Care Home: The Wren

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What the care home does well During our visit the manager and staff were seen to provide personal care and support in a sensitive and flexible way that respected people`s dignity and privacy. They also encouraged them to retain as much personal independence as possible. Those living there were well groomed and appropriately dressed at the time of our unannounced visit and they appeared to be content and well cared for. Comments (contained in preinspection surveys) from relatives of people living at the home included; `the home gives a high quality of care to my relative`, `they provide safety, security and good care`, `they also provide me with support`, `always listen and provide answers to my questions`, `they take care of my relative very well`, `the staff are very caring`. What has improved since the last inspection? Some areas of the home have been re-decorated and refurbished and the way medicines are looked after at the home has improved. Staff and the manager have accessed suitable training to ensure they have the skills to care for and support people living at the home properly. Also the range of leisure and social activities available to those living at the home have increased. This has enabled them to increasingly participate with the local community. What the care home could do better: During this visit a number of issues were identified that need to be addressed to improve the quality of the service provided to those living at the home. These issues are detailed in this report. However they include the need to improve the quality of the environment, the way care records are maintained, the content of the complaints procedure, and the ways in which they check the quality of the service provided to those who live there. Key inspection report Care homes for adults (18-65 years) Name: Address: The Wren 92 Carlton Road Whalley Range Manchester M16 8BE     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: Michael Murphy     Date: 1 9 0 3 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 Wren 92 Carlton Road Whalley Range Manchester M16 8BE 01618818658 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Margaret Monteith care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home The Wren is a care home providing personal care for a maximum of eight people with learning disabilities who may also have a physicalsensory disability. The Wren is a detached property set within its own grounds. The home is three storey, with a basement area used for offices, storage and laundry facilities. The residents bedrooms are on the ground and first floors. All the bedrooms are single; three of the rooms have shower facilities. There is a kitchen and dining room on the ground floor with a lounge situated on the first floor. There is a small lounge area situated on the first floor for the use of relatives of residents when visiting. This enables the resident and their relatives to spend time together in privacy, if required. There are toilets and bathrooms situated on both the ground and first floors. These are accessible and meet the identified needs of the residents. The home is situated in a residential area in Whalley Range, within easy reach of public transport links into Manchester City Centre. The home is a family run business. The fees for the home are based on individual assessment of needs. Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 8 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection included an unannounced visit to the home on the 19th of March 2010. During the visit we talked to people living at the home, staff and the registered home manager. We also looked at documents and records the home have to keep such as care records, medicine records, written policies and other records. Before the inspection, we also asked the registered home manager to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home sees the service they provide the same way that we see the service. We felt this form provided some useful information. Care Homes for Adults (18-65 years) Page 5 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. 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 6 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 7 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A suitable process was in place for assessing people who wish to be admitted to the home. However the information about the home that is provided to those people was in need of review, updating and amendment. Evidence: We were informed by the registered manager that there had been no admissions to the home since the last key inspection in April 2009. We were told that all people who applied for admission to the home would be seen and assessed in their present setting. For example at their own home or in hospital. Their care and support needs would be assessed and they would be invited (with their supporters if desired) to make trial visits to the home. This is to ensure the home can meet the needs of new users of the service properly. The registered manager stated her pre-admission assessment would involve consultation with the persons relatives/supporters and supplement those conducted by health/social care professionals involved with the person. Care Homes for Adults (18-65 years) Page 8 of 28 Evidence: Written information has been produced by the home to assist potential users of the service (and their supporters) in making a choice about the suitability of the home for them. However (as at the last inspection) this information was seen to be in need of review, updating and amendment. In particular one of the documents refers to the CSCI (now the CQC) being involved in the determination of fees charged - this is not the case. It is also stated that people using the service will need to purchase chiropody services and wheelchairs. Whilst this is true if the service provided is on a private basis the document should also reflect such services are also provided by the NHS. The accuracy of the information in these documents is important so that people who may come to live at the home (and their supporters) are fully aware what they will be responsible for following admission. As identified in the last key inspection report in April 2009 there is still a need to produce these documents in a more suitable way for people who intend to use the service. For example in Picture, plain English or audio form. This can be of great