Inspection on 03/11/09 for Haven Lodge Care Home

This is the latest available inspection report for this service, carried out on 3rd November 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haven Lodge Care Home 18/12/06

Haven Lodge Care Home 31/01/06

Haven Lodge Care Home 05/07/05

Haven Lodge Care Home 08/03/05

Haven Lodge Care Home 07/12/04

Haven Lodge Care Home 04/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Haven Lodge Care Home 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rebecca Shewan     Date: 0 3 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 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 30 Information about the care home Name of care home: Address: Haven Lodge Care Home 2 Alexandra Street Sherwood Rise Nottingham NG5 1AY 01159621675 01159109879 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Wesley John Stala care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The 3 named service users be accomodated within the establishment. A Variation must be submitted to CSCI for any additional out of category service users. Date of last inspection Brief description of the care home Haven Lodge is a three storey converted, semi-detached building, offering accommodation for up to eleven (11) people with mental health problems, two (2) of whom are now over 65 years of age. (The registration has been amended to reflect that these individuals can be accommodated for as long as their needs continue to be met). The home is situated in a mixed residential and office area, a short distance from the city centre. There are good transport links in the area. The care home accommodation is on two floors with no lift access to the second-floor, this may pose difficulties for persons with physical mobility problems. There are eleven (11) single bedrooms, a variety of communal facilities and there is a garden area to Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 3 11 1 1 0 2 2 0 0 9 Brief description of the care home the rear of the building and paved area to the front of the building. The current range of fees (on the date of this report) are £331 per week. Potential new people find out about the service by word of mouth, placing authorities, healthcare professionals and by contacting the management of the home. 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: This unannounced inspection took place during the morning and afternoon of the 3rd November 2009. Incident reports and the homes Annual Quality Assurance Assessment (AQAA), held by the Care Quality Commission, were read before the inspection. The AQAA that was sent to us by the service is a self-assessment, which focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The inspection of the home took seven hours. A tour of the home was undertaken and the Administration Manager, two staff and four people who use the service were spoken with. The main method of inspection we use is called case tracking, which involves us Care Homes for Adults (18-65 years) Page 6 of 30 choosing three people who live at the service and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Records such as care plans, staff files and medication records were also viewed. Nine people were accommodated at the home at the time of the inspection. The Care Quality Commission (CQC) referred to as we throughout this report, also conducted surveys of staff and people who use the service. The responses received were generally positive in many of the aspects of care and provisions provided. Comments from surveys have been incorporated into the body of this report. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? There is an up to date Statement of Purpose and Service Users Guide in place, which inform people who use the service of the provisions provided. There is an assessment of all the needs and expectations of people using the service, which ensures that needs can be addressed and met by the home. Care plans have been rewritten in order to demonstrate exactly how peoples needs are to be met. Accurate identification and response to risks to the health or safety of people using the service are appropriately assessed and recorded, whilst unnecessary risks to health or safety of people are identified and so far as possible eliminated. There is a duty roster of persons working at the care home in place and a record of whether the roster was actually worked is also maintained, in order to ensure that the home is appropriately staffed at all times. In order to safeguard the people accommodated at the home, staff working at the care Care Homes for Adults (18-65 years) Page 8 of 30 home are recruited after all appropriate checks have been conducted. To allow staff to conduct their roles efficiently, staff training has been improved with a full record being kept of any training attended. In order to ensure that medication errors do not occur, there are appropriate arrangements in place for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. in order to ensure that people monies are safeguarded, full and individual records are now kept about finances held on an individuals behalf and this money is no longer pooled. In order to ensure that people complaints are recognised, all complaints are treated in accordance with the homes complaints procedure. Peoples personal care needs and other private information is not made available to people who do not require that information, ensuring that information relating to individuals is Data Protected. What they could do better: Care plans and review documentation must be updated to include the signature of the individual whom the plan relates to or should be signed by their representative. This will provide evidence that the person using the service is involved in the care plan and review process. Where a person may lack capacity this information should also be recorded. Risk