Care Home: Laburnum House

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Laburnum House Second Drive Landscore Road Teignmouth Devon TQ14 9JS The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sue Dewis Date: 0 8 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Laburnum House Second Drive Landscore Road Teignmouth Devon TQ14 9JS 01626774662 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): laburnumdaycare@hotmail.co.uk Rotel Ltd Name of registered manager (if applicable) Miss Samantha Jane Carus Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 13 0 care home 13 learning disability Additional conditions: The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability- Code LD The maximum number of service users who can be accommodated is 13. Date of last inspection A bit about the care home Laburnum House cares for up to 13 adults with learning disabilities under 65 years old. A company called Rotel that owns two other homes for adults with learning disabilities in South Devon runs the Home. The Home is in a residential area of Teignmouth within walking distance of the town centre, bus routes and the train station. There is level access into the front of the Home, but steps throughout the rest of the building may present difficulties to someone with a mobility problem. All of the bedrooms are en-suite and single, with additional toilets, showers and a bathroom. Twelve of the bedrooms are in the main building with a self-contained flat in the grounds. There are a number of communal rooms throughout the Home. 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: Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This unannounced visit took place over 8 hours, at the beginning of October 2008. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to people living at the home and staff. At the time of writing the report, responses had been received from 4 people living at the home and 5 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 2 people living at the home were spoken with individually and 3 in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 2 staff and the acting manager. A full tour of the communal areas of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files Some people living at the home have limited verbal communication skills, and as we are not skilled in their other methods of communication it was difficult for us to have any meaningful communication with these people. However, the interaction between the people living at the home and those who care for them was closely observed. We were joined for this inspection by an Expert by Experience and their supporter. Experts by Experience are people who have used the services we are inspecting. Their role is to bring a different and independent view to the inspection process by working alongside inspectors, observing and gaining the views of people who use the service. The Expert by Experiences background knowledge of using services enables them to ask different questions and explore different themes. They are able to pick up on and note details, such as care practices, accessibility within the home, interaction and non-verbal communication between staff and people who use the service. People who use the service are able to talk openly and differently to the Expert by Experience and this makes them feel valued. Following the visit the Expert by Experience sent us a report on their findings. Information from this has been included in the main report. What the care home does well Laburnum House provides all individuals with their own bedroom and en suite facilities and there are a good variety of communal areas to enjoy. Individuals have plans of care that are well written, and help staff to provide care and support in a consistent way. Personal and health care needs are well met. People who live at the home have opportunities to have a say on how they are supported. They have regular meetings to discuss, holidays, outings, activities, and menus and a representative meets regularly with the company directors to discuss any issues or suggestions they may have. In addition the home uses surveys to ask individuals if they are happy with all aspects of care and support received. The home provides a good range of meals, taking into consideration individuals likes and dislikes. What has got better from the last inspection What the care home could do better Staff should work to encourage people who live at Laburnum House to be as independent as possible, including being involved in meal preparation. Recordings that are made about people should be in line with the Data Protection Act. The registered providers must ensure that staff files have clear evidence to show that all checks have been completed so that people who live at Laburnum House are protected from being exposed to staff that may not be suitable to work with vulnerable people. All new staff must complete an induction programme that meets nationally recognised standards, and demonstrates that staff are competent and knowledgeable to do their job effectively. Staff should also receive specific training in caring for people with a learning disability, Protection of Vulnerable Adults and the Mental Capacity Act. The home must be well maintained, be clean and comfortable and provide people with a homely place to live. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Sue Dewis CSCI 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 02079792000 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 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 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 is a good assessment and admission process in place, which means that people thinking of moving into the home can be sure that their needs will be met. Evidence: There is a Statement of Purpose and Service User Guide for the home. The 4 people living at the home who returned survey forms all felt that they had had enough information prior to moving into the home to help them make their decision as to whether they wanted to live there. A copy of the Statement of Purpose and Service User Guide is kept in the main lounge. Both documents contain good information but it may be more useful to people living at the home if it were made more user friendly. One person had been admitted to the home on the day before the visit, and their admission information was looked at and the process discussed with the acting manager. A health care needs assessment and several risk assessments had been obtained prior to their admission. The individual had made several visits to the home before their admission and the home had completed assessments during these visits, to determine if the person was suitable for admission. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the service intends to implement a feedback system to allow the individual to reflect on their experience. 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 . People can generally be assured they will receive sufficient support to achieve their personal goals and that risks to their personal safety will be properly identified and managed. However, people are not encouraged to achieve their full potential. Evidence: The plans of care for three individuals were looked at in some detail. They were well organised and contained a detailed assessment of the individuals abilities. They also contained detailed instructions for staff on how to meet the persons needs. The plans have been made more user friendly, some pictures have been added and they are all written in the first person. For example, there are sections on understanding my condition, My medicines and medical needs and my behaviour. This helps people to be more involved in decisions about their care. The plans contain clear risk assessments and highlight any triggers for possible behaviours that may challenge the service. The plans also contained good risk assessments on a variety of topics, such as getting up, bathing and medication. Two staff and the acting manager were spoken with, as well as the previous registered manager. They told us about how they support people to make decisions about some areas of their lives. For example, getting up and going to bed times, whether to go to day services and what they want to eat or drink. However, during the visit there was little evidence that some of these choices are real, in so far as there were few genuine alternatives. For example if people choose not to go to services there is nothing for them to do at the home. Although some people who do not go to day services do go out and about. Evidence: Daily recordings are made in several places including on the computer and in individual diaries. Many of the entries were simply no change and did not describe anything else about the persons day and therefore have limited value. A communication book is maintained that contains personal information and is in contravention of the Data Protection Act, as people could not see information relating to them, without seeing information held about other people. This, and the duplication of the recording of information was discussed with the acting manager, along with the possibility that important information may not get recorded if there are too many places in which to record it. It was concerning to see that a Mental Capacity Act assessment had been completed for an individual indicating that the person cannot make a decision about seeing a GP. Such assessments should only be completed on a one off basis, they are specific to a decision and a moment in time and are not ongoing. One person told us that staff and other people living at the home regularly walk through their private space as a short cut and they were very unhappy about this. This was discussed with the acting manager who needs to ensure the privacy of this individual is maintained. The Expert by Experience that visited with us commented in their report that Looking at care plans there was no communication passport for non-verbal residents. The care plans should be made more accessible. 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 . People who live at Laburnum House are generally able to take part in activities that suit their needs and wishes, and are supported to access the local community and maintain contacts with family and friends. However, there is little to occupy them if they do not wish to access day services. Evidence: The company who own Laburnum House, Rotel, also have two other homes in the local vicinity and they offer day services for all their homes, in a central location in Torquay called FOCUS 2000. The day service is run five days per week and transport is provided for this. The day service offers a range of activities both educational and recreational. The people who live at Laburnum House can attend this day service up to five times per week. People are supported to access the local community for shopping and some are able to access the local shops independently. Staff said that they encourage people to go out on trips and outings as much as they can, although staffing does not always allow for individualised outings. Some people go to the local church and are involved with activities there. People are currently looking forward to a holiday in Euro Disney. There seems to be little to do within the home if people choose not to go to day services. Whilst it is accepted that people can choose whether they attend day services or not, the reality is that if they do not go to day services there is nothing to do at the home. Although some people may choose to do nothing, more opportunities within the Evidence: home should be on offer. Staff said they are busy during the day cleaning the home and doing laundry and said they did not have the opportunity to spend much time with people who stayed at the home. We were told that most people had limited contact with their family, although the home tries to encourage contact by letter and the possibility of email contact was discussed. We were told that one person went to Greece every year to meet up with family and staff helped them to do this. Individuals sexuality was not directly discussed, but there is a section in individual plans of care that covers this area and shows that the home has given thought to how individuals may wish to express their sexuality. The menu plan was looked at and discussed with a member of staff. There appears to be a good variety and choice available and individual likes and dislikes are taken into consideration when menus are planned. Several people commented via survey forms that they liked the food. Although, at lunchtime people were not asked what they wanted on their sandwich or what type of bread they wanted. It was previously recommended that people are given the opportunity to be more involved in the preparation of meals. However, at lunchtime, people were not encouraged to help prepare their lunch, rather they sat in the dining room while staff made sandwiches. There was some discussion with staff on how to ensure individuals were more involved in general activities and how more social interaction between staff and individuals could be encouraged. The Expert by Experience that visited with us commented in their report that The residents told me if they do not go to the day centre theres not much to do. It seems if the residents are able and proactive they get the support they need to join the community. Six of the residents are going to France on holiday soon. The residents will be going to a pantomime Aladdin near Christmas. At Christmas the staff dress up like Father Christmas. The residents were given for lunch some sandwiches and fruit and a yoghurt - all the same, white bread with ham and tomato. This was laid out on the table already on plastic plates. Not appetising! The residents should have been helped to make their own sandwiches. 