help for people intending to use the service in making as much an informed choice as possible. Care Homes for Adults (18-65 years) Page 9 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. Whilst people using the service appear to be cared for and supported appropriately written care plans and risk assessments need to be formally evaluated more regularly to ensure that any change in their care and support needs are recognised promptly and appropriate action is taken by staff. Evidence: Each person using the service had an individual written plan of care that described the care and support they needed and what actions staff needed to take to ensure this. There was evidence that people using the service and their supporters were being consulted about the care and support being provided. However most of the care plans had been written some time ago and were not being regularly evaluated. It is important that care plans are regularly reviewed and evaluated to ensure that any changes in the care and support needs of people using the service are recognised and appropriate action taken by staff. It is strongly recommended (as a matter of good practice) that care plans are formally evaluated at least monthly. Care records contained a range of information that reflected individual peoples likes Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: and dislikes and their life history. Further information had also been gained from the relatives and friends of people using the service about their preferences. This enabled staff to provide them with appropriate support to make as many decisions about their lives as possible. Staff continue to successfully use picture prompts to ascertain individuals wishes in relation to their daily lives. For example in relation to their choice of food and what they would like to do. There was evidence in the care records that identified possible threats to a residents health and safety but these need to be developed and recorded in more detail to ensure they describe things that need to be done to keep people safe at the same time as maintaining their freedom and independence. They also need to be evaluated more regularly. Comments (in pre-inspection surveys) from supporters of people using the service indicate that they are of the view that the management and staff support their relative to make as many daily decisions in their life as is possible and safe. Care Homes for Adults (18-65 years) Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home were supported to enjoy a stimulating lifestyle and access a wide range of social and leisure activities. Residents were encouraged to make as many personal choices in their daily lives as possible Evidence: Three of the four people currently resident at the home continue to attend local authority day care centres three times per week and staff support them do so. People are also encouraged and enabled to access a range of activities in the local community. For example there are regular shopping trips both locally and into Manchester. Pub/cafe outings are popular and people at the home had recently become members of a local social club and were due to attend a folk singing night on the evening of this visit. The family and friends of people living at the home were actively involved in life at the home. People living at the home are supported by staff to go out as a group or individually. The home has access to a vehicle and also use Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: buses, trains and taxis to access outings/activities. Care records contained a range of information that reflected individual peoples likes and dislikes and their life history. Further information had also been gained from the relatives and friends of people using the service about their preferences. This enabled staff to provide them with appropriate support to make as many decisions about their lives as possible. Staff continue to successfully use picture prompts to ascertain individuals wishes in relation to their daily lives. For example in relation to their choice of food and what they would like to do. The home values and seeks to reflect the racial and cultural diversity of the people living at the home and the local community in which it is situated. Discussion with registered manager, staff on duty and responses contained within 2 returned pre-inspection surveys indicate that people at the home are supported to retain contact with their family and friends. There are no unreasonable restrictions to visiting people at the home and they can receive their visitors in private. The daily routines of the home were flexible - especially as there were only four people living at the home at time of this visit - staff were observed to promote independence and to interact positively and warmly with them, all areas of the home designated for them is accessible to people. This includes the garden areas and the home has a passenger lift and disabled ramp to the outside. The kitchen was seen to be clean, organised, fitted and appropriately equipped. It was well stocked with food. Staff and people living at the home go shopping for food ever one to two days locally. A record of meals taken is kept. Menus were very varied, balanced and provided good choice and were made from fresh produce. Mealtimes were flexible and people living at the home are provided with three meals a day - with snacks available at other times (including at supper). Staff served and assisted people appropriately with their lunch on the day of this visit. Care Homes for Adults (18-65 years) Page 13 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Proper arrangements were in place to ensure the personal health care support provided to those living at the home is consistent and appropriate. However care records need to be updated regularly to reflect this is the case. This is important to ensure residents are confident they will be cared for and supported appropriately. Evidence: During our visit staff were observed to provide personal care and support in a sensitive and flexible way that respected peoples dignity and privacy. They also encouraged them to retain as much personal independence as possible. Times for getting up, going to bed, having a bath, having a meal and other activities seemed to be very flexible especially as at the time of our visit only four people were living at the home. Those living there were well groomed and appropriately dressed (in their own