Inspection on 12/03/09 for 3 Welholme Road Care Home

This inspection was carried out on 12th March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Welholme Road Care Home 25/03/08

3 Welholme Road Care Home 22/01/07

3 Welholme Road Care Home 13/02/06

3 Welholme Road Care Home 27/10/05

3 Welholme Road Care Home 21/02/05

3 Welholme Road Care Home 20/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 3 Welholme Road Care Home 3 Welholme Road Grimsby North East Lincs DN32 0DY     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Kate Emmerson     Date: 1 2 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: 3 Welholme Road Care Home 3 Welholme Road Grimsby North East Lincs DN32 0DY 01472359574 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Prime Life Ltd care home 16 Number of places (if applicable): Under 65 Over 65 0 0 mental disorder, excluding learning disability or dementia physical disability Additional conditions: Date of last inspection Brief description of the care home 16 8 3 Welholme Road is a care home that is registered to provide personal care and accommodation for up to 16 service users with a mental disorder (excluding learning disability or dementia), 8 of whom may also have a physical disability. Prime Life Ltd owns the home. The home is on a main bus route to the centre of Grimsby and overlooks Peoples Park. It is in keeping with other properties in the area and has large enclosed gardens with a car parking area. Accommodation is based on two floors. All bedrooms are for single occupancy. A passenger lift offers disabled access from the main house to bedrooms situated on a lower level corridor. Further bedrooms are provided on the first floor. Bathrooms and toilets are provided on both ground and first floors. There is a range of communal areas including two lounges, dining room, and a service users kitchen. The home is comfortably furnished and is domestic in character. The current fees for the home are variable depending on individuals needs but start at Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home £311.62 per week. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection report is based on information received by the Commission since the last key inspection of the home on 4 March 2008 and a site visit to the home. The site visit to the home was unannounced and took place on 12 March 2009. The manager was available throughout the visit and we spoke to staff and people living in the home during the inspection. We examined some of the records in the home including those relating to the care people living in the home received, health and safety records and staff recruitment and training records. Care Homes for Adults (18-65 years) Page 6 of 32 An Annual Quality Assurance Assessment (AQAA) document asking for information about the home was sent out before this visit and the information was considered as part of the inspection of this service. Unfortunately this had not been fully completed and contained mainly corporate statements and very little specific detail about the home. Twenty surveys were sent out to people living in the home and staff, seventeen of these were completed and returned. The comments from these and from discussions during the site visit are also included in the report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - only when it is considered that people who use the services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? Care plans have continued to improve and the manager had worked hard to progress these. The staffing levels were adequate to meet individual needsalthough staff felt they would like more time to spend with people.. Activites had improved and were seen to be taking place during the inspection. Care Homes for Adults (18-65 years) Page 8 of 32 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 32 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 32 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. Peoples needs were assessed prior to admission and the home had good procedures in place to ensure people would feel supported on admission. Evidence: The manager stated that admissions to the home were always planned in advance. This enabled her to implement the homes admission procedures with the person who would be using the service. This included a preassessment meeting and a visit to the home with lunch provided. People were provided with information about the home and the manager arranged for the person to be introduced to a host friend during the visit. The manager had introduced these measures to enable people to feel comfortable on admission and to establish links with other people living in the home and the staff. Records were maintained to evidence that these processes had been completed. We examined the care files for three of the people living in the home. There was evidence in each file that peoples needs had been assessed before they came to live at the home.The assessments were a combination of the homes pre-admission Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: information and assessment of needs completed by the authority funding the persons placement. The home had discontinued the use of the their assessment format in an effort to simplify their processes. However this format allowed for very detailed information to be recorded and the manager was advised to continue with its use to ensure a full record of the information gathered at assessment was held on file. One person who lived in the home said I have been to a number of homes and not settled but I really do feel part of a big family. Care Homes for Adults (18-65 years) Page 12 of 32 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. The manger had continued to try and improve the care planning processes and there was some good practice in this area. However there needs to be more consistency to ensure care plans detail all the care people require and that these are kept up to date. People living in the home were able to make decisions about their life and were supported to be as independent as possible. Evidence: The manager had been working at improving the care plans in the home since the last inspection. She had researched best practice in this area and new care plan formats had been introduced. Care plans were being reviewed and transferred onto the new formats. Where a risk had been identified, risk assessments had been completed and to minimise risk action plans had been