Inspection on 05/12/08 for Brampton View

This inspection was carried out on 5th December 2008.

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

Brampton View 11/01/08

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.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Brampton View 421 Welford Road Northampton NN2 8PT     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: Sally Snelson     Date: 0 5 1 2 2 0 0 8 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. the things that people have said are important to them: They reflect 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 31 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Brampton View 421 Welford Road Northampton NN2 8PT 01604475333 01604472892 keithmsaada@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Msaada Care Limited care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 6. The registered persons 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 are within the following category: Learning disability - code LD Date of last inspection Brief description of the care home Brampton is a registered residential home for six people with a range of learning disabilities and complex needs. The home is situated on the Welford Road 3 miles north of Northampton town centre. The home offers ground floor accommodation. Access to the home can only be gained via remote controlled gates. The home is in an area between Kingsthorpe and Boughton. With transport you can access Kingsthorpe shopping centre, which includes shops, recreational, and leisure facilities and is also only a short bus ride away from the town centre. Fees are currently 1500-1850 pounds per week. Fees charged will be based upon individual assessment of needs and requirements. Examples of individual items not included in the fees are: - toiletries, clothing and shoes, additional monies towards eating out or entertainment. See the homes Statement and Purpose for all additional items that service users maybe required to buy. Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 6 Care Homes for Adults (18-65 years) Page 5 of 31 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 was carried out in accordance with the Commission for Social Care Inspections policy and methodologies, which requires review of the key standards for the provision of a care home for younger people that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment, the AQAA, has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Feedback was given throughout the inspection to the manager, Millie Mlilo and the operational director Keith Millhouse. Care Homes for Adults (18-65 years) Page 6 of 31 During the inspection the care of two people who use the service was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input What the care home does well: What has improved since the last inspection? What they could do better: There are some areas that need to be improved and these are described in the inspection report. It appears that the manager is not fully aware of exactly how the home is running and must have a better overview of the service. Shortfalls have resulted in the following recommendation or requirement being made. The Statement of Purpose, and the Service Users Guide must include all the required information, and be up-to-date. Consideration must be given to the format of these documents. The pre-admission assessment should include details that confirm that the service has the required staff and equipment to meet the assessed needs of the person using the service. A daily record of the care provided and how the resident has responded must be kept. It must be apparent that people using the service have been involved in making decisions about the lives and the care they receive. The care planning documentation should be more organised. It must be more apparent how activities are chosen and how they meet the needs of the particular resident. Care Homes for Adults (18-65 years) Page 8 of 31 There should be a record kept of what people eat. Staff must ensure that an accurate record is kept of the medication administered. It must be clear what people using the service are expected to contribute towards finacially. The staff team must have the competencies and qualities required to meet the needs of the residents. Staff must be regularly supervised. Staff should have a job description that is relevant to their role and defines their responsibilities All the staff files should be kept together. There must be a formal process to assess the quality of the service provided. All health and safety checks should be carries out in accordance with the home;s policy and these should be accurately recorded. The manager should give consideration to becoming the registered manager. 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 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 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service understands the need to inform people about what is offered but the documents on display were not up-to-date and were not available in formats that suited all the people using the service. Evidence: We asked for a copy of the Statement of Purpose and were provided with the document that was kept in the entrance hall of the home. The manager informed us the the quality manager had recently reviewed the document. However the information was not current and consequently not accurate. For example it described the home as a nursing home, when this was not its purpose, and did not include all the information required by schedule 1 of the National Minimum Standards. It was apparent that over the last few months the home had been admitting people who were being bought back to Northamptonshire from out of county placements and was being used as an assessment placement. This is perfectly acceptable, as long as the Statement of Purpose reflects this. There also needed to be a Service Users Guide Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: that was written in more detail to explain to the people using the service exactly what was provided. For example it should inform them about arrangements for paying for activities, including meals out, and holidays. We also noted that the certificate on display, named a manager who had not been in post for a year, and that the displayed insurance certificate was also out of date. We were advised that the insurance certificate was an oversight and a copy of the current one would be faxed to us and the original displayed immediately. The service was also informed that they are required to let us know immediately when a registered manager resigns, so that a new certificate can be produced that shows the post as vacant. During the inspection we tracked the care of two people who had been admitted to the service since the last inspection. Both had been visited by a member of staff before moving in and had been given the opportunity to visit Brampton Lodge in advance. However, although people had been visited by staff prior to moving in it was difficult to see how the home had made the decision that needs of a prospective resident could be met. Care Homes for Adults (18-65 years) Page 12 of 31 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. People who use the service would benefit from the opportunity to make more decisions about their lives, so that they could be part of the planning of the way the home was run. Evidence: While we were sampling care plans it