Care Home: Terrance House

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What the care home does well Terrance House provides accommodation for up to 55 people with mental health problems in Margate, Kent. The home benefits from a relatively stable and experienced staff team. Service users are encouraged to maintain their independence and take decisions on a daily basis affecting their own lives. Both residents and staff commented on the relaxed and friendly atmosphere in the home. Prior to admission service users needs are assessed and they are offered trial stays in the home to enable them to make an informed choice. There is a day centre for the service adjacent to the home that provides a range of activities for service users and other activities are organised in the home including visiting entertainers and trips out. Healthcare issues for service users are well managed and it was reported that the home receives good support from health and social care professionals. Medication issues are well managed and the facilities are suitable for the needs of the home. The home has a complaints process in place and there was evidence that complaints have been dealt with appropriately. There have been no adult protection alerts related to the home in the past 12 months. Staffing rotas showed evidence that sufficient care staff are on duty at all times to meet the needs of the service users. Good recruitment practices are followed and all new staff work through a competency based induction programme with in their first 6 weeks of employment. A supervision structure ensures that staff receive the support that they require, which was confirmed by staff spoken to and records maintained. The health and safety of the service users is protected and evidence was available to show that all required checks have taken place and service certificates gained. The home conducts audits of key health and safety issues on a regular basis. What has improved since the last inspection? The home have reviewed and updated all individual service user files, which provide clear guidance to enable staff to meet the assessed needs of service users. The plans are reviewed regularly and the key worker structure promotes the involvement of service users in this process. There is evidence that the home have responded to comments made regarding the food. Service users are involved in the menu planning process and commented that the meals in the home are of good quality. Aspects of the environment have been improved including some redecoration and carpeting in areas of the home amongst other things. The organisations own quality monitoring processes have been introduced and include monthly reports and surveys. What the care home could do better: 2 requirements and 4 recommendations have been made as result of this inspection process. Discussions were held with the organisations Estates Manager who acknowledged that there is work to be completed on the premises and that an action plan has been developed identifying the planned improvements. It is required that the organisation completes the work identified with this plan within appropriate timescales. The examination of the staff training matrix demonstrated that some staff have not received updated mandatory training and other courses relevant to their roles. A discussion was held with one of the training managers who outlined changes to the way this is organised and delivered. It is required that all staff receive the training that they require to fulfill their duties. Recommendations were made in relation to reviewing and updating the service user guide, expanding the scope of surveys within the quality monitoring processes and ensuring that the manager applies for registration with the Commission. Key inspection report Care homes for adults (18-65 years) Name: Address: Terrance House 7-21 Belgrave Road Margate Kent CT9 1XG     The quality rating for this care home is:   two star good 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: Joseph Harris     Date: 2 9 0 9 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 29 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 29 Information about the care home Name of care home: Address: Terrance House 7-21 Belgrave Road Margate Kent CT9 1XG 01843220715 01843231639 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Terrance House Care Ltd care home 46 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 46 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: Mental disorder, excluding learning disability or dementia (MD). Date of last inspection Brief description of the care home Terrance House is a 46 bedded service supporting people with mental health issues. The home is owned by the High Meadows group, which has 8 other services in the South East of England. The house is located in the town centre of Margate, Kent a short walk from the seafront and shopping district. There are good public transport links to and from the town. The home has a car park to the rear of the home and a small garden area. The Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 46 1 9 0 9 2 0 0 8 Brief description of the care home premises are arranged over 4 floors and comprise of 6 former terraced houses converted into one home. Their is a shaft lift connecting all of the floors, but due to the layout of the service it is not suitable for people with significant mobility problems. The home has a day centre attached to the service and the organisation training department in an adjacent building. The scale of fees and charges are included within the service user guide and are available on request from the manager of the home. