Care Home: Hillside

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What the care home does well Service users present as being relaxed and comfortable with staff indicating they feel safe and secure with them. Service users say they like the staff and that they are friendly. There is an open and friendly atmosphere. People living at the home are supported in maintaining contact with their family and friends. Robust recruitment processes are followed to help ensure the home employs only appropriate staff. What has improved since the last inspection? There is a newly appointed Manager who intends to submit an application for registration with us in the near future. The Manager recognises where improvements are needed. Each service users` care plan now includes a Personal Planning Book, presented in a way they can more easily understand. Since our last site visit in 2007, the fish pond has been fenced off for service users` safety. Sleep-in staff members now have appropriate facilities. What the care home could do better: Five Requirements are made as a result of this inspection. The home must develop its care plans to be more comprehensive. Risk assessments must also be more comprehensive and recorded in response to incidents and changes in service users` welfare. The home must be able to show that there are always enough staff on duty at all times and they have the training, service specific and mandatory, so they have the skills and knowledge to meet service users` needs. Some parts of the home must be made good to better promote infection control. We strongly recommend the facilities for the storage of medicines are reviewed to fully comply with the latest guidelines from the Royal Pharmaceutical Society. The Manager undertook to ensure that all staff members are aware of the need to promote service users` dignity and to adhere to COSHH guidelines at all times. Key inspection report Care homes for adults (18-65 years) Name: Address: Hillside Cranbrook Road Hawkhurst Kent TN18 5EF     The quality rating for this care home is:   one star adequate 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: Gary Bartlett     Date: 3 0 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Hillside Cranbrook Road Hawkhurst Kent TN18 5EF 01580752124 01580752140 chislehurstcare@totalise.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Chistlehurst Care Ltd Name of registered manager (if applicable) Mrs Audrey Avril May Hodges Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 20 The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - LD Date of last inspection Brief description of the care home Hillside is registered for 20 clients with a learning disability. Due to limited space the home usually accommodates 18 clients. There is a separate house on the same site which caters for more independent clients and is not subject to registration. Hillside is a large detached property on two floors standing in its own grounds. It is located in a rural area within walking distance of Hawkhurst main centre, which has a small high street where there are the amenities of a large village including pubs, Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 20 Brief description of the care home chemist, cottage hospital, bus terminus, bank and supermarket. There are local bus services to the larger surrounding towns. Car parking is available on site. The home is staffed by a manager, senior carers and carers who between them provider 24 hour care. There is one wakeful and one sleep in person on duty at night. Charges for clients at the time the report was written range from £473.46 per week to £841.70 per week. There are additional charges, details of which can be obtained from the Manager. 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: one star adequate 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 was conducted by Gary Bartlett, Regulatory Inspector, who was at Hillside from 10.45 a.m. until 6.30 pm. Judgments about quality of life and choices were taken from direct observation and by discussion with the service users, the Responsible Individual, the manager and staff. Some records and parts of the building and grounds were inspected. The organisation had completed an Annual Quality Assurance Assessment, from which a limited amount of information could be used to inform the inspection process. The Inspector would like to thank everyone involved for their contribution to the inspection. Care Homes for Adults (18-65 years) Page 6 of 30 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. 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 7 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 8 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sound policies and procedures in place to ensure prospective service users are properly assessed prior to being offered a place in the home. Evidence: The home has an assessment and admission policy and procedure to ensure each admission is undertaken in a planned way. The Manager described how prospective service users would only be admitted to the home after a full assessment of needs. The forms seen included facilities for the assessments of personal support, health care needs, religious and cultural needs and social interests. This would be inclusive of information received from relatives and health care professionals and is the starting point for service users individual care plans. Further assessments are undertaken after the service user has been admitted to the home. The people living at Hillside have been there for a number of years and there have not been any new admissions since 2007. The registered provider said there is a current review of the service being provided, taking into account its stated aims and possible development. Therefore, very careful consideration would be given to new admissions. Care Homes for Adults (18-65 years) Page 9 of 30 Evidence: Future staff training programmes and the staff structure form part of the review. This is to ensure that staff will have the necessary skills to meet service users specialist care needs. Care Homes for Adults (18-65 years) Page 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users would benefit from improvements to their care plans and be better safeguarded by more comprehensive risk assessments. Evidence: Each service user has a care plan. Three were inspected in detail. The care plans give some information about individuals health care needs but are not always detailed about how support is to be given. Nor are they always inclusive of strategies or directives for meeting service users needs. Although being reviewed, the care plans do not include short or long term goals. Therefore, it is difficult to assess peoples progress in maintaining or achieving independence. The Manager understands that staff must have clear information about meeting service users needs and is designing a new care plan format to help achieve this. Each care plan includes a Personal Planning Book that is written in a way to be more easily understood by the service user. