Care Home: Jasmine Lodge

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What the care home does well Staff spoken with stated that they find the manager `very supportive`. They also stated that there are good systems in place for ensuring that when there are changes to care plans or medication a note is put in the communication book for all staff to read. Residents` bedrooms are personalised and those seen, looked comfortable and homely. All communal areas are also well maintained and are homely in design. There are good systems in place for ensuring that staff keep up to date with mandatory training and seven of the thirteen staff have completed a National Vocational Quallification at level two or above. Another two staff are working towards this qualification. What has improved since the last inspection? The format for carrying out risk assessments has changed and over half of the residents now have a completed document on file. Staff have also attended a risk management training day. Staff work hard to ensure that all residents are given regular opportunities to use their local amenities. The kitchen has been repainted and one of the residents` bedrooms has been redecorated. Detailed records are kept of all maintenance tasks and they show that all maintenance is attended to quickly. There are also improved systems in place to ensure that all equipment is tested and serviced at regular intervals. What the care home could do better: Four requirements were made as a result of this inspection. They include the need to record that when a resident declines a meal offered, a suitable alternative is then provided. In addition the home needs to review staff levels to ensure that there are sufficient numbers of staff on duty at all times. Staff must receive regular formal supervision and the Primary Care Trust (PCT) must ensure that they are carrying out monthly monitoring visits to the home. Key inspection report Care homes for adults (18-65 years) Name: Address: Jasmine Lodge Station Road Northiam East Sussex TN31 6QL     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: Caroline Johnson     Date: 0 4 1 2 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 27 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 27 Information about the care home Name of care home: Address: Jasmine Lodge Station Road Northiam East Sussex TN31 6QL 01797252097 01424651641 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Hastings and Rother Primary Care Trust care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 6. 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 Jasmine Lodge is a purpose built bungalow situated in a residential area on the outskirts of the village of Northiam. The home is registered to accommodate six adults with learning disabilities. There are six single bedrooms. Communal areas include a lounge and dining room. There is a very large garden area to the rear of the property, which includes a patio area. Off road parking is available at the front of the home. The registered providers for the home are Hastings and Rother Primary Care Trust and they also manage nine other Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 6 2 9 0 9 2 0 0 8 Brief description of the care home homes in the area. Fees for the service range form 1331 to 1366 pounds per week for a block contract. Care Homes for Adults (18-65 years) Page 5 of 27 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: For the purpose of this report the people living at Jasmine Lodge will be referred to as residents. As part of the inspection process a site visit was carried out on 04 December 2009 and it lasted from 11:00am until 17:00pm. The registered manager facilitated the inspection. During the visit there was an opportunity to observe some of the residents in their surroundings. Time was also spent talking with a member of care staff in private. Two care plans were examined in detail. Other documentation seen included: staff rotas, training, menus, health and safety, quality assurance and leisure activities. Care Homes for Adults (18-65 years) Page 6 of 27 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 27 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 27 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 ensures that they can meet the assessed needs of the residents accommodated. Evidence: There is a detailed statement of purpose in place that has been updated in recent months. In addition there is a service user guide. The guide includes information that is out of date and it states that residents meetings are held monthly when this is not the case. The Registered Social Landlord has given notice to the Primary Care Trust (PCT) and the contract will cease to exist in April 2010.The terms and conditions of residence/licence agreements have still not been updated and it is now over eighteen months since the PCT took on ownership of the home. There are no vacancies at the home and there have been no new admissions since the last inspection. Residents needs are assessed at regular intervals and details of how residents communicate are included in individual care plans. Care Homes for Adults (18-65 years) Page 9 of 27 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. Care plans provide detailed information about the needs of the residents and how they are to be met. Evidence: Two support plans were examined in detail on this occasion and another was partly examined. In each case the information provided was person centred and included very detailed advice and guidance for staff to follow to ensure that each individuals needs could be met. In addition to the support plans that staff use on a daily basis there is a reference folder in place for each resident. Person centred planning (PCP) meetings are held six monthly and records show that there is detailed planning in advance of these meetings. At the meetings a list of recommendations are drawn up of