developed. Both old and new care plan formats showed examples of good practice in care planning Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: but more consistent application would provide the improvements the manager had been working hard to achieve. For example there were examples of very detailed monthly evaluations of the care plans but this process was not completed in all cases. This had lead to care plans not always being updated as necessary, for example where a person had had a plaster of paris pot removed the care plan had not been updated. People living in the home had not always signed to agree their care plans. Discussion with staff indicated that they respected peoples right to make decisions. People living in the home confirmed that they were able to make decisions about their life and felt their needs were met. One person said we are always given a choice what we want to do, you are always encouraged and another said they do everything they can do for you and also encourage you to be as independent as you feel well enough to be each day. Care Homes for Adults (18-65 years) Page 14 of 32 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. People felt they were able to exercise choice in their daily lives and they enjoyed the meals provided. Access to activities had improved but planning to meet individuals needs with regard to activities was inconsistent. Care plans were not followed in regard to monitoring peoples nutritional status and this may put peoples health at risk. Evidence: Some of the individual care plans included detailed action plans that would support people to maintain and develop their social, emotional, communication and independent living skills. This included opportunities for people to fulfill their individual spiritual needs. Some of the care plans also clearly detailed peoples social involvement and relationships. There was some very good practice seen but again there was inconsistency in completing care plans in these areas. Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: Provision of activities was restricted to some extent by staff having to complete other tasks such as cleaning and cooking and support people when they had to go out for appointments. Staff stated in surveys that they would like to have more time to spend with people. We observed staff involving people in one to one activities or small group activities during the inspection. The home did not employ any kitchen staff, however all of the care staff undertake food hygiene training and prepare the meals. People spoken to stated that they were happy with the quality of meals provided for them and confirmed that they had a choice of what they would like to eat. People living in the home were involved in menu planning during service user meetings. Records of food provided were kept although these had not been consistently completed. Peoples nutritional needs were assessed but peoples nutritional status was not monitored as stated in care plans as they did not have accurate scales. Care Homes for Adults (18-65 years) Page 16 of 32 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. The majority of peoples health needs were met. Medication administration practices were safe but the storage facilities required some improvement. Evidence: The care files evidenced that people living in the home have access to appropriate health care professionals to meet their individual health care needs. This included appointments with doctors, dentists, chiropodist, and psychiatrists. There was evidence that staff supported and encouraged people to attend appointments. People living in the home confirmed that when they see health care professionals either in the home, or in the community then they always have the opportunity to be seen in private unless they ask for support to attend the appointments. One person said I am always given good advice and pointed in the right direction and another said I have always found the staff act upon my problems even if I am having a bad night or day. Care plans were detailed in relation to health care needs and diary sheets detailed the Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: actions taken to meet peoples deteriorating health needs. However they were not monitoring people nutritional status as identified in care plans due to a lack of accurate scales. This may mean problems are not detected in a timely manner which in turn may have a negative effect on peoples health. None of the people living at the home administered their own medication. All of the staff administering medication had received appropriate accredited training. The records for receipt, administration and disposal of medication had been maintained. Some medication prescription details were written by hand in the administration records. To reduce the risk of errors hand written entries require a second person to check the entry for completeness and accuracy and then each entry countersigned this was not being completed. The medication trolley was dirty and required cleaning. The room where the medication was stored contained hot water pipes and the room was very warm on the day of the inspection. Excessive temperatures can damage the medication and the manager was advised to monitor the temperature of the room at least daily to ensure that the temperature of the room does not exceed twenty five degrees centigrade. Controlled drugs were held in the home at the time of the inspection. The homes storage facilities did not meet the new safe custody regulations. The manager stated that a new cupboard had been ordered. She was advised to inform us when this had been fitted. The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 requirements for CD storage are, in brief, a metal cupboard of specified gauge with specified double locking mechanism which is fixed to a solid wall or a wall that has a steel plate mounted behind it and fixed with either Rawl or Rag bolts. Suppliers of controlled drugs cabinets can confirm that a cupboard meets the legal requirements. We recommend that care homes request formal confirmation when purchasing such a cabinet. Care Homes for Adults (18-65 years) Page 18 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although there was a complaints procedure and people knew how to complain there was little evidence that the home took peoples complaints seriously and acted upon them as records were not held. Evidence: People living