Inspection on 17/06/09 for Birnbeck Care Home

This inspection was carried out on 17th June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Loramar House 2 St Pauls Road Weston Super Mare North Somerset BS23 4AF Lead Inspector Jacqueline Sullivan Key Unannounced Inspection 17th June 2009 02:48 Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 1 This report is a review of the 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. 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 home adults 18-65 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. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 2 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 Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Loramar House Address 2 St Pauls Road Weston Super Mare North Somerset BS23 4AF 01934 626498 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) www.Icdisability.org Leonard Cheshire Disability Manager post vacant Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 14. First inspection. Date of last inspection Brief Description of the Service: Loramar (application to be registered as Birnbeck) House provides personal care for up to 14 people with learning disabilities, aged from 18 to 65 or over. It is set in a residential area within easy reach of local amenities, the town centre and the beach. The home caters mainly for people who are highly dependent but also has facilities for several more independent residents. The home has its own minibus, a sensory room and an annexe room for use for structured in-house activities. The fees levels for the home are assessed according to the individual needs. Loramar House DS0000073182.V376173.R01.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 one star this means the people who use this service experience adequate quality outcomes. The site visit was completed by Jacqueline Sullivan (Regulatory Inspector) and Sue Fuller (Pharmacist Inspector). The inspection took place over one day. This was the first inspection as the home is now managed by Leonard Cheshire. During the inspection we spoke with the manager and the senior carers. We also interviewed four members of staff and interacted with the people living at home. We looked at the health records and care documentation of the people who live at the home. We were particularly interested in the changes that the people who live there have experienced since the new provider took over the management and running of this home. We were pleased to note that, although the rating is currently adequate, this provider and manager was able to demonstrate positive outcomes for people who live there. What the service does well: The manager and staff team have a good understanding of the needs of people who live in the home. They have started to review all the care plans to ensure that people’s wishes, feelings and aspirations are met. The organisation has worked hard to improve the environment to make it both safer and more homely. The atmosphere is friendly and relaxed within the home and people confirmed that the staff team were listening to their views. The manager and the staff team have good relationships with people who live there. One person said about the manager,” I trust him.” Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 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. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 7 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 Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 8 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the 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 benefit from having their needs assessed. EVIDENCE: The home’s Statement of Purpose was sent to the Commission following the inspection. It has not been included in this inspection but will form part of the next inspection. The people who live at the home were living there when Leonard Cheshire took over as Provider. No new people have been admitted since that date. Therefore for the purposes of this standard we are using the care plan completed by staff members from Leonard Cheshire using their own observations and information from the last provider. These were seen to be in place. As will be recognised later in the report some care plans were more detailed than others. The home has changed its name to Birnbeck and this information has been sent to the Commission. However at the time of this report, we had not formally received this request. Therefore, the name on this report has not been Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 9 changed. This will be completed by the time of the next inspection and the provider informed if any addition information is needed by ourselves. The home undertakes full and comprehensive assessment of prospective residents so that they are able to make an informed decision about the capacity of the home to meet health and social care needs of the individual. Individuals are given the opportunity through the admission assessment; preadmission visit and trail period to make an informed decision that the home is suitable and can meet their needs. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people who live at the home have benefited from having their care plans reviewed. Some people would further benefit from more detailed risk assessments. People are able to make decisions about their lives. EVIDENCE: We looked at three peoples files and saw that the quality of the information in each was inconsistent. Two people had detailed plans, which included their aspirations, wishes and feelings, and detailed plans for the future. These plans had been updated by the manager and it was evident that they had been Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 11 completed with the person living at the home. The other seven people at the home had the care plans that were inherited from the previous provider. These were relatively basic (see further evidence in the health care section of this report) and serve as a starting point for new plans. However, the manager is aware of this and has a plan in place to complete them. For one person who wishes to live independently we could see there was a detailed plan about how this was to happen. We spoke with this person and it was clear he was happy about the plans and he and another person, who wished to do the same move, had been consulted about how they wished to live. We looked at the risk assessments in place for the residents. We noted that the risk assessments completed by the manager need to be further developed. They are largely generic and do not indicate measures in place to reduce the particular risks to individual residents. Many of the people who live at the home have limited communication and the staff rely on their knowledge of the person, information in the care files and their observations. We could see that people had a real choice in the food they wished to eat and the in house activities they wanted to do. They were no residents meetings in place and consideration should be given to introducing these for the more verbal people who live at the home as an additional way of seeking their views. However, on speaking with them we were assured that their views were listened to by the staff team. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 12 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): This is what people staying in this care home experience: 12,13, 5,16 and 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have opportunities to engage in meaningful daytime activities within the home and the community but these could be further developed. Resident’s benefit from regular contact with their friends and relatives. Residents enjoy a good standard of food. EVIDENCE: We met the member of staff who was filling in for the cook who was on holiday. She showed us the menu but said that they tend to use this as a rough guide. She was cooking three meals. One was roast pork for the Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 13 majority of people. There was also burgers and chips for one person who did not want pork and sandwiches for a resident who preferred to eat the pork for tea. The staff member had restricted English so found it difficult to explain how the residents choose the food they eat. Two residents told us they liked the food and one person gave thumbs up sign when asked if they liked the food. The manager told us that there is a picture board on display, which informs residents of the food choices for the day. This was not displayed as the hall was being painted. We noted that the choices are healthy and well balanced. However so the staff team are assured that every one is eating a balanced diet it is recommended that they record the food that people eat. The standard of food was good and the fridge was seen to contain a wide selection of snacks and fresh vegetables. The cook records the fridge and freezer temperatures daily but as she had been away for two days these had not been done. The range of activities at the home and in the community that is available for people could be further developed. We saw one person receiving a foot massage and we were told that this service would be increased. We saw that a down stairs bedroom was a working activity room and we saw one person doing an activity with a staff member. There is a daily timetable of events for residents, which includes for example swimming on Mondays. However we recommend that each person has an activity plan in place which is regularly reviewed. Discussions with the staff team and residents confirmed that visitors are welcomed into the home. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 People using the 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 living in the home would benefit from improved care plans, to ensure that their needs are met. Medicines are looked after safely in the home. EVIDENCE: People living in the home are registered with a local doctor’s practice. Medicines are supplied to the home using a monthly blister pack system. All the medicines used in the home are given by staff. Suitable storage is available for people to keep their medicines in their own room. As discussed, action is needed to make sure that one medicine kept in a fridge has improved storage. Suitable storage is available for medicines which need additional security. The pharmacy provides printed medicine administration record sheets for staff to complete when they give medicines. These are kept with each person’s Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 15 medicines, along with a copy of the home’s medicine policy. This means that staff can be clear about how to give medicines safely. We saw some medicines being given at lunchtime. Medicines were given from the labelled containers provided by the pharmacy. Staff signed the administration record as they gave the medicines. We checked a sample of medicines and these indicated that they had been given as prescribed by the doctor. The records of administration had been completed fully. Staff record all the medicines received into the home. Staff told us that they have a medicines disposal book to record how unwanted medicines are disposed of, but this was at the pharmacy at the time of the inspection. We looked at three people’s care plans to see whether they had information about their current medicines. There was little information about medicines in the files. We saw that two medicines have been supplied without clear dosage instructions and had no written confirmation of the current dose in the person’s file. This means that staff cannot confirm the correct dose and increases the risk of mistakes being made. Staff told us that they were trying to address this. A form is available for staff to complete if someone living in the home sees the doctor. However the space for recording the outcome of the visit is very small so little information was seen. One person had a particular health care problem and had seen the doctor about this but there was no care plan to ensure that staff knew how best to look after the individual. This could mean that the person did not receive the most appropriate care to help them. The organisation has provided medicine training for staff to make sure that they can give medicines safely. The manager told us that he has also their pharmacy to provide some training for staff. He also told us that checks of staff competence in giving medicines will be done. This helps to ensure that medicines are given safely. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the 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 who live in the home do not have the necessary information to enable them to make a complaint. People who live in the home would be further protected if the staff team further developed their systems. EVIDENCE: We asked to see the complaints book but were told that there was not one. However it was evident from talking to the manager that he resolves resident’s complaints but does not record them. He told us how one person complained that the carpet in their bathroom was a different colour to the rest of the room so he had it changed. We asked if the residents had a copy of the complaints procedure and we were told they had not been given one. We require that all residents be given a copy of the procedure to ensure that they or their representatives know how to complain formally. POVA (Protection of Vulnerable Adults) training has taken place for the staff team, at their induction and subsequent training. We spoke with two staff members who were able to demonstrate a good understanding of how to safeguard the people they care for. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 17 When we spoke with a staff member about the whistle blowing procedure they were able to evidence they understood it and explained how they had used it appropriately. We spoke with the manager about the issue they had raised and was told that he knew about the incident but had not followed the matter up as yet. In order for a whistle blowing procedure to be fully effective prompt action should take place. This issue is relevant to the staffing standards but is also relevant here, as effective whistle blowing is another way that people who live in the house are protected from abuse. A recommendation has been made that there is a system in place to ensure that there these matters are investigated fully. Another issue that is relevant in this section of the report is that of the protection of vulnerable people from financial abuse. The manager told us about an issue about the resident’s finances. He had uncovered this issue and has dealt with it appropriately. We spoke with the finance representative for Leonard Cheshire and he explained the situation to us and how it was being dealt with. A recommendation has been made that the manager ensures that the placing authorities for each person is kept informed about the situation. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are benefiting from an improved environment but the work should be completed promptly. EVIDENCE: The home is being refurbished by Leonard Cheshire as they are committed to providing a safe and homely place for people to live. During the inspection we saw that work was taking place. We spoke with the manager about the length of time this was taking as it has now been several months. There were some health and safety issues like the placing of the ladders that concerned us. Mostly, we were aware that the hall is still incomplete and that this detracts from the house having a homely appearance and feel for the people who live there. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 19 However we are mindful of the extent of the work that needed to be completed and are assured that the work is being completed systematically. We were told that the fire alarm and electrical system have been made safe. We were pleased to note that the home did not have a strong odour in the hallway as the drains and sewage systems have been repaired. One person told us there was too many locks and they felt” Locked in “. We saw that there were many locked cabinets in the home and consideration should be given to having one central cupboard for items that need to be safely locked away. We spoke with two people who lived there and saw their bedrooms. Both bedrooms were seen to be individualised and comfortable. Both people were very positive about the new improvements to the house. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. People using the 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 would be better assured that the staff team are working consistently if the supervision of staff and staff meetings were more frequent. People are mostly protected by the homes recruitment practises. People who live in the home are cared for by a well-trained staff team. EVIDENCE: We looked at staff supervision records and noted that here is a failure to provide adequate and appropriate supervision to staff so that management can formally review and monitor their practice, look at performance and give staff the opportunity to express any concerns and discuss their professional development. There is also infrequent staff meetings. A recommendation has been made that these meetings are more often. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 21 Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected. However, to further protect the residents we recommend that there is a system in place to ensure that staff Criminal Record Checks are updated every three years. Staff training was seen to be frequent and tailored to meet the needs of the people they care for. Recent training includes: individual service planning, health and safety awareness, protection of vulnerable adults and English for carers. We spoke to two staff in detail who confirmed that staff morale is high. They were able to demonstrate a commitment to caring for the residents well and had a good understanding of their needs. We observed three other staff working with the residents and noted they were sensitive and respectful. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People using the 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 resident’s benefit from a well run home. The residents can be confident that their views underpin all self-monitoring, review and development by the home. The health, safety and welfare of the residents is promoted and protected EVIDENCE: The registered manager has been in post since March 2009. He has a vast experience of working with adults with learning difficulties. He has a NVQ 3 Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 23 (National Vocational Award) in promoting independence and a NVQ 4 in social care. Discussions members of staff and two people who live in the home confirmed that he is well liked in the home and very supportive. He presents as committed and enthusiastic about he care of people who live in the home. One staff member said, “He is a lovely manager, I feel well supported.” He said, “I would like to see peoples lives improved and fulfil their potential”. Evidence from observations of the residents and discussions with two people confirmed that he is putting this into practise and the level of care for people has improved since he has been in post. He has a challenging job as he is a new manager to the home and he is also involved in setting up another similar home. Once the work on the second home is complete he told us that he will apply to the Commission to manage both homes. As he is currently dividing his time between the two homes we need to be assured that the staff and residents are clear about the arrangements in place to manage the home in his absence. Therefore we are making a recommendation about this issue. It was evident from talking to people who live in the house that their views are listened to by the staff team. In particular those of two people who wish to live more independently. Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 24 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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 3 X 2 X 3 X X 3 X Version 5.2 Page 25 Loramar House DS0000073182.V376173.R01.S.doc 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 YA6 Regulation 12 (1) Requirement The registered person must ensure that the intended goals and objectives of support for all people using the service should be clearly identified in care plans. The registered person must ensure that all the resident receive a copy of the complaints procedure. Timescale for action 01/02/10 2 YA22 22 01/02/10 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 YA14 Good Practice Recommendations The registered person should ensure that there is a clear plan for each person about the activities they are to take part in and then clear recording about whether this activity took place The registered person should ensure that the refurbishment work should be completed promptly. The registered person should ensure that there is a system in place to ensure that CRB checks are updated every DS0000073182.V376173.R01.S.doc Version 5.2 Page 26 2 3 YA24 YA34 Loramar House 4 YA23 5 6 7 8 YA37 YA36 YA17 YA19 three years. The registered person should ensure that peoples’ placing authorities are kept informed about the financial issue discussed in the report. The registered person should ensure that any issues arising from the whistle blowing procedures are investigated promptly. The registered person should ensure that there are clear arrangements in place about how the home will be managed when the manager is absent. The registered person should ensure that the staff team meetings and staff supervision is more frequent. The registered person should ensure that the staff team record the food that people eat. The registered person should ensure that care plans include relevant information about medication and details of how a person’s identified health needs will be met by staff. This is to make sure that people receive appropriate care. The registered person should ensure that individual risk assessments are one each persons files. 9 YA9 Loramar House DS0000073182.V376173.R01.S.doc Version 5.2 Page 27 Care Quality Commission South West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: 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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