Care Home: Proctor Residential Home Ltd

What the care home does well The person whose comments were sought during the inspection about the home told us that they participate in the planning of their lives, they attend ICPA meetings where needs are discussed, they can make their own social arrangements and holidays are arranged by the home. We were also told that their privacy and dignity is respected and staff know how to meet their needs. Comments made by the staff indicate that they have an insight into the needs of the people at the home and have a clear understanding about the issues that can affect the person, for example, medications and loss of contact with family and friends. What has improved since the last inspection? Since the last inspection one member of staff was employed to undertake supervision with the staff and to develop a personalised approach to meeting needs. What the care home could do better: Seven requirements were made at the last inspection and six have passed the given timescale. However, there are five requirements outstanding. This means that there is a history of non-compliance with requirements and raises concern about the manager`s sincerity in actioning requirements that will improve the standards of care for people living at the home. Repeated requirements are based on the introduction of a personilised approach to meeting needs, reviewing medication protocols, updating the WhistlBlowing procedure and assessing the potential of fire in the premises. The manager must ensure that these requirements are met to prevent any further action being taken for noncompliance. There are six requirements arising from this inspection and focus on developing risk assessments for activities that may involve an element of risk, for example, returning to the home drunk and leaving the home without staff support. The arrangements for occupation, education and leisure must form part of the personalisation approach to meeting needs and must form part of the care planning process. Medication profiles must be devised for people on regular prescribed medications to ensure that the administration of medications are done safely. The Safeguarding Adults policy must be updated to ensure that staff are clear about the actions to be taken for reporting abuse. Key inspection report Care homes for adults (18-65 years) Name: Address: Proctor Residential Home Ltd 40 Filton Avenue Horfield Bristol BS7 0AG     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: Sandra Jones     Date: 0 6 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 30 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 30 Information about the care home Name of care home: Address: Proctor Residential Home Ltd 40 Filton Avenue Horfield Bristol BS7 0AG 01179354403 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Proctor Residential Home Ltd care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: May accommodate up to 5 persons, 2 of whom can be 65 years and over Date of last inspection Brief description of the care home Proctor House is a care home providing personal care for five service users aged between eighteen and sixty four years. The home is situated in a suburban area, and located on a bus route that gives access to local shops, leisure and other amenities. The home is in keeping with the local neighbourhood. The home has undergone re-registration with the Commission for Social Care Inspection as the business has moved from a sole trader to a limited company. In addition the manager of the home has changed from Mrs Kendall to Mr Kendall (the son). Mrs Kendall remains the provider. The home primarily provides personal care to service users with a mental disorder. It is a quiet home that would best be suited to those who prefer a quieter lifestyle. Fees range from #600.00 - #1000.00 per week. 1 2 1 1 2 0 0 8 5 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 30 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: The Annual Quality Assurance Assessment (AQAA) was sent to the home for completion which the manager returned the AQAA completed. Prior to the visit some time was spent examining documentation accumulated through reports, surveys and the AQAA. This information was used to plan the inspection visit. The four people living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The homes policies and procedures were also used to confirm the findings. The views of the manager, staff and three people using the service were gathered through face to face discussions Care Homes for Adults (18-65 years) Page 5 of 30 Care Homes for Adults (18-65 years) Page 6 of 30 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. Care Homes for Adults (18-65 years) Page 7 of 30 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 30 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 30 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. The Statement of Purpose must be more transparent to ensure people wishing to live at the home can make decisions about they way their needs will be met at the home Evidence: The Statement of Purpose is currently in draft form and will be further updated to include information about the admission procedure, visitors policy and the way the range of needs can be met at the home. Since the last inspection one person has left the home, leaving a vacancy, with no admissions. Care Homes for Adults (18-65 years) Page 10 of 30 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. Care plans are not seen as essential to meeting the needs of the people at the home. People may not be receiving up to date care from staff because care plans are not reviewed. Individuals are not active in planning the care and support they need. Risk assessments must completed to ensure that where risks are identified, preventative measures are taken to lower the level of risk. Evidence: The case records of three people living at the home were examined to assess the care planning process. Annual care review meetings are convened by the care coordinator with health and social care professionals, home staff, where appropriate relatives and the person present. An action plan arising from the review to meet the changing needs of the person is provided in the ICPA and through the homes review process, homes care plans are updated. It is acknowledged that homes care plans are reviewed following the ICPA meeting. However, there is little correlation between the homes care plan and the ICPA. ICAP plans are based on multi agency decisions about the changing needs of the persons and homes care plans must be linked to the ICPA. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: There is some evidence that a person centered approach to meeting need is being used. Care plans must include the persons likes, dislikes and preferred routines and show that the person had a say about the way their care is to be delivered. The progress made by the individual is not currently monitored and to ensure that the the individuals needs are met, action plans must be monitored. Members of staff must monitor the action plans and record the progress. Members of staff report on the individuals well being and daily reports include the staffs observation of the person, outcomes of visits, activities and behaviours exhibited. The care planning process was discussed with three staff on duty. While it was acknowledged that care plans are not personalised, a senior member of staff said that the staff are knowledgeable and understand about empowering people, adopting a person centered approach will then be a quick process. A senior carer explained that they are responsible for developing and monitoring care plans. A care assistant said that daily reports and information conveyed through handovers are mainly used to keep up to date about the people at the home. One person living at the home agreed to give feedback about their involvement in the care planning process. This individual told us that they attend ICPA meetings and is able to make decisions about what to do. The manager said that the people at the home have capacity to make decisions about all aspects of their life. People with Community Orders are accommodated which means that they must take medications prescribed otherwise they may be recalled to hospital. Risk assessments for activities that may involve an element of risk are in place for fire safety. The manager must develop specific risk assessments for people that may abscond without staff support and returning home drunk. These assessments must include the options considered and the action plan must establish that the preventative measures reduce the level of risk. Care Homes for Adults (18-65 years) Page 12 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home would benefit from more involvement in developing life skills and must be more involved in shaping their lives. Evidence: The manager said that the people at the home have opportunities for occupation and leisure. We were also told that holidays and outings are organised throughout the year. A week-end away was organised to Blackpool, concerts and pub visits every Thursday are also organised. People are independant in the local community and the manager provides transport to people that wish to visit their preferred community. While records show that weekly outings to the pub are organised, leisure, occupation and education must form part of the care planning process for the person. Leisure and occupation was discussed with one person at the home and were told that Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: its their choice to arrange their social life. This individual said that they would like paid employment and confirmed that an enjoyable weekend away to Balckpool had taken place. The Visitors policy is not currently included within the draft Statement of Purpose. The manager has reassured us that the policy along with the rules of the home and expectation of both parties will be added to the Statement of Purpose. The way Privacy & Dignity is respected at the home is included within the Statement of Purpose. All bedrooms are single and locakable, mail is handed to the person unopened. The manager said that people at the home will take pride in their personal space by keeping it tidy and help with clearing dishes from the table but there is no expectation that individuals participate with household chores. Comments about the way individuals rights are respected were sought from the staff on duty. We were told that knocking on doors and waiting for an invitation to enter, giving people choices and ensuring personal care was undertaken discreetly were the way people are respected as individuals. Proctor house caters for people with diabetic and West Indian diets. The records of food provided shows that a continentaly style breakfast, a light lunch and cooked evening meal is served at the home. The variety of fresh vegetables, tinned and frozen foods supports that people at the home have a varied diet. Care Homes for Adults (18-65 years) Page 14 of 30 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. The health and personal care that people receive is based on their individual need and care plans must be detailed to ensure the care is consistently delivered. Medication systems must be made reviewed to ensure there are safe systems of medication administration. Evidence: A record of health care appointments and visits is maintained showing that people visit their GP, have access to health and social care professionals. Records also confirm that people have input from psychiatrists, mental health professionals, visit hospitals and have community nurse involvement. Comments about the health care arrangements were sought from the staff and people at the home. The staff told us that the accompany individuals on health care visits and pass on any advise given and the staff comments from staff were confined by one person. The manager said that with the exception of one, people at the home are independent with personal care. Care plans in place list the need and the possible trigger that can Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: be exhibited when performing personal tasks. However, the actions in terms of personal care and the way the person is to be coaxed is not included. Care action plans must specify the actions to be taken for each trigger and the