Care Home: Grafton Manor Head Injury & Rehabilitation Unit

What the care home does well The home is clean and the staff and the people say the `home is nice`. We are told by staff that the home is good at helping people to learn skills to make them more independent. One person told us that `it was lovely here` and `staff are nice` and they had learned new skills. A variety of comments were received about the food that is offered to the people. One person told us that `the food is very nice`. Another person said `we have choices and the food is very nice and tasty`. The people spoken to told us that if they did not feel well, the staff would look after them and inform the doctor. They also say if `I am not happy I will talk to the staff`. The staff enjoy working at the home and it was said `I absolutely love it`. The staff say that they work very hard to meet the needs of the people. They get training to help them meet the people`s needs. They say they get `good support from the manager`. The staff were observed talking and listening to the people and offering advice in a positive manner. What has improved since the last inspection? The home has a new needs assessment summary to ensure all information needed about the person is recorded by the home. The home has recruited more staff to ensure the people`s needs are met. The staff have detailed induction training when they start work so they have skills and knowledge to meet people`s needs. The home has a new manager What the care home could do better: The home should ensure all staff receives at least 6 supervisions per year to find out how they are working with the people in the home. Ensure needs assessments has all the information stated in the standard Ensure the working care plans have information recorded in more detail telling the people how their goals are going to be met and in a format that the people will understand. Key inspection report Care homes for adults (18-65 years) Name: Address: Grafton Manor Head Injury & Rehabilitation Unit Grafton Regis Manor Nursing Home Bozenham Mill Lane Grafton Regis Towcester Northants NN12 7SS     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: Ansuya Chudasama     Date: 2 7 1 0 2 0 0 9 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 28 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) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Grafton Manor Head Injury & Rehabilitation Unit Grafton Regis Manor Nursing Home Bozenham Mill Lane Grafton Regis Towcester Northants NN12 7SS 01908543131 01908542644 mamos@partnershipsincare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Partnerships In Care Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: No one falling within the category MD may be admitted into the home where there are 26 service users of this category already accommodated within the home. That one bedroom within the chantry measures 10 square meters with additional en suite as agreed in variaiton application number V000020532 Date of last inspection Brief description of the care home Situated halfway between Northampton and Milton Keynes, Grafton Manor is a magnificent building dating back to the 15th Century. Set in 7 acres of landscaped gardens, it provides a relaxing environment for assessment and rehabilitation programmes. The accommodation comprises of 13 single rooms in the main manor house with a further 6 bedrooms in the Chantry along with a cottage, bed-sit and flat Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 26 2 3 1 2 2 0 0 8 Brief description of the care home offering a choice of accommodation to suit individual needs. There is a range of communal areas within the different units and the people are able to enjoy the garden areas. Weekly fees range from three thousand two hundred and thirty one pounds for rehabilitation and two thousand and three hundred and ninty six pounds for long term care. Care Homes for Adults (18-65 years) Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies which require review of key standards for the provision of a care home for younger adults that takes account of the peoples views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. We looked at the Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We also looked at the information from the last key inspection and the records of any other visits that we have made to the home in the last 12 months. Information we have about how the home has managed any complaints and things that have Care Homes for Adults (18-65 years) Page 6 of 28 happened in the home, which are reported under notifications and are a legal requirement are also looked at. The report refers to we this is because the report is written on behalf of the Quality Care Commission. We last inspected this service on 23rd of December 08. The manager helped out with the inspection process. During this inspection we tracked the care of two people who use this service. This involved reading their care records and also talking to them wherever possible to obtain their views on the service. We also spoke to most of the other people who live in the home. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to some of the staff who were on duty. Care Homes for Adults (18-65 years) Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Care Homes for Adults (18-65 years) Page 8 of 28 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 28 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 28 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. Peoples needs assessments are undertaken by the home to find out if their needs can be met by the home. Evidence: The home has a statement of purpose and a service user guide. The manager informed us that the documents had been up dated with the relevant information needed. The manager says that the staff read the information to the people from the documents. The inspection report is kept in the office and given to people interested in coming to the home. The peoples files looked at showed that there were assessment admission details of the person being admitted to the home. However the information gathered was based more on the persons medical needs. There was not much information on the social needs of the person. This was discussed with the manager and we were told that a new needs assessment summary was introduced and this included recording information on the persons social needs. Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: The home recently discharged a person from the home as they could not meet the persons needs. Evidence showed that the person was not compatible with the people already living at the home. All the people in the home have contracts so there fore they know their rights and responsibilities of staying at the home. The AQAA says what we could do better is to further encourage people to visit the unit prior to admission. Care Homes for Adults (18-65 years) Page 12 of 28 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. The people have care planning documents to ensure staff have the information to meet the peoples needs. Evidence: We looked at two peoples care plans in detail and discussed their care needs with staff on duty. The staff showed that they had good understanding of the care needs of the people. The people have treatment plans and we were told that the nurses, occupational therapist, physiotherapist, and speech therapist do their assessment and write the treatment plan. We are told that the staff work with the people by telling them how they are going to meet their needs. The treatment plans seen talked about goals. However it did not state how these goals are to be achieved. Information that was being