Care Home: Parkgate Manor

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What the care home does well The Registered Manager ensures that all complaints and any safeguarding Adult Procedures are dealt with effectively and comprehensively. Care plans are informative and the Registered Manager works well to ensure that all the residents health care needs are addressed. The home has good links with external health care professionals and the community learning disability teams. Comments were gained from visiting professionals such as social workers & reviewing officers some of these were` I have recently placed a service user at Parkgate Manor and have been impressed at the level of professionalism extended to me, kindness, courtesy extended to the service user and their family` `I would like to state how pleasant it was to visit Parkgate Manor to carry out reviews on a few residents, the home was a fantastic sight and staff were very friendly and welcoming. What has improved since the last inspection? In their annual quality assurance survey, twenty residents commented they would like more outings. During the summer months, staff formulated a busy activity schedule and ensured everyone had a choice regarding which trips/ activity sessions they went on. Ten residents wanted to attend an evening class at a local college and some people asked for pet care and cookery courses to be offered in the day care facility. The home has also been redecorated externally and internally all common hallways have been redecorated and carpets replaced. A new kitchen has also been refitted in the home. What the care home could do better: The service is well run and the Registered Manager was co operative and helpful throughout the whole inspection process. Two areas of improvement were discussed with her during the day, one in relation to storage of controlled medicines and one in relation to the offer of employment letter. The Registered Manager addressed these issues instantly. The home is not arranged to provide accommodation to residents in clusters of 10 people or less, as stated in the National Minimum Standards, this was discussed with the Registered Manager and the service is to give consideration to this in the future. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Parkgate Manor Catsfield Battle East Sussex TN33 9DT     The quality rating for this care home is:   two star good service 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: Alexis Reilly     Date: 2 4 0 9 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. the things that people have said are important to them: They reflect 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. Care Homes for Adults (18-65 years) Page 2 of 27 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. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 27 Information about the care home Name of care home: Address: Parkgate Manor Catsfield Battle East Sussex TN33 9DT 01424773251 01424777072 enquiries@parkgatemanor.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Sally Ann Tester Type of registration: Number of places registered: Mr Roger Williams,Mr Brian Scarles care home 40 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 40. 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 Parkgate Manor is a large detached house and provides residential care for up to 40 adults over the age of 30, with a mild to moderate learning disability. The home is set in extensive grounds, approximately 2 miles from the town of Battle. Residents rooms are on the ground and first floors, and there are a variety of attractive communal rooms. The gardens are also a well-used resource. The home has its own day centre, offering a range of opportunities in artistic, domestic and work related activities. The residents also access a wide variety of community events and educational facilities. Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 40 Care Homes for Adults (18-65 years) Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: Our inspection began at 9.30am and lasted until 3pm, as part of the inspection the inspector examined four care plans in total, one of these was a recent admission so the inspector was able to evidence the admission process of the home and preadmission documents. The inspector also examined the following documents in relation to individuals placed in the home, the care plan documents and risk assessments, waterloo charts, copies of external and internal reviews, the activities plan and activities daily log, and record of residents finances. The inspector was also able to evidence that the home involves external agencies for input with the residents and saw evidence of dietitian, physiotherapy, chiropody input, and previous speech therapy input. The inspection also looked at the way the service records accidents and incidents and copies of any regulation 37 notices sent to the CSCI. The inspector looked at Care Homes for Adults (18-65 years) Page 6 of 27 training records for staff and evidenced all staff are trained in Makaton. As part of the inspection the inspector looked at the record of complaints, concerns and compliments kept in the home, the menus, service user guide, and terms and conditions of contract. In relation to staffing the inspector examined a selection of recruitment files, training matrix, supervision notes, team meeting notes, staffing rota, skills for care induction and training booklets. The inspector interviewed the Head of care, and one support worker and the Registered Manager spent time with the inspector throughout out the inspection. Residents were seen briefly in the home in the afternoon of the inspection. A partial environmental tour was carried out which included the four residents bedrooms who the inspector had case tracked, the laundry, medication cupboard, kitchen, downstairs and upstairs office, two lounges and a large conservatory. 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 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. Care Homes for Adults (18-65 years) Page 8 of 27 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and health care 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 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service understands the importance of having sufficient information when choosing a care home. Admissions are not made to the home until a full needs assessment has been undertaken . The assessment is conducted professionally and sensitively and involves the individual and their family or representative where appropriate. Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and to help them understand how the home is organized and run and the facilities and services available. This ensures the person feels comfortable in their surroundings and enables them to ask any questions about life in the home. The home does not offer the opportunity for people to live in clusters of up to ten people and this is reflected in their Statement of Purpose. Evidence: The service has had two new residents admitted in the last 12 months. The inspector examined the admission documents for one of these and can confirm that a comprehensive assessment took place which included a visit to Parkgate for Care Homes for Adults (18-65 years) Page 10 of 27 Evidence: assessment, and to met the home and residents. An overnight stay for a further assessment was arranged to ensure the prospective resident fitted in with the other residents placed at Parkgate manor. The Registered Manager contacted the staff from previous placements and families as part of the assessment process. A key worker was allocated and introduced to a new resident prior to them moving in and was on duty when they arrived at the home. All residents are introduced formally to new people at a residents meeting. The inspector looked for direct evidence that the Registered Manager had assessed the individuals needs and then formulated the care plan around them. This was clearly demonstrated, examples of these were; a identified need in the pre assessment documentation that the person needed an unhurried atmosphere when eating and to keep in touch with their family. These points were then identified and included in the care plan. The home does not currently offer residents the opportunity to live in clusters of no more than ten people within the home. This was discussed by phone with the Registered Manager following the inspection, she has amended the Statement of Purpose to reflect this, and will be giving further consideration to how the home is organized. Care Homes for Adults (18-65 years) Page 11 of 27 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Service involves individuals in the planning of care which affects their lifestyle and quality of life. Care plans are person centered and are agreed with the individual. Plans are written in plain language are easy to understand and look at all areas of the individuals life and includes a range of information that is important to them. The care plan is a working document reviewed regularly involving the person and their representatives as appropriate. There are procedures to ensure that people using the service are informed of their rights and this with the comprehensive care plans ensure that residents receive a good comprehensive package of care. Evidence: The inspector examined four care plans and associated documents and can confirm that care plans match needs identified in the pre assessment stage. An example of recording was in relation to a resident who is offered their meal first to enable them maximum time to eat it and to not feel rushed. Care plans are person centered and include input from families and other professionals, areas of importance are identified Care Homes for Adults (18-65 years) Page 12 of 27 Evidence: and noted. Examples of recording were also found on how the service manages more challenging behavior, highlighting the importance of staff spending time with individuals and promoting them about the daily activities before they become anxious. Care plans were also supported by risk assessments and behavioral risk assessments, reviews of care plans are carried out and during this time external agencies and family members are invited, if they are unable to attend minutes from the meeting are sent to them. The service has started to compile the my health plans for residents some of these need to be completed and signed by the resident if appropriate. The Registered Manager ensures that residents are kept up to date with any new information and enables them to make their own choices. An example of this was a resident given the choice of whether to attend a family members funeral. The Registered Manager informed residents at the residents meeting about the new standard of consent to treatment and leaflets were handed round in order for them to be able to make choices about their care and to know that this is their right. Care Homes for Adults (18-65 years) Page 13 of 27 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a strong commitment to enabling residents to develop or maintain their skills including social emotional communication and independent living skills. The staff practices promote individual rights and choice but also consider the protection of individuals in supporting them to make informed choices.The staff team help with communication skills both within the service and in the community to enable residents to fully participate in daily living activities. The service is committed to the principles of inclusion and promotes and fosters good relationships with neighbors and other members of the community thus ensuring the residents to live a full and inclusive life. Evidence: The inspector saw a record of the activities in the individual care plans, and also the activity logs. The record of completed and planned activities on offer was also examined. During the environmental tour the inspector evidenced the notice board in Care Homes for Adults (18-65 years) Page 14 of 27 Evidence: the home which has the planned activities and residents meetings dates on it. Residents are kept informed of upcoming events on the notice board in the home and these are also mentioned at the monthly residents meeting. Residents are encouraged to attend activities inside and outside the home, and attend college courses church and as many local events as possible. The Registered Manager feels it is important for the service to maintain a high profile in the local community. Residents are regularly invited to take part in events organized by local organizations in the community such as the Catsfield WI, Catsfield parish council and the