way the person is to be coaxed by the staff to undertake personal care. Medications are administered through a monitored dosage system by senior staff and records of administration are signed following administration of medications. The sample of checks of medications held corresponded with the records of administration. We were told by the manager that homely remedies administered when required from a stock supply are not maintained. A record of medications no longer required is maintained at the home and signed by the pharmacist to indicate receipt of the medication for disposal. Medications profiles that list the individuals medication with its purpose and side effects are in place for three people. Profiles must be reviewed to ensure that all prescribed medications are included within the profiles and are in place for each person that has regular prescribed medications. Care Homes for Adults (18-65 years) Page 16 of 30 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. People at the home can express their concerns and have access to effective complaints procedures. Updating and reviewing the Safeguarding Adults and WhistleBlowing procedures will ensure that people at the home are better protected from abuse Evidence: The Complaints procedure is included within the Statement of Purpose and one individual giving feedback named the individual that would be approached with complaints. Staff consulted said that complaints received would be recorded and passed onto the manager for investigation. There was one complaint received at the home since the last inspection, the records show that an investigation tool place and the complainant was satisfied with the outcome. The homes Safeguarding procedure includes the definition of abuse with the actions to be taken. However, the procedure is vague and must be reviewed to make clear to staff the actions that must be taken when abuse is suspected. The WhistleBlowing policy in place has not been reviewed and must be updated to make clear the purpose of the procedure and the staffs responsibilities. The WhistlebBlowing procedure must reassure staff that if they report poor practice they will be protected from reprisals and may be subject to disciplinary procedure if they witness poor practice and do not Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: report it. One person living at the home was asked if they felt safe at the home and this individuals response was not always. The levels of aggression and violence exhibited by people at the home was discussed with the members of staff on duty. One member of staff said that some people at the home can become aggressive at times. The staff at the home said that the policy of the home is no confrontation and to give people space and time to calm down. Care Homes for Adults (18-65 years) Page 18 of 30 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 property is fit for purpose and people have a comfortable environment Evidence: Proctor House is a terrace property in a residential area that has the appearance of a domestic dwelling. It is arranged over three floors, with communal space on the ground floor and bedrooms on the ground and first floor. The property is close to shops, amenities and bus routes, which are used regularly by the people at the home. Since the last inspection, the conservatory was replaced and one bedroom was redecorated. We were reassured by the manager that stained and soiled carpet tiles were going to be replaced. Bedrooms are single and the opportunity was taken to view a number of bedrooms. The furniture and fittings are provided by the home and personal belongings reflect the personality of the person. It was noted that bedrooms are lockable and individuals have a lockable facility in their rooms. There is a hand washbasin, adequate floor covering, nurse calls and a radiator in each room. A full bathroom is located on the first floor and a shower and toilet on the ground floor. The ratio of bathrooms and toilets are less that three people sharing. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: There is a sitting/dining room, conservatory and visitors room. The combined seating and dining room has seating for four people and dining space for four people. The conservatory is used as a designated smoking area with additional facilities for making light snacks and refreshments. The visitors room is accessible to residents and used for private visits. The laundry area is adjacent to the kitchen and has the washing machine and a locked COSHH cabinet. The floor covering and painted walls ensures easy cleaning. The washing machine is domestic and has can reach 95 degrees C. Care Homes for Adults (18-65 years) Page 20 of 30 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. People receive a consistent service from a stable staff team that are skilled and suitable to work with vulnerable adults. Evidence: The current staff team is stable and staffing levels have not changed since the last inspection. The staffing rota in place show that two staff are rostered throughout the day with the service provider and manager working supernumerary. Ancillary staff are employed to keep the home clean and at night there is one person sleeping in the premises. Since the last inspection staff have attended mental health training, medication and Food Hygiene training. Staff meetings occur four times per year and a staff meeting took place during the inspection. We were given the opportunity to join the staff meeting where the minutes of the previous meeting, training attended, future arrangements for care planning and training needs were discussed. Feedback from staff was sought about supervision and we were told that the manager Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: delegated a senior member of staff the responsibility of providing 1:1 to the staff. This member of staff said that supervision are individuals, monthly and generally training, personal development and performance is discussed. Members of staff confirmed that supervision was taking place monthly where duties of the role and training needs were discussed. Comments about the skills of the staff was sought from one person