Care Home: The Willows

Similar services:

• Insight - Eastchurch
• Southfields
• Thorndene
• Magenta
• Seabourne House
• 33 St John`s Church Road
• Dovedale Court
• Lyncol House

What the care home does well Eight of the thirteen care staff have completed NVQ (national vocational qualification) training at level two or above. The majority of the staff team have completed all their mandatory training. In addition they have attended specialist training that has been identified as necessary to meet the needs of the residents accommodated. The home is decorated to a good standard and bedrooms have been personalised. Staff advised that they are being supported well. They have found the past few months difficult but advised that a number of positive changes have occurred as a result. One staff member said `we have direction now and know what is expected of us`. Another said `the team is beginning to bond`. What has improved since the last inspection? Two care plans have been completely reviewed and updated and amendments have been made to other care plans as changes have occurred. A new format for carrying out risk assessments has been introduced and three residents now have the new format on their files. All staff are now receiving regular supervision and staff spoken with stated that the manager is very supportive and has made a number of very positive changes since she took on the management of the home. Very thorough auditing has been carried out in relation the management of medication and where shortfalls were identified they have been addressed. Monies owed to residents as a result of changes to the way in which their DLA (disability living allowance) payments are managed are now in the process of being repaid to residents. The home now reports to the Commission all matters that are notifyable under Regulations. An independent advocate is now supporting the home with carrying out residents` meetings on a monthly basis. What the care home could do better: As a result of this inspection four requirements have been made. Similar requirements have been made previously. Whilst some progress has been made in relation to care planning, risk assessments and increasing leisure opportunities for residents, it was expected that further progress would have been made in these areas. These areas will continue to be monitored closely. The Trust must continue to monitor the home on a monthly basis, report their findings to the home and monitor the actions taken by the home to address any recommendations they have made. Continued emphasis needs to be placed on improving staff morale. Key inspection report Care homes for adults (18-65 years) Name: Address: The Willows 30a The Finches Bexhill-On-Sea East Sussex TN40 1UF     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: Caroline Johnson     Date: 2 0 0 1 2 0 1 0 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 28 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 28 Information about the care home Name of care home: Address: The Willows 30a The Finches Bexhill-On-Sea East Sussex TN40 1UF 01424732935 01424751641 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Hastings and Rother Primary Care Trust care home 6 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 6. 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 The Willows is a purpose built bungalow situated in a quiet residential area of Bexhillon-Sea, with nearby access to local amenities, bus and rail routes. The home is registered to accommodate six adults with learning disabilities, some of whom also have physical disabilities and a visual impairment. Accommodation is provided in six single bedrooms that are decorated and furnished to reflect individual tastes and interests. Communal space is provided by way of a lounge and kitchen/dining room. There is also a large conservatory that has been furnished as a sensory room. Bathroom and toilets offer the appropriate adjustments and facilities to meet the needs of the people who live there. The home has an attractive garden to the side of the Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 6 2 2 0 9 2 0 0 9 Brief description of the care home property and off road parking is available at the front of the home. The registered providers are the Hastings and Rother Primary Care Trust (PCT). The PCT also manages nine other homes within the Hastings, St Leonards and Rother area. Fees for the service range from 1331 to 1366 pounds per week for a block contract. Care Homes for Adults (18-65 years) Page 5 of 28 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: For the purpose of this report the people living at the Willows will be referred to as residents. As part of the inspection process a site visit was carried out on 20 January 2010 and it lasted from 10:10am until 16:50pm. An interim manager facilitated the inspection. During the visit there was an opportunity to meet with and observe the majority of the residents in their surroundings. Time was also spent talking with staff generally in the course of their duties and time was spent with two staff members in private. Three care plans were examined in detail. Other documentation seen included: - staff rotas, training, menus, health and safety, quality assurance and leisure activities. Following the last inspection of the home in September 2009 a warning letter was sent to the Responsible Individual (RI) detailing the Commissions concerns regarding the poor rating given as a result of the inspection. A detailed improvement plan was requested and received, outlining how the Trust was intending to improve standards in Care Homes for Adults (18-65 years) Page 6 of 28 all areas. The registered manager is on extended leave and in his absence an interim manager has been appointed to manage the home. This manager is currently registered in respect of another home run by the Trust. She is assisted by another member of senior staff who is also working in the home on a temporary basis. This is the second key inspection to be carried out in this year (2009/10). It should be read in conjunction with the report carried out in September 2009 as not all standards were assessed on this occasion. Care Homes for Adults (18-65 years) Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Care Homes for Adults (18-65 years) Page 8 of 28 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 28 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 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that they can meet the assessed needs of the residents accommodated. Evidence: The homes statement of purpose is currently under review. Each of the residents has been given a copy of the homes service user guide. Since the provider took on ownership of the home in 2008 there has been no licence agreement in place. It has been reported that there is a draft document in place but due to a number of changes that will occur in the forthcoming months there are a number of areas that need further clarification before the document can be finalised. It was agreed that in the interim the current document should be amended to reflect the current position. Prior to the last inspection the Registered Social Landlord gave notice of termination of their contract and they no longer carry out this role. The Trust is continuing to look for a new housing association to take on this role and there are interim arrangements in place until this can be arranged. Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: There have been no new admissions to the home since the last inspection. All but one of the residents has had a social care assessment completed in recent months and this is currently underway for the remaining resident. Care Homes for Adults (18-65 years) Page 12 of 28 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 care plans that have been updated provide detailed information about the needs of the residents and the actions required by staff to ensure that they are met. Evidence: At the time of the last inspection a requirement was made to include up to date information in care plans about the assessed needs of the residents and how they are to be met. It was confirmed that two care plans had been completely updated and that amendments had been made to the other four care plans in relation to changes that have occurred since the last inspection. In relation to the two care plans seen that had been updated it was noted that they included more detailed advice and guidance and that where professional advice and guidance had been obtained this had been incorporated into the care plans. The Trust are now using an updated format for risk assessments known as ramp 11. It was confirmed that four assessments had been completed and had been sent to the head office for ratification. One had been returned and was in the relevant case folder. Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: Two included minor amendments that needed to be made and they were located in the office. Prior to sending the draft report out the manager confirmed that the updated risk assessments for these two residents had been completed and they were now in the relevant folders. Minutes of review meetings (referred to by the home as the PCP(person centred planning meetings) were not up to date on two of the files seen. In a third the minutes had been removed as another meeting had just been held and the minutes were being typed up. The manager confirmed the day following the inspection that in relation to the two care plans seen review meetings had been carried out during the year and that the updated minutes were now in the files. Some of the review meetings were out of date but dates have been set to ensure that they are held as soon as possible. A local advocate is now helping to chair residents meetings. Two meetings have been held. The first meeting was held jointly with the staff meeting and it was felt that residents meeting should be separate to the staff meeting. The home is continuing to explore with the advocate how the best outcomes can be achieved. Care Homes for Adults (18-65 years) Page 14 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Work needs to continue to ensure that residents are involved in a greater variety of stimulating and fulfilling activities. Evidence: There was a record in each of the residents files detailing the activities that they have participated in. Regular activities include staff reading to residents on a one to one basis, observing meal preparation, observing laundry, sensory sessions such as hand and feet massage, spa baths and trips out to cafes and restaurants. Staff stated that they try to ensure that residents are taken out every day and they make full use of their location by taking regular walks on the seafront. It was noted that some of the residents had been to a show in London the week prior to the inspection. One resident had been to a club the week prior to the inspection. A staff member spoken with stated that they are going to give all the residents the opportunity to try out this club to see if they would like to go on a regular basis. Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: Staff have been asked to look at a range of activities locally and to make arrangements to take residents to try out the activities. Activities that will be tried include swimming and bowling. The manager advised that arrangements are also going to be made invite a few aromatherapists to visit individual residents to see if they would benefit from a session and to see if residents relate to one aromatherapist better than another. One staff member stated that activities are sometimes not able to happen if there are not enough drivers on duty. A support and activity record is maintained and recording of this has improved greatly since the last inspection. There are better descriptions of the activities that residents are doing and how residents have responded during the activity. It is acknowledged that some planning has begun so the residents will have increased opportunities to participate in activities however a lot of work is still required to make this a reality for the residents. Care Homes for Adults (18-65 years) Page 16 of 28 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. Better auditing of the systems in place for ensuring that the healthcare needs of residents are met have assisted in raising standards in this area. ensuring that key information is located correctly would assist this further. Evidence: The arrangements in place for the management of medication in the home were examined in detail. It was noted that two separate external audits have been carried out in recent months in an attempt to improve how medication is managed in the home. A few recommendations were made to the home as part of this process and these have generally been addressed. For a period of time two staff were responsible for the administration of medication for each drug round but this has now been reduced to one staff member. A daily stock audit is carried out. The storage of medication seen was in order and record keeping in relation to medication administered was also in order. All staff receive training on the administration of medication and before they are allowed to administer medication they must have completed a competency assessment. The manager advised that training had been provided to managers the day prior to the Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: inspection on how to assess competency. Following the last inspection the weighing scales was repaired and a record is now kept on a monthly basis of each residents weight. Records showed that residents are support to attend a range of appointments for specialist advice and support. It was noted in relation to the two care plans that have been updated, that specialist guidelines have been incorporated into the care plans. In relation to one individual the outcome of specialist appointments were not included in the care plan but were found located in a folder in the office. Each of the residents has a health action plan in place. However of the three care plans seen, none contained the most up to date plan. Care Homes for Adults (18-65 years) Page 18 of 28 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. There are systems in place to ensure that anyone who wishes to make a complaint can do so. Evidence: It was reported that there have been no complaints since the last inspection of the home. There have been three safe guarding referrals since the last inspection. The investigation of these referrals is still ongoing. Staff spoken with were clear about the adult protection procedure and it was noted that all staff have had up to date training on the subject. A staff member spoken with stated that the manager had provided staff with training on the Deprivation of Liberty standards (DOLS)and that they found the session very informative. Care Homes