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: The Manager acknowledges there is little detailed care planning for social care support and is intending to address this. Staff members spoken with generally have a good understanding of the importance of promoting service users choices but these are not always recorded. The care plans should include more information about what a service user can do for themselves, the individuals aspirations and how they make choices in their life. Of the daily records seen, some are more detailed than others in being descriptive of the days activities and in conveying how the service user has responded during the day and how they feel emotionally. Accurate and detailed information gives a full picture of the persons lifestyle and helps when it comes to reviewing peoples care plans. The Manager is aware of this and is monitoring the quality of the daily records and offering support and guidance to staff where required. The records we saw show that service users are supported in having access to health care services such as dentists, opticians and chiropodists. There are risk assessments for some activities but they are not consistently comprehensive. It is not evident the risk assessments are always reviewed in response to incidents or changes in peoples welfare. This must be addressed to better safeguard people. Some service users have communication difficulties. From observation, the staff members have an understanding of the most appropriate communication styles for each individual. The home does not act as appointee for any service users and there are regular and effective audits of the homes handling of service users finances. From observation and discussion, it is evident that service users have confidence in the staff team and the interaction is warm and friendly. Care Homes for Adults (18-65 years) Page 12 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users should be more consistently supported in their individual choices and development of their life skills. Evidence: The Manager stated that, until she took post, activities for service users had become mainly in-house, along with some attendance of day services commissioned by the local authority. This was confirmed by the records seen. She described how she is developing a programme of more activities in the community. This includes trips to the theatre, bowling, a night club and discos. As she learns service users individual preferences and abilities she is intending to better support them in using the local community facilities. As mentioned earlier in this report, the home uses a care planning system that provides adequate facility for recording individuals personal and health care needs but Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: there is little detailed care planning for social care support. Some service users care plans show they have communication difficulties. Although staff members were seen to be able to communicate with each of them, it is not evident in the care plans that more innovative or individual communication styles have been explored. Accordingly, it is not always clear how service users are consulted about their choice of activity. Service users are welcome to entertain visitors at the home. The Manager said several service users like to attend a local church each Sunday and are supported in doing this. Service users tell us they like the food. The Manager said she ensures the meals offered provide a balanced and nutritious diet and take account of peoples cultural needs as well as any medical conditions. Service users are not currently involved in the food shopping for the home. We observed that three service users have a soft diet. The meals had been blended as a whole. As a result, there would not be any contrast of tastes and the meal looked unappetising. We also saw that a Senior Support Worker did not recognise that a service user was struggling to eat their meal independently because the plate guard was in the wrong position. The Manager undertook to address these matters without delay. Had she not done so, we would have issued Immediate Requirement Notices in respect of the promotion of dignity. Care Homes for Adults (18-65 years) Page 14 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improved recording will better show how residents are supported with their personal and health care needs. Evidence: The staff members we spoke with generally have a good understanding of the individual requirements of each service user. Through discussion with the service users and staff and assessing various records, it is evident that service users have access to health care support. Improved care plans will better show that staff members are made aware as to the type and nature of the support required for individuals personal and intimate care needs and how these needs are being met. The Manager is monitoring records of care to help ensure they are more consistent in quality of information included. As mentioned earlier in this report, the Manager undertook to remind staff of the necessity to promote service users dignity. The instance of poor practice we observed being that someone was struggling to eat their meal independently because the plate guard was in the wrong position. This was not recognised or acted upon by the staff member present. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The current arrangement for the storage of medicines is adequate but does not fully comply with the latest guidelines from the Royal Pharmaceutical Society. For example there is limited space and there are not hand washing facilities. It is recommended these arrangements are reviewed as soon as is practicable. The temperature of the room is now being monitored to ensure medicines are stored at an appropriate temperature. The Manager described how it is intended to provide an approved drugs cabinet instead of using a secured drugs trolley. We inspected the Medication Record Administration Record (MAR) sheets completed for four service users during April 2010. These had been completed appropriately. Medications are only administered by staff authorised to do so. No service users staying at Hillside currently manage their own medicines. The Manager said that if a service user wished to do so, the home would look at the possibility of providing support through a risk assessed framework. Care Homes for Adults (18-65 years) Page 16 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to offer comment or complaints. Service users will be better protected when all staff members have had up to date training in safeguarding vulnerable adults. Evidence: The home has a clear, up to date and readily available complaint procedure. The procedure is also available in a pictorial format for service users. Records are kept of complaints, their investigations and outcomes. The AQAA indicates the home has not received any complaints in the last twelve months. The Commission has not directly received any information regarding complaints about the home in that time. The Manager stated it is intended to undertake Capacity Assessments of the service users as part of the review of their care plans. This will help the home ensure peoples best interests are being promoted. Nobody at the home is an appointee for service users financial affairs. Most service users are supported with their finances by their relatives. We inspected the records of financial transactions made in support of three service users. These were detailed and the appropriate receipts were in place. There are procedures for protecting service users from abuse. The homes training Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: matrix shows that two staff members have not had training in safeguarding, five last had the training in 2006 and two in 2007. The Manager recognises it is important that all staff members have a good understanding of the up to date protocols to safeguard vulnerable adults and is arranging training for them. It is strongly recommended this training be undertaken in the soonest possible time. There is one ongoing Safeguarding Vulnerable Adults alert at the home. Care Homes for Adults (18-65 years) Page 18 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 good 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 generally clean and comfortable environment. Evidence: Hillside was converted for use as a residential home from a large family home on the outskirts of Hawkhurst. A house for supported living clients is in the homes grounds. To the rear of the main house is a separate building which is used as a workshop. This was seen to be left open and unattended on several occasions during our visit. This meant that service users could gain access to the materials in there, such as paint stripper and sharp implements, which should be stored securely. The Manager undertook to address this straight away. This negated the need for us to issue an Immediate Requirement Notice. Service users can use the patio area and garden where there is an ornamental pond that has been fenced off for safety. The bedrooms seen are well personalised and reflect the occupants interests and tastes. From parts of the grounds, it is easy to see into some bedrooms on the ground floor. It is recommended the occupants of these rooms be consulted about fitting net curtains to their bedroom windows to provide them with more privacy. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: Aids and equipment needed by service users are provided such as grab rails, hoists including an in bath hoist, pressure mattress and mobility aids. The ground floor dining room is arranged to give space for wheelchair users. Showering and bathing facilities are provided on each floor. A communal shower has damaged tiles. These must be replaced to better promote infection control. At the time of our visit, most parts of the home were clean, with the exception of the kitchen on the first floor. The Manager agreed to arrange for the kitchen to be cleaned and for the areas where there were broken or missing tiles to be made good. The home does not employ domestic staff and care staff are required to include cleaning in their daily duties. The Manager stated it is planned to have the main kitchen refurbished in the near future. There are now suitable facilities for sleep-in staff to use. Previously, they had to use a bed-settee in the first floor lounge. There is a laundry on the ground floor with a washing machine and tumble driers and racking for clothes storage. A washing machine and tumble drier are also situated in the kitchen/dining room on the first floor. Staff and service users are aware they must not do any laundry on the first floor before or during meal preparation and serving. There is protective clothing available for staff members to use when needed. The staff practices seen during the site visit showed they were conscientious in reducing the risks of cross infection. Care Homes for Adults (18-65 years) Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Robust recruitment processes are followed to ensure only properly vetted people work at the home. Staff members are caring, but the home must be more able to readily show they have the necessary skills to meet service users care needs and are available in sufficient numbers at all times. Evidence: Robust recruitment processes are followed to ensure only properly vetted people work at the home. People applying to work at the home have to complete an application form, provide two references and have Independent Safeguarding