assessments must be updated to include how individuals respond in risk associated situations and the actions staff must take to minimise these. This will provide staff with data as to how to monitor and manage incidents/events that have an impact on an individuals risk taking decisions. Individuals who choose to self medicate must be appropriately risk assessed. Risk assessments will safeguard individuals who choose to self medicate and will allow staff to monitor how the individuals manage their administering their own medications. Recommendations for good practice were made in relation to: That the use of white correction fluid in care plans and other legal documents should cease. That two signatures are obtained for all transactions made in respect of individuals Personal Allowance accounts. That the managements decision to introduce an Activities Record Book is completed. That staff files are updated to include a statement of physical and mental health and a recent photograph. That a record is maintained of all informal discussions held with people who use the service, to ensure that appropriate action plans can be put in place to address issues Care Homes for Adults (18-65 years) Page 9 of 30 raised. 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 10 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 11 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. The home provides detailed information to prospective new people and their family/representative, allowing them to make an informed choice about their admission to the home. There are appropriate processes in place for assessing potential new people to be accommodated, with services being offered to only those whose needs can be met Evidence: We observed that the Service User Guide and Statement of Purpose are provided to all new and existing people who use the service and that these documents were found to be clear in detail and covered all items required under the National Minimum Standards. The Administration Manager reported that they are aware that people who use the service, need to be referred to by one term of address in these documents (as they are currently referred to as service users/residents/clients.) Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: From documents viewed and discussions held we observed that the homes Registered Manager and/or a Senior Carer or the Administration Manager carry out pre admission assessments. Records viewed provided evidence that the home also obtains a copy of a care management assessment from a placing authority where these exist. Care Homes for Adults (18-65 years) Page 13 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals care plans are clear in detail and are being further developed to ensure they are suitable for meeting the needs of the person who uses the service. Risk assessments encourage the person who uses the service to maintain their independence and are being developed further to ensure they detail all elements of risk and any associated behaviours. Evidence: The Administration Manager confirmed that care plans had been reviewed and updated in the last few months. We observed a sample of individual care plans and it was noted that these were detailed in content and covered all aspects of the individuals needs and limitations. We observed that support plans allow the assessor to gain a good overview of individuals medical, social and personal care needs. We evidenced that care plans are not currently devised with the involvement of the person using the service. We observed that signatures of the individual that the plan Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: relates to were not present, indicating that the person is not included in the care plan and review process. Discussions were held with the Administration Manager as to how if a person lacks capacity or if a representative is involved in this process then this information should also be recorded. We observed that the staff of the home work with the people who use the service, in order to assist them to meet their physical/medical needs, as well as personal aspirations that are within their limitations. We observed that staff are committed in supporting individuals to lead their lives as independently as possible. People using the service make their own informed decisions and have the right to take risks in their daily lives. We looked at the records of all accounts held and found that they were well maintained and we observed that individual wallets were utilised for storage of individual accounts. We observed that all accounts are maintained by the homes management team and are kept in a secure lockable place. Accounts for all personal allowances were viewed and we observed that one person signs for each transaction, discussions were held relating to good practise being two signatures for any transaction. The Administration Manager reported that the home does not take any responsibility for any of the individuals other finances and that most people have family, friends or representatives who protect their financial affairs. We observed that progress has been made to ensure that risk assessments are in place. From the risk assessment sampled we observed that were not signed or dated, making it difficult to determine whether they were current/relevant. Risk assessments were also written in a manner that did not provide staff with information as to how an individual may react in the risk situation and any behaviours that may occur. Signatures of individuals that the risk easement relate to were also not observed. Care Homes for Adults (18-65 years) Page 15 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. The home provides social, cultural and recreational facilities that are selected by the people who use the service and conducted at a time of their choosing. Meal