Inspection on 14/08/08 for 15 Thompson Drive

This inspection was carried out on 14th August 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Thompson Drive 13/09/07

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOME ADULTS 18-65 15 Thompson Drive 15 Thompson Drive Codnor Derbyshire DE5 9RU Lead Inspector Janet Morrow Unannounced Inspection 14th August 2008 11:00 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 1 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 15 Thompson Drive Address 15 Thompson Drive Codnor Derbyshire DE5 9RU 01773 570163 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) M & A Dispensing Chemist Ltd Janet Wain Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category 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 category: Learning Disability - Code LD The maximum number of service users who can be accommodated is 3 2. Date of last inspection 13th September 2007 Brief Description of the Service: 15 Thomson Drive is a detached bungalow in a residential area in Codnor, close to local facilities and shops. All bedrooms are single rooms. The Home has a large lounge, dining room, kitchen and bathroom. Service users have access to a garden and seating area. The Home has a small staff team operating on a rota basis, providing one member of staff on duty at all times when service users are at the Home. Verbal information supplied in August 2008 stated that the weekly fees were £618.51. Copies of inspection reports can be provided by the manager of the home and are available on the Commission for Social Care Inspection website at www.csci.org.uk 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day for a total of 4.75 hours and concentrated on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The manager was present during the inspection visit. One member of staff was spoken with and one person currently accommodated in the home was also spoken with. Two visiting professionals were spoken with by telephone after the inspection visit. Two staff surveys were received. There had been a recent concern raised by external professionals regarding one person living at the home and this was discussed with the manager. Care records, a sample of policies and procedures and staff information were examined. A tour of the building took place. What the service does well: What has improved since the last inspection? The maintenance of the home had improved and the communal areas, with the exception of the bathroom, had been well decorated and provided with good quality furnishings. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 6 Staff induction had improved as the home was now using the ‘Skills for Care’ Common Induction Standards. Visiting professionals commented that the home had improved its response to specialist advice following a concern raised earlier in the year. What they could do better: Assessment information, including risk assessments, needs to be updated to address changing needs. This is to ensure that people receive the correct assistance and staff have up to date information. Recruitment procedures must ensure that all necessary checks are obtained prior to staff commencing work, as required by the Care Homes Regulations 2001. Consideration should be given to ensure a workable on call system for staff to receive assistance in an emergency. There should be a planned programme of activities to suit individual needs. Medication administration practice needs to improve to ensure that medication is secure in its container and medication administration record (MAR) charts are signed accurately so it is clear whether or not medication has been administered. This is to make sure people are safe and minimise the risk of errors. There must be a complaints record that clearly shows what action has been taken in response to concerns. This is to provide a clear audit trail of complaints and to ensure peoples’ concerns are addressed. Safeguarding training must be provided for all staff to ensure they know what to do if abuse is suspected and to make sure people in the home are safe. The bathroom must be refurbished to ensure it is safe and comfortable to use. All staff, including the manager, must be provided with moving and handling training and there must be an appointed First aid person on duty at all times. The manager must also update her food hygiene training. This is to make sure that the health and safety of all in the home is addressed. Staff training should include specialist subjects such as epilepsy and autism and dealing with challenging behaviour. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in updating care information does not ensure that peoples’ needs are always met. EVIDENCE: Two peoples’ care files were examined and showed that there was information available from the assessment and care management process. However, there were no recent risk assessments in place and the last review of an environmental risk assessment was in 2005. This does not ensure that needs are updated regularly. One person’s file had relevant information from other professionals and there had been a change in their needs but this was not reflected in the assessment documentation or by entries in their care plan. A recent enquiry had raised issues regarding the home’s ability to met one person’s needs and although there had been some issues, these were now being addressed. A visiting professional stated that they thought the home had 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 10 ‘improved’ its approach to this individual and were now responding to specialist advice. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Potential risks to peoples’ safety had not been identified and this left them vulnerable to hazards. EVIDENCE: Two peoples’ care files were examined and both had a care plan in place. Care plans had a satisfactory mix of personal needs and goals and were holistic. Both plans contained clear instructions for staff to deliver the care. There were standard areas on both care plans, such as personal care, communication and social needs, with additional individual areas of need. However, on one care plan there was no information for staff on how to deal with behavioural needs, although these had been highlighted as an issue from other professionals. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 12 Although there had been a formal review with the funding authority in July 2008, the care plan had not been updated from this review. There were no risk assessments in place for individual needs and the care documentation did not reflect how people were encouraged to make decisions and choices. One person had their own key to their room but there was no assessment available to say if there were any risks involved with this. The manager stated that no one currently had an advocate but she was aware of who to contact if necessary and had information on the advocacy service provided under the Mental Capacity Act 2005. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lack of a planned programme of activities meant that opportunities for individual personal development were limited. EVIDENCE: All three people attended a day centre operated by the Local Authority. One person spoken with had their own hobbies and used a computer on their own room as well as doing jigsaw puzzles. The other two people appeared to have fewer interests catered for at the home. However, the manager stated that a new member of staff was in the process of being appointed and would be able to spend time in a one to one basis and take people out more. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 14 The home had been on holiday to Scotland in 2007 and the manager stated that they were hoping to book another holiday for September 2008. This was recorded in the minutes of a meeting for people living in the home. One person spoken with stated that they ‘liked living here’ and confirmed that they could choose what they wanted to do and were ‘independent’. The manager stated that they made regular use of a local pub and food shops and one person was well known by local people who chat with the person while out walking with staff. One member of staff encouraged those interested to assist with keeping the garden tidy at the home. Staff spoken with said that routines in the home promoted peoples’ independence and included personal hygiene routines and housework as well as work in the garden. Food stocks in the kitchen were at a good level and included fresh fruit and vegetables. The Home’s menu showed a varied range of nutritious and appetising meals provided. One person spoken with said they ‘liked the food’. The food budget was discussed wit the manager and she stated that this was satisfactory and allowed her to purchase a variety of foods to suit individual tastes and for special occasions, such as birthdays. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication practices did not ensure the safety of people in the home. EVIDENCE: Health care needs were generally met and specialist help was arranged when needed. However, the concern raised recently in relation to one person indicated that their needs were not fully met and that specialist advice was not being fully adhered to. Meetings with other professionals had indicated the type of response needed and one professional commented that the home had improved recently in its response to specialist advice. Regular visits to opticians, dentists and chiropodists were recorded on the care files. The home had recently obtained personal health files for each individual, which they intended to put into use. Weight was recorded regularly. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 16 One person’s file had specific information recorded regarding their epilepsy and a chart was maintained of seizures. Observation during the inspection visit confirmed that staff and people living in the home enjoyed warm relationships and there was a friendly atmosphere. Medication was stored securely in a locked metal cabinet. All three peoples’ medication administration record (MAR) charts were examined and showed some discrepancies in the recording of the medicine administered. Two people did not sign hand written charts. All three charts had gaps where there should have been signatures for medicines administered. Staff were also not following the sequence of days on the blister pack so it was difficult to tell whether or not the medicine had been administered on the correct day. Two tablets had also come loose from the blister pack and were found in the cupboard. There were no homely remedies apart from Paracetamol and this was kept separately with records of what was administered being maintained in a separate book. The manager stated that there were no controlled drugs on the premises. However, the storage provided was inadequate for controlled drugs should they be required as there was no double locking facility. Staff spoken with stated that they had undertaken medication training as part of their National Vocational Qualification (NVQ) training and there was an in house video on medication administration. The home did not have a copy of the Royal Pharmaceutical Society Guidelines on administration of medicines in care settings. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in complaints and safeguarding procedures did not fully ensure the safety of people living in the home. EVIDENCE: The content of the home’s complaints procedure was satisfactory and stated that complaints would be responded to within fourteen days. However, there was no mechanism for recording any complaints or what action had been taken to resolve them. The manager stated that no complaints had been received at the home since the last inspection in September 2007. The financial records of personal allowances for people living in the home were examined. The cash held corresponded correctly with the record and was stored securely. Receipts for purchases were available. Withdrawals identified on bank accounts also corresponded with the home’s record. However, only one member of staff was signing the record and there was no internal audit mechanism to check that records were correct. The home had an ‘Adult Protection Procedures and Prevention of Abuse’ written policy as well as copies of the statutory Safeguarding Adults Procedure. The home’s policy stated that people living at the home had a right to withhold consent to a referral being made to the Local Authority following suspicion of 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 18 abuse. This is not acceptable as the Local Authority are the lead agency for dealing with suspicions of abuse. This was raised as an issue at the last inspection in September 2007. A concern raised by the Local Authority in July 2008 had been addressed. Staff spoken with were aware of their responsibility to report any suspicions of abuse but had not received any training in safeguarding adults. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained, which ensured that people had safe and comfortable accommodation. EVIDENCE: The communal areas of the home were well furnished, clean and tidy. The only exception to this was the bathroom, which was in need of refurbishment as there was a broken handrail by the bath, a broken towel rail and the toilet was unstable. The manager stated that the bathroom was due to be refurbished. There was a pleasant garden area to the side of the home. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 20 All three bedrooms were seen and were furnished according to individual needs and were personalised. None of the rooms had lockable storage space. One person used the key to their room independently. The laundry facilities were domestic and satisfactory and the home was found to be clean and hygienic, with no unpleasant odours. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practices and lack of training in core areas did not fully ensure the safety of people living in the home. EVIDENCE: One staff file was examined and showed that some of the information required by Schedule 2 of the Care Homes Regulations 2001 was missing. This included identity information and a full employment history. A Criminal Record Bureau (CRB) check was in place but the Protection of Vulnerable Adults (POVA) First check showed that the person had commenced work prior to the home receiving it. Insufficient information at the point of recruitment was raised as an issue at the previous inspection visit in September 2007 and continued failure to obtain such information could lead to legal action being taken. The rota for 4th August 2008 – 17th August 2008 was examined. There were sufficient staff on duty when people were in the home, with one person being available in the morning and evening and the manager was supernumerary. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 22 However, the recent concern raised by other professionals concerned a lack of staff for an emergency. There was no formal ‘on call’ system other than the manager being called out but she did not live in the area and was not easily accessible in an emergency. This means that should an emergency occur, there is only one staff member available to deal with it, therefore leaving other people in the home unsupervised. The staff member spoken with confirmed that they were undertaking National Vocational Qualification (NVQ) training at level 3. New induction arrangements had been introduced that used the ‘Skills for Care’ common Induction Standards and the staff file examined showed that the staff member concerned was receiving supervision on a regular basis, with records showing it had occurred in March 2008 and May 2008. Both staff surveys received responded that their induction covered everything they needed to know ‘very well’ and one commented that it ‘gave me great insight into each individual’. Mandatory health and safety training took place although the manager’s moving and handling and food hygiene training were not up to date. There was no evidence seen of training in other areas relevant to the needs of people in the home, such as dealing with challenging behaviour, autism, epilepsy or specialist communication. Staff spoken with stated that they had not had any training in areas not related to health and safety, other than via NVQs. Visiting professionals spoken with also stated that they thought additional training in specified areas would be useful. Both staff surveys responded that they received training relevant to their role. One survey responded that they ‘usually’ had the right support, experience and knowledge and one responded that they ‘always’ did. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run in the best interests of people living there. EVIDENCE: The manager was registered with Commission for Social Care Inspection and was undertaking the Registered Managers award. She had experience in care, although not previously in learning disability. Staff spoken with described the manager as ‘sound’ and said they received sufficient support in their work. Both staff surveys responded that they met with the manager ‘regularly’ for support. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 24 Quality assurance processes needed further development. The owners were undertaking monthly audits, as required by Regulation 26 of the Care Homes Regulations 2001, and records of these visits showed how they intended to improve. However, there had been no recent surveys to gain the views of relatives or visiting professionals, although the records of the July audit indicated that this was due, and there was no annual plan of how they intended to improve the service. This was recommended at the previous inspection in September 2007. Meetings of people living in the home took place and records showed that these discussed meals and outings and individual rooms. They had taken place in February 2008 and May 2008. The records of maintenance at the home showed that fire equipment had been checked in May 2008 and that portable electrical appliances had been checked in March 2008. There was a record to show that gas safety was due to be checked in September 2008. A staff member tested fire alarms weekly. A valid insurance certificate was on display. Staff received mandatory health and safety training and records showed that fire safety and health and safety training had occurred in September 2007 and food hygiene and moving and handling in November 2007. However, the manager’s training in food hygiene and moving and handling was out of date. Staff spoken with stated that they were booked onto a First Aid course but it was unclear from the records whether all staff had received First Aid training. 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) (a) Requirement Assessment documentation must be updated to reflect changes in care need to ensure all needs can be met. All avoidable risks to which service users may be exposed must be identified and recorded in order to minimise these risks and maintain service users’ health and safety. Previous timescale of 01/11/07 not met. Timescale extended to one month from inspection. A planned programme of activities for service users should be developed, in line with individual care plan goals, in order that service users personally develop. Previous timescale of 01/11/07 not met. Timescale extended by one month from inspection. Medication practice must ensure that medication administration record (MAR) charts are accurately signed to ensure peoples’ safety. DS0000069784.V370169.R02.S.doc Timescale for action 31/10/08 2. YA9 13 (4) 14/09/08 3. YA12 16 (2) (n) 14/09/08 4. YA20 13 (2) 30/09/08 15 Thompson Drive Version 5.2 Page 27 5. YA20 13 (2) Medication dispensing packs must be secure to ensure that medication is stored safely and errors are prevented. A secure double locking facility must be provided to recommended specifications to ensure the safe storage of controlled drugs. There must be a format to record complaints and their outcomes to ensure peoples’ concerns are listened to. Staff must be provided with training in recognising and preventing abuse to vulnerable adults and in responding appropriately when suspected. The bathroom must be refurbished to ensure it is safe and comfortable to use. 30/09/08 6. YA20 13 (2) 30/11/08 7. YA22 22 (3) 31/10/08 8. YA23 13(6) 01/01/09 9. YA24 23 (2) (b) 01/01/09 10. YA34 19(1)(b) Schedule 2 Staff must not be employed 01/11/08 unless required information and documents, relating to their recruitment, are in place. This is necessary to ensure the safety of people living in the home. Timescale extended to cover any new staff employed. There must be one first aid trained person in the Home at all times, to make sure that service users receive appropriate treatment in an accident. 01/12/08 11. YA35 13(4) 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Home’s Service Users Guide should include service users’ views of the Home and be in a format suitable for the individual service users. A ‘person-centred’ approach should be followed with service users, and health and care planning documentation should reflect this. Pictures or symbols, appropriate to individual service users’ degree of understanding, should be included as well as recorded personal likes and dislikes. Care plans should be reviewed and up dated to reflect a change in needs. 2. YA6 3. YA6 4. YA9 Service users should be supported to take responsible risks as part of an independent lifestyle. Staff should be aware of opportunities for ‘positive risk taking’. Staff should be provided with training in understanding and managing epilepsy. The home should obtain a copy of the Royal Pharmaceutical Society Guidelines on administration of medicines in care settings. The day of the week should be recorded beside each of the seven rows of tablets within blister packs. Two staff signatures and the date should accompany handwritten entries on medicine records to ensure a clear audit trail. The Home should be working towards providing all documents, to which service users should have access, in an ‘easy read’ format. This should include the complaints procedure. 5. 6. YA19 YA20 7. 8. YA20 YA20 9. YA22 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 29 10. YA23 Two people should sign financial records and an audit should be carried out to ensure money is properly accounted for. The Home’s ‘Adult Protection Procedures and Prevention of Abuse’ should be amended to fully reflect safe practices. 50 of care staff should achieve a National Vocational Qualification (NVQ) at level 2 in Care. Consideration should be given to operating an ‘on call’ system so that emergencies can be responded to appropriately. Staff should be provided with training in non-physical intervention strategies in response to challenging behaviour. Staff should be provided with training applicable to the needs of people living in the home such as epilepsy and autism. Quality questionnaires should be sent periodically to relatives, staff and external professionals, as well as service users. An annual plan should be developed, covering all aspects of the running of the Home, to assist with quality assurance processes. The manager must update her health and safety training in moving and handling and food hygiene. 11. 12. 13. YA23 YA32 YA33 14. YA35 15. YA35 16. YA39 17. YA39 18. YA42 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 15 Thompson Drive DS0000069784.V370169.R02.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!