Care Home: Springfield House

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What the care home does well The service provides an excellent environment in which to live and each person is provided with a large modern en suite bedroom. The living areas are spacious, modern, clean and comfortable. The gardens proved a safe outdoor environment. Comprehensive assessments are carried out prior to admission to ensure assessed needs can be met. The home has a proactive approach to consulting people in the home to identify their aspirations and personal goals. The home provides a range of activities, social and leisure events that meet the needs of the people using the service. Staff work hard to achieve personal goals where possible. What has improved since the last inspection? There were no requirements made at the last inspection. What the care home could do better: Staff training must improve and requirements have been made to ensure this. Moving and handling, fire safety, adult protection, first aid, challenging behaviours and person centred planing are all in need of updating. Care plans need to be reviewed and made relevant but user friendly. Currently they are too bulky and important information may be missed. When information and/or risk assessment are reviewed the out of date information needs to be archived . The care plans must be relevant and current. Systems need to be developed to ensure health care needs are recorded appropriately, recorded and acted upon. The organisation must fulfil its obligations to external safeguarding agencies at all times. Systems need to be developed to ensure that staff have read and understood the homes policies and procedures. All staff must receive structured supervision from staff that have been appropriately trained at least six times a year. This needs to be planned and recorded. Key inspection report Care homes for adults (18-65 years) Name: Address: Springfield House 81 Epple Bay Road Birchington Kent CT7 9EW     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: Sue McGrath     Date: 1 2 1 0 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 31 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 31 Information about the care home Name of care home: Address: Springfield House 81 Epple Bay Road Birchington Kent CT7 9EW 01843842574 01843847134 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.achuk.com Aitch Care Homes (London) Ltd care home 10 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 10. 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 Springfield House is located in a quiet residential area of Birchington in Thanet Kent, and is well suited for the purpose of young adults having ready access to a shopping centre, mainline services and community facilities. The home is registered for up to 10 adults with a learning disability. All of the 10 bedrooms at Springfield House are single and have en-suite baths, showers or wet room facilities. The house has been newly refurbished to a very high standard, with a large spacious lounge, separate dining area, visitors room and kitchen that is easily accessible to Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 10 Brief description of the care home residents with or without support. The garden is very spacious and includes a centrally heated summerhouse that is used as a sensory room. The home has its own people carrier which is able to carry seven passengers. The fees for this service range between £1380 and £2000 per week. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and regulations and that the outcomes are promoting the best interests of the people living in the home. The actual site visit was carried out by 1 inspector over the course of 1 day. We (the Commission) spent time touring the building, talking to some of the people living in the home and relatives where possible. We also spoke to the manager and staff and reviewed a selection of assessments, care plans, medication records, menus, staff files and other relevant documents. Prior to our visit an Annual Quality Assurance Assessment (AQAA) had been sent to us within the required time limit. The AQAA is a self-assessment, required by law. This assessment focuses on how the service considers they are meeting the outcomes of Care Homes for Adults (18-65 years) Page 6 of 31 the people using the service and where it feels it can make improvements. It also provides statistical information about the service. Information from the AQAA has been used in this report where appropriate. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Care Quality Commission (CQC) to be able to make an informed decision about each outcome area. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. At all times the manager and staff were helpful and demonstrated a pro-active approach to ensuring that service users were being supported to the best of their abilities and resources. This report contains evidence and judgements made from observation, conversation and records. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 31 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 31 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. People considering living in the home have sufficient information on which to make an informed decision as to whether the home will meet their needs. Comprehensive pre admission assessments ensure individual needs and aspirations are taken into account when determining the suitability of the placement. People living in the home have the security of an individual written contract detailing fees and terms and conditions with the home. Evidence: The home has a Statement of Purpose on its website and is currently developing a pictorial edition for use by the people who live in the home. The manager explained how the organisation has its own referral team which completed the initial assessment of any prospective person wishing to move into the home. This was in addition to the referral paperwork submitted by the relevant care manager. Following