in the home were able to describe how they could use the complaints process and were confident that they could talk to any of the staff if they had any problems. However there was some varied feedback from surveys suggesting that some people did not feel listened to by all members of the staff team. Comments included it is the carers job to listen to the clients and they always do, the manager is to busy to talk and staff listen to you more than the hospital and have more time for you. The Annual Quality Assurance Assessment (AQAA) document had not been completed in relation to whether the home had received any complaints or made any safeguarding referrals.The manager stated that no complaints have been received by the home since the last inspection and there had been no safeguarding referrals. However whilst examining a staff members file there was a record of action taken following a complaint made by a person living in the home since the last inspection. The manager was unable to locate the complaints file for a record of this complaint Care Homes for Adults (18-65 years) Page 19 of 32 Evidence: and the investigation undertaken. Staff spoken with showed that they had a good understanding of their role in dealing with Safeguarding Adults issues. Computer held records showed that staff had completed safeguarding training in 2008. This training was provided through provision of a booklet with questionnaires. Whilst the majority of staff had completed these the records showed that four staff had not returned the booklets and one had been returned but had not been marked. The manager had not monitored the return of these documents and was unaware that the staff had not returned these. The staff personnel records showed that they had all received the appropriate security vetting through Protection of Vulnerable Adults(POVA) first and Criminal Record Bureau checks before they were employed to work with people living in the home and have access to their personal information. This practice ensures that people living in the home are protected. There were clear records of all of the service users financial transactions that the care staff supported them with. Finances were audited regularly and a report complied. The most recent report found the finances to be managed satisfactorily within the home. Care Homes for Adults (18-65 years) Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents have been provided with an environment that is clean with communal space suitable for their needs. Although there was evidence of ongoing refurbishment of the home, issues that could be a hazard to people living in the home or cause a negative effect on the appearance of the home had not always been identified and addressed in a timely manner. Evidence: A partial tour of the home was conducted as part of the inspection. We viewed some of the bedrooms, communal space and bathing facilities. People said that they enjoyed living in the home and felt it was kept clean and tidy. One person said the home is beautifully kept and clean and another said the home is very clean. The information provided to the Commission prior to the inspection stated that the company had invested heavily in the home to address structural issues, external decoration, new guttering, roofing and similar and as well we have refitted key areas in the home. Although there was evidence of ongoing refurbishment of the home and redecoration of some of the bedrooms the manager and staff in the home must be more proactive in identifying and addressing issues that could be a hazard to people living in the home or cause a negative effect on the appearance of the home. Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: For example the dining room had been very well redecorated in an American diner theme but one of the coffee tables in this area had a glass table top which was not secured and could easily be displaced causing a hazard to people in this area. One of the ground floor toilets was missing a toilet seat and a window in a bedroom would not open or close fully. One person living in the home had purchased a kettle and this was placed on and being used from the floor of their bedroom. Whilst this person was relatively independent this could put themselves and others at risk of accidental scalding. Curtains in the lounge were not hung correctly and had shrunk, a carpet in a bedroom was very stained and there was a significant patch of damp to the ceiling in another bedroom. The ground floor shower room had black mould to the the walls and ceiling. At the last inspection we advised that the entrance hall to the building was in need of redecoration but this had not been completed. Care Homes for Adults (18-65 years) Page 22 of 32 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. People living in the home were supported by staff in sufficient numbers who were supervised and had undertaken training. The staff vetting procedure was sufficiently robust to ensure the safety of the people living in the home. Evidence: The current staffing levels consist of the manager, and two care staff during the day and two staff at night. There is no additional ancillary staff available in the home, therefore the care staff have responsibility for the cleaning, cooking and laundry as well as care. Staff also accompany people to appointments which can entail staff being out of the home for long periods. Staff felt they offered a good service to people but a couple stated in surveys that they would like more time to spend with people living in the home. One said we could offer a better service if we were allocated more staff. Staff training records supported the evidence that the staff have the necessary experience, knowledge and skills to care for people. This included records of induction training and mandatory training that is required for the care staff and specialist training in relation to the mental health needs of the people living in the home.Interviews with the care staff also evidenced that they had a good understanding of individual needs.The staff also confirmed that the home enables and Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: encourages staff to complete qualifications in care. The employment procedures of the home ensure the safety and protection of the service users. Staff who been employed to work at the home had an appropriate POVA first or Criminal Record Bureau certificate to ensure that they had not