Care Home: Westbourne Care

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What the care home does well People living in the home showed signs of well being. They were interested in our visit, they wanted to show us their belongings and tell us about what they had been doing. People made comments that they liked the home such as `I have lived here a long time I like it.` People had very good relationships with the staff, we saw people asking staff about concerns they had (broken glasses), discussing their interests (football, wrestling and Doctor Who) without any reservations. The home has been improving care plans and looking at how they can make these more about the individual person. Included in this improvement was the development of a hospital plan which the person takes with them when they go to hospital. This helps the medical staff because it states how the person shows that they are upset or in pain, how they communicate, what foods they like and so on. Staff acknowledged people`s ethnic background, culture, religion, sexuality and disability differences and needs in these areas are met. People are assisted to understand their feelings and this includes managing their feelings following the death of a person that lived in the home. People attend day services and activities arranged and have leisure equipment such as TVs, music centres and computers in their rooms and this helps to ensure that people feel occupied. The medication was given out as the doctor prescribed it and people have regular check up appointments with the GP, opticians and so on; this helps to keep people well. People have the opportunity to raise concerns in a meeting held weekly. There is also a chance to speak to a member of staff privately if they want. People are helped at that meeting to make healthy choices of meals and choices of leisure activities. The home is warm, clean, comfortable and homely. There are the appropriate checks of the building to ensure that it remains safe for people. A large number of the staff in the home have completed a National Vocational Qualification level 2 in care. This means that staff have had training about caring for people. There was a desire amongst the manager and staff that the best interests of the people living in the home should be served. What has improved since the last inspection? One side of the home has had the stairways redecorated and carpeted and we saw that there was an intention for the other side of the home stairways to be refurbished soon. There has been an improvement on infection control in the home. There is now a sluice washing machine, which handles any soiled laundry. The Food Standards Agency has rated the home 5H, which means that it has an excellent standard of food hygiene. The fridges and cookers in the homehave been replaced. What the care home could do better: Where people have short term or new needs the home should develop a care plan and a copy of this plan needs to be kept with the other plans. There needs to be a review of the homely medication process to ensure that each person can safely have any homely medications held in the building. The home needs to assure itself that a person can effectively use any `as required` medications if they have them. If the medication has not been used for some time the need for it should be reviewed. All staff files should contain evidence that a Criminal Records Bureau enhanced check for this home has been undertakeneven when the check itself has been destroyed. This is to ensure that people are safe to work in the home and the home has evidence of checks for inspection. Some staff training needs to completed in more timely way. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Westbourne Care 53-55 Stockfield Road Acocks Green Birmingham West Midlands B27 6AR     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jill Brown     Date: 0 2 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Westbourne Care 53-55 Stockfield Road Acocks Green Birmingham West Midlands B27 6AR 01217644231 01217644231 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr J Wilson,Mr Philip White care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Residents must be aged under 65 years. Date of last inspection Brief description of the care home The service provides care and accommodation to eleven people who have a learning disability. The building comprises two adjoining three storey houses of traditional style, which have been converted to form separate but adjacent accommodation. People are accommodated over all three floors of the premises and offers both single and double rooms. Although the buildings are adjacent people have chosen to occupy each house separately in terms of females and males. The communal facilities have therefore been duplicated in both households consisting of lounge, dining room and kitchen. Communal bathing and toilet facilities are provided throughout. The premises are close to local bus and rail links. Westbourne offers people a choice of recreational facilities including television, radio, DVD and video. Most people have these in their own rooms. Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 11 Brief description of the care home There is also an option to be connected to cable television in their rooms at their own expense. To the rear is a large, mainly lawned garden with some shrubs and potted plants. This area forms a popular recreational area where people from both houses can spend time together. There is also a green house in which some people enjoy growing plants. Access within the home for those with impaired mobility is problematic, the home does not have a shaft lift between floors. The current fee rate was not available we understand that there is wide range of fees as a number of people have lived at the home for a long time. Fees do not include the costs for Chiropody, hairdressing, transport, clothes or meals out. When all service users go out for an activity the home subsidises the expenses for this. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: We visited the home without notice on a day in April 2009 and undertook a key inspection where we looked at the majority of the National Minimum Standards. The home gave us information in an Annual Quality Assurance Assessment (AQAA) before the key inspection. The AQAA shows how the home rates their performance in the areas set out in this report. During the inspection two peoples care was case tracked, this involves looking at all the records about this person and how the home manages their care. We spoke to almost all the people living in this home. Some of the people have some difficulties communicating verbally. We looked around parts of the building and viewed the health and safety checks that Care Homes for Adults (18-65 years) Page 6 of 30 had been undertaken. We spoke to 2 staff and the manager of the home. We have received no complaints about the home before we inspected. The home was last inspected in April 2007. What the care home does well: What has improved since the last inspection? One side of the home has had the stairways redecorated and carpeted and we saw that there was an intention for the other side of the home stairways to be refurbished soon. There has been an improvement on infection control in the home. There is now a sluice Care Homes for Adults (18-65 years) Page 8 of 30 washing machine, which handles any soiled laundry. The Food Standards Agency has rated the home 5H, which means that it has an excellent standard of food hygiene. The fridges and cookers in the homehave been replaced. 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 set out 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 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is available to people considering the service and this is coninuing to be developed so it is accessible to all people. The service has a process that ensures that information is collected about peoples needs and that people can experience the service. This ensures that people can choose the service and the home can decide whether they can meet their needs. Evidence: The home has a service user guide and statement of purpose available. We were shown drafts of these which they hoped would be more accessible to people that may be considering the home. The home has been using widget, a picture or symbol language to pass information on, however this has become complicated and not as useful as they hoped. The home has had no new people admitted since the last inspection in April 2007. Previous inspections found that the home had enough information to give to people. There was an admission procedure that states that people should visit the home a Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: number of times and have a trial period of a month before they had make the decision whether the home would suit them. People living in the home have been at the home for some years. People seen on the inspection were happy with the care they received. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assisted to be involved in their plans of care and these enable them to have the lifestyle they wish. Risk assessments are completed to enable people to undertake activities and have their care delivered safely. Evidence: Each person has a written care plan and two of these were looked at in detail. Information had been collected in the past about peoples background, life history, food preferences and social interests. All areas of diversity had been considered by the home and this meant that peoples cultural, sexuality, religious and disability needs were being acknowledged and where possible met. Some information had been collected more recently about what makes a good day for the person and this, with what makes a bad day for the person, can help the home ensure that people have good experiences. Information was available about how people communicate. We found a number of plans had been rewritten showing that the home were reviewing Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: and trying to improve the standard of care planning. One care plan looked at was in the middle of this process. One person had recently had a hospital admission and the tasks that needed to be undertaken about the persons catheter care was not in the care plan however instructions were found on a chart in the persons room. The care plan should be the place for all information about a persons care as everyone knows where the information is. If it is practical for part of the plan to be elsewhere this should be a copy. During the inspection we found that all the people that we spoke to were welcoming and were observed to be smiling, showing good eye contact and other signs of well being. A number of the people living in the home wanted to talk to us about their interests and their day to day life. Risk assessments were found for all activities undertaken and these had been regularly reviewed to ensure that risks were minimised as far as practically possible for protection of people from injury. Key workers complete a monthly update and include information about the persons satisfaction with the support provided for them. People made positive comments about the services they receive such as, I have lived here a long time I like it. More importantly people in the home were seen to be confident in how they talked with staff, we saw one person talk about what they wanted doing with their hair, another about their glasses being broken, others about the next football match and their plans for a holiday this year. People have a meeting held weekly where they choose activities that may not be on their programme. Staff make the necessary arrangements for the request to be fulfilled. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home make choices about activities and meals and this promotes individuality and independence. A wholesome and varied diet is offered and individual requests are catered for. Evidence: A large number of people at the home attend day services; one person spoken to was spending their time with these services working in gardens another person was spending time on a drama production. One person was working in a charity shop a number of days per week. People spoken with showed that they were happy with the activities they were undertaking during the day and have the opportunity to plan further activities at the meetings. Care plans outline peoples interests which helps new members of staff. People had leisure facilities within their bedrooms; for example one person had a desk Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: on which they could create jewellery. A mixture of computers, televisions and music centres were found in peoples rooms. It was clear that peoples interests were encouraged, people told us about their interests of wrestling, Doctor Who, football and music. People have the ability to lock their rooms if they wish. At the last inspection the home had information available to staff about diversity such as religious, ethnic and disability diversity. This was still available and assists staff to meet the diverse needs of the people living in the home. People were helped to maintain relationships with their relatives and people were able to have visitors if they wished. People within the home choose the food they are to eat at a weekly meeting. What people eat is recorded. Some of these recordings were sampled and we found that people were offered choice and healthy choices. For example lunch time provision when people go to day services consisted of a sandwich, fruit and yoghurt. People are guided to choose for a main meal 1 vegetarian, 2 fish and 4 meat per week. The manager stated that they were guided by a dietician that this was a easy way to try am maintain a balance of meals for people living in the home. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home have the benefit of regular contacts with health professionals as well as assistance when they are ill and this helps to maintain their well being. People receive medication as prescribed and this maintains their health. People are assisted to express their concerns about ageing and dying and this helps their wellbeing. Evidence: Care plans have a dedicated section for health that includes the Health Action Plan. The health action plan contained information about peoples medical conditions and how they affect the person. It showed when people had contact with health professionals to maintain their health as well as contacts when the person was not well. The file looked at showed that the person saw health professionals about their epilepsy and the GP for a medication review and to ensure the persons health was good enough to do a fitness course. The person had access to a chiropodist and an optician. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: People have been provided with a hospital book this is to help health professionals should the person be admitted to hospital. This information in the hospital book includes how to communicate with the person, how they show pain and they are upset, food they like and dislike and health information such as the person has seizures. In one example the date of the last seizure had not been updated and the home should look at this to find a method that makes this possible. There was a clear documented procedure for the ordering, checking, storage, administration and disposal of medication. The home has a homely medication agreement with the GP. This agreement needed reviewing and consideration given to it being specific per person. The drug trolley had peoples daily money stored inside, it is important that access to the drug trolley is only when prescribed drugs need to be administered to ensure good control. Checks of medication against the administration records were correct. One person has been prescribed a medication to be given in an emergency it was on the trolley and the person had a supply. This has not been used for a long time and should be reviewed with the GP and if appropriate an assessment carried out to ensure that the person still knows how it is to be used. Staff talked to were clear about medication processes. People in the home are encouraged to talk about their feelings about ageing and death. A person living in the home sadly died since the last inspection and the home are to hold a memorial for them. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have good access to times and people to raise their concerns. The home has policies and procedures in place to ensure that peoples safety is maintained. Evidence: The commission and the home have not received complaints about how this service provides care for people. The home had at the last inspection pictorial complaints procedure for people they have tried to develop more procedures but have used widget and this makes the communication over complicated. People living in the home have access to a meeting every week and time every week to talk individually to a member of staff about any concerns they may have. This means that small complaints can be dealt with before they escalate. We talked to the manager about methods of pulling this information together so it can help the home with continual improvement. The homes adult protection policy was seen at the last inspection and was considered appropriate. In the daily records there was incident described that should have been discussed with the persons social worker. There have been no concerns for some time as there has been no contact since the incident with the person. We looked at how the home manages peoples money and found that money held for people is checked on daily basis and this helps to ensure that mistakes are found Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: quickly. There are receipts kept for money that is spent. People in this home contribute towards cable TV and the internet and towards the homes transport where they pay a portion of the petrol costs. One person paid for an item that which was due to a health condition and this should be provided by the home. The home could not demonstrate that the appropriate checks were being completed before staff were employed (See staffing section). Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is comfortable, clean and homely. People are encourage to have belongings that are impotant to them in their rooms. Evidence: The home is in two converted houses that have been linked. Each house has its own lounge, dining room, kitchen bathroom and bedrooms. Generally women tend to live one side and men the other but they are encouraged to mix. The homes annual quality assurance assessment (AQAA) said that fridges and cookers in both houses had been replaced. The carpet on the stairway in 55 and a shower have been replaced and doors in 53 in 55 have been revarnished. The manager could show the owners plans to have 53 stairway redecorated and carpeted. People have very individually styled rooms that reflect their interests. (Please see Lifestyle section) Rooms were comfortable and suited to peoples needs. One person had moved to another room since the last inspection so their needs could be met better. In one bedroom there was some staining on the ceiling that suggested that water had leaked on to it and it is recommended that this investigated to prevent problems in the future. Some rooms had shower cubicles in these are not in separate facilities and consideration should be given to screening of these facilities to preserve Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: the privacy and dignity of people living in the rooms. A recommendation made at the previous inspection to have a washing machine with a sluice cycle had been met. The home had had a visit from the Food Safety Department and received an excellent award for their hygiene and food storage measures in the homes kitchens. Staff have training in health and safety and this means that staff are aware of issues within the building that may cause risks to people. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The process of recruitment does not ensure that people employed are safe to work with vulnerable people. There are enough staff to provide care for people living in the home. Staff have the appropriate training but some training to update skills is delayed and this may mean that people do not have the benefit of staff with the current knowledge. Evidence: We took 4 weeks of rotas away for analysis and found that there are usually 3 staff on the early shift and 3 staff on the afternoon shift and one staff member on awake night duty and one on sleep in duty. The managers hours were not recorded on the duty rota we had but the home has since confirmed that they did not give us the working version. On occasions on the version we had there were not 3 staff available in the afternoon but the third staff member arrived later at 5pm. There appeared to be enough staff to meet the day-to-day needs of the people in the home. The homes AQAA said that the staffing level is maintained with a reserve bank of known staff so people have a consistency of staff working with them. We looked at the files of four staff working in the home and found that although had a Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: process of recruiting staff that included application forms, references and required checks they were not up to date with current practice. The home were accepting Criminal Record Bureau (CRB)checks undertaken by other agencies and could not evidence CRBs for 2 people. It is important that these checks are completed by the home in a timely way to ensure that people are cared for by people who are safe to work with vulnerable people. The home has before this report has been finalised applied for all the relevant CRBs and are now aware how this the CRB forms can be destroyed with enough evidence retained to meet the requirement. The homes AQAA stated that all staff have completed at least an NVQ2 or equivalent and the files sampled suggested that this was the case. The homes AQAA said that they could do better in the recording of supervisions and fire training. It said that they needed further training in Moving and Handling. We received a copy of the homes training matrix and found that the home had arranged update training in Moving and Handling and first aid in May 2009. A large number of people had received training in Fire safety at the beginning of the year. Staff had recent training in safeguarding and this helps to ensure that people are kept safe. Some people in the home use Makaton signs and training needed to given to staff to update them in this method of communication. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clearly run with the best interests of the people living there at its heart. However further checks were needed in the recruitment of staff and clarity in safeguarding to ensure that people were not put at risk. Evidence: The homes AQAA states that the registered manager has completed the Registered Managers Award the recognised course for people managing care homes. She has also completed The National Vocational Qualification Level 4 in care, which looks at the needs of people using the service. Throughout the inspection she showed that she was able to manage the demands of the day to day running of the home. Staffing recruitment and records needed improvement to ensure they meet the current requirements. We have been given assurances that the remedial action needed has been undertaken. The AQAA was completed in sufficient detail for it to be used as a review of the service the home provides and as part of the action plan for future improvement. The providers visit the home regularly and produce a report of this visit. From these Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: reports we could see that they talk to people living in the home, the manager and staff. There is information that shows that they have looked at the environment and what plans they have to undertake routine repairs. The home surveys professionals and relatives of people regularly and uses this information to improve the service. We looked at the most recent surveys and found one professional survey and surveys from relatives saying that the service was good. People living in the home have the opportunity of a group session weekly to say if they are unhappy about anything and there is an opportunity given at this time for them to speak to a member of staff on their own. We looked at the health and safety records for insurance, gas, electrical and fire safety and found that certificates were available to say that these services had been checked. People living in the home are involved in fire drills and this means it is more likely that people will respond well in case of a fire. The home said that they undertake fire checks weekly but these were not always recorded. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 34 19 You must ensure all staff 31/07/2009 have a Criminal Records Bureau enhanced disclosure. Each Criminal Records Bureau enhanced dislosure must have the home as the place of work. A record should be kept of the date of any disclosure, the number and whether it is free from any convictions. This is to ensure that staff are not employed should they pose a risk to vulnerable people. 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 7 Where people have short term or new needs, a copy of the plan to meet these should be kept in the care plan documentation, so it reflects the total care for the person. An as required medication should be reviewed to ensure 2 20 Care Homes for Adults (18-65 years) Page 28 of 30 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 that it is still required and can be used appropriately by the person if needed. 3 4 20 20 The homes medication trolley should only be used for the storage of medication. Homely medication kept by the home should be reviewed with the GP to ensure that it is safe with other medications the person is using. Any concerns that may have a safeguarding element should be discussed with social services and a record kept to ensure that ehanced monitoring if necessary can take place. The home should consider methods of screening shower facilities in peoples bedrooms to ensure that peoples dignity and privacy is not inadvertently compromised. Records that demonstrate that the homes checks of fire safety must be completed. 5 23 6 26 7 42 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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. 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