the referral, a transition period based on the individual needs of Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: the individual person takes place to ensure the suitability of the placement. Each person has the opportunity to choose a key worker to assist them in settling in and in planning future activities and events. Care pans evidenced documentation in support of the above procedures. The home is currently full with three people on their waiting list. The manager confirmed that people living in the home with a permanent placement had an individual written contract detailing fees and terms and conditions with the home. Care Homes for Adults (18-65 years) Page 11 of 31 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. People living in the home are mainly supported in making decisions about their lives and their assessed and changing needs, but the manner in which this information is recorded may cause confusion and mean staff have the potential to use out of date information. People in the home are supported to take risks as part of an independent lifestyle but again the recording of risk assessments needs to be reviewed. People living in the home can be confident that information about them is appropriately handled. Evidence: Three individual care plans were viewed and were very detailed but often bulky and not user friendly. Most people had between 5 and 6 individual files and this was considered as excessive. A lot of the information had been superseded by more relevant information and assessments, but these were often difficult to find and could Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: easily mean that staff would read out of date information. This issue was discussed with the manager who realised the problem with this overload of information. The manager agreed to review the files and to keep the relevant information and risk assessments in one file and to archive any information that was no longer relevant. Some areas of the care plans, such as death and illness, were poorly completed and several such as gender preference for cares had not been completed. The manager again produced information showing how behaviours and responses to given activities were recorded and analysed monthly to inform care plans. The manager confirmed that episodes of challenging behaviours had dropped drastically recently. All information was seen to be securely stored in the managers office. Staff were aware of confidentiality in the home. Care Homes for Adults (18-65 years) Page 13 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are offered a wide range of activities that meet their social, leisure and educational needs both within the home and the local community. The rights of people in the home are respected. People in the home are supported in maintaining appropriate personal and family relationships. People living in the home enjoy a varied and balanced diet that is of their own choosing. Evidence: The care plans viewed and further discussion with staff confirmed that a wide range of activities were offered to the people in the home. These ranges from educational Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: course to improve life skills to social activities. Three people attended college for music, maths and drama, two attended Thanet College for cooking and arts and crafts and two went to Canterbury College. Leisure activities included ten pin bowling, swimming, garden community projects, music lessons, and visits to local public houses. One person demonstrated his skills he had learnt on his full sized drum set in his room. A music therapist visits the home monthly and also an outside activities organiser comes in twice a week to arrange games and craft session. He also arranges outside activities including walks in the park and on the beach and treasure hunts. The home has recently looked for other ways to improve the lives of the people there and these include finding a website for people with learning disabilities very similar to facebook and they are hoping to start using this soon. People living in the homes are supported to carry out domestic chores and are encouraged to keep their own personal rooms tidy. The home has moved its visitors room to the front of the house and this had proved popular with the people in the home and their relatives. The home has the use of two cars/ people transporters and this enables easy transport to activities. This year 3 people went for a holiday to Haven Holidays in Hastings, 2 went to the Isle of Sheppy in a holiday camp and 2 went on a camping holiday specifically designed for people with learing difficulties. For the people who would not benefit from a holiday away from the home, days out were arranged and these included trips to Drusillas Zoo and a local wildlife park. The home often uses Widget which is a pictorial learning aid. Evidence was seen in the kitchen that staff had prepared widget recipes for people to follow. All the menus were in pictorial format and some areas of the kitchen had widget pictures indicating what was in the cupboards. The quality of the food was also viewed and it was found to be good quality branded food. One person who completed his own shopping had purchased a basic range but this was only for his own consumption. All other frozen foods were branded makes. The manager explained that one person liked to make instant whip type desserts and here they normally used cheaper brand as often the dessert was spilt and was not eaten by anyone. The menus seen looked varied and the manager confirmed the people in the home had a choice over their food. Residents accompanied staff on shopping trips to purchase food and make daily choices as to the Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: meals they wanted. Some participated in the preparation and cooking. Evidence seen in care plans and daily logs confirmed that people were encouraged to maintain contact with relatives and friendship and relationships were also