updated in the plans was not always dated by staff doing this. Also the information recorded in the progress is not always Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: updated in the plan. We discussed this with the manager and we were told that they had recently started reviewing the treatment plans and the guidelines and have combined the two documents into one document called the care plan. This was because the word care plan was said to be more positive than treatment plans. We were told that the information being recorded in the care plan is made easier for the people to understand and they are also involved with this process. A range of risk assessments are in place that enable the people to take risks as part of an independent lifestyle. The information recorded in the risk assessment was not always recorded in treatment plans. This was discussed with the manager and we were told that they were developing a new format for risk assessments. Reviews by the funding authorities were taking place of the people funded by them. We were also told that the professionals have a ward round once a week to discuss the peoples needs. The peoples information was kept secure in the office. The AQAA says our plans for improvement in the next 12 months is to have further involvement from service users in making choices and identifying their own goals for the future to address their needs and have more information and feedback from the advocate to enable us to work with individuals to meet their personal needs and goals. Care Homes for Adults (18-65 years) Page 14 of 28 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. Meals served are nutritious and plentiful with a menu which changes each day so that the people have choices to meet their needs. Evidence: The people have a daily programme and we looked at one programme, which had the names of all the people saying what they did from the time they got up to 7 pm in the evening. We sat with the people in the main lounge watching a documentary on dinosaurs. We observed some people were enjoying the video but a few people appeared bored and were not interested in watching the video. We were told that the home needed more educational activities and a list was drawn up of the activities that staff and the people wanted. The manager was dealing with this. Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: We were told by staff that there were enough staff on duty and the people were now going out more often. One person told us that I like the park and the sweets. Another person told us that it is nice here and they were settling in the home. We were told that some of the people do paintings and the pictures are displayed on walls. Some of the other activities the people do include using the gym and doing exercises, playing different games and WII computer games. The people were also getting ready for their themed Halloween party. One person told us that they also went out for meals, shopping, and to the cinema. The home has purchased a vehicle that is suitable to accommodate people who use a wheelchair. This also ensures all the people are able to go out in the community. The outside of the lounge garden area had a table and chairs and an area that kept the people dry when they went out for a smoke. The meals for the day are recorded on the board in the dining room. The people have several choices and we are told that if they do not like what is recorded on the board, they can ask for some thing else. We were told by staff and the people that the food is nice and tasty. We also sampled the food and this was hot and delicious. We observed that there was a very positive atmosphere in the dining room with staff and the people having a good conservation. We also noticed some of the people that we had observed at the last inspection looked very well and were doing more for them selves. Most of the people in the home maintain contact with their families and friends. Some people visit their families for weekends and families also visit the home. We were told that the home has peoples meeting to get their views about living at the home. However we were told that this did not happen often. The home has an advocate who has been trained in brain injury to provide support to the people when needed. We are told in the AQAA that the Grafton Development Centre is now complete and this houses a new gymnasium for residents as well as a session area and small kitchen area to provide teas and coffees. Care Homes for Adults (18-65 years) Page 16 of 28 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The peoples health care needs are being met. Evidence: We observed staff interaction and noticed that they talked to people in a respectful manner and were careful to preserve their dignity. The people we spoke to informed us that the staff knocked on their doors before entering their room. This was observed on the day of the inspection. Evidence in the care records showed that people are offered support for their physical and emotional health needs. There were records of health professionals and hospital appointments, and people have access to the opticians, dentists, and other health care professionals when required. The people told us that if they did not feel well, they would tell the staff. There were guide lines recorded for people who needed support with personal care. One person spoken to said that they were capable to doing their own personal care and staff made sure that they did this properly. Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: We were told that the nurses gave out medication and had received the accredited training for this. There were medication profiles for each person. The medication records looked at showed that there were times when staff had forgotten to sign the medication record. The nurse spoken to state that they monitored the medication and said that they would speak to the person that had forgotten to sign the record. The home did have a controlled drugs cupboard and the medication checked was correct. The medication policy checked was out of date and this was discussed with the manager. An updated medication policy was sent to CQC the day after the inspection. The AQAA notes what we could do better says the review of treatment plans needs to be more clearly shown. Care Homes for Adults (18-65 years) Page 18 of 28 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. The peoples concerns are listened by staff to ensure they are protected from any harm. Evidence: The home has a complaints policy, and the procedures for making a complaint is given to people coming to the home. The AQAA states that the home received 3 complaints and all were resolved within 28 days. Two complaints were up held. The complaints procedures were being followed by the home. The staff spoken to informed us that they had completed the safe guarding of vulnerable adults procedures training. They had good understanding of this and understood the peoples behaviours to know if they were unhappy or not feeling well. The home has made 33 safe guarding referrals to the safe guarding team of social services and some of the incidents were substantiated. We were told by the safe guarding team that the action plan the home puts into place for the incidents reported was satisfactory. The home had followed the proper procedures by contacting the deprivation of liberty safeguards authority about a restrain being put in place for a person in the home to keep them safe. The home was visited by the advocate from the organisation and it was said that the home had followed the proper procedures in maintaining the person was kept safe. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: We were also told that a persons mental capacity to make decisions was discussed at a continuing health care assessment. It was said that the funding authority, safe guarding of vulnerable adults representative, family, independent advocate, and the home were involved in discussing the persons needs. The out come of the decision was that the person was not able to make decisions for them selves and they needed to go to a placement where the persons needs could be met. We read the statement information made by a doctor about people not having capacity to consent to their placement treatment. This was discussed with the manager and we were told that they have been given information about the Mental Capacity Act and application template by an NHS advisor to their home. It was said that all the relevant people will be involved in completing the information about capacity for the people living in the home. Most of the people spoken to were capable of informing staff if they had any concerns or if they were not happy. They told us that they would tell the manager, family, or staff of any complaints they had. Care Homes for Adults (18-65 years) Page 20 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and meets the needs of the people. Evidence: The home was clean and the people tell us that they like living at the home. There is no smoking in the home. The people go out in the garden to smoke. There are chairs and a shelter has been put in the garden to protect the people from the rain. The bedrooms all have en suite facilities. The people tell us that they like their rooms. The manager informed us that they have requested a pathway to be laid around the grounds to help the people who use a wheelchair to make better use of the gardens. The home has a rolling maintenance plan to ensure the home is kept to a good standard. We are told that the Chantry unit is on the list to be decorated and furniture had been ordered for the small lounge in the main building. The AQAA says that We now have a Health and Safety Officer who visits the unit 2 days a month to review our risk assessments and safe systems of work, ensuring our policies reflect government regulation. Care Homes for Adults (18-65 years) Page 21 of 28 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. The homes recruitment procedures are robust to ensure the people are protected from potential harm. Evidence: The staff recruitment files were looked at in detail. Evidence showed that the relevant information was being obtained to ensure the people are safe guarded from any harm. Staff told us that they had good induction training where they worked with experienced members of staff before they started work. They had completed all the statutory training and other training related to the people they look after. It was also said that all the staff had completed training in management of violence and aggression. Staff spoken to informed us that they were getting supervision but this was not happening at least six times per year. We were told by staff that there was enough staff on duty and the working hours were also better. The manager informed us that they had a successful recruitment open day and had recruited permanent and bank staff. Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: The staff say that they enjoy working at the home, and it was said that they looked after the peoples needs well. They supported the people to learn skills. One staff said that they get job satisfaction from seeing a resident move on to more independent living and doing so well. We were also told that the care staff and nurses had monthly meetings and these were good in discussing what was happening in the home and looking at peoples needs. The staff spoken to told us that they worked well as a team. The AQAA says our plan for the next 12 months is to have a comprehensive record of management supervision taking place for the required amount of times for each member of staff annually. Care Homes for Adults (18-65 years) Page 23 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interest of the people. Evidence: The manager of the home has many years experience of working with people with brain injury. They had worked at the organisations other sister homes as the registered manager of the homes. The manager has been managing the home since this year when the previous manager left. The manager has applied to become the registered manager of this home. They have completed the application form. They were now waiting for their criminal record bureau (CRB) checks to be posted to them. The manager says that they have an open door policy and are available to any one who wants to talk to them. We were told by the manager that they will be moving their office into the main building where the staff office is situated. This is so they are near and accessible to the staff and the people living in the home. The staff tell us that the manager is very supportive and listens to staff. It was also said that the manager mixes well with staff. The people spoken to also liked the manager and the staff. Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: The AQAA says what they have done well is to have a full time clinical manager who is an RMN and is supernumery on the staff working rota to provide support to staff and focus on meeting the residents needs. The accident and incident records show that these were being recorded appropriately and the relevant agencies were being informed of the relevant incidents that they needed to know. The home carries out regulation 26 visits to monitor the home. A peoples questionnaire survey was carried out for 2009. An action plan was undertaken to answers where the people were not happy about an activity. However a lot of the information was very positive about th home. The staff questionnaires had been sent out and the manager was still waiting to get all the surveys back. We were told by the manager that they will be undertaking surveys of families and professionals involved with the home to find out their views on how the home is meeting the peoples needs. The manager also said that they now have appointed a quality monitoring person for the home to monitor the homes aims and objectives and how peoples needs are being met. The fire alarm system was being tested on a weekly basis. The emergency lighting was done on a monthly basis. We were told that fire drill practice was also happening on a regular basis and the people were involved in this process. Health and safety checks of the home was being undertaken to ensure the systems were working satisfactory. We were told by staff that they had received fire and prevention and control of infection control training. Care Homes for Adults (18-65 years) Page 25 of 28 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 28 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 1 2 2 6 Ensure peoples needs assessments has all the information stated in the standard. Ensure that the care plans explain in detail how the peoples goals are to be achieved with time scales. This is so the people are aware how the staff are going to help them meet their goals. Update peoples care plan when a persons needs change to make sure all the staff have up to date information they need to meet the persons needs. Provide 6 supervisions per year for staff to monitor their practice to find out how they are meeting the needs of the people. 3 6 4 36 Care Homes for Adults (18-65 years) Page 27 of 28 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. Copyright © (2009) Care Quality Commission (CQC). 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