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection process culminated in a site visit to the service by Regulatory Inspectors Joe Harris and Anne Butts on 29th September 2009. The site visit commenced at 10:00 hours and lasted for approximately 6 hours. Prior to the site visit a range of documentation was examined including the Annual Quality Assurance Assessment (AQAA) completed by the home. The AQAA provides a summary of what has changed in the service over the past 12 months, areas of improvement and issues that require improvement. The AQAA also contains statistical information about the service. Other records examined included the past key inspection report, notifications received from the home and any information from other sources. During the site visit a tour of the premises was conducted and discussions were held with a number of senior managers for the High Meadows group, the deputy manager, staff and service users. No visitors were present and available for interview at the time of the visit. Care Homes for Adults (18-65 years) Page 6 of 29 Records and documents were examined relating to service users, staff, medication, training and health and safety amongst other things. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: 2 requirements and 4 recommendations have been made as result of this inspection process. Discussions were held with the organisations Estates Manager who acknowledged that there is work to be completed on the premises and that an action plan has been developed identifying the planned improvements. It is required that the organisation completes the work identified with this plan within appropriate timescales. The examination of the staff training matrix demonstrated that some staff have not received updated mandatory training and other courses relevant to their roles. A Care Homes for Adults (18-65 years) Page 8 of 29 discussion was held with one of the training managers who outlined changes to the way this is organised and delivered. It is required that all staff receive the training that they require to fulfill their duties. Recommendations were made in relation to reviewing and updating the service user guide, expanding the scope of surveys within the quality monitoring processes and ensuring that the manager applies for registration with the Commission. 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 9 of 29 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 10 of 29 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. Service users are able to make an informed choice about moving into the home and their needs are assessed. Evidence: The home has a statement of purpose and service user guide and these documents have been updated to reflect the change in ownership of the service. The service user guide, although providing a brief summary of the facilities and expectations of the home, would benefit from being reviewed and further updated. The current guide has a number of policies and procedures included which are not necessarily appropriate for introductory information. This also makes the guide difficult to read and does not focus on what prospective service users need and want to know about the home. Refer to recommendation 1. The home has an established pre-admission assessment process in place. 4 new service users have moved into the home since the last inspection and the records of two of these individuals were examined. In both cases the home had completed their own in-house assessment form and had received care plans and background information from care managers. One or two senior members of staff visit the Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: prospective service user in their current accommodation prior to the initial trial visit. Once it has been identified that the home should e able to meet the individuals needs they are invited for trial visits to the service. These are arranged on a flexible basis and are designed to provide an induction into the home for the service user and as part of the assessment process. Following admission the individual is subject to a three-month trial period after which a multi-disciplinary review is held to discuss the placement. Care Homes for Adults (18-65 years) Page 12 of 29 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. Individual needs and choices are assessed and planned for. Evidence: Three individual service user plans were examined all of which have been recently updated and redesigned. The individual files are kept in an organised and logical order. Plans of care address all key areas of assessed need and have been developed in good detail ensuring that staff have clear information to be able to meet service users needs in a consistent manner. Residents are involved in the development of the plans of care and sign them to show that they have read and agreed them. The plans are reviewed and updated as required on a monthly basis. Complex areas of need are further addressed using management strategy plans kept at the front of the folder. A preliminary risk assessment is completed for all service users and any medium or high risk areas are linked to the plans of care providing clear guidance to ensure the levels of risk are minimised. The risk assessments are developed in a positive manner promoting responsible risk taking. There is evidence of review. Service users confirmed that they are able to make choices affecting their daily lives. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: All people spoken to said that they have access to their personal allowances when they wish and are able to choose their daily routines. Care Homes for Adults (18-65 years) Page 14 of 29 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. Service users have a lifestyle that suits their needs. Evidence: The home offers a good range of organised activities for the service users differing needs. There is an attached day centre that is attended on a regular basis by a number of residents. The centre offers a variety of activities including those focusing on skills development. Other events are arranged in the home every week including quizzes, bingo and trips out using the homes minibus. An aromatherapist visits frequently, which has reportedly proved to be very popular and a music for health session is brought in monthly. Outside entertainers also visit the home on a periodic basis. Service users are free to spend their time as they wish, organising their own routines and accessing the nearby town centre and facilities of Margate. Staff are available to support residents in the community if they require it. A priest visit frequently to hold a Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: service for 3 Roman Catholic service users and it was