Authority (ISA) and Criminal Records Bureau (CRB) checks and attend an interview. New staff members have to undertake an induction programme. We inspected the file of two staff members and the required documentation is in place. The Manager acknowledges that, prior to her taking post; staff training had not been kept up to date as it should. The home has provided us with a training matrix that shows there are substantial gaps in mandatory training and staff members have not had training in social care for people with a learning disability. The Manager has undertaken to organise relevant training in the soonest possible time. Until this is Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: done, it is not evident that all members of staff have the skills to meet service users needs and to comply with current legislation and good practice guidelines. NVQ training is also to be arranged for some Support Workers. Staffing levels are geared to peak times of activity and service users attendance at day centres. Taking account of the high physical needs of one service user and that care staff are also responsible for cooking and cleaning, the staffing levels need to be reviewed to be sure that adequate numbers of staff are always on duty to meet service users needs and to enable them to participate in activities they may choose, particularly at weekends. There was some discussion about the necessity of ensuring staff supervision is provided by senior staff who are trained and have the competencies to do so. Care Homes for Adults (18-65 years) Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home benefits from a manager who is experienced and understands where changes need to be made to improve the standard of service. Evidence: The Manager has been in post since December 2009. She has been working for the company in various roles since 2001 and has extensive experience of working in the care sector. The Manager has an NVQ level 3 in Social Care and is about to commence studies for a management qualification. She is intending to submit her application for registration with us in the near future. Until the current Manager took post, there had not been a registered Manager at Hillside since early in 2008. This is not compliant with the Care Standards Act 2000 and is contributory to the deficits in care planning, recording and staff training noted elsewhere in this report. There is a sound system of auditing transactions made on service users behalf. The home is looking at obtaining individual money wallets for each service user. Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: There are systems for the regular checking of fire safety systems. Staff members spoken with have an understanding of emergency procedures. The organisation undertakes monthly visits to the home to monitor the quality of the service. We had sight of four of these reports and they record where improvements are needed. There are regular meetings and surveys to request the views of service users, their relatives and external agencies. Care Homes for Adults (18-65 years) Page 24 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 25 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 1 6 17 The registered person shall maintain records as specified in Schedules 3 and 4. It is a legal requirement for the registered person to keep records of care that are up to date and specific in detail of information required. All service users must have a comprehensive and detailed care plan that is inclusive of personal, health and social care needs by the given timescale, if not sooner, and which is maintained thereafter. 30/07/2010 2 9 13 The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. It is a legal requirement for the care home to minimise 30/06/2010 Care Homes for Adults (18-65 years) Page 26 of 30 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 risks as far as is practicable. Risk assessments must be more comprehensive and recorded in response to incidents and changes in service users welfare. Comprehensive risk assessments must be in place by the given timescale, if not sooner, and maintained thereafter. 3 30 13 The registered person shall 30/07/2010 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person has a legal responsibility to prevent infection, toxic conditions and the spread of infection at the care home. High infection risk areas such as communal showers and the first floor kitchen must be made good, where necessary, to promote infection control and maintain adequate hygiene standards. This must be done by the given timescale, if not sooner. 4 33 18 The registered person shall, having regard to the size of the care home, the statement of purpose and numbers and needs of 25/06/2010 Care Homes for Adults (18-65 years) Page 27 of 30 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 service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. It is a legal responsibility to ensure there are always adequate numbers of staff on duty to meet the care and social needs of service users. A review of staffing levels, taking into account service users current needs and staff duties must be undertaken. The details and results of the review must be received by the Commission by the given date if not sooner. 5 33 18 The registered person shall, 25/06/2010 having regard to the size of the care home, the statement of purpose and numbers and needs of service users, ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training. Care Homes for Adults (18-65 years) Page 28 of 30 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 It is a legal responsibility to ensure the staff group has the knowledge and skills to meet service users needs. A detailed training plan to show that all staff will have received mandatory training and training in social care for people with a learning disability must be must be received by the Commission by the given timescale. This must include details of training courses attended and booked, including details of the training providers and any accreditation they may have. 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: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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