promoted. Care Homes for Adults (18-65 years) Page 16 of 31 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. Health needs are met and service users have full access to all professional health care services as required. Whilst people benefit from detailed care plans some areas of the plans and some records need to improve. The peoples welfare was protected by the homes policy and procedures with regard to the handling and administration of medication. Evidence: The care plans viewed evidenced that each person was registered with a GP and had access to other healthcare professionals as required. There was also evidence that people have access to opticians and chiropody. One concern raised was in regards to the recording of any test results. Evidence was seen in two care plans that blood tests had been taken but no evidence could be found of any results. There needs to be system in place to enable staff to follow through appointments and/ or medical tests and for results to be recorded and appropriately acted upon. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: Epilepsy care was managed well with sound records maintained. The care plans included a section on ageing, illness and death but this appeared to be focussed on death only and was very basic. The home needs to expand this section to include illness and ageing. Medication was appropriately stored in a drugs cabinet within a locked medication room. The manager confirmed that only trained senior staff actually adminster the medication and that she regularly assesses their competancies. The manager also confirmed she regularly audits the medication administration records. Care Homes for Adults (18-65 years) Page 18 of 31 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 living in the home know their complaint and concerns will be listened to and acted upon. Lack of training and a lack of willingness to co-operate with safeguarding requirements means that there is the potential for people to be at risk. Evidence: The home had a clear complaints policy and procedure for the people who lived there and the staff. The AQAA confirmed that four complaints had been received this year and the manager explained these were concerns rather that full blown complaints and had all been dealt with appropriately. The manager was advised to record these appropriately as no evidence was showing in the complaints book. There is one outstanding Safeguarding Vulnerable Adults alert on the home that is currently being dealt with by Social Service Safeguarding team. Initially the organisation had not fully co-operated with investigation and the Commission had to intervene and sent a warning letter to the organisation. This refusal to co-operate with Social Services has the potential to put service users at risk and is not in line with best safeguarding practises. Training records evidence not all staff had been trained in adult protection. No staff had received any Mental Capacity Act training, although the manager was hoping to Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: source some soon. Care Homes for Adults (18-65 years) Page 20 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable and safe environment with ample personal and communal space to meet their needs. Evidence: The premises were found to be spacious with all the furnishings and fittings of a high standard. People there had their own keys to their rooms if they wished. All of the bedroom were spacious and decorated to a high standard. Each individual had their own belongings and equipment and each room was personalised to their own taste. One person had a full sized drum kit and an organ both of which he had learnt to play. This person was very happy with his room. All of the bedrooms had en-suite facilities, some with assisted baths and some with showers. There were communal toilets and a bathroom on the lower floor which were suitable for wheelchair users. Hot water controls, radiator guards and window restrictors had been fitted throughout the building. The manager confirmed the home met with the requirements of fire safety. Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: There was a large communal lounge and a separate dining room. The kitchen was modern, domestic and was clean and tidy. There was a separate laundry room with industrial equipment and sluice facilities. The visitors room had been moved to the front of the house and was pleasant and welcoming. The home had a secure rear garden with a summerhouse that was fitted up as a sensory room. There was level access throughout the ground floor with ramps onto the patio and out into the garden. The home was very clean and hygienic on the day of the inspection. Comments from families confirmed the home was always clean and tidy Care Homes for Adults (18-65 years) Page 22 of 31 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. People who live in the home benefit from the support of carefully selected staff but gaps in staff training have the potential to put them at risk of poor practise. People do not benefit from having staff who receive regular supervision. Evidence: The staff training matrix was viewed and it was noted that several areas of training had not been completed. The matrix supplied showed 15 members of staff. 10 staff had completed a one day first aid course but there were no members of staff trained to the recommended Department of Health First Aid at Work. The manager later confirmed that senior staff had been booked onto the appropriate 4 day course following the inspection. Records showed that 12 staff had completed Safeguarding Vulnerable Adults training but for some this was in 2007. 9 staff held Basic Food Hygiene certificates and only 11 staff had Moving and Handling training. Nobody had completed any Mental Capacity Act training. Another concern was that only 7 staff had completed any fire training and this was done in 2007. There was no evidence that any training had taken place in person centred planning and the manager had earlier confirmed this was in use in the home. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: Records also evidenced that 7 of the 15 staff had completed a National Vocational Qualification (NVQ) to level 2 or above, however a further 5 staff were working toward their award. 1 staff member was working toward level 3 and 3 were working toward level 4. A requirement will be made regarding the level of training to be provided. Two staff files were viewed and were found to contain all of the information required by regulation. However, the manager was reminded that this information should be available for inspection as some was stored at the companies head office and had to be faxed through during the imspection. Evidence was seen in these files that staff undertake an appropriate induction but supervision was not as regular as is required under regulation. The manager stated that supervision was not as regular as it should be. The staff rota indicated that the home employs 6 staff every morning, 5-6 every afternoon and have 2 waking nights with an on call system in operation for emergencies. The home is registered for 10 people. Care Homes for Adults (18-65 years) Page 24 of 31 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. Concerns in the senior management of the service have the potential to put service users at risk. People opinions are central to how the home develops and reviews their practise, as the home has appropriate ways of making sure they continue to get things right. The health, safety and welfare of residents and staff are promoted and respected. Evidence: There has been a new manager in post since the last inspection and she is currently registering with the Commission. The new manager is experienced in the care of people with a learning disability and who display challenging behaviours. She is also undertaking the necessary qualifications ie NVQ 4 in Leadership and Management. She showed great empathy toward her client group and this was confirmed by a relative who said she was very understanding and supportive of the people in the home and that he was very happy for his Son to be at there. Staff said she was approachable Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: and supportive. The manager was aware of the issues in the home and was working hard to address the relevant issues. The manager also stated she felt well supported by her staff and more senior management. However the recent safeguarding alert raised, in which senior management refused to share information with the safeguarding team, could have put service users at risk. The home had undertaken quality reviews and the feedback had been very positive from families and some Care Managers. The manager is currently working with other Care Managers to address some of their concerns. People living in the home were consulted on an individual basis to seek their views on personal goals and lifestyles within the home. A good standard of record keeping was evidenced in the home and the manager is now aware of the need to keep care plans relevant and current. Policies and procedures are in place and are regularly updated as required. This is normally done on an operational level. The was no evidence that staff had read or understood these policies and the home will be required to put a system in place to ensure this is evidenced. Provider visits are conducted monthly to judge the quality of care being offered in the home and a written report was available for inspection at the home. Care Homes for Adults (18-65 years) Page 26 of 31 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 27 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 The registered person shall keep the service users plan under review. In that all care plans must be reviewed and made current and relevant to the individual. 30/11/2009 2 19 12 The registered person shall 30/11/2009 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. In that a system is put in place to ensure medical checks and test results are robustly monitored and acted upon. 3 23 13 The registered person shall make arrangements, by training staff or by other means, to prevent service users being harmed or suffering abuse by being 30/11/2009 Care Homes for Adults (18-65 years) Page 28 of 31 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 placed at risk of harm or abuse In that all staff undertake Adult Protection training. 4 23 13 The registered person shall make arrangements, by training staff or by other means, to prevent service users being harmed or suffering abuse by being placed at risk of harm or abuse In that at all staff must cooperate with outside Safe Guarding Authorities requests. 5 32 18 The registered person shall 31/12/2009 ensure that at all times suitably qualified, competent and experienced persons are working in the care home. In that staff receive training in an accredited First Aid course, Moving and Handling, Challenging Behaviours, person centred planning and fire safety. 6 36 18 The registered person shall 30/11/2009 ensure that persons working at the care home are appropriately supervised. In that staff received structured supervision, from 31/10/2009 Care Homes for Adults (18-65 years) Page 29 of 31 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 staff that have been trained to do so, at least six times a year and that this is planned and recorded. 7 37 8 The registered provider shall 31/12/2009 appoint a person to manage the care home. The manager must completed her registration with the commission. 8 40 17 The registered person shall ensure that staff are fully aware of all policies and procedures within the home In that there is a system in place that evidences all staff have read and understood the homes policies and procedures. 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 30/12/2009 Care Homes for Adults (18-65 years) Page 30 of 31 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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