Care Home: H.C.S. (Enfield) Ltd (Holtwhites Hill)

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What the care home does well The home provides a high standard of care and support to a group of residents who have a range of complex physical care needs. The service works consistently and professionally with the people living in the home and in partnership with other care professionals. This means that people who use the service keep well and make progress on an individual basis. The manager and staff demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs, especially in relation to their communication needs. The residents were also observed to have a good relationship with the staff and there is a strong sense of community. The residents are supported to have their individual needs met by a key working and care planning system. They are also supported to access a range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. One relative commented that the service was, "First class". The home has a well established and very stable team of staff who are being supported by a professional and motivated manager. The home is very comfortable and homely and the residents each have a single bedroom that is personalised to their taste. The home also has access to a vehicle that is helpful in facilitating some of the community activities. The people living in the home are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures and health and safety procedures. What has improved since the last inspection? Seven requirements and two good practice recommendations were issued at the last key inspection. The service has now complied with all of these. As a result of this: Medication records are more detailed. The shower facilities in the home have improved. Recruitment procedures are now more robust. Staff have undertaken epilepsy training, fire training and first aid training. Staff received supervision on a more regular basis. Peoples` care plans are updated and made available to them and their families. Peoples` privacy is better maintained by staff at the home. What the care home could do better: As a result of this inspection one requirement and three good practice recommendations have been issued.Although staff have good training opportunities the registered person must ensure that refresher courses are available so that staff can update their knowledge and skills when required. The sensory room in the home should to be refurbished and tidied up. Action that the manager takes as a result of quality assurance reports should be recorded so that there is evidence that improvements have been made. Night staff should undertake fire drills so that they are confident what action to take in the event of a fire occurring during the night. Key inspection report Care homes for adults (18-65 years) Name: Address: H.C.S. (Enfield) Ltd (Holtwhites Hill) 221 Holtwhites Hill Enfield Middlesex EN2 8BX     The quality rating for this care home is:   three star excellent 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: David Hastings     Date: 0 5 1 1 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: H.C.S. (Enfield) Ltd (Holtwhites Hill) 221 Holtwhites Hill Enfield Middlesex EN2 8BX 02083420537 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: holtwhiteshill@btconnect.com H.C.S.(Enfield) Ltd care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Limited to eight adults of either gender with a learning disability (LD) who may also have a physical disability (PD). Date of last inspection Brief description of the care home Holtwites Hill is a care home for eight younger adults with a learning disability. Four of these places are also registered for younger adults with a physical disability. The home is owned by M.H.J. Crausaz, which is a company specialising in the care of people with learning disabilities, which also owns other homes in the Enfield area. The service is located near to Enfield. The house is detached and there is a downstairs extension offering fully disabled accessible bedrooms. Two of these rooms have an en suite shower room and there is a separate disabled accessible bathroom. There are a further four bedrooms upstairs. There is a comfortable lounge, a dining area and a conservatory. Upstairs there is a small multi sensory room. The staffing of the home consists of the manager, senior carer and a team of care workers. There are three to four care staff working on a morning and late shifts and the night shift is covered by two waking night staff. All the people who live at the home have a day activity Care Homes for Adults (18-65 years) Page 4 of 28 4 4 Over 65 0 0 Brief description of the care home provided either at a day centre or at the home. At the time of the inspection there were seven residents living in the home. Fees charged at the home range between nine hundred pounds and nine hundred and thirty nine pounds per week. A copy of this Inspection report can be requested directly from the home or via the CQC website (web address can be found on page 2 of this report.) 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: 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: This Key unannounced inspection took place on 3rd November 2009. In total the inspection lasted 6 hours. We were assisted by the manager who was open and helpful throughout the inspection. We spoke with 4 staff on duty during the inspection. We met 4 residents of the home and we spoke with 3 family members over the phone. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. Prior to this inspection we sent out surveys to staff and residents and their relatives. We received 6 surveys back from staff and 8 surveys from residents and their relatives. All residents had been helped to fill out these surveys by their key worker. The home also prepared a self-assessment (AQAA) and this was submitted to the Care Homes for Adults (18-65 years) Page 6 of 28 Commission. This information was used as part of the inspection. 