stated by the deputy manager that the needs of people of other faiths are catered for should they wish to attend their own places of worship. A number of residents commented on the relaxed atmosphere in the home and the range of activities. One person said, Ive lived in a few homes and this is most definitely the best. Another resident said, I get on well with all the staff, we can have a laugh and joke. The home has a full and part-time cook and menus are planned in conjunction with service users needs and wishes. Special diets are catered for and advice sought where appropriate. A record of meals is maintained that show evidence of a healthy and balanced diet. The home has taken on board comments made from feedback by residents with regard to the choice of meals and portion sizes. The cook stated that all of the kitchen equipment is in good working order and that the food budget is appropriate for the needs of the home. This was in evidence with a sufficient range of fresh and good quality food in stock. One resident said, The food is very good, Ive no complaints. I had ham and chips today, it was very nice. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and healthcare needs of service users are met. Evidence: The personal care needs of service users are addressed within the plans of care and clear guidance is provided based on individual preferences and requirements. Residents confirmed that staff are respectful of their needs and that they have good relationships with all staff members. Interactions observed were positive and staff communicated and related with residents in a relaxed and respectful fashion. Healthcare records are maintained and show evidence of the outcomes of appointments with healthcare professionals. The home reported that they receive good support from General Practitioners and local community mental health services. All residents are registered with local GPs and receive regular visits or input from other healthcare professionals as required. The service monitors the health needs of service users and refers any concerns appropriately. Service users are encouraged to be as independent as possible in relation to their healthcare needs, but staff support service users to medical appointments as required. Residents have access to complimentary healthcare services such as chiropodists, opticians and dentists. An aromatherapist also visits the home regularly. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: Medication administration records were examined and all were seen to be well maintained and up to date. The home retains records of returned and destroyed medication as well as any controlled drugs in use. The home liaises with responsible medical officers to ensure that medications are reviewed as required. The storage facilities in the home are suitable for purpose and medication was seen to be stored in an orderly and organised fashion. There is appropriate CD storage and the dedicated medication room is maintained at a recommended temperature. Staff administering medication have received medication training, but it is recommended that this training is reviewed to ensure that these staff have the required information and competencies to carry out their duties. Refer to recommendation 2. Care Homes for Adults (18-65 years) Page 18 of 29 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. Service users views are listened to and acted upon and they are protected from abuse. Evidence: The home has a complaints process in place. The procedure has recently been updated and contains all relevant information. However, the copy on display in the home had not been updated and the deputy manager agreed to change this. Service users spoken to said that they would feel comfortable raising any concerns or complaints with staff. It was stated that the majority of issues are dealt with on an informal basis. There has been one official complaint since the last inspection and evidence was available to show that this had been dealt with appropriately. A record of complaints is maintained and the outcome of any investigations recorded. The home has policies and procedures in place relating to abuse awareness and adult protection protocols. Information relating to the Mental Capacity Act is available in the home. The majority of staff have received training covering adult protection issues and the Mental Capacity Act and senior staff have completed courses addressing the Deprivation of liberty safeguards. There have been no adult protection alerts raised in connection with the home since the last inspection. Care Homes for Adults (18-65 years) Page 19 of 29 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 premises are suitable for the needs of the service users. A planned programme of redecoration and refurbishment is in place. Evidence: A tour of the premises was undertaken and the home is suitable for the needs of the service users. A discussion was held with the estates manager of the organisation who outlined work that has been completed and planned improvements to the environment for the future. It was acknowledged that areas of the home would benefit from redecoration and refurbishment. It was stated that there is a projects team attached to the organisation and an improvement plan has been developed. Parts of the service have been redecorated and re-carpeted and the garden area has been improved. An used part of the home is due to be refurbished to create a supported living service. The estates manager stated that planned works have been completed slower than anticipated due to other priorities within the group. Refer to requirement 1. Service users expressed satisfaction with the environment in general, stating that there is a comfortable atmosphere in the home and that they are able to personalise their bedrooms as they wish. One person said, I like the home, theres space to get away and have some private time if i wish. The home was clean and hygienic on inspection and the laundry and kitchen facilities are suitable for the needs of the service. It was reported that all equipment is in good Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: working order and the home meets the requirements