Care Home: Mansion House

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What the care home does well Observations of support give to residents by staff through the inspection showed they understood individual needs and supported people in a consistent manner. Systems for supporting people with their finances are secure. Records of the management of incidents are in keeping with the associated risk assessments. What has improved since the last inspection? The manager was clear that there were improvements needed in the home to develop the support provided to individual people. When he started he had identified that the home lacked direction and motivation and he said that many systems now introduced were in their infancy but was confident that these would improve the support for people living in the home. Staff moral has improved and members of staff we spoke to were enthusiastic about the future of the home. Meal times have improved and people are being supported in changing the menu. What the care home could do better: Service user guides would benefit from being kept in a location which is more accessible for residents in the home. Care plans would benefit from fully identifying how to support individual people with their personal care needs. The development of the plans with the individual residents will further support their needs. One to one support needs are not always managed in a consistent or meaningful manner. Staffing levels do not always support this. The new manager has started to support staff with whistle blowing procedures and understanding their accountabilities and this needs to continue so as to promote best practice and ensure that people feel confident and safeguarded in the home. New staff need to complete an full induction. Key inspection report Care homes for adults (18-65 years) Name: Address: Mansion House 15 Mansion Row Brompton Gillingham Kent ME7 5SE     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: Anne Butts     Date: 2 3 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 29 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 29 Information about the care home Name of care home: Address: Mansion House 15 Mansion Row Brompton Gillingham Kent ME7 5SE 01634841280 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: mansion.house@ilg.co.uk www.ilg.co.uk Kent Assessment Training Services (Medway) Ltd care home 15 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 15. 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 Mansion House provides care and support for up to 10 residents. Bedroom accommodation (single rooms, five of which have en-suite facilities) is on the ground, first and second floors. Residents and staff have the use of a garden and there is parking at the front. Independent Living Group Ltd owns the business together with some 33 others in Hampshire, Sussex and Kent. There is a separate smaller premise in the grounds that is undergoing refurbishment to accommodate a further 2 or 3 residents. The web-site Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 15 Brief description of the care home www.ilg.co.uk provides information about the companys objectives and makes available on download a copy of its Guide to Residential Care with advice to parents and others on managing a successful transition. Weekly fees are £1080 to £2500. Additional charges are made for hairdressing, chiropody, toiletries and personal spending. ILG Ltd contributes about £250 towards an annual holiday for residents and the company meets the costs of accompanying staff on outings and planned holidays. Care Homes for Adults (18-65 years) Page 5 of 29 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 was a key unannounced inspection which was carried out over one day by two inspectors, who spent approximately six hours in the home. Time was spent looking around the environment, talking to staff and reviewing assessments, care plans, staff records and other relevant documents. We spoke to the manager, members of staff and two residents in the home. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Care Quality Commission (CQC) to be able to make an informed decision about each outcome area. The Annual Quality Assurance Assessment has not been returned within timescales. Care Homes for Adults (18-65 years) Page 6 of 29 The owner has appointed a person to run the home on a day to day basis in the position of manager. They are not registered with the commission, but will be referred to as the manager within this report. At the time of our visit the manager had been in post for approximately four weeks. Work has started to identify shortfalls within the home and address these. Care Homes for Adults (18-65 years) Page 7 of 29 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 8 of 29 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 9 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the opportunity to visit the home prior to moving in and have their needs assessed. Evidence: There has not been any new people move into the service recently. There is information available for prospective residents about the homes service and facilities. Different methods of communication are available dependent upon the needs of the individual. There were two different versions of the service user guide on the care plan files. There was a copy of a symbol version of the complaints procedure on file. At present the people do not freely have access to these files, and this may benefit from being reviewed so that they are kept in a location which is more accessible for the residents in the home. The manager was clear about the assessment process for people moving into the home. In that any prospective residents would undergo a full assessment of need and Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: this would include appropriate assessments from health care professionals. Admissions assessments are completed by the organisations admissions team. The manager said that he plans to expand upon these further. Depending on the support needs of the individual, the home will ensure that people are supported through the assessment process in a manner that meets their individual needs. This will include a visit to the home and the opportunity to meet people who are currently living there. Care Homes for Adults (18-65 years) Page 11 of 29 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. Essential life care planning has been introduced and once these are fully implemented and developed they will further support people with their individual needs. Evidence: Care plans and risk assessments are currently undergoing review and re-development. The new manager said that he had identified that the documentation which was in place was not identifying the needs of the individual. We looked at the care planning documentation for two people living in the home. In both files there were new essential life plans in place. These gave a lot of information about choices, likes and dislikes and also identified what was important to individual people. Communication methods with individual people were clear. Daily routines are included, but there is limited guidance on how to support each person with their personal care needs, and this would benefit from being expanded upon. Neither plan contained information about the persons needs with regard to sexuality. Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: Both plans seen were in a written format and people may benefit from pictures to help them get more involved in their own plan. Both plans had goals for the future identified but no timescales set to achieve these. Both plans contained monthly key worker reports which summarise the persons wellbeing. Some of the forms in the file are not being used or are repeat information. Risk assessments and incident forms are kept in separate files for each person. Risk assessments established individualised procedures for managing people with any challenging behaviours and staff we spoke to were clear about individual needs. The level of assessed support is dependent upon individual needs. Some of the residents in the home are assessed as needing one to one support for up to ten hours a day with other people assessed as needing five hours of one to one support. Staff rotas and members of staff we spoke to indicated that staffing levels may not always allow for people to be supported in a meaningful manner. This has the potential to place some restrictions on the support provided to people, however the manager and senior staff were aware of this. Care Homes for Adults (18-65 years) Page 13 of 29 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 supported by staff in meeting their daily needs. Evidence: The manager said that he is currently working with staff to develop key working systems and promote ideas to support people living in the home with a personal development programme. Staff are taking responsibility for individual areas in the home. Residents are encouraged to take part in activities and care plans were clear about individual preferred pastimes. There is an activity planner for the week and a description of a typical days routine. New activity evaluation sheets have recently been introduced to encourage staff to record how the person chose the activity and what went well about it. Records viewed showed that people had participated in a range of activities including one person who does weekly dog walking at a local Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: kennels. There are plans to further support people with personal development in accordance with their individual needs. People are supported to maintain relationships and contact with family and friends, where they wish to do so. The daily routines of the home enable people to choose how they prefer to spend their day. One person is currently being supported to move rooms to another bedroom which is their preferred choice. The manager has reviewed how mealtimes are managed. This is now a more interactive social time with staff joining people at lunchtime. Individual needs have been reviewed and people are now being supported in a manner that supports them. The manager said that key workers are currently working with residents to develop their menu preferences so that the menu can be reviewed. The menu is now being written up on a blackboard each day and residents are encouraged to tack their choice of meal. Some of the residents are able to participate in some of the meal preparation and are encouraged to do so. Care Homes for Adults (18-65 years) Page 15 of 29 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. People are generally well supported with their personal and healthcare needs. The development of further support for people with their mental capacity will benefit people. Medication is well managed and supports individual residents. Evidence: Daily living choices, including times of getting up, going to bed, eating meals and personal care are flexible to allow for peoples individual daily routines. As identified earlier in this report there is a lack of guidance for staff as to how to support people with their individual personal care needs and this needs to be developed. Records showed that each person has a health action plan. This has been kept up to date. There are records in place to monitor individual healthcare needs. Mental health care needs are kept under review and the manager said that where there had been an identified change in anyones needs, then a referral was made to an appropriate healthcare professional. There are mechanisms in place to