the activities that need to be carried out within the next six months. This can include purchases to be made, plans to try out new activities and ideas for day trips to be arranged. In relation to one resident there was evidence that some of the recommendations made had been actioned but in relation Care Homes for Adults (18-65 years) Page 10 of 27 Evidence: to another there was no evidence that they had been addressed. The home is in the process of introducing a new format for carrying out risk assessments. It was reported that four of the six residents now have the new format completed. Residents meetings are not held as the majority of the residents use non verbal communication. The home is good at recording choices and decisions made as part of the PCP process but work needs to be done to record this information in relation to the choices and decisions made by residents on a daily basis. Care Homes for Adults (18-65 years) Page 11 of 27 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. Residents are offered opportunities to participate in a varied programme of activities. Records of meals served dont show that all residents are receiving a varied diet. Evidence: Since the last inspection the day care provider used by the Trust that had been contracted to provide each resident with a minimum of three sessions a week was given notice and no longer provides a service. Instead staff now facilitate the majority of the activities. Each of the residents has a programme showing an ideal week for the residents. As activities are arranged they are recorded on individual programmes. There is evidence that residents make full use of community facilities in the mornings with regular opportunities for shopping trips and visits to places of interest. Programmes also show a large number of household tasks as activities. A couple of residents attend Church every other week and one resident enjoys being taken to football matches. Care Homes for Adults (18-65 years) Page 12 of 27 Evidence: It was reported that staff support residents to maintain contact with their families and friends. Each of the residents are supported to have an annual holiday and the home has put together a folder showing photos of all the activities that the residents participated in whilst on holiday. The home has a minibus with a hydraulic ramp. In addition, once a week they have use of a dial a ride scheme. On the day of inspection two residents were out for the day Christmas shopping with two staff that were working additional hours to facilitate this activity. Two residents were supported to attend a music activity in Hastings and two residents stayed at home. In the afternoon an aromatherapist visited and spent time with each of the four residents in the house. Menus seen looked varied and well balanced. In relation to one resident it was noted that they regularly decline their lunch meal and on occasions other meals. On one day recently it showed that all three main meals were declined. There were guidelines in place stating that this resident should be offered an alternative if they decline food and staff spoken with stated that this always happens in practice but records very rarely show that this has happened. Care Homes for Adults (18-65 years) Page 13 of 27 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 home is good at ensuring that the healthcare needs of the residents continue to be met. Evidence: The arrangements in place for the management of medication in the home were examined and were in order. It was also noted that a senior pharmacy technician from the NHS had also recently visited the home and observed medication been given and examined storage arrangements. No recommendations were made as a result of that visit. All of the staff team were up to date with medication training. It was reported that each of the residents has a health action place but in two out of three files seen there were no plans present. The home ensures that residents are supported to attend a range of healthcare appointments as required to meet their individual needs. Staff observed in the course of their duties were courteous and treated residents with respect and dignity. Guidelines for the use of rectal medication on an as required basis were examined and the manager advised that they had been agreed with the local gp. It was noted that Care Homes for Adults (18-65 years) Page 14 of 27 Evidence: the guidelines were the same for three residents despite there being differences in the type and frequency of seizures experienced by residents. Following discussion with the manager in relation to one of the residents it was agreed that further discussion should be had with the gp to clarify the actions to be taken should this resident experience a seizure. Care Homes for Adults (18-65 years) Page 15 of 27 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are procedures in place to ensure that anyone wanting to make a complaint can do so. Evidence: It was reported that there have been no complaints since the last inspection of the home. There is a detailed complaint procedure in place. A simplified version of the procedure is available, a copy is also included in the service user guide and there is a copy on display at the entrance to the home. The home continues to look at any expressions of dissatisfaction made by residents to determine if they could in fact be raising concerns/complaints and will look to develop recording procedures to address any such areas noted. There is a detailed procedure in place on the protection of vulnerable adults. Records showed that all of the staff team have had training on the subject. A staff member spoken with was clear about what they should do if they suspected abuse of any form. Care Homes for Adults (18-65 years) Page 16 of 27 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. Accommodation provided is homely, comfortable and has been decorated to