Care Home: Fairburn Mews

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What the care home does well All but one of the surveys returned were very complimentary of the home and of the staff support. One person was generally happy with things but gave information about some issues they had been having with a member of staff. These issues were discussed during the inpesction and had already been resolved. People said : "I have been out with the staff to some lovely places, I like to go out for a drink"....."I also like to go to rugby on Sunday and they always take me" "If I tell them I want to go out they take me" "They don`t always understand me, some of them have to get someone else to understand me but always someone knows what I am saying" "I am very happy here. I tell them what I want to do and they help me to do it" The home has very good procedures in place to make sure that people who come to live at the home will receive the care and support they need. People who live at the home are involved in planning their care and in making sure that the support they need is given how they want it. People are supported and encouraged to live as independant a lifestyle as possible and any risks are managed well. Staff support people to make choices about their lives and the home offer excellent services to enable people to enjoy leisure and social opportunities. There are excellent systems in place to make sure that people have access to healthcare services appropriate to their needs. People who live at the home told us that they know who to speak to if they have a problem and they know that their concerns will be acted upon without delay. people know who their keyworkers and named nurses are and have developed very good relationships with them. Staffing levels are very good and staff are trained and supported to do their jobs. The home is well managed and processes are in place for continuous improvement and development. What has improved since the last inspection? The staff team has been strengthened by new appointments of nursing, care and activities staff. Systems for care planning have been improved.More social and leisure opportunities have been made available to people who live in the home. The registered manager, with the support of the staff, has made sure that the views and needs of the people who live there are at the centre of any decisions made about the running of the home. Systems for people to access appropriate healthcare professionals have been strengthened. What the care home could do better: The service is running very well and whilst the manger has plans for further improvement there are no obvious areas of need from the view of the inspector. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Fairburn Mews Wheldon Complex Wheldon Road Castleford WF10 2PY     The quality rating for this care home is:   three star excellent service 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: Gillian Walsh     Date: 1 2 0 1 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. 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. 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. Care Homes for Adults (18-65 years) Page 2 of 30 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. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Fairburn Mews Wheldon Road Wheldon Complex Castleford WF10 2PY 01977521784 01977521785 fairburnmews@exemplarhc.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Fairburn Health Care Ltd Name of registered manager (if applicable) Mrs Anne Louise Filson Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia physical disability Additional conditions: The maximum number of service users who can be accommodated is: 20 The registered person may provide the following category of service only: Care home with nursing - code N, to service users of the following gender: Either, whose primary care need on admission to the home are within the following categories: Dementia Code DE; Mental Disorder, excluding learning disability or dementia - Code MD and Physical Disability - Code PD Date of last inspection Brief description of the care home Fairburn Mews is a new, purpose built facility offering nursing and social care, within dedicated units, to 10 people aged 18-65 suffering from Huntington?s Disease in the downstairs Lowrie Suite, and 10 people aged between 18-65 with mental health problems on the upstairs Hulme Suite. The home shares a site with two other care Care Homes for Adults (18-65 years) Page 4 of 30 care home 20 Over 65 0 0 0 10 10 10 Brief description of the care home homes situated on the outskirts of Airedale village and Castleford town centre. There are limited local facilities although this is partly compensated for by the home having access to a minibus which is used to take residents to nearby shopping and activity centres. Secure garden areas have been developed and residents have use of patio areas accessed from the home. All bedrooms are single, ensuite, well equipped and several of the rooms on Lowrie Suite have double beds. Communal areas are spacious and comfortable. In December 2006 the scale of charges at the home are #1274.38 #3114.91 per week with extra charges being made for hairdressing, toiletries, chiropody and some trips out. Information about the home is available from the home in the Statement of Purpose and Service User Guide. All current and prospective residents are given copies of these documents and the Service User Guide contains the summary of the last inspection report. Care Homes for Adults (18-65 years) Page 5 of 30 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: three star excellent 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 last key inspection of this service was completed on 14 December 2006. As part of this inspection we sent a self assessment form to the home manager who completed the form and returned it to us. In this the manager gave us very good detailed information about the home, what they think they are doing well and how they plan to maintain or improve services for the people who live at the home. We also sent out a number of surveys to people who live at the home so that they could tell us directly how they feel about how they are supported and cared for and Care Homes for Adults (18-65 years) Page 6 of 30 how they think the home is managed. All of the ten surveys we sent out were completed and returned. In addition to this one inspector made an unannounced visit to the home to meet with people who live there, to talk to staff and to review documentation, procedures and records. On the day of the visit the inspector was advised that current fees for people living at the home range from one thousand three hundred and twelve pounds sixty five pence to two thousand seven hundred and fourty pounds twenty six pence per week. All weekly fees are worked out according to the care needs assessment of the individual. The inspector would like to thank all of the people who took time to complete surveys or to otherwise help in the inspection process. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use the services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? The staff team has been strengthened by new appointments of nursing, care and activities staff. Systems for care planning have been improved. Care Homes for Adults (18-65 years) Page 8 of 30 More social and leisure opportunities have been made available to people who live in the home. The registered manager, with the support of the staff, has made sure that the views and needs of the people who live there are at the centre of any decisions made about the running of the home. Systems for people to access appropriate healthcare professionals have been strengthened. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not move into the home until they and the staff at the home are confident that their needs can be met and that a plan is in place should problems occur. Evidence: The home manager and care manager explained that before an agreement is made to offer care to a person wishing to live at the home, a very thorough assessment of their needs is completed. This usually entails the home manager and care manager visiting and working with the person in their current environment and spending as much time as they think is necessary with the person to fully assess their needs and expectations. The manager said that this could take up to a full day. A member of care staff is also often involved in this assessment so that the person has the opportunity to meet a member of staff who will be directly involved in their delivery of care. Wherever possible, people are encouraged to spend time at the home as part of this Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: assessment process, again this is for as long as is felt needed and can involve an overnight stay. Families are included in this process wherever this is appropriate. All of the ten people who live at the home who responded to the Commissions surveys said that they were given plenty of information about the home. Some people said they had visited before they moved in whilst others said their family had done this on their behalf. The home manager also explained that wherever there are any doubts about the suitability of a placement, a contingency plan is put in place with the placing authority or involved professionals for if the placement is unsuccessful for any reason. This may be that the person does not like the home or staff feel that they are unable to meet the persons needs sufficiently. Comprehensive assessments from the home and from placing authorities were seen during the visit to the home. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service know that their care plans reflect their needs and that their decisions about their care and lifestyle are reflected. Evidence: Care plans for six of the people who live at the home were looked at during the visit. All of the care plans contained clear information to inform staff of what actions to take to support the person to meet their needs in a way which would encourage independence whilst maintaining dignity. Daily care needs were care planned separately to more acute or immediate needs and all were based on a series of up to date assessments covering various aspects of the persons health and welfare. This included nutrition, moving and handling and skin integrity. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: Wherever appropriate to the individuals needs, care plans for managing aggresive, threatening or challenging behaviours were in place. all of which contained deescalation processes relevant to the individual. Where risks were present within the individuals daily life, either unavoidable risks due to the persons health or risks which the person chose to take as part of an independent lifestyle, a full risk assessment was in place. All of the care plans seen had been signed by either the person themself, their relative or representative or, in one case note had been made that the care plan had been read to the person concerned who had agreed it but did not wish their family to sign it and were unable to sign it themself. Throughout the documentation, it was evident that the individuals right to make decisions about their care and their lifestyle had been the main consideration in the development of the care plans and risk assessments. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent 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 are supported, encouraged and enabled to plan and experience a lifestyle of their choosing. Evidence: One of the the people who lives at the home said that they would like to have some paid part time work. The care manager said that they were exploring ways in which to support this person in this as they felt it would help with their feelings of self worth. None of the other people living at the home have expressed any wish to undertake employment or further education at the moment. The care manager said that anybody wishing to do this would be supported and enabled by the staff at the home. People have previously attended colleges, educational courses and been members of local clubs and gyms. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: Those who wish, work out a programme of what they would like to do on a weekly basis and staff make sure that this is kept to. This supports and promotes independence and enables people to make decisions for themselves. People living at the home said in surveys and during the visit, that they were able to decide how they spent their time. One person said they liked going out shopping and others said how much they enjoyed going to local rugby matches. The home has its own mini-bus and share of a people carrier so that outings can be easily arranged. The home now has three dedicated activities staff which means that there is at least one person in the home seven days a week to support people in their leisure needs. During the visit staff were seen enjoying taking part in leisure activities with the people who live at the home. There is an activities room where people can spend time playing pool, board games or use the computer if they wish. A Nintendo Wii has also been purchased after people said in a meeting that they would like one. The care manager said that this years summer holidays were already being planned. This means that people who live at the home can choose where they would like to go and the activities staff will assist in making the arrangements including sorting out the staff to go along to maintain care and support. People living at the home have recently been working on developing the garden. A pergola is now in place along with some raised gardens and a greenhouse was to be erected the day after the visit. People living at the home are planning to grow herbs and vegetables. A person who lives at the home showed the inspector the new sensory bathroom. Whilst bathing peoples own music is played into the bathroom and a choice of lighting effects and images on the wall from a projector are available. Documentation showed that people are using this to enjoy a long soak in the bath whilst enjoying the music and sensory effect for relaxation. As part of encouraging and supporting people to keep in touch with friends and relatives, a recent initiative has been for the home to provide everybody with a pack of personalised writing paper with their address and room number on it. People spoken with said that their friends and families are welcomed and it was evident from care documentation how much peoples relatives are involved with the home. The manager told the Commission in a self assessment document about how Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: families are invited on trips and to to social occasions as well as just visiting the home. People said how good the food is at the home. Again people are encouraged to make choices about where and what they eat. Drinks and snacks are available whenever somebody would like one. Care is taken to make sure that people with swallowing difficulties due to their condition have meals and drinks of their choice appropriate to their needs. Care Homes for Adults (18-65 years) Page 17 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent 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 have the benefit of excellent systems to ensure and promote their health and well being. Evidence: The homes manager told the Commission in a self assessment document that many of our service users were on referral identified as being non compliant with delivery of care and treatment, however through care planning, setting of realistic goals and developing therapeutic relationships we have achieved a far higher level of compliance resulting in great improvements in people’s health and quality of life. From speaking to people and reviewing care documentation during the inspection visit, it was evident that this is the case. Careful care planning involving the individual and where appropriate their relatives and other people involved in their care, makes sure that people recieve the care they need in the way they prefer to recieve it. One person who lives at the home said in a survey staff always do things right for me Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: The manager said that they have maintained and developed very good relationships with healthcare professionals involved in the care of people who live at the home. A local GP holds a weekly clinic for their patients who live at the home within the home. This means that people can have appointments with and speak to their GP with the minimum of staff intervention. In addition clinics are held every 8 weeks with the consultant neurologist, to review the needs of the people under their care. Staff are also working with the psychiatrist locally who has accepted the care of people living at the home affected by early onset dementia. The manager also said that they have improved links with SALT (speech and language therapy)services and dieticians and now have direct access to these services for advice and input for people who need it. Whenever possible people attend local clinics and healthcare services and are supported to attend outpatient hospital appointments. The home also maintains links with the Huntingtons society to make sure that they are kept abreast of new initiatives and good practice. The home also has an on site physiotherapist who will assist and inform staff in supporting people who benefit from her services. During the visit a sample of medications for people from both units of the home were checked. The care manager said that comprehensive audits of medication sytems continue at the home by staff who are given dedicated time to do this. This means that any errors or anomalies are spotted and can be dealt with immediately. On the day of the visit all of the medications checked were correct and good systems were seen to be in place for managing medications safely. Care Homes for Adults (18-65 years) Page 19 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are confident that their concerns will be listened to and appropriate actions taken. Staff know what to do to make sure people are safe from abuse. Evidence: All of the people who responded to the Commissions surveys said that they would know what to do and who to speak to if they had a complaint. People indicated that they know who their key worker and named nurse are and said that they would speak to them or to the manager. Documentation in the compaints book showed that whenever a person raises a concern or a complaint, it is looked into thoroughly without delay. Records showed that all staff have had training in adult protection. Since the last inspection wherever there has been any