identify triggers Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: and guidance in care plans on how to support people. We spoke to a member of staff who was clear about any intervention methods which may be needed and the use of SCIP techniques to distract and diffuse the situation through talking and reassurance to people. Observations of support give to residents by staff through the inspection showed they understood individual needs and supported people in a consistent manner. The manager demonstrated a good understanding of the Mental Capacity Act and Deprivation of Liberty safeguards. He said a best interests meeting had been arranged for one resident and the Independent Mental Capacity Advisor (IMCA) was seen to arrive at the end of our visit. The manager has also arranged a meeting with an IMCA to discuss a number of possible deprivation or restriction of liberty issues within the home so that they can address these and fully support people. Medication is stored appropriately. The temperatures of the fridge and room are monitored. All controlled drugs are administered and recorded in line with the Royal Pharmaceutical Guidelines. Medication is administered and checked by senior staff. No residents currently manage their own medication. Care Homes for Adults (18-65 years) Page 17 of 29 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. The complaints procedure serves to protect people in the home. Improved awareness of safeguarding issues will further protect residents. Systems for supporting people with their finances are secure. Evidence: The home has a complaints procedure and it is accessible to residents in the home. It is also written in a picture format so as to make it easier for some people to read. The manager told us there had been two complaints and that these had been recorded. One of the complaints had been referred through to safeguarding. The home is currently subject to a safeguarding investigation. There are whistle blowing procedures in the home and staff are being made aware of these procedures by the new manager through staff meetings. The manager said that he was keen to ensure that staff were aware of their accountabilities and be made confident in raising any concerns. Prior to this staff had not been confident in raising concerns and the manager was aware of this. Staff we spoke to said that they now felt confident about speaking to the manager about any concerns. Staff have had training in SCIP procedures, which is training on how to support people through non intervention management. Some staff have also received training in Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: safeguarding vulnerable adults procedures, but not all. People are supported with managing their finances and we saw that system used is secure. A record is made of the tags number and this is checked at each handover. The records were completed in detail and were accurate. Receipts are maintained for all transactions. Senior staff hold the key to the money drawer. Care Homes for Adults (18-65 years) Page 19 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home meets the needs of the residents, ongoing refurbishment of individual bedrooms will further benefit people. Any possible restrictions on liberty within the environment are currently under review. Evidence: There is currently a refurbishment programme in place. Communal areas have been redecorated and new furniture has been purchased for the dining area and the activities lounge. An upstairs lounge area is also currently being refurbished which will allow people another choice for a communal room. Bathrooms are impersonal and clinical in nature and the manager said that he hoped that this would also be addressed. Individual bedrooms varied in that some were seen to be more homely than others and were more personalised to the individual. Other rooms, however, were bare and did not give any identity of the person and were in need of redecoration. The manager said that he had requested that the key workers work with individual residents to look at how they could improve their bedrooms and how people would like them decorated. The manager had identified that locks on doors were broken and the majority of these Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: had now been addressed. Many of the television sets were behind perspex screens and the manager said that he was looking at reviewing this. Staff have been allocated areas of the home which they are responsible for improving the environment. The manager said he wanted to give staff more control and autonomy and that this was working well. Staff spoken with were enthusiastic about this. Pictures are being out up around the home that reflect peoples tastes and preferences. Some parts of the home impose some restrictions on liberty in that the garden area is currently fully accessible to people as there is a key pad code and residents have to ask staff if they want to go out in the garden. The manager said that he was not fully confident that the garden was currently safe and the people who owned the neighbouring land had erected a large unsightly corrugated fence. He had made a complaint about this. Overall the home was clean and the laundry was well equipped. Staff told us that residents are encouraged to participate in cleaning and personal laundry duties. Care Homes for Adults (18-65 years) Page 21 of 29 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 have a good understanding on the people living in the home. Ongoing training is further developing their skills. One to one care needs to be kept under review to ensure that all residents benefit from allocated meaningful support. Evidence: Key workers are allocated to individual residents and staff support and communicate with people in a respectful manner. People responded positively with staff and we observed a good rapport between staff and residents. Rotas showed that there are usually eight members of support staff on duty, although sometimes this was reduced to seven. As earlier identified in this report many of the service users need one to one support and if staffing levels are reduced for any reason this has the potential to be difficult to manage. Staffing levels need to be kept under review. There are two waking night staff and additional ancillary staff. Staff moral was seen to be improved and members of staff told us that they felt things were improving in the home. Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: Staff recruitment records showed that people are employed in line with regulations and that records are maintained to evidence this. There were references and completed criminal records bureau (CRB) and protection of vulnerable adults (POVA) checks in place for new members of staff. There is an induction procedure in place for new members of staff, but of the staff files viewed it was not evidenced that this was always completed. The manager said that he was aware of this and also wanted to review the induction procedure for staff. Staff are being supported in accessing training including safeguarding vulnerable adults, mental capacity act, food hygiene and health and safety. All staff have recently benefited from SCIP training and other specialist training programmes are planned including epilepsy, makaton, care planning and autism. This will further support people with their individual specialist needs. The training matrix showed that some staff had completed a national vocational qualification. The manager said that individual supervision needed addressing, and as he was new in position had held staff meetings and were using these as a platform to support staff and ensure that he worked closely with them to understand and implement the aims and objectives of the home. Care Homes for Adults (18-65 years) Page 23 of 29 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 residents now benefit from having a manager who has a clear development plan and vision for the home. Evidence: At the time of our visit the manager had been in post for approximately four weeks. He was able to demonstrate a clear understanding of the needs of the home and the people who lived there. Prior to this the home had lacked guidance and direction and staff had become demoralised. The manager clearly understood the key principles and had identified the priorities and was focusing on ensuring that the best outcomes for individual people were promoted. He said that the registered provider was supporting him and the staff to make improvements. Where he had identified possible health and safety concerns the provider had supported him with addressing these. He told us that resources are being made available as he requires them. We requested that an Annual Quality Assurance Assessment (AQAA) be completed and Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: returned prior to our visit, this did not happen. At the time of this report the AQAA had not yet been returned and we have not been able to use this to inform our inspection process. The registered provider has a quality assurance programme in place and regular visits are carried out in accordance with regulation 26. The manager told us that the registered provider had recently carried out an internal inspection of the home and the care provided and were supporting him with his proposed action plan. There are records maintained of incidents and action taken at the time. The forms detail the action taken and this is consistent with the risk assessments seen. The manager also said that he was currently in the process of setting up fortnightly team meetings with a behavioural professional so that incidents could be reviewed and assessed. This would enable the home to become more proactive in addressing the needs of the people living in the home. Care Homes for Adults (18-65 years) Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 29 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 15 The registered provider shall 05/02/2010 ensure that there is a written plan for residents which fully identifies how their needs will be met. This is so that people are fully supported with their individual needs. The registered provider shall 05/03/2010 provide rooms suitable for the needs of the service users. This is so that all people living in the home benefit from having rooms that meet their individual needs. 2 25 16 3 31 17 The registered provider shall 01/02/2010 ensure that there are staff working in the home in such numbers that meets the needs of the people living in the home. This is so that individual people fully benefit from Care Homes for Adults (18-65 years) Page 27 of 29 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 meaningful one to one support and that this is kept under review. 4 35 18 The registered person must ensure that there is a structured induction programme in place that reflects the Sector Skills Councils specifications and that staff complete the induction. This is so that staff are competent to work in the home. 5 37 7 Any person who carried on 23/03/2010 or manages an establishment or agency of any description without being registered under this part in respect of its (as an establishment or, as the case may be, agency of that description) shall be guilty of an offence. Care Standards Act 2000 (11 (1)) In that an application be made for a registered manager by date set. 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 22/02/2010 Care Homes for Adults (18-65 years) Page 28 of 29 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. 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