church. Residents attend village art classes on a weekly basis. A course was run in flower arranging in conjunction with Sussex downs college and some of the residents at Parkgate Manor had their work entered into the catsfield flower show. In conjunction with local colleges Parkgate have arranged course in pet care, flower arranging, gardening and drama these have been held at Parkgate Manor. Residents have also attended evening classes in African drumming, cooking, gardening, computers and sport. Residents agreed two documents at their residents meeting, Residents Rights and Parkgate Charter outlining the rights and responsibilities of all people at Parkgate manor. Staff are also trained in Makaton to ensure individuals can use their preferred method of communication. The inspector saw a sample of the menus in the home these looked appetizing and varied and used fresh ingredients. Care Homes for Adults (18-65 years) Page 15 of 27 Personal and health care 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 receive personal and health care support using a person centered approach. Support is provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal health care needs including specialist health nursing and dietary requirements are clearly recorded in each person centered plan or health action plan. Residents are given the support they need to manage their medication. Thus ensuring the residents health as well as personal care needs are addressed comprehensively. Evidence: As part of the inspection the inspector examined four care plans in detail it was evident that residents at Parkgate Manor receive additional health care support and access physiotherapy speech therapy dietitians, and chiropody. Residents are supported by the Community learning disability team and the Registered Manager has ensured the staff at Parkgate manor have a good relationship with the CLDT. Residents wishing to manage and administer their own medication are fully supported to do this by the staff team this is supported by risk assessment and action plans. Care plans have a section on dying and funeral plans and personal wishes are discussed with the residents. The inspector spoke with the Head of Care and a support worker in the home they both Care Homes for Adults (18-65 years) Page 16 of 27 Evidence: confirmed and discussed examples of ways personal care is delivered which promotes peoples dignity and independence. A sample of sheets which record the administration of medicines were examined and found to be in order. The home must ensure they have a suitable storage facility for medicines in the home, this was discussed during the inspection and the Registered Manager actioned the purchase of a suitable cabinet before the inspector finished the inspection. Care Homes for Adults (18-65 years) Page 17 of 27 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and any issues of safeguarding vulnerable Adults are dealt with effectively clearly and speedily. The Registered Manager has demonstrated she holds the residents safety and best interest at the center of her practice. This ensures that the residents placed in the home are safe and their best interests protected. Evidence: The inspector examined the record of complaints in the service and two previous safeguarding issues that had been raised in the home over the last two years. The inspector can confirm the complaints and the safeguarding issues were dealt with speedily clearly and comprehensively. In the case of the most recent safeguarding investigation the Registered Manager demonstrated their ability to continue to protect the best interests of the resident by providing additional staffing until a suitable home could be found which could offer a placement for this persons more complex needs. This ensured that residents needs were continually met until such time as the issue was resolved. Complaints are dealt with appropriately a record kept and any action recorded. The Registered Manager is open and honest in her approach and has demonstrated through discussion she holds the residents safety and best interests at the center of her practice. Care Homes for Adults (18-65 years) Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The home is a very pleasant safe place to live. The home is well lit clean and tidy and smells fresh. The service employees maintenance personal to ensure the home is kept in good order ensuring the residents have a safe and comfortable place to live. However the service is not organized into smaller units of no more than 10 residents, the Registered Manager is giving consideration to this, which will ensure residents independent living skills are promoted. Evidence: As part of the inspection the inspector carried out a partial tour of the home the inspector found a comfortable and clean environment provided for residents with a range of communal areas for people to choose where they spend their time. Each resident is encourage to personalize their bedroom and bring in their own personal items to make their room more individual. The service has implemented a redecoration program over the last 24 months in which all the communal area have been redecorated and common hallways re carpeted. The kitchen has been refitted with a steel kitchen. The service employs maintenance personal and also laundry personal, carpets in the home are regularly cleaned to ensure they remain clean and odor free. Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: In the last 12 months the main staff office has been divided into two so that meetings can take place in private and the upstairs office has been converted into a meeting / quiet room. New toilets have been fitted downstairs and new sinks have been fitted in some bedrooms and new furniture has been ordered as part of the refurbishment program. Two new shower rooms have been installed on the ground floor. The whole outside of the house has been redecorated, and the maintenance plan demonstrates a number of the rooms had had new carpet, bedding, curtains, redecoration and furniture. However the Registered Manager must give consideration to organizing the home into smaller units, so that a cluster of no more than 10 residents share a staff group, dining area or other common facility. Care Homes for Adults (18-65 years) Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All staff receive relevant training that is focused on delivering improved outcomes for residents. The home puts a high level of importance on training and staff report that they are supported through training and supervision to meet the individual needs of people in a person centered way. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice, with the home recognizing the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Evidence: As part of the inspection the inspector examined a number of staff files, recruitment files, record of supervision , list of staff training and interviewed two staff and spent time with the Registered Manager. The inspector can confirm that all staff are trained in Makaton and the Registered Manager and Head of care have completed Mental Health capacity Training. Staff receive supervision every 6 weeks and their is a senior management meeting every three months. Five support staff work the morning and afternoon shifts plus the Registered Manager, Head of Care and Administrator. The home employees two cleaners who work 7 hour shifts and three maintenance staff who work 8.5 hours each day two are on each shift and one of these does the mini bus driving. Recruitment files were found to be in good order, however there was an issue Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: that the offer of employment did not state that the person would be on a period of supervised induction prior to receiving all the relevant information back. This was raised with the Registered Manager during the inspection and they immediately addressed this changing the letter of offer of employment. The inspector can also confirm that it was only one staff recruitment file which did not have all relevant documentation back prior to employment in the home. The supervision of this member of staff was also confirmed by the inspector by talking to the staff member in question and also the head of care. The Registered Manager confirmed that at no times are staff left unsupervised with a resident until documentation is back. All staff complete the common induction standards program from skills for care and staff are supervised during their induction period. Staff receive appropriate training and supervision. Eight staff have achieved NVQ level 2 and two staff are currently doing NVQ level 3 all staff have completed the TOPPS skills for care induction. Care Homes for Adults (18-65 years) Page 22 of 27 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. The manager has a clear understanding of the key principles and focus of the service based on organizational values and priorities. They work to continuously improve services. They provide an increased quality of life for residents with a strong focus on equality and diversity issues and promoting human rights, especially in the areas of dignity respect and fairness. There is also a focus on person centered thinking. There is a strong ethos of being open and transparent in all areas of running of the home. Therefore ensuring residents receive a comprehensive package of care in a well run home. Evidence: The inspector examined the quality assurance documents in the home and read the comments from the surveys kept at the home. Some quotes from the surveys were, I am happy with what is being offered, very happy, since x has been at Parkgate Manor my family have noticed x looks so well, and although x is confused they seem content. Yes the residents are well entertained, If possible could you do fairs or Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: similar on a Saturday or Sunday as working during the week, We can always telephone if there is anything at all, perhaps a few more day trips out. The home also collates and publishes the results from their surveys. Residents survey results from January 2008 have been published and are given to visitors at the home. Twenty residents commented they would like more outings. During the summer months staff formulated a busy activity schedule and ensured everyone had a choice regarding which trips/ activity sessions they went on. Ten residents wanted to attend an evening class at a local college, and some people asked for pet care and cookery courses to be offered in the day care facility. This was addressed and a range of activities offered. The service has a Walkie talkie system in place in the offices in order to maintain communication with all staff at any point during the day and maintain in constant contact with them via this system. Weekly room checks and monthly health and safety checks are carried out in the home and maintenance personal are employed and work daily. Organization of the activities program is undertaken by the Registered Manager and the Head of Care. The Registered Manager has been in post for over 20 months and is completing their RMA. The Head of Care has completed her NVQ level 3 and is registered for the NVQ level 4. The Registered Manager was part of the inspection process and was found to be helpful and informative throughout the inspection, two areas of improvement were discussed with her during the day, one in relation to storage of controlled medicines and one in relation to the offer of employment letter. The Registered Manager addressed these issues instantly. The home completed and returned their AQAA (annual quality assurance assessment) when we asked for it, the timescale given for return was extended by 48 hours as the home experienced some technical difficulties. The completed document was comprehensive, detailed and informative. It identified areas where the service had improved in the last year and others where further developments were being planned or would benefit residents and other stakeholders. Care Homes for Adults (18-65 years) Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 24 23 The Registered Manager must give consideration to no more than then people sharing a staff group, dining area, or other common facility. To ensure that people are living in no more than clusters of up to ten people to promote independence. 24/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 26 of 27 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 © (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. Care Homes for Adults (18-65 years) Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!