Inspection on 03/12/09 for Primrose House (Morecambe) Ltd

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

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Primrose House (Morecambe) Ltd 19/01/06

Primrose House (Morecambe) Ltd 26/07/05

Primrose House (Morecambe) Ltd 08/03/05

Primrose House (Morecambe) Ltd 01/06/04

Primrose House (Morecambe) Ltd 10/03/04

Primrose House (Morecambe) Ltd 28/10/02

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Primrose House (Morecambe) Ltd Primrose House Middleton Road Middleton Morecambe Lancashire LA3 3JJ     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: Marie Cordingley     Date: 0 3 1 2 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: Primrose House (Morecambe) Ltd Primrose House Middleton Road Middleton Morecambe Lancashire LA3 3JJ 01524853385 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Dgrundyprimrose@aol.com Primrose House (Morecambe Limited) care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection Brief description of the care home Primrose House (Morecambe) Limited is a home for up to 6 people with severe learning and physical disabilities. The present (purpose-built) building opened in 2001 but the Primrose House service has been in operation since 1988. The service was established as a charitable organisation by one of the parents of a current service user who found that there was no satisfactory service provision existing locally to meet complex needs. A Board of Trustees appointed a Registered Manager to undertake the day-to-day management of the home. A responsible person has also been appointed to monitor Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 6 Brief description of the care home the service. The Board of Trustees meets on a regular basis to review the service and plan future developments. The ethos of the home is to provide quality services to people who have a profound learning and physical disability and it believes that opportunities should be provided to enable the people supported to live independent lives within the confines of their disability. The current fees range from 1065 to 1083 pounds per week. 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: 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: The inspection of this home included a site visit which was carried out on an unannounced basis. This meant that the manager and staff did not know the visit was to take place until we arrived. During the visit we spent time with residents, talking to them and observing their daily routines. We also held discussions with staff at the home and the manager. We carried out a tour of the home looking at communal areas and a selection of residents private accommodation. We also viewed a variety of paperwork including residents care plans and staff personnel files. Prior to our visit we wrote to the manager and asked him to complete a very comprehensive self assessment. This gave us a lot of information about how the home is managed. In addition, we wrote to a selection of residents and staff and asked them Care Homes for Adults (18-65 years) Page 6 of 30 to take part in a written survey about their opinions of the service provided. Unfortunately no responses were received. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Adults (18-65 years) Page 8 of 30 Throughout our inspection we found that the majority of information provided to residents and their representatives for example, the homes complaints procedure and Service User Guide is currently only available in a standard written format. The majority of people who live at the home are not able to access written information. As such, we discussed with the registered manager the need to consider alternative ways in which this information can be provided, for example, audio or pictorial formats. Peoples individual plans contain a very good level of information and we found that the home works well to plan peoples care in a person centered manner. However, as with other information provided by the home, these are mainly produced in a standard written format. Staff have a good understanding of residents social care needs and the support people require in this area is well documented. However, we found that current staffing levels may result in residents not having regular opportunities, particularly at weekends to pursue their valued activities and hobbies. We identified a number of concerns in relation to the way peoples medicines are managed in the home. We noted a number of errors in records we viewed and were concerned that stock in the home was not properly recorded. We were unable to find evidence that medicine stock and records are regularly audited by the manager or that the competence of staff to deal with medication is formally assessed. Systems need to be improved and careful monitoring must be in place to ensure that people receive their medicines as prescribed. People who live at the home make additional payments in relation to transport. We looked at records of these charges and found that they lacked clarity in terms of exactly what people were paying and receiving for these extra payments. We discussed this with the manager and have made a requirement in relation to the matter. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 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. The manager ensures that carers have a good understanding of residents needs. Evidence: A Service User Guide is available for anyone who would like information about the home. The guide includes information about the service provided and facilities available and gives the reader a picture of daily life at the home by describing arrangements for areas such as mealtimes and activities. In discussion the manager confirmed that the Service User Guide is currently only available in a standard written format. We advised the manager to consider producing the guide in some alternative formats to help ensure that everyone has equal access to this information. There have been no new residents admitted to this home for almost fourteen years. As such we were unable to examine the processes followed by the manager when admitting a new resident. However, in discussion the manager demonstrated an understanding of the need to ensure that a thorough assessment of need is carried Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: out for any prospective resident before a decision is made whether to offer them a place. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care and support is planned in line with their individual needs and wishes. Evidence: During our visit we viewed a number of residents individual plans. We found these documents to be very comprehensive and completed to a good standard. The plans we viewed covered all aspects of peoples daily lives and contained detailed guidance as to how people would like their support to be provided. The level of information included in peoples plans was extremely detailed meaning that carers would have a good understanding of the support people required. For example, one residents care plan gave details of the various ways she liked to have her hair styled and instructions for carers on how to do each style. We also noted that peoples individual plans were written in a very person centered manner. The resident themselves was the focus of the plan and their support was centered around their individual strengths and needs. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: We found evidence that the home use a variety of creative methods to help ensure that people are involved in their own care planning and each persons file included very detailed information about their preferred methods of communication. This means that residents have the opportunity to say what is important to them and how they would like their care to be provided. Whilst we found that individual plans were of a very good standard in terms of the information they provided, we did note that the majority of the information within them was recorded in a standard written format. The majority of residents living at the home would not be able to access this information and we advised the manager to consider making the information available in formats that are more accessible and meaningful for residents. In discussion the manager demonstrated a very good understanding of recent changes in the law that apply when making a decision on behalf of someone who is not able to do so, in their own best interests. We found very detailed records of any decisions that had been made on behalf of residents and evidence that the manager had involved peoples representatives and other professionals when making such decisions. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Carers understand the importance of providing regular activities that residents enjoy. However, current staffing levels mean that this is not always possible. Evidence: When we viewed peoples care plans we found that there was a good level of information about their hobbies, preferred daily routines and likes and dislikes. This sort of information is important to help ensure carers can provide activities that are in line with peoples individual needs and wishes. We saw lots of examples of individualised activity plans and were able to confirm that peoples individual timetables included activities that they enjoyed and responded positively to. We also noted that all the people who live at the home were given the opportunity to Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: enjoy regular holidays and that much attention was paid to the planning of peoples holidays to ensure that they were in line with their personal needs and preferences. We found that the support people required to maintain valued relationships with friends and family was clearly stated in their plans and regular reviews were carried out by the manager to ensure that this support was regularly provided. Carers we spoke with were able to tell us what residents enjoyed doing and give examples of support provided for people to pursue their hobbies and leisure interests. However, we received some feedback that current staffing levels at the home meant that people were not always able to engage in things they enjoyed doing, particularly those activities outside of their home. We viewed rotas which confirmed the feedback we received, that particularly at weekends, the home often worked on two carers throughout the waking day. As the majority of residents require two staff with some aspects of their personal care, this means that people cannot be supported to go out. We discussed this issue with the registered manager and advised him to review staffing levels to ensure that people have the support they need to enjoy full and varied lifestyles. There was a good level of information recorded about peoples dietary needs and their food likes and dislikes. We were also able to confirm that catering staff employed at the home were fully aware of peoples individual preferences and ensured that meals were provided in line with these. We found evidence that when professional advice had been given to staff regarding particular residents from for instance, a dietitian or speech therapist, this advice had been included in peoples individual care plans and was regularly reviewed. Records of meals served demonstrated that people are provided with a varied and nutritious diet. However, we noted on the day of our visit that there was no information provided to residents about what was on the menu for the day. We discussed this with the manager and recommended that he consider how such information can be provided for residents, for instance through pictorial menus. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health care is carefully managed. However, procedures for managing peoples medication need to be improved to help ensure their safety and wellbeing. Evidence: Each persons individual plan we viewed included comprehensive health information. Peoples health action plans included details of their specific health care needs and general areas such as optical and dental care. We saw evidence that people living at the home are supported to access specialist services when they require them such as community health care. In addition, we noted that any advice given to staff by community health professionals had been included in the residents care plan. Some people who live at the home require some specialist health care and we found that there were good processes in place to ensure this care was provided safely. Appropriate agreements had been made with the relevant organisation about providing specific health care and training was in place to ensure that carers were competent to do so. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: During our visit we looked at a selection of medication records and the stock of medicines within the home. When we viewed medication records we found some errors that had occurred, for example, occasions when carers had signed to say they had given medication when they hadnt and other examples where carers had not signed when medicines had been given. Other issues included unexplained omissions on medication records and hand written information on records that was unclear and difficult to understand. We attempted to carry out a stock check of some boxed medications but were unable to because there was no clear records of the number of tablets held in the home. It is important that the manager keeps such records so that checks can be carried out to ensure people are receiving their medicines as prescribed. We could not find any evidence of regular medication audits being carried out by the manager and whilst we were able to confirm that all staff who administer residents medication had received training in this area, there was no evidence that the manager had processes in place to assess their competence on a regular basis. We discussed our findings with the manager and advised him that procedures needed to be improved to help ensure peoples good health and wellbeing. We have also made some requirements and recommendations in relation to this area. 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. The homes robust safeguarding procedures help ensure that people are protected from harm. Evidence: There is a complaints procedure in place which provides guidance to anyone wishing to raise a concern. The procedure includes advice on the time scales within which people should expect their complaint to be dealt with and what they should do if they are not satisfied with the way their complaint has been addressed. We noted that the complaints procedure was posted at various points within the home and we viewed a copy. The procedure was well written, encouraged people to raise concerns and provided reassurance that the manager would respond appropriately to any such concerns raised. However, we did note that the complaints procedure was only available in a standard written format which would not be useful to the majority of people who live at the home. We discussed this with the manager and advised him to consider ways in which the procedure could be made more accessible. All homes are required to have written procedures in place that must be followed if it is alleged or suspected that a resident has been the victim of any kind of abuse. These Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: are generally referred to as safeguarding procedures. We found that the manager and the staff members we spoke to had a good understanding of the procedures and carers told us they were confident that they would be well supported by the manager if they had to raise any concerns in line with safeguarding procedures. We were also able to confirm that the majority of staff members had received training in safeguarding and were aware of their responsibility to report abuse or bad practice in line with the homes whistle blowing procedures. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home are provided with safe, comfortable accommodation. Evidence: During our visit we carried out a tour of the home. The home is a modern, single storey building with easy wheelchair access throughout. We noted during our tour that all areas were warm, clean and comfortable. All accommodation at the home is offered on a single room basis so no resident has to share a bedroom. We viewed a selection of residents bedrooms and found that they were nicely decorated and personalised in line with individual residents tastes. In general, we found that the the home was well maintained and furnished to a good standard. We also noted that people have access to safe outdoor space which is well maintained. The manager confirmed that there are a procedures in place to help stop the spread of infection throughout the home. We were also able to confirm that all staff had been provided with training in the area of infection control. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive their care from well trained, well supported staff. However, current staffing levels mean that residents are not always able to engage in activities outside their home on a regular basis. Evidence: We viewed personnel files for several staff members and these confirmed that the home follow thorough recruitment procedures. Records confirmed that all potential staff members are asked to attend a formal interview and complete an application form which includes a full employment history. At least two references are obtained, one being from the most recent employer where possible. In addition, no staff member is allowed to start work until Criminal Records Bureau and POVA (protection of vulnerable adults) clearance has been obtained. Records and discussions with staff confirmed that all new staff members are provided with induction training to familiarise them with the home and the policies and procedures. A more detailed programme is then followed in line with Skills for Care standards which covers areas such as good principles of care. Carers we spoke with told us that they had found their induction training very useful. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: One carer said I had a lot of support and I was given lots of help to find my feet. The home has a good approach to training and records viewed confirmed that carers are provided with training in the key health and safety areas as well as additional training in areas such as safeguarding and medication awareness. In addition, we were able to confirm that over half the carers employed at the home hold National Vocational Qualifications in care at level 2 or above. Records of staff supervision showed that carers are encouraged to undertake courses to help them develop their skills. We also noted that each staff member had a personal development plan in place which was regularly reviewed. We viewed rotas and discussed staffing levels with the manager and carers. We found that staffing levels appeared to be adequate to meet peoples basic care needs but didnt always allow opportunities for residents to engage in their chosen activities, particularly activities outside of their home. We discussed our findings in relation to staffing levels with the manager and advised him to review staffing levels whilst taking into account the social needs of people living at the home. We also made a requirement and some recommendations in relation to the matter. 