living at the home. This individuals said that the staff were OK and they know hoe to meet their needs. Care Homes for Adults (18-65 years) Page 22 of 30 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 aims and objectives and needs of the people are not fully met, assessments must be completed to ensure the environment is safe for the people living and working in the home . Evidence: Comments from the manager were sought about the way the aims and objectives of the home are met. The manger said that since the last inspection, the conservatory was replaced, a new security system was installed and a member of staff to work between two homes was employed. The manager also told us that the intention is to increase the variety and frequency of activities and to open the sister home. Members of staff were consulted about the leadership of the home and we were told that there is a transparent and relaxed approach. Other staff said that the manager is approachable and supportive. The manager will be using a commercially purchased Quality Assurance package that is linked to NMS to review the quality of care provided at the home. From the Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: assessments of the NMS and action plan will be implemented to improve the outcomes for people at the home. We were told by the manager that the fees charged range from £700.00 - £1,500.00 per week. While fire risk assessments are not in place, the fire log book evidenced that the manager takes steps to prevent an outbreak of fire at the home. Nevertheless, fire risk assessments that look at the potential of fire in the home to develop an action plan to reduce the risk must be formulated. Within the risk assessments the checks of fire alarm systems and practices that will be conducted to maintain a safe environment for people at the home and staff must be included. External contractors are used to check the portable equipment and the gas boiler. Certificates issues by contractors show that the home complies with associated legislation. Care Homes for Adults (18-65 years) Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes R 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 19 12 The registered person shall 30/01/2009 make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. A protocol must be developed for people that have when required medications to ensure its administered consistently. 2 23 12 The registered person shall make arrangements, by training staff or by other measures, to prevent services being harmed or suffering abuse or being placed at risk of harm or abuse. The Whistle Blowing policy must inform staff that its their duty to report poor practise and may be subject to disciplinary procedures if they witness poor practise and do not report it. 30/03/2009 3 35 12 The registered person shall make arrangements, by training staff or by other measures, to prevent services being harmed or suffering abuse or being placed at risk of harm or 20/03/2009 Care Homes for Adults (18-65 years) Page 25 of 30 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 abuse. Members of staff must attend safeguarding adults training 4 39 24 The provider shall establish 01/12/2009 and maintain a system for evaluating the quality of the service provided at the home The manager must introduce a Quality Assurance System 5 39 24 The Quality Assurance system must be further develop to ensure residents views are reflected into future reviews and planning for the home 12/11/2009 6 42 23 The provider must ensure that the requirements of Regulatory Reform (Fire Safety) Order 2005 are complied Fire risk assessments must be reviewed to include the practises and checks undertaken to prevent an outbreak of fire. 30/03/2009 Care Homes for Adults (18-65 years) Page 26 of 30 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 12 The manager must where possible ascertain the wishes and feelings for the purpose of providing care to the people at the home. The manager must then ensure that the people at the home have a say about the way thier care is to be delivered. 19/03/2010 2 9 13 The manager must ensure that any risk that involves people living at the home must be free from avoidable risk. Risk assessments for activities that involve an element of risk for must be formualted. This includes leaving the home without support and returning to the home drunk. 19/12/2009 Care Homes for Adults (18-65 years) Page 27 of 30 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 3 12 12 The manager must ensure 19/03/2010 that arrangements are in place for the education, care and occupation of the people at the home. Individuals needs for leisure, occupation and education must form part of the care planning process. 4 18 15 The manager must prepare a care plan as to how individuals health and welfare are to be met. The manager must ensure that where personal care needs are indetified, they form part of the care plan and included is the way the individual is to be prompted by the staff. 31/03/2010 5 21 13 The manager must make arragements for the safe handling of medications. Medication profiles must be devised for people on regular prescribed medications. Within the profiles the name of the medication, its purpose and side effects must be included. 26/12/2009 Care Homes for Adults (18-65 years) Page 28 of 30 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 6 23 13 The manager must make arragements to prevent people bieng harmed or being places at risk of harm or abuse. To then protect people from abuse, the manager must review the Safeguarding Adults and Whistleblowing procedures. 26/01/2010 7 42 23 The manager must comply 26/12/2009 with Regulatory Reform (Fire Safety) Order 2005. Fire risk assessments that assess the potential of fire in the premises must be conducted so that preventative measures can be taken to reduce the level of 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 6 The progress of the care plans must be monitored monthly by the staff at the home, this will ensure that where needs change the delivery of care can adapted Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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