suspician of abuse, the home have acted quickly and appropriately in reporting the matter under local safeguarding policies and procedures. On the day of the inspection the manager was attending a safeguarding meeting with the local authority following a referral she had made in relation to a suspected medication error made by a nurse who no longer works at the home. Due to the timely actions of the staff in the home and the manager this issue has been resolved. Care Homes for Adults (18-65 years) Page 20 of 30 Care Homes for Adults (18-65 years) Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean and comfortable home with all the equipment to meet their needs and is decorated wherever possible to their tastes and requirements. Evidence: People who responded to the Commissions surveys said that staff help help to keep their rooms clean and tidy. On the day of the inspection the home was clean and tidy whilst still appearing comfortable. A range of equipment and adaptations are available for people who need them and any further equipment identified as needed is obtained without delay. Decoration for bedrooms is chosen by the person living in it and decoration for communal areas is chosen collectively by the people who live at the home. The new sensory bathroom and the development of the garden are welcome improvements to the environment. Care Homes for Adults (18-65 years) Page 22 of 30 Care Homes for Adults (18-65 years) Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience 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 supported by a caring and well trained team of staff all of whom have been checked to make sure that people are protected. Evidence: Staffing levels within the home are at a high level to make sure that people recieve the care and support they need. Each unit of ten people is staffed with one nurse and five care staff during the daytime. In addition to this there are activities, administrative, housekeeping, catering and maintenance staff. The home manager is always supernumary and the care manager and senior nurses are also given supernumary time to concentrate on care and quality audits and staff training. In order to make the process more accesible for care staff, the company have recently started to do their own NVQ (National Vocational Qualification) training in conjunction with City and Guilds. One member of staff is an assessor and another is training to become one. Another member of staff is training to be an internal verifyer. This training will continue until Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: the home has a number of trained assessors. Five of the current care staff team hold the NVQ level two in care and some have also achieved level three. Several care staff are currently training for the award. The homes training matrix shows that all staff are up to date with mandatory training including fire training, moving and handling, health and safety and protection of vulnerable adults. Other training relevant to the needs of the people who live at the home is also undertaken by staff. So far this has included palliative care training from the Macmillan nurses, the care manager has acheived the certificate in Phlebotomy and training in caring for people with Huntingtons disease. A selection of staff recruitment files were seen during the visit. All of the files contained evidence to show that all appropriate checks and clearences are undertaken before new staff start working at the home. All new staff then follow a programme of induction which includes a full week of training before working in the home and continues to lead into NVQ. documentation relating to this process was seen during the inspection. Observations made during the visit were that people living at the home and all staff have a comfortable and mutually affectionate relationship in which staff display skillful and professional attitudes. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home can be assured that their views and their wellbeing are integral to the high quality management processes at the home. Evidence: The registered manager said that she is continuing to study for the registered managers award. However due to some changes in the structure of the award this was put on hold for a short time to make sure that the programme she follows is the most up to date and appropriate for a registered nurse. In addition to this training records that the registered manager continues to up date herself on all aspects of mandatory training and has undertaken other training including health and safety at a higher level. The home has a number of systems of quality monitoring to make sure that the service they provide is of a high quality and in the best interests of the people who live there. This includes the distribution and analysis of annual satisfaction surveys, but on Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: a more regular basis, meetings for the people who live at the home where they can put forward any concerns they may have or make suggestions as to how they think the service can improve. Prior to the visit the manager had completed and returned the self assessment document known as an AQAA to the Commission. In this the manager gave detailed information about any improvements the service has made, where they think they are now and any actions they can or have planned to take to further improve the service. The company that owns the home has robust systems in place for ensuring the health and safety of all of the people living or working at the home. These systems are followed and kept up to date by making sure that all staff undertake health and safety training and that key personnel such as the home manager and the maintenance person are trained appropriately. The home has a health and safety committee which meets three monthly to discuss any relevant issues in the home. An action plan is then developed to address any issues highlighted. This meeting is chaired by the home manager who has obtained an advanced health and safety award. Minutes of the last meeting were seen during the visit. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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. 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