clothes) at the time of our unannounced visit and they appeared to be content and well cared for. They were also supported by staff to access health care services on a regular basis. Each person had a completed health action plans in place. However these need to be completed in more detail and updated more frequently. And as stated earlier in this Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: report care plans and risk assessments need to be improved. All people living at the home are registered with a local GP and have a yearly health check. The registered manager informs us these have recently been completed for all 4 people at the home. Evidence was seen in the care records of residents being able to access medical services. Two relatives expressed the view that their relatives are being supported properly and their care and support needs were being met by the home. The way peoples medicines are looked after in the home was in the main secure and organized. However a requirement was made about the need to provide a special type of storage cabinet for certain medicines. There were policies and procedures relating to medicines at the home that ensure they are safely managed. The senior staff at the home look after the medicines and have had recent training in respect of this. Care Homes for Adults (18-65 years) Page 15 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information about how to complain needs to be reviewed, updated and produced in a more user friendly format. Suitable processes were in place to keep people safe. Evidence: Information on how to make a complaint was displayed in the home. However this document needed to be amended to include details of how to contact the Care Quality Commission if required. Also to be more informative and effective it should be reviewed to ensure people living at the home (and their supporters) are clear about each stage of the complaints process is. It is also strongly recommended that the complaints procedure is developed in a format that is suitable for the people living at the home. We were informed by the registered manager that no complaints have been received since the last inspection.The CQC have not received any complaints about the home. Responses from relatives of people living at the home indicate they know how to complain if they felt it necessary. The home operates safeguarding and whistle-blowing policies (including those developed locally and operated by Manchester social services) that seek to keep people living there safe. Staff spoken to were aware of the importance of safeguarding and protecting people at the home and described their role in doing so. They confirmed they have been provided with safeguarding training. In relation to the Mental Capacity Act the registered manager informed us that no people living at the home were subject to a deprivation of liberty authorization and Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: that no one living at the home was having their liberty deprived without authorization. No safeguarding issues have been raised with the CQC in respect of the home since the last inspection. Care Homes for Adults (18-65 years) Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the home was clean, warm and free of malodour improvements are needed to improve the quality of the environment and therefore the comfort of people using the service. Evidence: The home was clean an free of malodour on the day of our visit. The lounge areas on the first floor were clean, warm, well lit, well ventilated and adequately and comfortably furnished. These room were provided with TVs, music centres, games and other leisure equipment. People using the service appeared comfortable and content with these areas that provided ample space for the four people living at the home at the time of this visit. Peoples bedrooms (three out of the four occupied were seen) were clean and warm and personalised. We were informed these rooms had been painted since the last inspection. However some of the carpets were quite badly marked and in need of replacing. These should be (in consultation with the occupant of the room) be replaced as soon as possible. There is also a need to provide people with a lockable storage space in each bedroom. We were informed by the registered manager that new bedroom furniture had been ordered. This will benefit peoples comfort a some of the furniture seen was quite marked due to daily wear and tear. The dining room is situated on the ground floor next to the kitchen. The dining room Care Homes for Adults (18-65 years) Page 18 of 28 Evidence: was clean, warm and suitably and adequately furnished. There was also a television in this room and a music centre. There is a bathroom and WC on each floor. These rooms were clean, warm and suitably equipped and adapted. However neither of these rooms were fitted with a privacy lock. The need to remedy this in relation to peoples privacy and dignity was discussed with the manager. It was also noted that the hot water tap on the washbasin in the first floor bathroom was not working at the time of our visit. We were informed by the manager that hot water temperatures are appropriately controlled to prevent people using the service being burnt by accident. Whilst it is acknowledged that a call system (for people using the service or staff to call for help in an emergency) has never been fitted at the home we are of the view that to ensure peoples safety the need for such a system is risk assessed and kept under regular review. Care Homes for Adults (18-65 years) Page 19 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. The staffing provision, staff recruitment procedure and the staff training provided at the home seek to ensure residents are cared for and supported safely and appropriately. Evidence: The registered manager and staff spoken to on the day of inspection were of the view that staffing levels were meeting the care and support needs of people living at the home. We observed that they were being cared for and supported in a timely way. Relatives of residents told us (in our pre-inspection surveys) that their relatives were receiving good care and support from the manager and staff. The registered manager informed us that she has not needed to recruit any staff since the last inspection in April 2009. However we established that they had a proper procedure in place for recruiting new staff. This is vital to ensure, as far as possible, that residents are being cared for and supported by suitable staff. The recruitment procedure included criminal records checks and another special check regarding the suitability of the applicant to work with vulnerable people. We were also informed by the manager that any staff recruited in the future would be provided by induction training that was provided by the home and the local authority training partnership thereby ensuring that such training met the requirements of skills for care and the Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: General Social Care Council. The programme of staff training was supporting staff to care for and support residents properly. Inspection of staff training records and discussion with staff and the registered manager demonstrated that staff training (including regular updates) is organised and appropriate. Training is provided by trainers employed by the home and the local authority training partnership. 