times are conducted in accordance with the wishes of the individual accommodated. Evidence: We observed that the people who use the service are encouraged to attend day centres in the local area. We observed that activities are not structured and that this is in accordance with the wishes of the people who use the service. Individuals and staff spoken with confirmed that regular and schedules activities result in poor attendance and dont go because it all gets too much!. The Administration Manager reported that at the present time there are no individuals Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: in active employment. Records viewed and discussions held confirmed that the people who use the service are able to access the local community. The Administration Manager confirmed that the religious wishes of individuals would be observed and arrangements would be made to allow people to attend places of worship, if any such requests were made. We observed that contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the wishes of the person accommodated. Any relationships that may be detrimental to the mental well being of the individual, are monitored and handled sensitively by staff and the management of the home. We observed that the people who use the service have access to all areas of the home to ensure that they have freedom of movement. Records viewed provided evidence that people are called by their preferred choice of address. Individuals, with or without assistance, conduct household chores/tasks. We observed the home has a daily menu system in use. People who use the service reported that they did not like weekly menus as its not very homely. We observed that medical, therapeutic or religious diets are provided as needed. Mealtimes were observed to be unhurried and a time for social interaction amongst staff and people who use the service. Care Homes for Adults (18-65 years) Page 17 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 who use the service are offered good provisions of health care and personal support by the home. Medication procedures ensure that precautions are taken to ensure errors do not occur and that medications are stored and administered safely and effectively. Evidence: We observed that personal support that is offered, is given in such a way as to promote and protect the persons privacy and dignity, whilst promoting their independence. We observed that staff respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in private and at a time and pace directed by the person receiving the care. Records viewed provided evidence that there is a Key Worker system in place. It was observed that staff had good relationships with the people accommodated and were respectful of their privacy. From the records sampled and from discussions with staff, it was evidenced that the health needs of the people who use the service are well met, with evidence of good multi disciplinary working taking place. We observed the home has established good Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: relationships with Healthcare Providers and Health Advisory Services. People whos use the service commented in surveys that It (the care home) provides good caring services to their residents. We observed that the home has good, clear procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. We noted that the home has developed an efficient medication policy. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. There were no Controlled Drugs being held by the home at the time of the inspection. We observed that suitable risk assessments were required for individuals who choose to be self medicating. Care Homes for Adults (18-65 years) Page 19 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 who use the service benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect individuals in the event of an allegation of abuse. Evidence: We observed that the home has a comprehensive complaints procedure in place. Records viewed and the homes AQAA provided evidence that the home has not received any complaint in the last twelve months. From staff files viewed we observed that both Criminal record Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. We observed that staff have attended training in the Safeguarding of Vulnerable adults, this was evident from the staff training matrix that was viewed. We observed that staff have ready access to the Multi Agency Safeguarding vulnerable Adults Procedures. Records viewed and the homes AQAA provided evidence that there have been no safeguarding Adults alerts raised in the last twelve months. 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. The home provides accommodation for the people who use the service that is appropriate, safe, hygienic and odour free, whilst infection control procedures are adhered to at all times. Evidence: We observed that the location and layout of the home are suitable for their stated purpose. The home has a friendly, relaxed atmosphere and we evidenced that all areas of the house and garden, including the patio area of the front garden , are accessible to the people who use the service. Survey responses included The service provides a homely environment for its residents. Staff were observed adhering to infection control procedures. We evidenced that the house was clean and odour free throughout, that there is a daily cleaning schedule and that appropriate laundry facilities were in place. Care Homes for Adults (18-65 years) Page 21 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of the people who use the service. Staff receive training is being updated to ensure that staff receive training that is appropriate to the job that they conduct. Evidence: We observed that a competent staff team meets the needs of the people who use the service. We saw that there is a clear staff rota in place, which details staff hours of working and staff job designations. We observed that a record of whether the roster was actually worked is also maintained. The home has a permanent staff team the Registered Manager, ten Senior Carers (whom all have a dual role - either domestic/catering and the Administration Manager is also a Senior Care/Caterer and a Domestic. The AQAA provided evidence that eight Senior Carers are trained in National Vocational Qualification (NVQ) level 2 or 3 in care or equivalent, whilst a further two Senior Carers are undertaking NVQ training. This was also confirmed in the staff training records and staff training matrix that were viewed. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: Staff recruitment files were viewed and it was evidenced that these files do not contain all items required under the Care Homes Regulations 2001. We observed that photographs of staff and a declaration of mental and physical health were not obtained. The Administration Manager confirmed that the application form is currently being updated to include a Healthcheck statement and that photographs would be taken of all staff and kept on their individual files. We observed that the home has an Equal Opportunities policy in place and is an equal opportunities employer. The homes training matrix and individual staff training records were viewed and it was evident that staff have received training in Induction, Fire Safety, Safeguarding Vulnerable Adults, Mental Capacity Act, Deprivation of Liberties and Medication in the last twelve months. Training in Health & Safety, Food Hygiene, First Aid,Infection Control, Moving and Handling is currently out of date. The Administration Manager confirmed that training dates and video training in these subjects are currently being sourced and that all staff would receive training in these key areas. The training matrix was viewed and this also provided evidence of future training dates being organised. Care Homes for Adults (18-65 years) Page 23 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 management and administration of the home is good, with evidence of consideration being given to the choice and opinions of the people who use the service. The health, safety and welfare of individuals accommodated and staff is protected at all times. Evidence: The Registered Manager has many years experience of working with younger adults with Mental Health issues and has achieved the Registered Managers Award. Staff spoken with said that the Manager was always friendly, approachable and pro active. We observed that the home has a Quality Assurance Procedure in place and that effective quality audits have been conducted in the last twelve months. Records viewed confirmed that Regulation 26 visits are not carried out by the Registered Provider as he attends the home on a daily basis. Records of staff meetings were viewed and there was evidence of actions taken to address any issues raised. The Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: Administrating Manager confirmed that informal residents meetings are held although no records are maintained of these. From the AQAA provided by the home and from records viewed it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (where applicable) had been carried out within the last twelve months. Care Homes for Adults (18-65 years) Page 25 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 26 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 6 15 That care plans and review 03/01/2010 documentation are updated to include the signature of the individual whom the plan relates to/ or their representative. In that this will provide evidence that the person using the service is involved in the care plan and review process. Where a person may lack capacity this information should also be recorded. 2 9 15 That risk assessments are 01/01/2010 signed and dated by the person creating them and by the person to whom they relate. In that this will provide evidence that the person using the service is involved in the risk assessment process and that risk assessments are current. Care Homes for Adults (18-65 years) Page 27 of 30 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 Where a person may lack capacity this information should also be recorded. 3 9 15 That risk assessments are updated to include how individuals respond in risk associated situations and the actions staff must take to minimise these. In that this will provide staff with data as to how to monitor and manage incidents/events that have an impact on an individuals risk taking decisions. 4 20 13 That individuals who choose to self medicate are appropriately risk assessed. In that risk assessments will safeguard individuals who choose to self medicate and will allow staff to monitor how the individuals manage their administering their own medications. 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 03/01/2010 04/12/2009 1 2 6 7 That the use of white correction fluid in care plans and other legal documents should cease. That two signatures are obtained for all transactions made Page 28 of 30 Care Homes for Adults (18-65 years) 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 in respect of individuals persoal Allowance accounts. 3 4 5 13 34 39 That the managements decision to introduce an Activities Record Book is completed. That staff files are updated to include a statement of physical and mental health and a recent photograph. That a record is maintained of all informal discussions held with people who use the service, to ensure that appropriate action plans can be put in place to address issues raised. Care Homes for Adults (18-65 years) Page 29 of 30 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 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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