Care Home: Mantley Chase

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Mantley Chase Ross Road Newent Gloucestershire GL18 1QY two star good service 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: Paul Chapman Date: 1 3 1 1 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 © (2008) 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: Mantley Chase Ross Road Newent Gloucestershire GL18 1QY 01531822112 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Holmleigh Care Homes Ltd Name of registered manager (if applicable) Mrs Mary Ann Theresa Badham Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 12 0 care home 12 learning disability Additional conditions: Date of last inspection A bit about the care home Mantley Chase is a large detached property in extensive grounds. It offers accommodation for up to twelve service users whose behaviour may challenge. The home has been adapted for it current purpose and opened in January 2004. The home has access to transport which enables them to make use of the local and surrounding areas. Since the previous inspection the provider has converted the coach house in the grounds to provide accommodation for three service users. This building was registered with the CSCI last year. 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 How we did our inspection: This is what the inspector did when they were at the care home We completed the site visit of this inspection process in November 2008 over a period of 8 hours. The registered manager was present through the site visit. On arrival at the home we completed a tour of the premises with the registered manager taking the opportunity to speak with people living in the home. Throughout the day we spoke with a total of 4 people living in the home. Some people have communication difficulties which makes it difficult for us to speak with them. We spoke to 6 staff individually asking them about their training and dayto-day life in the home. As part of the inspection process the manager sent us a completed CSCI AQAA (Annual Quality Assurance Assessment). This AQAA was thoroughly completed and provided us with information to discuss at the site visit. The AQAA documents what the service does well, what it could do better, how it has improved in the past 12 months and what improvements are planned for the coming 12 months. It also provides us with other information about staffing, complaints, health and safety precautions and policy/procedure reviews. We examined a wide range of documents relating to 3 of the people living in the home, this was to see whether their assessed needs were being appropriately met by the care plans in place and in turn whether there was evidence of those needs being met. In addition to this we looked to see that plans were person centred and people were not being put at unnecessary risks. Other documents we examined included staff training records, health and safety records, menus and policies and procedures. What the care home does well Potential new admissions to the service are thoroughly assessed by the manager and her staff which minimises the risk of people being admitted whose needs cannot be met. Comments from a relative included Im really impressed. The format of care plans has been reviewed and as a result the plans now in place provide the reader with a good level of detail enabling staff to meet peoples needs more consistently. People living in home are supported by a committed staff team to lead active and fulfilling lifestyles that meet their current needs. Peoples personal care needs are identified and plans are in place that provide staff with a good level of detail enabling them to meet them. Feedback from other health professionals is very positive about the service. They give examples of the staff following recommendations and being well prepared at meetings. The home is comfortable, warm and friendly and maintained to good standard. Staff receive training in a wide range of topics to meet specific needs in the home and maintain peoples health and safety. What has got better from the last inspection What the care home could do better 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 Paul Chapman 33 Greycoat Street London SW1P 2QF 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 . The service assesses information about potential admissions to the home before they are offered a service. This minimises the risk of people being admitted to the service whose needs cannot be met. Evidence: Since the previous site visit was completed 1 person has been admitted to the home from another home in the organisation. We examined the information gathered as part of the admission process which included information provided by previous carers. As part of this information there was also a care plan completed by the funding authority. The manager explained that to support the transition process 2 staff from the persons previous home had worked in the home for 2 days, this had been judged not to work effectively and as a result after 2 days this was halted. Feedback from other health professionals show that these admission/placement has been really effective for the person. We spoke to a relative of the person admitted to the service who said that they were really impressed with the home and that her son had improved significantly since moving in. We met with the person who moved in to the home, they appeared very happy and relaxed about the staff and other people living in the home. They stated that they were happy at the home. We saw evidence in 3 files of signed residency agreements. These state what the service provides and what is expected of the person to maintain their residency. Evidence: The manager stated that they intend to review the admission process to ensure that future admission are managed as effectively as possible. The manager has developed an information pack in an easy read format that each person will be given. Staff will go through this document pack with each person and ask them to sign in agreement where it is appropriate. 