may be prescribed. The additional category of E applies to one named service user only. This category will cease if the named service user leaves the home on a permanent basis. This home may accommodate 12 people who have learning disability (associated with physical disability) who require nursing care . Date of last inspection Brief description of the care home 1 and 2 Crosby Close is a care home providing nursing care and accommodation for 12 adults with learning and physical disabilities. It is owned and managed by Macintyre Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 0 12 12 Brief description of the care home Care and is a short distance away from St Albans City Centre and the local amenities. The home was opened in 1996 and consists of two detached bungalows, each accommodating 6 service users, in a close of similar buildings. All the homes bedrooms are single and 10 of the bedrooms have en-suite facilities. Each bungalow has its own garden, which is easily accessible. The Statement of Purpose is available in each bungalow and is in a pictorial form. A copy of the Service User Guide has been given to each service user and discussed with them. A copy of the most recent inspection report can be obtained from the manager. The service is contracted to Hertfordshire County Council. Care Homes for Adults (18-65 years) Page 5 of 29 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: The information in this report is based on an unannounced visit to 1 & 2 Crosby Close by one inspector between 14:15 and 18:10 hours. For the purposes of this report the inspector acting on behalf of the Care Quality Commission is referred to as we. The visit was timed to meet with the people living at Crosby Close as they returned from their planned day time activity and to review relevant care, personnel and health and safety records with the manager. We have reviewed the information we have received about this service since our last key inspection on 25th November 2009. People have not raised any concerns with us about the quality of the service or the wellbeing of the people who live at Crosby Close since we last visited. Care Homes for Adults (18-65 years) Page 6 of 29 At the time of the last visit on 29th November 2009 the management changes that MacIntyre Care had told us about to take this service forward had not been completed. Therefore we decided to bring the next key inspection forward so we could carry out a further review. Where standards had been met at the last visit and this visit did not indicate they had changed we have used information from relatives and health care professionals that we used in our last report. At that time the manager provided an Annual Quality Assurance Assessment (AQAA). The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also provides us with numerical data. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? The action MacIntyre Care told us about to improve the management and development of the service has now taken place. Four senior support workers have been appointed and an application to register a manager with the Commission is in progress. The manager has also been able to recruit new support workers and registered nurses to increase the team of permanent staff. This will reduce the need for staff to work additional shifts and use of agency staff who may not be so familiar with the residents and systems in place. Three residents have recently been on holiday. This is a major step forward for residents and staff. The people who live at Crosby Close now have care plans in place that reflect MacIntyre Cares approach to person centred planning. The manager is introducing systems, through staff training and supervision that will enable the feelings of residents, who may have limited verbal skills, and any concerns they may be expressing, made more explicit and acted upon. A laminated Hospital Passport has been introduced for each resident so that hospital staff have clear information available to them about how that person needs to be supported when they visit hospitals or attend appointments. In our last report we referred to a review of how resident finances are managed in Care Homes for Adults (18-65 years) Page 8 of 29 relation to expenditure to do with the home and who should incur the costs. This has now taken place and money refunded to residents where it was identified they were not responsible for the costs. The planned refurbishment of each house has continued and a new kitchen has been installed in House 1. Further work is planned. 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 9 of 29 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 10 of 29 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 moving into Crosby Close can be confident that relatives and professionals, who are aware of their needs, will be fully involved in their move to Crosby Close. This is to make sure the service can meet the complex needs of people moving into the home and support is available to make sure the move is carried out safely. Evidence: There have been no new admissions to Crosby Close since our last visit on 25/11/09 and the people present at that time have continued to receive the support they need. Following our last visit we reported that detailed arrangements, involving social workers and the community health care transition team were in place, to support people moving into Crosby Close, and the staff who will be caring for them. People told us that staff were willing to listen and learn from their experiences and knowledge of caring and professional contact over many years. We found that detailed assessments are received from health and social care professionals who know the person concerned. People are introduced to the staff and Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: other residents during day visits and over night stays. This gives the staff the opportunity to make sure specialist equipment and individual risk assessments are in place to care for that person safely. Care Homes for Adults (18-65 years) Page 12 of 29 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 can be confident that opportunities are being created for them to be more involved in decisions about their lives supported by their link worker and senior support workers. Evidence: A major review of care plans has been completed so they provide a more detailed person centred approach focused on peoples aspirations and choices rather than care needs. Staff are receiving the training and support they need to develop skills to encourage service users to be involved in the ongoing development of their plan. Risk assessments for activities inside and outside the home are recorded. These reflect the complexity of the care people are receiving and their diverse needs and vulnerability. The manager reported that the risk assessments are currently being reviewed and updated. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are increasingly being encouraged to be involved in choices about their lifestyle and the things that provide them with comfort and wellbeing through the changing focus of staff. Evidence: The people who live at Crosby Close attend educational and social care day facilities during the week. There appear to be good communication links between services to support service users and report any changes that may have an impact on their health or wellbeing. The manager reported that recent change of day service for one service user has resulted in increased opportunities to be out of the house. Our last report referred to the manager increasing opportunities for people to take part in social and leisure activities outside their home. Since our last visit staff have taken three people away on holiday. This is a new development as people had not Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: been offered holidays for sometime and shows an increasing confidence among staff to look beyond peoples health care needs and find out what is possible. The manager reported on steps taken to increase service user involvement with planning menus, and rather than a rolling menu that was in place, is now organising menus and shopping, based on weekly meetings with residents. It is intended that discussions will move beyond menu planning to other aspects of how peoples home is being run. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the support they need to make sure their dignity is promoted and their personal and health care needs are maintained. People can be confident there are systems in place to make sure people have their prescribed medicines safely. Evidence: Each person has a detailed personal health plan that describes how staff need to their individual needs and information from other health care professionals they have contact with. A review of health plans is nearing completion. A laminated Hospital Passport has been introduced to enable staff to provide hospitals and other specialist services with concise information about the person concerned that they can refer to. We were impressed with the level of support staff provide to residents when they are admitted to hospital. Where staff are providing personal care and support they make a record of this. Staff work closely with the relevant learning disability teams and specialist support services. Appropriate systems for enabling people to take their prescribed medicines are in Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: place and regular audits are carried out to make sure staff are following the procedures in place. Care Homes for Adults (18-65 years) Page 17 of 29 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. There are policies and procedures in place to protect people living at Crosby Close and provide staff with the training they need to promote positive outcomes for the people who live there. Evidence: The manager is introducing staff to systems that will enable them to reflect on whether service users who are not able to express themselves verbally have concerns and complaints, which need to be addressed. The communication section of their care plan prompts staff to record how people feel and respond when they are having a good day or a bad day. There is now also a section on the daily record that staff can identify an issues that arise or are emerging. These will be transferred to an individual complaint record for each service user that will enable the manager to track how the information is reviewed and action taken. We have not received any complaints between our reviews and the manager reported that no complaints about the service had been received. Staff record Best Interest decisions where people are not able to make their views known. Staff training in relation to the Mental Capacity Act does not currently appear to be available through the organisation itself. We have therefore recommended that the manager accesses the Hertfordshire County Council e-learning training available to care home providers. Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: Staff receive training in relation to safeguarding vulnerable adults and have access to a Whistleblowing procedure that tells that what to do if they need to disclose information about the service. Issues related to the safe use of equipment, which has the potential to restrain people is recorded as part of each persons care plan. We have not received any notifications about the people who live at Crosby Close that would raise concerns about their safety or welfare. Care Homes for Adults (18-65 years) Page 19 of 29 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. Crosby Close provides people with a comfortable place to live and work is continuing to make further improvements to the decor, furnishings and personal feel of the home. However work needs to be done to improve the lighting for residents and staff and introduce an infection control audit to review standards. Evidence: Each person has their own room fitted with the specialist equipment they need, including overhead tracking hoists, which are also available in the bathrooms. Peoples personal interests and need for sensory equipment to aid relaxation and stimulation is also reflected in how rooms are decorated and set out. In addition to the sensory room on House 1 there is now a mobile sensory unit that can be taken to the persons own room or other areas of the home. Staff have continued to personalise areas of the home with pictures that are relevant to the people who live there and have recently attended an exhibition of specialist equipment for people with disabilities to get further ideas. Our last report referred to the poor quality of the lighting. We also understand this has been raised with the provider in relation to the health & safety of staff using computer equipment. Further action needs to be taken to address this problem. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: Both houses were fresh and clean on the day we visited and their are suitable arrangements in place for the management of peoples laundry. Staff have attended infection control training but have not yet introduced an audit of these standards. We have raised this on previous occasions. Care Homes for Adults (18-65 years) Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that they will be supported by staff who are checked for their suitability to work with vulnerable people and receive the regular supervision and training they need. Evidence: The new manager has been able to recruit additional support workers and nursing staff. This will increase the staff team and reduce the effect of staff being stretched by covering additional shifts. The increase in supernumerary time reported following our last visit continues to free up time to spend with service users. We looked at the information available to support the recruitment of four new members of staff and were able to confirm that appropriate checks had been carried out before people start work. These include relevant references, a criminal records check and in the case of nursing staff a review of their personal identity number with the Nursing & Midwifery Council. Information on the checks carried out on agency staff working at Crosby Close are also available. New staff are started on an induction. On the day we visited moving and handling training was taking place. Crosby Close has two moving and handling trainers. Experienced staff were also showing new staff how to support people who needed assistance with eating and drinking. Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: Our last report stated that the number of care staff with qualifications in care at NVQ level 2 or above had not reached the 50 bench mark standard for care homes. A number of staff have achieved awards at level 3 and the manager has taken action to sign further staff up for NVQ training. There is now a planned supervision programme that enables the manager to check staff are receiving the support they need. Care Homes for Adults (18-65 years) Page 23 of 29 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 can be confident that there is now a management team in place to focus the service on providing a wider range of experiences for the people living at Crosby Close Evidence: Our last review of Crosby Close indicated that plans to improve the service that had been put forward by MacIntyre Care were not fully in place. An application to register the manager under the Care Standards Act has been forwarded to us. A team of four senior support workers is now in place. This is felt to be key to developing a more person centred approach to supporting the people who live at Crosby Close. Our last report confirmed that the management function had been split away from the clinical role required to support the complex nursing needs of the people who live at Crosby Close. This has continued and staff confirmed it is working well and providing a renewed focus on social care. The lead nurse has been allocated an external mentor to provide clinical supervision and updating on nursing issues. They will also be available to meet with the nursing staff. Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: Our last report indicated issues had been raised by the funding authority in relation to the use of service user money on items for general use in the home or to decorate rooms. A financial audit took place on 26/3/10 and there has been a further review by the local authority. Individual responsibilities for expenditure have been clarified and money reimbursed to service users where applicable. The new manager has audited the staff training records and intends to put a planning matrix in place to enable training needs to be identified and ensure all statutory training is kept up to date. There has been a change of area manager and we saw the latest Regulation 26 report that providers are required to make to report on the quality of the service to the board of directors. Clear records of the daily, weekly and monthly health and safety checks are kept. Care Homes for Adults (18-65 years) Page 25 of 29 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 26 of 29 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 24 23 The registered person is required to carry out a review of the quality of lighting provided and let us know what action they are going to take. This is to make sure that the people living in the home are provided with an environment that supports their sensory needs and staff are able to work safely. 30/07/2010 2 30 13 Introduce an infection control audit that meets current Department of Health standards for care homes and the Hygiene Code. Provide CQC with confirmation of the action taken. This is to protect people living nd working in the home. 30/07/2010 Care Homes for Adults (18-65 years) Page 27 of 29 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 23 Ensure staff have access Mental Capacity Act training and arrange access to the Hertfrodshire County Council training where this is not made available by the registered provider. Care Homes for Adults (18-65 years) Page 28 of 29 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. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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