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 home is well managed and run in the best interests of people who live there. Evidence: The registered manager of the home has extensive experience and throughout the inspection demonstrated a good understanding of his role. In addition, the manager communicates a genuine commitment to person centred working and was able to give a number of examples of how this had been put into practice throughout the home. Prior to our visit the manager completed a comprehensive self assessment which explored all aspects of the service. The assessment was completed to a very good standard, gave details of a number of improvements that had been made since the last inspection and also demonstrated that the manager was able to identify areas for improvements and address them. The home has processes in place to ensure that standards of care and outcomes for people using the service are constantly monitored. Such processes include the regular consultation with residents relatives through surveys and an external quality Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: monitoring system (ISO). However, we made a recommendation that quality assurance processes be revisited to ensure that there are systems in place to monitor all aspects of the service, for instance medication. We looked at records of some residents personal finances during our visit and found some aspects of additional charges relating to costs of transport were very unclear. We advised the manager that records needed to be improved to state clearly what charges people were paying and exactly what they were receiving for these additional payments. There is a health and safety policy in place which is supported by a number of individual procedures such as infection control and fire safety. Discussion with staff and records viewed confirmed that the manger ensures that all carers are provided with training in the key health and safety areas at the start of their employment. We also noted that the manager closely monitors training and ensures that refresher training in areas such as moving and handling is provided to all staff at regular intervals. 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 20 18 The manager must ensure that all carers who deal with residents medication are competent to do so. This is to help ensure the safety and wellbeing of people who live at the home. 03/01/2010 2 20 13 The manager must carry out 03/01/2020 regular audits of all medicines and records. This is to help ensure that the manager can identify any errors and rectify them. 3 20 17 A record must be maintained 03/01/2010 of all medicines received into the home, administered and disposed of. This is to help ensure that the manager can monitor that people receive their medicines as prescribed. 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 4 33 18 The manager must ensure that there are sufficient numbers of staff on duty at all times to meet the assessed needs, including social needs, of people who live at the home. This is to help ensure that people who live at the home receive support that is in line with their individual needs and wishes. 03/01/2010 5 41 17 Clear records must be kept of any additional charges made to residents. This is so that people are aware of what they are paying for. 03/01/2010 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 1 The Service User Guide should be provided in a variety of formats. This is to help ensure that more people have access to the information within the guide. Peoples individual plans should be produced in formats that are accessible. This is to help ensure that residents are enabled to be involved in their own care planning to as great an extent as is possible. Staffing levels should be reviewed in line with the social needs of people living at the home. This is to help ensure that people who live at the home are provided with regular opportunities to engage in activities both inside and outside the home. Page 28 of 30 2 6 3 13 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 4 14 Detailed protocols should be in place to provide staff with guidance in relation to supporting people when out in the community. This is to help ensure that carers support people safely when out in the community. Consideration should be given to the introduction of pictorial menus for residents. This to improve information provided to people who live at the home and their opportunity to make choices. Processes for ordering residents medicines or items such as dietary supplements/liquid thickener should be reviewed. This is to help ensure that people dont run out of the items they require. Clear information in relation to residents as and when required medicines should be maintained in the home. This is to help ensure that residents receive their medicines when they need them. Any hand written entries on medication administration records should be witnessed and double signed. This is to help reduce the risk of errors. A record of sample signatures for all staff who admister residents medication should be kept in the home. This is to help the manager identify any issues in relation to a staff members competence in this area in a timely fashion. The manager should consider making the homes complaints procedure available in a variety of different formats. This is to help ensure that more people have access to this information. The staffing rota should identify the positions of staff on duty at all times. This is so that the manager can demonstrate their are sufficient staffing levels within the home. Quality assurance processes should be reviewed to ensure that the manager monitors all areas effectively. 5 17 6 20 7 20 8 20 9 20 10 22 11 33 12 39 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). 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