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 . The care plans for each person provide a level of detail that enables staff to meet peoples needs consistently and allow for an accurate review of peoples changing needs. People are given choices Evidence: We examined the care records for 3 people currently living in the home. Each person was seen to have the following care plans: - Activities, Behavioural management, Personal hygiene, Family contact, eating and drinking, daily living skills, Maintaining a safe environment, communication and sleeping. Since the previous inspection was completed the manager and her deputy have reviewed the format in which care plans are written, and the level of detail each care plan provides. The sample of documents we saw now provide a really good level of detail and explain what staff need to actually do. This is really good practice. Reading a couple of these plans a little more detail is needed, this was brought to the attention of the manager. The manager stated that all but 2 people living in home have this new style of care plan and they are in the process of completing care plans for these people at present. Key workers are expected to complete monthly reviews for each person in the home. Information included in this review process will be sleep charts, records of food eaten, activity charts, regulation 37 notifications, and records of behaviour management incidents. In some cases staff are completing the review form created by the manager, but they should ensure that this is always done for a consistent approach. This becomes a recommendation of this inspection report. The information gathered for the monthly review is then collated for peoples annual reviews. Comments from other professionals working with the home have been positive about the detailed information made available in reviews. Evidence: An area we identified as not being addressed by care plans was peoples sexuality, we discussed this with the manager and her deputy and it becomes a recommendation of this inspection report that this is addressed. Person Centred Plans (PCP) were in place for the 3 people whose records we were examining. The manager explained that they plan to make them more accessible to both staff and people living in the home. The plans we saw all needed dating. We spoke to a couple of people living in the home about being able to make choices from day-to-day. Examples they gave included activities, shopping, food, laundry and when they complete chores. Whilst discussing choice with the manager and her deputy we identified that a future development to enable people to make choices would be the introduction of pictures for people with communication difficulties. This becomes a recommendation of this inspection report All of the 3 files we examined contained a range of risk assessments that identified potential risks, and provided guidance on minimising those risks while enabling the person to complete the activity. 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 . People living in the home take part in a range of activities that are led by their choice and supported by staff. People have choice about what they eat and there is a wide range of meals prepared to meet peoples likes and dislikes. Evidence: Speaking to people living in the service, the staff and looking at records showed the following activities take place: Watching TV, going out for a drive in the house car, visiting the snoozeleem, going to discos at a social club, visiting Weston-Super-Mare, pub trips, picnics in the summer, visiting car boot sales, grocery shopping, cinema, playing computer games, using a jacuzzi, attending the organisations day centre, Rainbow club, going for walks, art and craft in-house and massage at day centre. Speaking to a couple of people in the home they explained being supported by staff to attend an England match at the new Wembley Stadium. Over recent months staff have been completing activity sheets for each person recording what they are doing half hourly. The manager said that this will change in the future with staff only recording hourly. The activity sheets we examined provided good evidence of what people do throughout their days. We asked staff whether they thought people in the home have good social lives. When speaking with staff during the site visit they were in agreement that all people get to go out regularly and have good social lives. Mantley Chase is made up of the main house and the coach house. 3 people live in the coach house. Speaking to 2 people living in the coach house they explained that they choose what they had to eat and were responsible for cooking it (with staff support as Evidence: required) most of the time. They explained that they sometimes have meals from the main house but this is usually on Sundays when they have a roast meal. There are good records kept for each person describing what they had to eat and drink. These records showed that people have a wide variety of meals. Speaking with people in the main house they stated they were able to choose what they wanted eat. Staff stated in their opinion, the food is nice and the food is chosen by the people living in the home. 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 . Care plans to address peoples personal care needs in most cases provide staff with sufficient information to allow them to meet peoples needs consistently. Where appropriate health professionals are involved in meeting peoples needs and staff follow the instructions/guidance of these professionals. Medication administration is managed effectively and this ensures that people are not put at unnecessary risks. Evidence: As identified earlier in this report since the previous inspection was completed the manager and her deputy have reviewed the format of care plans, and the level of detail provided in them. This also applies to the care plans available to meet peoples personal care needs. Care plans examined by us showed that in the majority of cases the plans had a good level of detail that would enable staff to meet peoples needs consistently. We identified a couple of shortfalls where greater detail was required and this was brought to the attention of the