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 . People who live at Laburnum House are supported in their personal and health care needs in a way that suits them. Systems for the administration of medicines are well managed. Evidence: The plans of care that were looked at, gave clear direction to staff to ensure that care and support is provided in a consistent way. Health care issues were clearly identified and any specific issues were followed up. People visit health care professionals on a regular basis as and when needed. Daily recordings show that staff are aware of and comment on individuals emotional well being, and 1:1 time with key workers gives people time to talk about any issues that might being causing them concern. There were good recordings relating to incidents around behaviour that may challenge the service. We found that the home stores medication in a secure manner and has in place a good system to record the receipt of medicines into the home. We also saw that there is now a system in place to record when medicines are taken out of the home and if they are returned to the home unused. The home has clear individual protocols for how medicines prescribed to be administered when required are to be used. All administration of medicines had been recorded on the Medication Administration Record charts. Records show that staff had received training in the administration of medicines and we were told that staff had received some specialist training. 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 . Peoples views are listened to and acted upon, but individuals may at risk from staff who have not been properly trained to recognise abuse and know their duty to report poor practice. Evidence: The home has a complaints procedure that is in an easy read format and is posted in various parts of the home. The contact details for CSCI needs to be updated to show the new details. Although the procedure is user friendly, there are parts of it that refer to completing forms and ways to enable people to access the process who cannot read and write were discussed with the acting manager. Minutes of meetings held at the home were seen and they record that everyone is asked if they have anything they want to raise. Since the last inspection one complaint has been received by the commission and this was passed to the provider to investigate. We were satisfied that this was appropriately investigated. Any complaints received by the home are recorded and the actions taken to resolve issues appear appropriate. Three staff files were looked at and they did not all contain all the information that would show that checks had been completed, to ensure that new staff were suitable to work with vulnerable people. One member of staff had not received any training in POVA (Protection Of Vulnerable Adults) issues. Although staff were aware of who to report suspected abuse to, within the home, they did not know who they could report suspicions to outside the home. See also Standard 35. Individuals finances were well managed and records show that two signatures are obtained for all transactions. We were told that most people living at the home are used to a budgeting system where by they receive a small amount of money on a daily Evidence: basis. We were told that this helps people save for holidays and more expensive items they may wish to purchase. The Expert by Experience that visited with us commented in their report that The residents have meetings to talk about any problems the residents may have also talk about and decide where to go on holiday.The staff manage the residents money. If the residents are able to they should be helped to manage their own money. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home has a poor standard of decor throughout and does not ensure that individuals have a safe, homely and comfortable environment in which to live. Evidence: A full tour of all the communal areas of the home and some of the individual bedrooms were looked at. Most of the home was reasonably clean and fresh smelling. The main lounge was light and airy and there were many pictures around the home that people had made at day services. The carpet in bedroom 7 has been recently replaced. However, several carpets around the home were very dirty as were the stair banisters and areas where people regularly touched. There were also food splashes on the ceiling of the dining room. The home does not employ a cleaner and cleaning of communal areas is delegated to staff on duty. There are only two care staff on duty at any one time in the day and with the needs of people living at the home to meet an uneasy compromise has to be reached, with neither task being performed well. People living at the home are expected to keep their own rooms clean and tidy with support. The building was generally poorly maintained. Window frames were rotting and the wallpaper was peeling from underneath one bedroom window. The floor covering in the dining room was also peeling. The lower floor corridor was very dark due to a combination of decoration and bad lighting. This was particularly concerning as an individual living on this corridor has poor sight. The home is in general need of refreshing and updating. The overall feel was somewhat depressing. This is concerning as current thinking suggests that peoples environment impacts on their state of mind and well being. The laundry is situated outside the main building and has an untreated concrete floor, which presents a risk of cross contamination. Staff said that they had not received Evidence: training in infection control, but that training may be coming up. Disposable gloves are available. The Expert by Experience that visited with us commented in their report that I was invited by one of the residents to their bedroom. The room was personalised. The room was a bit gloomy and needed a lick of paint. The bathroom was smelly. I noticed the home was smelly and the carpets were not very nice. Theres lots of artwork done by the residents round the home. But no photos of the residents activities or holiday photos around the home. I felt the home was very impersonal. 