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: As a result of this inspection one requirement and three good practice recommendations have been issued. Care Homes for Adults (18-65 years) Page 8 of 28 Although staff have good training opportunities the registered person must ensure that refresher courses are available so that staff can update their knowledge and skills when required. The sensory room in the home should to be refurbished and tidied up. Action that the manager takes as a result of quality assurance reports should be recorded so that there is evidence that improvements have been made. Night staff should undertake fire drills so that they are confident what action to take in the event of a fire occurring during the night. 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 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. The home carries out an assessment of individuals needs so that they know that the home is able to meet their needs before they decide to move in on a trial basis. Evidence: We inspected four case notes for people living in the home and these all contained detailed assessments as part of the person centred plans prepared by the home. This information was comprehensive and provided a good basis for the care plan goals that were in place. In addition the residents also had assessments provided by social services. No new people have moved into the home in the last year. The admission process is in the statement of purpose. This explains that potential people wishing to consider moving to the home are able to make visits to the service as part of this process. The manager confirmed that visits for potential residents would take place including over night stays. Care Homes for Adults (18-65 years) Page 11 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are supported to have a person centred care plan that reflects their individual wishes. They are supported by the staff to express their views and make choices in their daily lives. Evidence: We inspected four case notes for the people living in the home. Each person has detailed individual person centred care plan. These incorporate goals that are realistic and clear. All plans were written in the first person and available in residents rooms. Everyone living in the home had their care plan goals reviewed in the last six months. Evidence from daily reports for each person indicated that their health and well being were monitored daily and care plans were being updated accordingly. Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: None of the residents have challenging behaviours but the person centred plans place a strong emphasis on understanding the residents non-verbal communication and linked behaviour issues to communication difficulties. Clear guidelines are in place to support improved communication with the residents from understanding their gestures and facial expressions to the use of pictures to support people making choices. Staff we interviewed had a good knowledge of the needs and wishes of the residents at the home. The four residents whose case notes were inspected all included individual risk assessments covering all areas of potential risk and these identified what action the home would take in response to the identified risks whilst at the same time promoting each persons independence. These had been reviewed and were up to date. Each person living in the service has a record of the individual arrangements in place to support them to manage their personal finances. A sample of residents personal finances were inspected and were accurate with clear audit trails. Throughout the inspection the staff were observed interacting with the residents and we could see that the residents felt relaxed and were enjoying the contact. Staff responded quickly to non-verbal requests from the residents and could tell when they wanted a drink or something to eat. Care Homes for Adults (18-65 years) Page 13 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are supported to have full and active lifestyles that reflect their interests and offer opportunities for the development of new skills. They also enjoy contact with their relatives. Evidence: The manager explained that the people living in the home access a range of activities based on their individual needs and interests. This includes going to a number of day centres, with two residents attending full-time and four part-time. The leisure activities the residents participate in include going to shows, shopping, bowling and eating out. Each person has a daily record and four were inspected and these showed that they were enjoying an active lifestyle and being supported to access local community resources. On the day of the inspection three of the residents went to their day centres. The residents have access to a company vehicle that is Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: wheelchair accessible. The manager told us that she has been encouraging staff to take residents out of the home on a more regular basis. The staff explained that one of the residents practices their Muslim religion through daily prayers and diet. The home organises creative activities including cookery where residents are supported to feel the ingredients and help mix the food. Peoples individual care plans also included how they were being supported to develop their independent living skills. The manager told us that all the people living in the home have contact with their families. They are made welcome in the home and the residents are supported to go to their family homes. Relatives that we spoke with confirmed that they were