Care Home: Ravenhill Way, 240-242

What the care home does well The AQAA had been completed and confirmed to us that the service were aware of their strengths and weaknesses and had a plan for the coming year that would continue to improve the lives of those living and working at Ravenhill Way. A comprehensive needs assessment was undertaken before a prospective resident was offered a place at the home. The people using the service were empowered to make decisions about their lives. Talking to residents, and from the responses in the questionnaires, it was apparent that people made decisions about their lives and that their decisions were supported by the staff. The residents were comfortable in the home and knew much about the running of it. Staff appeared to understand confidentiality and had spoken to the residents and recorded their wishes for sharing information with various agencies and individuals. We spoke to a couple at the home who felt happy pursuing a relationship within the home. Staff working at this home were committed to enabling residents to develop or maintain their skills, social lives and relationships. The home had built good links with health staff and would support people living at the home to make healthy choices. The home had an open culture that allowed residents to express their views and concerns in a safe and understanding environment. Residents told us they felt safe and were well supported by the staff team. Residents also had access to an external advocate. The lay out and design of the home allowed for small clusters of people to live together in a non-institutional environment. The home was clean, tidy and homely. The home worked to clear health and safety policies. Staff were aware of the policies and knew how to put theory into practise. What has improved since the last inspection? Since the last inspection arrangements must be made to ensure safety valves were fitted to all hot water taps used by people in the service. This was done immediately following the last inspection as required. People were being encouraged not to smoke in many areas of the home to protect against the risk of fire starting. The recruitment procedures ensured that all staff had been correctly checked and had all the necessary references before they were offered employment. The recording and administration of medication had improved. What the care home could do better: Requirements and recommendations made as a result of this inspection are included in this report. They include:Information provided for residents must be current and in a format that is suitable for them to understand. The service must ensure that plans of care and risk assessments include all of the needs of a person using the service and are kept under review. There should be evidence that people using the service are involved in the day to day running of the home. Controlled drugs must be stored in the correct cabinet. There must be evidence that staff have the skills and expedience to provide the care and support expected of them. Consideration must be given to the staff complement to cover planned activities. Key inspection report Care homes for adults (18-65 years) Name: Address: Ravenhill Way, 240-242 Lewsey Park Luton LU4 0XZ     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: Sally Snelson     Date: 3 0 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: Ravenhill Way, 240-242 Lewsey Park Luton LU4 0XZ 01582477145 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): ravenhillway@together-uk.org www.together-uk.org Together Working for Wellbeing Name of registered manager (if applicable) Type of registration: Number of places registered: care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Ravenhill Way Care Home provides accommodation for ten adults with mental health problems. The provider is Together Working for Wellbeing and the owner of the property Aldwyck Housing Association. The building consists of two houses linked together by a conservatory with five single rooms available in each house. Each house has separate facilities, lounge/diner, kitchen, bathrooms and toilets. There is a shared garden with patio area to the rear. The houses both have four floors with no lift. The home is situated next to a small shop in a predominately residential area with local amenities and public transport routes near by. There is parking available to the side and front, shared by the shop. 0 9 0 1 2 0 0 9 10 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: This inspection was carried out in accordance with the Care Quality Commission (CQC)policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection was a key inspection, was unannounced and took place from 09:15hrs on 30th November 2009. The managers post is currently vacant. The previous manager had recently accepted redundancy and left the role with very short notice. Since when a member of staff, Care Homes for Adults (18-65 years) Page 5 of 30 Tina Broadhurst, had taken the responsibility for running the home supported by the service manager. During the inspection the care of two people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. We also looked at recruitment, training health and safety documentation, medication records and food planning as well as touring the building. Any comments received about the home, plus all the information gathered on the day was used to form a judgement about the service. Four service users had completed surveys, and the acting manager and service manager had completed an AQAA in advance. We would like to thank all those involved in the inspection for their input and support Care Homes for Adults (18-65 years) Page 6 of 30 What the care home does well: What has improved since the last inspection? Since the last inspection arrangements must be made to ensure safety valves were fitted to all hot water taps used by people in the service. This was done immediately following the last inspection as required. People were being encouraged not to smoke in many areas of the home to protect against the risk of fire starting. The recruitment procedures ensured that all staff had been correctly checked and had all the necessary references before they were offered employment. Care Homes for Adults (18-65 years) Page 7 of 30 The recording and administration of medication had improved. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 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. Documentation available to people using the service was not kept up-to-date. A comprehensive needs assessment was undertaken before a prospective resident was offered a place at the home. Evidence: The statement of purpose available stated it was 2008-2009 but did not have a specific review date. We were aware that much of the information was out of date. For example it referred to the registered manager who had left the service more than a 12 months previously and included names of staff that no longer worked for the service. The acting co-ordinator was not aware of a service users guide and had not provided a prospective resident with any such documentation. There had been no new admissions to the service since the last inspection. However in order to assess the standard about admissions assessments and to met the requirement made at the last inspection we were able to sample the assessment made on a prospective resident for the vacancy in this service. The documentation Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: supported that staff were aware of the needs of this person and he/she had started to have visits to the home and to met the residents. It was expected that a permanent move would take place after the Christmas holiday. In the files we sampled we saw contracts between the resident and Maca, (the name of the service provider before it became together) and between the resident and the housing association. These documents had not always been signed and dated so we were unsure if the residents were aware of the contracts and indeed if they had a contract with together. Care Homes for Adults (18-65 years) Page 11 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. The people using the service were empowered to make decisions about their lives but further development was needed to ensure clear and consistent information was recorded in their care files so that consistent care was sure to be provided. Evidence: We looked at the care plans, referred to by the service as support plans, for two of the residents. There were plans for most aspects of care. In some cases they had been written in detail, but in the main they needed to be built upon to provide the necessary instructions to ensure care and support would be provided consistently, particularly when staff did not know the resident well. Hand written notes suggested that some of the plans were being reviewed and that goals were being considered. However most of the paperwork, had not been dated and signed, but simply gave the date it was effective from so it was not always possible to know when it had been written and if, and when, it needed to be updated or reviewed. It was apparent that some plans of support had not been reviewed in the last six months. The regulations state that care plans must be reviewed at least six monthly. We discussed the need to Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: show that plans had been reviewed even when no changes were made. The acting coordinator confirmed that she and the company were aware that the care plans needed to be worked on and that the company were in the process of introducing a mental health recovery plan which would be person centred and focus on moving the resident forward. There was no evidence in the current plans that they had been written with the involvement of the resident. Talking to residents, and from the responses in the questionnaires, it was apparent that people made decisions about their lives and that their decisions were supported by the staff. The residents were comfortable in the home and knew much about the running of it, but were not directly involved in the development of the home. Again the acting co-ordinator told us that they were considering involving residents in staff meetings and staff interviews, but this had yet to be put in place. People living in the home were being supported by staff to take risks. Appropriate risk assessments were in place, but once again if they were not kept under review and accurately documented they were not meaningful. For example a risk assessment suggested that a resident should have staff to support her when out, but we were told she was now able to leave the home unaccompanied and this document had not been updated. Staff appeared to understand confidentiality and had spoken to the residents and recorded their wishes for sharing information with various agencies and individuals. We spoke to a couple at the home who felt happy pursuing a relationship within the home. Care Homes for Adults (18-65 years) Page 13 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff working at this home were committed to enabling residents to develop or maintain their skills, social lives and relationships. Evidence: The nine people currently living at the home participated in a variety of different courses and interests according to their preferences. The home had developed a guide to whats on the area and there were posters around the home advertising events within, and outside, the home. On the day of the inspection we spoke to one resident who was going to a day centre, a couple who were attending the gym, as well as two people who chose to stay in the home. One of these had the opportunity to go out but had chosen, in view of the cold weather, to remain at home. Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: As already discussed two of the residents lived as a couple at the home and others had regular contact with family and friends. The company supported, by providing staff and money towards the cost, excursions out and holidays, if this is what the residents wanted. The home ran as two units and the four or five residents in each unit got together to decide menus and who was cooking when. One resident said We have our own day to cook and we choose what to have. It was confirmed that an alternative meal was always available, if the rest did not like the chosen menu. Two of the residents were given a budget, known as the self catering budget from which to provide their lunch and main meal. There was information throughout the home about healthy eating. All the residents had access to the kitchen and could make drinks and snacks as they wanted. Occasionally one of the kitchens was closed at night but access to the other was easy and acceptable to the residents we spoke to. As at the last inspection we were concerned that the ratio of staff to residents would not allow for more than one resident to be supported to go out at a time. However from talking to people and case tracking the residents we did not see any evidence that people using the service had to forego activities or events because staff were not available to support them. Care Homes for Adults (18-65 years) Page 15 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 home had built good links with health staff and would support people living at the home to make healthy choices. Medications procedures were adequate but needed to provide a better audit trail. Evidence: At the time of the inspection there were nine people living at Ravenhill Way. None of the residents needed assistance with care continually, but many needed prompting and intermittent support. At the time of the inspection none of the people using the service had nursing needs. In the past when people had nursing needs the community nurses had supported these. Community Psychiatric Nurses (CPNs) were frequent visitors to the home and staff had good relationships with them, and the GPs, and consultants, involved in residents care. Staff encouraged people to regularly attend health screening and health appointments, including opticians and dentists. Staff correctly reported accidents and incidents and these were reviewed, for audit purposes, by the area manager on a regular basis. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: The medication policy described how people would initially be assessed to self medicate. Currently no one was completely self-medicating but some people were able to administer certain of their medications, or be supported to manage their medications. The medication record sheets (MAR) in the home were well kept, but because of the way medications were signed into the home it was not possible to provide a clear audit trail. We were concerned that the controlled drugs held in the home were not stored in an appropriate way according to the guidelines of the Royal Pharmaceutical Society of Great Britain. The controlled drugs were double locked in a safe but this did not comply with the guidance but did not put people under immediate risk. Care Homes for Adults (18-65 years) Page 17 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had an open culture that allowed residents to express their views and concerns in a safe and understanding environment. Residents told us they felt safe and well supported by the staff team. Evidence: Four of the people using the service had returned questionnaires to us. They all told us that they knew who to speak to if they were not happy, and how to make a complaint. We saw copies of the complaints procedure around the home and believed residents had enough information to receive the correct help. We had not received any complaints about the home since the last inspection; there had been one complaint made directly to staff and this had been appropriately dealt with and we could see from the investigation process that lessons had been learnt. Discussion with the acting manager confirmed that she was aware of the need to document any complaints and also to document the investigation process that was undertaken when dealing with a complaint. Residents also had access to an external advocate. The home had a safeguarding policy and the acting co-ordinator was able to answer questions about the safeguarding processes. Staff attended regular safeguarding training updates and the safeguarding of vulnerable adults was part of the induction process. We saw evidence that staff had supported a residents who did not want to receive a Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: visitor who called at the home. Each file included a pro-forma that could be used if a resident was missing and the police needed to be involved. Money held by the home on behalf of residents was checked and found to be correct and appropriately held and used. Care Homes for Adults (18-65 years) Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lay out and design of the home allowed for small clusters of people to live together in a non-institutional environment. The home was clean, tidy and homely. Evidence: With the exception of on-going maintenance and decoration there had been no major changes to the environment and the comments made and the last inspection remained appropriate. The service consisted of a two storey building that was spread across two homes joined together by a conservatory. The environment appeared homely and comfortable and people spoken to said they were happy at the home. Peoples bedrooms are furnished to reflect individuality. The lounge and dining rooms were welcoming and they were decorated to ensure a homely environment could be maintained. One resident showed us his bedroom and told us he was satisfied with the cleanliness of it. He told us the cleaner would do his room, or he could do it himself, which he chose to do. Staff told us that if necessary they would support a resident to maintain an acceptable standard of cleanliness. Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: The AQAA told us that Staff had received training for Infection Control & COSHH, health and safety and Swine flu Pandemic Plan. There was an antibacterial hand wash in all communal hand washing areas and appropriate signs were displayed reminding staff and residents about good hand hygiene. There was a cupboard where chemical cleaners could be locked away. Residents told us that they had set times to use the laundry but this could be flexible if needed. During the tour of the building we noted that a blind was missing from one of the bathrooms. Staff told us that this was in the process of being replaced. A couple who chose to use one bedroom told us that they chose to keep the second bedroom as a bedroom although they had been offered it as a lounge. Care Homes for Adults (18-65 years) Page 21 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were clear regarding their roles and what was expected of them. People using the service reported that the staff working with them knew what they were meant to do, and they were satisfied with the care and support they received. Evidence: Staff within the home had roles according to their experience. A key-worker system was in operation to support individual residents. The AQAA advised us that the home employed nine care staff and one cleaner to care for the nine residents. There were a minimum of two staff on duty during the day and a waking and sleeping staff member at night. On the day of the inspection one carer was on duty with the acting co-ordinator.This carer went out with one resident on a pre-planned trip. We had been told that additional staff were used to cover busy periods. All of the staff team had completed an induction course and done some additional training which was documented in their personal file. The acting co-ordiantor told us that she was updating training records so that it was easier to see what training staff had done and were to do. There were some gaps in the specialist training completed by the staff. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: A variety of different training methods were in place including on-line training. One member of staff had completed the train the trainer course and was used to cascade trsining and updates. The acting co-ordinator told us that staff meetings could be used as training sessions. Two staff files were sampled and it was apparent that staff had been recruited correctly and had not started work until all the appropriate checks and references had been undertaken. During the inspection we were unable to locate the application form for one of the carers but we did see all the other documentation. Staff commented that they wished to try and encourage service users to become involved in the recruitment process. Recently all staff had been receiving regular supervision that was recorded. Care Homes for Adults (18-65 years) Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home worked to clear health and safety policies. Staff were aware of the policies and knew how to put theory into practise. Safeguarding was given high priority and the home provided a range of policies and guidance to underpin good practise. Evidence: The company has gone through a period of re-structure and at the same time the registered manager left her position. A senior carer was currently acting into the role, but did not want to be considered for the position, which was being advertised. The acting manager referred to as the acting co-ordinator was competent in her role and was well supported by the service manager. The staff on duty were obviously supportive of the current management arrangements and worked well as a team. Quality assurance questionnaire were sent out regularly by the company. We were told that each home received an individual report of the evaluation. We had to remind the home to send us there AQAA but when it arrived it was a Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: complete document that indicated that the service had plans and knew what they needed to do to make improvements. The staff team had weekly meeting and as already mentioned these could be used as a training opportunity. The service manager regular visited the home and supported the staff team. The acting co-ordinator told us, we embrace change. Staff were aware of the Mental Capacity Act 2005 deprivation of liberty safeguards. Policies and protocols were in place and an easy read copy of the codes of practise were available for the people using the service. The acting co-ordinator stated that she was reviewing policies and procedures as they were discussed, but she was aware that a new manager would want to make some procedural changes. Health and safety checks were routinely carried out and a resident was encouraged to support this process. Care Homes for Adults (18-65 years) Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 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 1 4 This refers to regulation 4,5, 01/01/2010 and 6 Information provided for residents must be current and in a format that is suitable for them to understand. This is so that people using the service are aware of what is provided and their contribution to the service. 2 6 14 This also refers to Standard 9 and includes Regulation 15. The service must ensure that plans of care and risk assessments include all of the needs of a person using the service and are kept under review. This is to ensure that a consistent standard of care and support is provided and 01/01/2010 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 that this care ands support meets the needs of the person using the service. 3 20 13 Controlled drugs must be 01/01/2010 stored in the correct cabinet. The controlled drug cabinet must comply with the current regulation and guidance of the Royal Pharmaceutical Society of Great Britain. 4 32 18 There must be evidence that 01/02/2010 staff have the skills and expedience to provide the care and support expected of them. This ensures that the staff team can provide the necessary care and keep themselves updated. 5 33 18 Consideration must be given 01/02/2010 to the staff complement to cover planned activities. This is to ensure that there are always sufficient staff on duty 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 8 There should be evidence that people using the service are involved in the day to day running of the home. Page 28 of 30 Care Homes for Adults (18-65 years) 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 2 34 Staff files should include the application form. 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. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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