50 of the care staff have obtained a national vocational qualification in care (NVQ). The remaining care staff were undergoing this training or were expected to do so in the near future. 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. Whilst the manager was seeking to ensure the health, safety and welfare of people living (and working) at the home were promoted and protected these need to be enhanced by addressing the issues raised in this report. Evidence: The manager is registered with the CQC, works full time at the home and is supported by a senior supervisor who provides cover for her when she is off. The registered manager was seeking to ensure the health, safety and welfare of people living at the home were promoted and protected. However these can be further enhanced by addressing the issues identified in this report. Whilst the home seeks the views of people using the service, their relatives and staff the manager needs to develop a system to regularly assess the quality of the service provided at the home. This is important to ensure that people living at the home (and their supporters) are confident they are being cared for and supported by a service that seeks to constantly improve standards. The manager should conduct regular documented checks (audits) on how well the home is run and take any action required if issues are identified. For example regular checks should be made in respect of, Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: among other areas, residents medicines, how care records are maintained and the state of the environment. The arrangements for the health and safety of residents (and others) in the home were adequate and appropriate. Staff are provided with regular training in respect of moving and handling, fire safety, food hygiene and the prevention of infection. Hazardous substances were being securely stored and gas and electrical systems had been checked/certificated regularly, we were informed hot water temperatures in resident areas are appropriately controlled. Written information provided by the home manager informed us that regular maintenance and servicing of equipment was being conducted. The fire alarm system was tested regularly and staff fire drill training was also recorded. Care Homes for Adults (18-65 years) Page 23 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 24 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 1 4 That the Statement of purpose and service user guide are reviewed, updated, amended and produced in an appropriate alternative format. To ensure prospective users of the service (and their supporters) are provided with accurate information when deciding if the home is appropriate for them 30/04/2010 2 20 13 That a suitable locked metal cabinet is provided for the storage of controlled medicines To ensure controlled medicines are stored safely and securely. 31/07/2010 3 22 22 That the complaints procedure is amended to provide the contact details of the CQC 30/04/2010 Care Homes for Adults (18-65 years) Page 25 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 To enable people to contact the CQC about a complaint if desired. 4 26 16 That the floor covering is replaced in those occupied bedrooms where it is marked/stained To ensure that the floor covering provided for the person using the service is of good quality and design 5 27 23 That the hot water tap on the handbasin in the upstairs bathroom is repaired To ensure this room provides suitable washing facilities for people using the service 6 27 12 That suitable locks are fitted 30/04/2010 to bathrooms/WCs in the home To ensure the privacy and dignity of people using the service. 7 29 13 That written general and individual service user risk assessments are made in respect of the need to provide a call alarm system within the home and that those assessments be kept under regular review. 30/04/2010 30/04/2010 30/07/2010 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 To ensure people using the service and staff are confident of speedy assistance in the case of an emergency occurring Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 6 That written care plans be formally evaluated at least once per month to ensure that any changes in the care and support needs of people using the service are recognised and appropriate action taken by staff. That entries in the daily record should be timed and properly signed by staff - not just with their first name. This is to ensure such records are as accurate and detailed as possible. That written risk assessments be developed and recorded in more detail to ensure they describe things that need to be done to keep people safe at the same time as maintaining their freedom and independence. That written health action plans should be completed in greater detail and reviewed regularly to ensure that that staff are aware of peoples current health needs. That the complaints procedure is produced in a format that is suitable and accessible for people living at the home. That each person who uses the service is provided with a lockable space within their bedroom. A formal system to regularly assess the quality of the service provided at the home should be implemented. This is important to ensure that people living at the home (and their supporters) are confident they are being cared for and supported by a service that seeks to constantly improve standards. 2 6 3 9 4 18 5 6 7 22 26 39 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. 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