made welcome by staff and one relative told us, I can go anytime I want. It was observed that there was a comfortable atmosphere in the home with the staff communicating appropriately with the residents. The residents were observed to be relaxed with the staff, smiling and making good eye contact. Care plans outlined residents likes and dislikes and preferred daily routines such as times for getting up and going to bed. The staff at the home cook for the residents and there is a four week menu plan. The main meal is in the evening and the senior carer has introduced lots of fresh ingredients in this menu plan. A relative we spoke to said the quality of food has improved a lot. The kitchen has recently been inspected by the local environmental health department and has been awarded 4 Scores on the doors. Care Homes for Adults (18-65 years) Page 15 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be assured that they will be assisted to access healthcare appointments to get the support they need. Medication systems within the homes are well organised. Evidence: On the day of the inspection people using the service looked well cared for, their clothes were clean and they were appropriately dressed. Family members we spoke with said they were very happy with the way their relative was being cared for at the home. Staff we interviewed were able to give examples of how they ensure the privacy of people they support. The healthcare records were inspected for four people living in the home. They had all been supported to access the GP, dentist, chiropodist and optician for their primary healthcare checks in the last 12 months. In addition the residents receive input for their specialist healthcare needs and it is also positive to note that a number of other therapy services including physiotherapy, occupational therapy, dietician and speech and language therapy have been accessed as required for specialist advice. Each person has an individual medical profile book which details medical appointments and outcomes. Alternative therapies are also available to residents such as Indian head massage. Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: Most residents are being weighed monthly however there have been some problems with this and records indicated that one resident has not been weighed for some time. It is important that everyones weight is monitored to ensure there are no underlying medical problems. The manager told us that this issue was being addressed and that facilities for weighing residents outside of the home were being investigated. Satisfactory records were examined in relation to the receipt, storage, administration and disposal of medication. Records indicated that staff have undertaken medication training and the manager told us that only qualified staff administer medication at the home. The manager carries out a weekly audit of all medication so that any possible errors can be dealt with. All as required medication have clear administration protocols. The home uses a blister pack medication system supplied by a local pharmacist. None of the residents self-administer their medication. Care Homes for Adults (18-65 years) Page 17 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. People living in the home can be assured that the correct systems are in place should they need to complain and that staff training and procedures are in place to protect them from the risk of being abused. Evidence: The home has satisfactory policies and procedures in relation to complaints and protection. These have both been written in a user friendly format. There have been three minor complaints received since the last inspection. The record of these complaints indicated that they were dealt with in an open manner and each record described the outcomes and action taken. Relatives we spoke with told us they were clear about what action they would take if they had a concern about the service. The home has an adult protection procedure to guide staff on what to do should they have suspicions of or receive a disclosure of abuse. Staff have received training in adult abuse and further training has been planned for those staff who have not had the training yet. Staff we spoke with were clear about their responsibilities to report any suspicions of abuse to the appropriate person. The manager was aware of the procedure for reporting any allegations of abuse to the appropriate authorities. Care Homes for Adults (18-65 years) Page 18 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 safe and cleaned and maintained to a good standard. Evidence: The home was clean and tidy throughout. There is adequate communal space available in the lounge, conservatory and kitchen. The downstairs of the home is designed to be fully accessible for people with a physical disability and has an accessible bathroom and two en-suite shower rooms. Some redecoration and refurbishment has taken place since the last inspection. The manager told us that the Organisation employs a maintenance assistant to deal with any repairs needed in the home. Each residents bedroom was well furnished and was homely and personalised. A sensory room is available on the first floor. This room is in need of refurbishment as it was untidy and contained some storage items. The laundry is on the ground floor. The washing machine was broken and the manager said the machine is being repaired. All toilets and bathrooms contained paper towels and anti bacterial soap to reduce the risk of cross infection. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: Training records indicated that staff have undertaken infection control training and relatives we spoke to said that the home was always clean. There were no offensive odours detected throughout the home. Care Homes for Adults (18-65 years) Page 20 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. People are supported by staff who have been properly recruited and who are receiving training and support relevant to their job. Evidence: The staff team consists of a manager, a senior carer, a cleaner and a team of fifteen carers. The staff turnover is low and most staff have been working at the home for a number of years. The manager explained that the home does not use agency staff. During the day there are usually four staff working. At night there are two waking members of staff. We observed supportive and friendly interactions between staff and residents. Relatives we spoke with said they were happy with the staff at the home. One relative told us the staff were, Very polite. The manager told us that 13 of the 15 care staff have completed their NVQ level 2 or equivalent. This exceeds the requirements of this Standard. Four staff files were examined from staff employed by the home. We checked these files to see if the homes recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: of identity and criminal record checks. Staff we interviewed were positive about the training opportunities provided by the Organisation. One staff member told us, I enjoy the training. Records indicated that most staff have completed the training they need to carry out their roles and responsibilities. In some cases staff require refresher training. This relates particularly to night staff. A new requirement has been issued that a training audit takes place and any gaps in training needs are addressed. Night staff must be supported to attend the training they require. The record of staff team meetings was inspected and these meetings take place on a monthly basis and discuss a wide range of operational issues. Staff supervision records were examined. These indicated that staff supervision takes place on a regular basis and staff confirmed they receive regular support with their work. Care Homes for Adults (18-65 years) Page 22 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 manager of the home knows the residents well and works hard to meet their needs. The health and safety of residents and staff are promoted and protected. Residents are able to have a say in how the home is run. Evidence: Since the last inspection a new manager has been employed at the home. Staff were very positive about the impact she has had on the service. Staff told us that the manager was very supportive, was a good listener and was good at resolving any problems. It was clear that the manager knows the residents very well and we observed excellent interactions between her and the residents as well as the staff group. The manager has nearly completed the required qualifications for her role and has applied to the Commission to be registered. We also saw records that the manager attends training on a regular basis to update her knowledge and skills. There are satisfactory systems in place to monitor the quality of care provision at the home. There are regular residents meetings as well as monthly visits to the home by the provider. Questionnaires are sent to residents and their relatives each year. These Care Homes for Adults (18-65 years) Page 23 of 28 Evidence: are then collated and analysed by the organisation and an action plan developed and sent to the manager for action. The manager was able to explain to us what action she has taken as a result of this quality monitoring. However this was not recorded. A good practice recommendation has been issued that action taken as a result of the quality monitoring exercise should be recorded to provide evidence that any issues have been dealt with appropriately. Training records examined indicated that staff have completed the required training however some refresher courses are required so that all staff are up to date with their training. This issue has been addressed in the training section of this report. Records in relation to fire safety were inspected. These were satisfactory but we noted that fire drills, although taking place on a regular basis, were not being carried out for night staff. A good practice recommendation has been issued that night staff undertake fire drills every three months. A fire risk assessment and fire emergency plan have been developed and were last reviewed in March 2009. The self-assessment (AQAA) confirmed that current certificates were available to confirm the maintenance for the gas system, electrical installations and portable electrical appliances. Care Homes for Adults (18-65 years) Page 24 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 25 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 1 35 18 The registered person must ensure that an audit of staff training takes place and any gaps in training including refresher training are addressed. This is to ensure that all staff at the home have the training they need to carry out their work effectively. 01/01/2010 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 24 The registered person should ensure that the sensory room is refurbished and tidied so it can be safely used by residents. The registered person should ensure that action taken by the home as a result of any quality monitoring exercises is recorded to provide evidence that improvements to the service are being made. The registered person should ensure that night staff undertake fire drills every three months so they are confident about what action to take in the event of a fire Page 26 of 28 2 39 3 42 Care Homes for Adults (18-65 years) 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 occurring at night. 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). 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. Care Homes for Adults (18-65 years) Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!