manager. All 3 of the records we examined contained OK Health checks and my health record documents. These document identify peoples health wishes and needs. Unfortunately none of the documents were dated and had not been reviewed recently. It becomes a recommendation of this inspection report that this is done. Each of the records we examined contained detailed notes of appointments with other health professionals. Feedback from health professionals who completed the CSCI questionnaires was really positive about the service and how staff were well organised at appointments, and that the team followed instructions provided by them to meet peoples needs. Medication administration was examined and procedures were seen to minimises Evidence: potential risks to people living in the home. All staff receive training (confirmed in training records, and by speaking to staff). Staff sign medication record sheets to confirm they have administered medication. Medication is audited monthly when it enters the home and where appropriate medication is returned to the pharmacist. No people living in the home administer their own meds. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People living in the home are not put at unnecessary risks due to the training and procedures in the home around safeguarding adults. People whose behaviour sometimes challenges the service are being put at unnecessary risk due to there being no individual guidelines around the management of their behaviour. Evidence: The home has an easy read complaints procedure. Speaking with staff they had a good knowledge of behaviours they may witness if someone was unhappy but unable to verbalise that. We spoke to a number of people living in the home about what they would do if they were unhappy, each person was clear about how they would make a complaint. Since the previous inspection the CSCI have received 1 complaint. The provider was asked to complete an investigation and this was resolved quickly and to the complainants satisfaction. People that live in the home sometimes display behaviours that may challenge the service. All staff receive training in physical intervention and good records are kept of when it is used. Each time physical intervention is used by staff they send a record of the incident to a qualified physical intervention trainer for analysis. At the time of this site visit the manager stated that they were about to write behaviour management guidelines for each person in the home. It is essential this is done as soon as possible to ensure that people are not put at risk by different methods being used. This becomes a requirement of this inspection report. No people manage their own monies. Staff manage all finances. All monies are checked twice a day by staff at shift handover and 2 staff sign to confirm the sums are correct. Receipts are obtained for the majority of purchases and all cash withdrawls from bank accounts via the cash machine. The majority of the staff team have completed training in safeguarding adults in the previous 12 months. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home provides people with a comfortable and homely environment that meets their current needs. Evidence: The previous inspection report made 15 requirements relating to the environment of the home. Completing a tour of the premises it was clear to see that all of these requirements had been addressed and extensive work had been completed by the provider. Communal areas and some bedrooms have been decorated, new furniture bought, a new kitchen fitted and new ornaments and pictures purchased. The home now feels really homely. The coach house was visited as part of the site visit and the manager said there is an ongoing programme of maintenance being completed with plans for a new floor covering and redecoration of the communal areas. Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Staff receive training to meet the needs of the people living in the home and this minimises the potential risk of peoples needs not being met. Staff are available in sufficient numbers to meet peoples needs and therefore people are not put at unnecessary risks. The homes recruitment procedures are thorough and do not put people at unnecessary risks. Evidence: We examined training records for the staff team. These showed that since the previous inspection was completed the majority of staff have completed training in the following topics: - fire safety, food hygiene, moving and handling, COSHH, first aid, behaviour management and equality and diversity. Records showed that new staff complete induction training. Staff we spoke to agreed that the training provided was very good and that their current needs were met. In addition to the training courses identified above staff 10 of the 14 staff that make up the team have completed NVQs (National Vocational Qualifications) to a least a level 2. The deputy manager has recently completed their Registered Managers Award. We examined the recruitment records for staff employed since the previous inspection was completed. This showed that all of the records required by these regulations were in place and therefore people living in the home are not being put at unnecessary risks. Staffing rotas were seen and showed that staff are available in sufficient numbers to meet the needs of the current group of people living in the home. This was confirmed by staff we spoke to. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The manager of the service is appropriately qualified and experienced which has led to people receiving a service that meets their current needs. Health and safety procedures and staff training ensures that people living in the service are not put at unnecessary risks. Evidence: The manager has considerable experience in working with people with learning disabilities and is appropriately qualified with the Registered Managers Award. People living in the home spoken with during the site visit were positive about the manager and the staff team stating that they felt they could talk to the manager and staff if they had any issues. As part of the inspection process we surveyed staff about the home. All of the comments were positive about the team and the support provided by the management team. Comments made by staff during the site visit included the team are like a big family, training is good, I have been doing updates for all my mandatory training, we have supervision every 3 months, maintenance issues are addressed pretty quickly and the manager is approachable. The manager stated that all of the current organisational policies are being reviewed by the quality assurance manager, while the local procedures (specific to the home) are being reviewed by them at present. Quality assurance in the home is being monitored through a range of regular checks completed by staff and the manager. This includes maintenance issues being audited weekly, medication records being audited monthly, Regulation 26 visits being completed monthly and shortfalls addressed. Speaking with people living in the home it is clear that the service is led by their needs and wishes. Evidence: The manager and her staff team complete a range of regular checks to minimise potential risks. Records showed that the following actions are taken: - Portable Appliance Testing (PAT) completed September 2008, hot water temperatures are checked monthly, Legionella test completed in February 2008, fridge and freezer temperatures are monitored daily and the food probe is used regularly to check cooked meats. Fire safety checks are completed regularly, but records showed that fire drills needed to be completed more frequently. In addition to these checks being completed staff completed regular training in a range of areas relating to health and safety. (see Standard 35). 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 6 15(2) b, 12(1) a The manager must review people?s care plans to ensure that they are all person centred. Where possible there should be clear evidence that people living in the home are involved in their development. 28/03/2008 2 7 15 The manager and staff 01/02/2008 should ensure that they record their input when supporting people to make decisions about their lives. In addition to this the manager should be mindful to record all of the staff actions when supporting people to go about their lives and learn new skills. 3 20 13(2) Topical creams must be 04/01/2008 labelled with the date the date they are opened. This requirement is carried over from the previous inspection report. Hand written medication instructions on administration sheets must be signed by the member of staff writing them. 3. Where medication has been discontinued staff must make it clear on the medication sheet, again the staff member must sign this. 4 24 16(2) f The coach house must have their own laundry facilities. 28/03/2008 5 24 13(3), 13(4) c The wooden fence between the kitchen and dining area must be painted as in its current unfinished state it poses a health and safety risk. 04/01/2008 6 24 23(2) b, d Above the laundry door a large piece of plaster is missing and must be replaced. 15/02/2008 7 24 23(2) b, d The ceiling in the communal laundry is bowing and must be repaired. 15/02/2008 8 24 13(4) a, c The safety fence at the top of 01/02/2008 the main stairs must examined and any sharp edges removed so that people are not being put at risk. 9 24 23(2) d, c The kitchen/diner must be decorated. Timescale not met 01/06/07. Requirement carried over from the previous inspection report 29/02/2008 10 25 23(2) d The bedroom that had water 14/03/2008 damage from the upstairs flat must be redecorated. 11 25 23(2) d The bedroom where water 14/03/2008 damage has been repaired above a curtain rail (by fire exit steps). Must now be decorated, as at present it is bare plaster. 12 25 23(2) d Downstairs bedroom. An area of the wall has been repaired/re-plastered. This must now be painted. 15/02/2008 13 26 13(4), 23(2)b The floor covering in the flat must be replaced. 29/02/2008 14 26 23(2) d The flat at the top of the 28/03/2008 house must be redecorated. Timescale not met 01/06/07. Requirement carried over from the previous inspection report 15 27 23(2) b, c, d The main bathroom must be decorated and the lock on the door must be replaced. 29/02/2008 16 27 23(2) b The doorframe to the downstairs shower room is split and must be repaired. 15/02/2008 17 27 23(2) c Staff must ensure that light bulbs are replaced as required. 04/01/2008 18 30 13(3) The registered manager 01/02/2008 must ensure that all areas of the home are clean and hygienic. Timescale not met 23/03/07. Requirement carried over from the previous inspection report On this occasion this relates to 1 bedroom in particular that smelt of faeces. The floor covering must be replaced. 19 32 7, 9, 19 schedule 2 Staff training records must be reviewed to ensure that all staff are up-to-date with their training. The manager must then write and tell us about her findings. 01/02/2008 20 34 7, 9, 19 schedule 2 Staff files must be reviewed and the missing information added to the files. The manager must be mindful of information required by these regulations so people are not put at unnecessary risks. 01/02/2008 21 39 24 A quality assurance system must be introduced into the home. 28/03/2008 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 23 12 The manager must ensure that each person has guidelines in place that accurately reflect the steps taken by staff in situations where peoples behaviour challenges the service. 31/12/2008 Failure to have these guidelines in place may mean that situations are managed inconsistently putting both the staff and person at risk. 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 6 6 The manager should ensure that each person has a care plan addressing their sexuality needs. The manager should introduce pictures of activities, foods, etc to further enable people with communication difficulties to make choices. 3 6 The manager should ensure that all staff complete the monthly review forms. 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. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) 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. 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