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 . Some people living at the home are unlikely to receive the support they need, as staff do not have the specialist skills and training they need to care for people with a learning disability. Recruitment procedures put people at risk of abuse from staff who may be unsuitable to work with vulnerable adults. Evidence: Three staff files were looked at during this visit. Not all the information was available to show that the providers have ensured that staff were fit to work with vulnerable people. One file contained only one written reference. The home must ensure that all required information is obtained prior to the person starting work. This will ensure that people who live at Laburnum House are fully protected from people who may be unsuitable to work with vulnerable adults. Also see Standard 23 Staffing levels are not sufficient to both meet the current health and social care needs of the people who live at Laburnum House and keep the home clean. One staff member said that they had received an induction, but that this only covered looking at policies, procedures and care plans and no principles of care were covered. All staff must receive an induction that is in line with Skills for Care recommendations. Both staff that we spoke with said that they had received training in fire precautions, moving and handling and first aid. They were also working for NVQ 2. However, neither had received any training specific to caring for people with a learning disability and had not completed the LDAF (Learning Disability Award Framework) training, which provides the underpinning knowledge for NVQ. The acting manager said that some training had been booked for the near future and this included Total Communication, infection control and epilepsy. Comments received from staff via survey forms were mixed in relation to training, Evidence: some felt they received enough, while others thought they needed more. All responders felt that though there were enough staff for the basics to be covered, more were needed to be able to take people out more. One person felt that communication needed to be improved between management and staff. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the agency intends to ensure all staff complete training in Equality and Diversity. 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 . People who live at Laburnum House benefit from a service that is generally well run and there are systems in place to ensure their views are considered in reviewing the care and support offered. Evidence: There is no manager registered for the home at present. The previous registered manager has moved on to another role within the company, but still provides some support to the acting manager. There is now a more formal quality assurance system in place to help monitor the quality of care provided at the home. Surveys are regularly sent out to family, health and social care professionals and staff. From their responses a report is produced that highlights any actions that are needed. Other ways the home helps to listen to the views of the people who live there are by house meetings, 1:1 key worker sessions where individuals are asked what they would like to see to improve their lives and by having a representative on a management board, to feed back to the providers any issues and ideas people who live at the home may have. Copies of minutes of these meeting were available for inspection. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Laburnum House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. Policies and procedures are not always inspected during the visit but the information provided on Evidence: the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. So that the risk of burning from hot surfaces is minimised, radiators within the home have been risk assessed and some are covered. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. Are there any outstanding requirements from the last inspection? Yes  No  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 1 34 17 The registered providers must ensure that staff files contain evidence of all relevant checks being completed and these must be available for inspection 31/12/2007 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 Description 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 Description Timescale for action 1 7 12 You must ensure people are 02/12/2008 supported to make decisions. This relates to appropriate Mental Capacity Assessments To ensure the Mental Capacity Act is appropriately complied with 2 24 23 The premises must be kept clean and reasonably decorated 03/02/2009 To ensure people have a comfortable place in which to live. 3 35 18 Staff must receive training appropriate to their role. In particular in the Mental Capacity Act, Protection Of Vulnerable Adults, Infection Control and Learning Disability. 03/02/2009 So that staff have the skills and knowledge to meet the needs of people living at the home. 4 35 18 All new staff must receive 03/02/2009 structured induction training. So that they have the skills necessary to work unsupervised Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 4 6 13 17 30 You should ensure that all recordings made about people are in line with the Data Protection Act. You should ensure that people are offered meaningful choices about attending day services People should be supported to be as independent in their daily routines as their abilities allow You should ensure the laundry has an impervious floor covering to help prevent cross contamination. Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web:www.csci.org.uk We want people to be able to access this information. 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