of the environmental health and fire safety departments. Hazardous substances are stored securely and universal precautions are in place to minimise the spread of infection. Care Homes for Adults (18-65 years) Page 21 of 29 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. There is an experienced, well supported staff team in adequate numbers. Staff training requires some updating. Recruitment processes are adhered to. Evidence: Over 50 percent of the staff team have achieved at least a National Vocational Qualification in care at level 2. Training records demonstrated that only 4 staff are yet to achieve this objective. Discussions were held with a number of staff on duty all of which demonstrated a good understanding of the needs of the residents and the service in general. All newly employed staff work through an induction programme. This covers issues specific to the service and a structured induction based on the Common Induction Standards. Completed examples of these were examined. The organisations training department is located in a building adjacent to the service and a discussion was held with a member of the training staff. The staff training matrix was examined, this demonstrated that whilst many of the staff have received the required mandatory training a number of gaps were evident. Some staff have received the required training, but they have not received refresher training within the required timescale. Refer to requirement 2. Some service specific training has been provided covering topics such as mental health awareness, diabetes, the Mental Capacity Act and dementia care. Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: Three staff personnel files were examined all of which contained all of the required information including evidence of CRB checks, two written references and proof of identity. A full employment history is gathered prior to employment and any gaps in this explored. Staff rotas for the current and previous two weeks were examined and demonstrated that there are sufficient staff on duty at all times for the needs of the service users. The home operates with 4/5 care staff throughout the day in addition to the manager, deputy manager, welfare officer and a range of ancillary staff. There are 3 waking staff on shift throughout the night. There is a staff supervision structure in place based on a cascading system. Staff records showed that staff receive regular formal supervision and annual appraisals. Care staff spoken to stated that they feel supported in their duties and that they receive the training that they require to fulfill their roles. Care Homes for Adults (18-65 years) Page 23 of 29 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 is well managed in the best interests of the service users. Evidence: The manager was not present at the time of the site visit. It was reported that she is currently working towards her NVQ level 4/Registered Managers Award. She has been in the role of manager for approximately 18 months, but has not yet applied for registration with the Commission. It was stated by a senior manager that the service manager is intending to apply for registration in the near future. Refer to recommendation 3. Both staff and service users were positive about her management style and stated that she provides good support and leadership in the home. There is a clear management structure within the service and she is supported by a deputy manager and a welfare officer who have clearly defined roles. The organisation has developed quality monitoring processes that include monthly monitoring reports, in-house health and safety audits and annual surveys of service users and relatives. The most recent feedback exercise did not include surveys being sent out to visiting professionals, it is recommended that feedback is sought from all stakeholders in the service. Refer to recommendation 4. Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: Documents and records relating to health and safety issues were examined. Service safety certificates including those for gas safety, electrical wiring, portable appliance testing and equipment maintenance had been completed and were up to date. Fire safety records are well maintained and completed and a record of all accidents retained. The service keeps us informed of any untoward occurrences in the form of regulation 37 notifications. Policies and procedures are in place relating to safe working practices. It was reported that the home meets legislation in relation to environmental health and fire safety. Care Homes for Adults (18-65 years) Page 25 of 29 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 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 24 23 (2) The registered person 05/12/2009 shall having regard to the number and needs of service users ensure that (b) the premises to be used as the care home are of sound construction and are kept in a good state of repair externally and internally; (d) all parts of the home are kept clean and reasonably decorated. To continue to update the environment in accordance with the company action plan. 2 35 18 (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users (c) ensure that the persons employed by the registered person to work at the care 06/12/2009 Care Homes for Adults (18-65 years) Page 27 of 29 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 home receive (i) training appropriate to the work they are to perform including structured induction training. To ensure all staff receive up to date mandatory training. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 1 20 To review and update the service user guide providing an informative and easy to read prospectus of the home. To ensure that all staff administering medication receive suitably detailed training and have the required competencies. The manager to be put forward for registration with the Commission. To further develop quality monitoring processes to include feedback from all stakeholders in the service including professionals. 3 4 37 39 Care Homes for Adults (18-65 years) Page 28 of 29 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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