for Adults (18-65 years) Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained and decorated to a good standard. Evidence: These standards were not fully inspection on this occasion. However it was noted that all areas seen during the inspection were clean. Twelve of the staff team have had training on infection control. the manger reported that new flooring would be fitted in the hallway and corridors. As it will take two days to complete this task arrangements are being made for this to be carried out in February 2010. Care Homes for Adults (18-65 years) Page 20 of 28 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. Residents are benefiting from the measures being taken to ensure that all staff are clear about their individual role and responsibilities. Evidence: There are three care staff on each shift and the managers hours are worked in excess of this. It was reported that there were 1.84 whole time equivalent hours vacant at the time of inspection. An appointment has been made to the full time post but this is subject to satisfactory recruitment checks being carried out. Agency staff are currently used to cover the vacant hours. It was reported that the home have a regular team of agency staff that are called upon as needed. Eight of the staff team have completed a National Vocational Qualification (NVQ) at level two or above. There were a few gaps noted in the provision of mandatory training but in most cases arrangements had been made for staff to be booked on refresher courses. Since the last inspection all of the staff team have had at least two formal supervision sessions. Staff advised that work has been carried out to ensure that everyone is clear about each others role and responsibilities and that further work is to be carried out in relation to this at planned team away days. Care Homes for Adults (18-65 years) Page 21 of 28 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. Recent improvements to the way in which the home is managed are beginning to benefit the residents and the staff. Continual monitoring is still required to sustain progress in the long term. Evidence: At the time of this inspection there were interim management arrangements in place and these are due to be reviewed in February 2010. The interim manager is registered with the Commission in relation to another service within the Trust. Another senior staff member from the PCT is also temporarily working in the home on a full time basis to support the interim manager. The manager advised that when she took up position in mid December her line manager initially visited the home on a weekly basis to provide support and this has recently changed to monthly support. They also have regular contact via telephone and monthly supervision is provided. Staff meetings are held regularly and detailed minutes were seen in respect of two Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: meetings. Other meetings had been held but the minutes had not been typed up at the time of the inspection. The manager confirmed that a staff team building day is being planned to be held in March 2010. Staff spoken with stated that they find the new manager very supportive. They stated that the last few months have been unsettling and it has been a very difficult time but that as a consequence of the changes improvements were being made. One staff member said we have direction now and know what is expected of us. Another said the team is beginning to bond. Staff confirmed that morale has been very low but the gradual positive changes are slowly helping to improve this. One staff member stated that they hope that the improvements can be sustained. It was noted that Regulation 26 visits that are required to be carried out on a monthly basis by the Responsible Individual or a representative on their behalf had not been carried out since the last inspection. However, the week prior to the inspection a visit was carried out and the second half of that visit was being carried out on the day of the inspection. Action points raised as a result of the last visit carried out in September relating to record keeping in August were almost completed. The manager confirmed that a new procedure has been put in place by the Trust to ensure that these visits are now carried out on a monthly basis. A new format for recording the findings of these visits has also been put in place with tighter timescales for ensuring that reports are sent to the home and for ensuring that action points are addressed. At the time of the last inspection it was reported that the procedure for carrying our surveys of the views of the residents had not been carried out this year. This remains the case. This was discussed with the operations manager who confirmed that there is no capacity within the senior management team to undertake this task at present. In the absence of this the home needs to look at alternative ways of seeking the views of the residents in relation to the care they receive. A range of auditing is carried out and records were in place to show that this had taken place in relation to medication, the management of finances and infection control. The manager confirmed that a health and safety audit had also been undertaken but the report was not available at the time of inspection. As required at the last inspection the home is now reporting to the Commission all matters notifyable under Regulations. At the time of the last inspection a requirement was made in relation to ensuring that monies owed to residents were repaid. It was confirmed on the day of inspection that the monies owed had been retrieved and that the cheques were now ready to be collected and lodged into individual residents Care Homes for Adults (18-65 years) Page 23 of 28 Evidence: accounts. Care Homes for Adults (18-65 years) Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 25 of 28 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 Regulation 15(1,2b) The registered person must ensure that all care plans are updated to include information about the assessed needs of the residents and how they are to be met. Residents must know that their assessed and changing needs are reflected in their care plans. 31/03/2010 2 9 13 Regulation 13(4a,c)The registered person must ensure that risk assessments be reviewed and where appropriate new risk assessments put in place following a change to the needs of residents. The risk of accidents and harm happening to residents and staff must be minimised. 31/03/2010 Care Homes for Adults (18-65 years) Page 26 of 28 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 12 16 Regulation 16(2mn) The registered person must ensure that residents are given regular opportunities to participate in meaningful and fulfilling activities. Residents must be enabled access to a variety of activities in line with their individual assessed wishes/needs. 31/03/2010 4 39 26 Regulation 26 The registered 31/03/2010 provider must ensure that unannounced visits are carried out on a monthly basis and that they accurately reflect what is happening in the home and there must be evidence to show how action points have been addressed. A copy of these reports must be sent to the Commission. So that the service is regularly audited. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 27 of 28 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. Care Homes for Adults (18-65 years) Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!