previously been involved in any abusive practices prior to starting employment. Staff supervision files showed that staff team receive ongoing supervision with a line manager. Staff also have annual appraisal sessions. Care Homes for Adults (18-65 years) Page 24 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall the manager has the skills, knowledge and experience to run the home effectively and protect the health, safety and welfare of the residents but there was a lack of management monitoring to ensure that all systems were maintained. Evidence: The manager had completed the Registered Managers Award and the NVQ 4 in care and has relevant experience of working with people with mental health needs. She had been proactive in trying to meet the requirements from the previous inspection. However she had no hours specifically set aside for dealing with management tasks such as monitoring systems in the home. She spent large parts of her day supporting people living in the home with personal care or involved in domestic tasks such as cooking. This is reflected to some extent in the requirements arising from this inspection and some hours specifically set aside for management tasks would assist the manager to meet these and maintain and develop the systems in future. Prior to the inspection the service was asked to complete an Annual Quality Assurance Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: Assessment (AQAA). This was received by the Commission but had not been fully completed. The company had completed some corporate statements in each section but the area that were specific to the service such as information relating to staff and the people living in the home had not been completed. Regular service user and staff meetings are held at the home. These were used to identify if the services being provided are appropriate to the needs of people living in the home and allowed individuals to air their views and to identify possible areas for development. Quality assurance surveys had been received by the home from people living in the home, relatives and professionals. These showed some varied comments about the quality of the service but the manager had not audited these to check if there were any issues that could be addressed and the quality of the service improved. The manager stated that the company usually complete an annual quality audit of the service but this was not completed in 2008. All of the appropriate maintenance and servicing records for the gas and electrical systems and other safety systems were available for inspection. These showed that the fire safety checks had not been completed at regular intervals. Weekly fire alarm checks had not been completed since 4 January 2009 and had only been completed monthly prior to December 2008. The manager stated that fire drills were completed monthly but records showed these had not been completed since 4 January 2009. A drill was completed on the day of the inspection at our request and staff were seen to act appropriately. Care Homes for Adults (18-65 years) Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 32 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 Care plans must be evaluated monthly and updated as necessary. To ensure that the care planned will continue to meet peoples needs. 01/07/2009 2 17 12 Individuals nutritional status 30/06/2009 must be monitored as per individual care plans. To ensure people maintain optimal health. 3 20 13 To monitor the temperature 30/06/2009 of the room used to store medication at least daily and ensure that the temperature of the room does not exceed twenty five degrees centigrade. To maintain the quality of the medicaion. 4 20 13 Hand written entries in medication administration records require a second person to check the entry 30/06/2009 Care Homes for Adults (18-65 years) Page 28 of 32 for completeness and accuracy and then countersign each entry. To reduce the risk of errors in hand written entries. 5 20 13 To provide a storage facility 30/06/2009 for controlled drugs which meets the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 requirements for controlled drugs. These are, in brief, a metal cupboard of specified gauge with specified double locking mechanism which is fixed to a solid wall or a wall that has a steel plate mounted behind it and fixed with either Rawl or Rag bolts. Suppliers of controlled drugs cabinets can confirm that a cupboard meets the legal requirements. We recommend that care homes request formal confirmation when purchasing such a cabinet. To provide safe storage for controlled drugs. 6 22 17 A record of all complaints 30/06/2009 made about the operation of the care home and the action taken in respect of a complaint must be maintained. To evidence that peoples complaints are taken seriously and acted upon. Care Homes for Adults (18-65 years) Page 29 of 32 7 39 24 The quality monitoring 31/07/2009 systems must be reintroduced including an annual internal audit and the auditing and publishing of results of service users surveys. To ensure the continued development and improvement of the home based on the views of people living in the home. 8 42 23 Fire safety checks and drills must be completed as per the homes fire risk assessment to ensure systems are in full working order and staff understand their role in the event of a fire. To minimise risk to people living in the home in the event of a fire. 30/06/2009 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 2 The detailed preadmission assessment should be reintroduced to ensure a full record of the information gathered at assessment is held on file. Care planning with regard to peoples social interests should be consistently applied to ensure individuals needs are met. The medication trolley should be cleaned regularly. Suppliers of controlled drugs cabinets can confirm that a cupboard meets the legal requirements, it is recommended that formal written confirmation is obtained. 2 3 4 14 20 20 Care Homes for Adults (18-65 years) Page 30 of 32 5 23 To ensure that people living in the home are protected the manager should ensure that all the staff have completed their safeguarding training. The manager should have some hours in her working week that are specifically dedicated to management tasks to ensure that systems are kept up to date. 6 37 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 32 of 32 - 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!