a good standard. Evidence: The home is well maintained and decorated to a good standard. A maintenance log is kept showing that when tasks are identified they are reported and attended to quickly. All equipment is tested and serviced at regular intervals. One of the main tasks that is outstanding is the flooring to the bath/shower room. This has been reported and quotes have been obtained. It was not clear however, when the work was going to be attended to. Since the last inspection the kitchen has been repainted and one of the bedrooms has been redecorated. Bedrooms seen over the course of the inspection were personalised. All communal areas are well maintained and decorated to a good standard. A good practice recommendation was made at the last inspection to review infection control measures surrounding the communal use of a moulded toilet seat specific to an individual resident. It was noted that this toilet is used by one resident only. The moulded seat is removed when not in use but as there is no toilet seat it is then Care Homes for Adults (18-65 years) Page 17 of 27 Evidence: unusable for anyone else. It was reported that there are sufficient toilets in place for all other residents and as none of the residents use toilets independently, the toilet in question is only ever used by one individual. Fire procedures were briefly examined and were in order. Records showed that the frequency of fire drills had increased as recommended at the last inspection. A fire risk assessment was carried out in May 2009. The manager advised that the PCT are reviewing their procedures around evacuation of residents at night in the event of a fire. Care Homes for Adults (18-65 years) Page 18 of 27 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. Staff would benefit from more regular formal supervision. A review of staffing levels needs to be undertaken to ensure that residents needs can be met at all times. Evidence: Records show that there are three care staff on duty in the mornings and two staff in the home in the afternoons until 4.30pm when another carer comes on duty. The managers hours are meant to be in addition to this but the rotas seen showed that there are occasions such as the day of inspection, when the manager is counted as the second member of staff in the afternoons. When there are two care staff in the afternoons this means that residents are unable to go out for activities but staff stated that they make the most of mornings and late evenings. It was noted that one resident has bed rest in the afternoons and requires assistance from two staff for hoisting purposes. On occasions when there are only two care staff, if this resident wanted to get up in the afternoon this would mean that there would be no staff with the remainder of the residents whilst they were being atended to. A list of each staff members individual role and responsibilities is on display in the office and staff spoken with were clear about this. Staff are provided with regular opportunities to update their mandatory training. Records showed some gaps in training but there was also evidence that training has been booked. Training on Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: dementia is not currently offered to staff but the manager agreed that this might be beneficial for the staff team. Four of the staff team have completed a National Vocational Qualification (NVQ)at level 2, three have completed level 3 and two staff were working towards this qualification at the time of inspection. Records showed that staff have not received regular formal supervision. It was reported that this has not been possible as the manager has had no other managerial support for the past few months. The deputy manager is on long term sickness and there has been no senior in post. However, in recent weeks a part-time senior has commenced working in the home and a manager from another home has been assisting for a few hours each week to help out with management tasks. This has enabled the manager to start addressing supervision and it was noted that the majority of the staff team had had a recent supervision. Care Homes for Adults (18-65 years) Page 20 of 27 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 well in the interests of those accommodated. However, a more robust regularly monitored quality assurance system would assist the home in raising standards even further. Evidence: The registered manager Mrs Selva Heffernan, has been in post for a number of years. She is a registered nurse in both learning disabilities and general nursing and also has a number of additional qualifications. She is also the moving and handling instructor for the Trust. The homes statement of purpose states that there should be a full time deputy and senior support worker in post. However, as stated previously the deputy is on sick leave and new part-time senior has recently commenced working in the home. This along with the fact that the manager is not supernumerary in the afternoons all reduce the amount of time available to the manager to keep up to date with management tasks. Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: Staff spoken with stated that the manager is very supportive and they can approach her at any time to discuss any problems they might have. Records showed that staff team meetings have been held periodically but at the last meeting staff were advised that these would now be held monthly. The Responsible Individual for the home delegates a member of the senior management team the task of visiting the home once a month unannounced and a report is written detailing the findings. Records in the home showed that the last visit was carried out in September to look at records completed in July and August. The visit carried out in August was to look at records in June. The PCT has recently written to the Commission to advise of difficulties in carrying out these visits. However, it is for the PCT to make suitable arrangements to ensure that these visits are carried out monthly and to satisfy themselves that the home is running effectively. During the visit carried out in September it was noted that there were 66 action points raised. Most of the actions points had been recorded as having been addressed. In 2008 the PCT introduced a new format for carrying out quality assurance monitoring. As residents have complex needs and are unable to give verbal feedback a system was introduced to look for evidence that their individual needs were being met. A member of the senior management team visited the home and along with support from staff assessed the quality of residents lives from a range of aspects. As a result of the exercise, where appropriate, recommendations were made to the home to ensure that there was more detailed recording kept. In addition timescales were set to achieve any recommendations made. In relation to one resident there was evidence that the recommendations made had been addressed. There was no evidence in relation to the second care plan examined that the recommendations made had been addressed. In addition the quality assurance system in relation to residents views has not been carried out this year. The PCT sent satisfaction surveys to relatives of the residents and it was noted that three relatives responded. In each case there were positive comments. In one case there was also some negative comments. However, when these were discussed with the manager it was reported that the issues raised had occurred a number of years previously. The arrangements in place in relation to the management of finances were examined in relation to two residents. The manager advised that they have asked an advocate to act on behalf of one resident as they have had difficulty clarifying arrangements for this resident. All records seen were in order and it was noted that resident had received back payments in respect of money that had been owed to them. However, it Care Homes for Adults (18-65 years) Page 22 of 27 Evidence: was also noted that rent costs appeared to have gone up. There was no evidence of any written notification to residents advising that their rent charges were increasing. It was therefore not clear where this decision had come from. Information provided in advance of the inspection along with information recorded in the visits undertaken by the PCT show that the home is ensuring that the equipment used by the home is tested and serviced at regular intervals. In advance of the inspection a range of surveys were sent to the home to distribute to residents, relatives and any visiting professionals. Unfortunately the wrong format was sent to the home in error but this was not brought to the attention of the Commission so some of the questions asked of people were in some cases not appropriate or not applicable. Three surveys were returned by residents. However, as residents have no verbal communication the comments recorded are the views of staff in the home. One visiting professional commented I have always found the staff very helpful, interested in the service users well being. The house is welcoming, friendly and I always look forward to visiting Jasmine Lodge. Two staff surveys were returned. One did not include any comments but ticked usually as a response to having enough staff and sometimes in relation to compatibility of residents. In relation to the second survey, positive comments included comfortable clean home geared to clients needs. Trained staff who care about clients and do their best despite barriers. Clients needs are met and more. Problems with staffing were also highlighted particularly during holidays and sickness and a lack of management cover at weekends. In addition comments in relation to staff having to put in extra time to arrange outings as a replacement for the lack of day care. The respondent also stated that the CQC are unhelpful and hindering - lots of paperwork and processes involved which deplete resources - less time for staff to concentrate on primary role - caring for and interacting with clients. Care Homes for Adults (18-65 years) Page 23 of 27 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 24 of 27 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 17 17 Regulation 17(2) Schedule 4 31/01/2010 par 13. The Registered person must ensure that a record is kept of the actual meals served to each residents to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition and otherwise. Residents must be offered a healthy diet and enjoy their meals and mealtimes. 2 33 18 Regulation 18(1a) 31/01/2010 The registered person must have regard to the assessed needs of service users and to the homes Statement of Purpose to ensure that at all times suitably qualified, competent and experienced persons are working at the care home in sufficient numbers for the health and welfare of service users at all times. Page 25 of 27 Care Homes for Adults (18-65 years) 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 Residents must be supported by an effective staff team. 3 36 18 Regulation 18(2) The registered person must ensure that all staff receive regular supervision. Residents benefit from well supported and supervised staff. 4 39 26 The Registered Person must 31/01/2010 arrange for the home to be visited once a month unannounced and prepare a written report on the conduct of the home. A copy of this report must be available in the home and a copy given to the registered Manager. There must be evidence to show how action points identified have been addressed. So that the service is regularly audited. 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 31/01/2010 Care Homes for Adults (18-65 years) Page 26 of 27 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 27 of 27 - 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. 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