was apparent, from the comments made by the people using the service, that the documents were familiar to them, and the information in them was shared with them. Unfortunately because there had been a number of admissions at the same time, staff had not had the opportunity to review the support plans as often as the manger intended. However there was no legal requirement for the plans to be reviewed more than 6 monthly. We did note, that the folders that included the plans, were not well organised, and that old information from past placements was stored with that which was current, and could be confusing to the reader. The manager was aware of the need to organise the files, and ensure that when changes were made they were dated, so that it was apparent when certain Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: reviews and changes had taken place. Daily logs were not always completed and there were in a number of gaps in one persons record, even though the box had been dated. It was unclear from reading support plans and talking to staff and residents how much autonomy each resident had with regards to making decisions. For example there was a four-week rolling menu plan, but at lunch this was not adhered to and a resident told us I have had an egg sandwich. We would have been encouraged if she told us it was because she fancied his but she then went on to say that the carer making lunch had chosen it for her. Staff confirmed that they knew the likes and dislikes of the residents and based the meals around their knowledge. Although we were told that people using the service participated in meal preparation the two residents who were catered for at lunchtime sat at the table in the kitchen waiting for the member of staff to prepare the food. At no stage in the preparation did the staff member suggest the resident should help. One resident told us they (meaning the staff) make our meals, they are our servants. We were aware that some residents were supported to manage their own finances. One person proudly showed us her bank card and described how much money she needed for her afternoon in town and to last until she next used the cash point. The manager stated that people living at the home were encouraged to participate in the running of the home, but there was little evidence of this either in practical sense, or in the way support plans were written. As some of the residents spoke to us about living independently and finding work we would have expected to see more support for them with skills associated with independent living. The service had good risk assessments that had been completed accurately by the staff and ensured that people were given the opportunity to take risks, and that ways to minimise risks were explored and documented. Care Homes for Adults (18-65 years) Page 14 of 31 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. Residents had the opportunity to participate in a number of activities, but it was not apparent how these were chosen and how they benefited from them. Evidence: The people using the service appeared to be kept busy and each had an activity plan in their bedroom to remind them what was happening. One resident told us that she did not enjoy all the things on her plan and that the planned activities did not always take place because of staff shortages. We noted that it was intended that all the people using the service went bowling on a Tuesday, watched a movie on a Wednesday and went to the pub on a Saturday. The manager told us that these were possible joint activities, and that people could do their own thing on the other days. By using the local pub and shops the people living at Brampton View became part of the community. One resident told us she would like a job and that she hoped the manager Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: would soon find her one. On the day of the inspection three of the residents went to the town to do some Christmas shopping with a carer. One of the resident could be independent whilst out, but she told us on her return that she stayed with the group and they all had lunch together. One of the residents who remained at the home was desperate to go out and had to wait for her key-worker who was due on duty at 15.30hrs. Staff supported residents to maintain links with their families and would help them with phone calls and transporting them to a family members home. Staff regularly transported one family member from his own home to visit his relative at Brampton View. We looked at the menu plans for the home. The menus offered a choice at each meal and it was expected that staff completed details of what each resident chose. However these records had not been completed for some week and it was apparent that the menu was not always adhered. Changing the menu is not a problem, but the home are required to keep records of what residents have eaten, so must record something. Staff were supporting some of the residents to eat more healthily and discouraging a lot of take-aways when people were out on a trip. Care Homes for Adults (18-65 years) Page 16 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health needs could be compromised by insufficient recording of the administration of the medications. Evidence: The people living together at Brampton had a range of differing health needs. It was apparent that staff sought advice from health professionals, and had written some clear guidance to ensure consistent care. For example the guidance for the use of the medication that should be given when a person had a seizure was concise. It detailed what needed to be done and the procedure to follow if there were no staff on duty who had been trained to provide the appropriate emergency treatment. Residents were supported to attend medical appointments, and to have optical and dental checks. Each resident had a document on file, referred to a hospital grab details which could be taken to the hospital with the resident if they were admitted in an emergency. Each resident was weighed regularly. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: Sampling of the Medication Administration Charts (MAR) indicated that charts were not always signed correctly and that omission codes were not routinely used. Staff did not use the back of MAR charts to record the actions that they took, and why they took a particular action. Following the inspection the manager told us that the omissions might have been when resident went home on leave. However, it would be expected that this would have been recorded using the appropriate code. There was no evidence that medication coming into the home was recorded on the MAR chart. It was therefore not possible to reconcile those medications that had not been supplied in blister packs. This is done by checking the stock total against the signatures as it is expected that the medication held by a care home can, and should be audited at any time. Care Homes for Adults (18-65 years) Page 18 of 31 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. There was a robust complaints procedure available. However people using the service must not be expected to use their personal money to pay the full cost for meals out, that replace the main meal provided by the home, or pay for staff refreshments. Evidence: The home had a complaints procedure that was available in each of the residents bedrooms. However we were not sure that the format it was in would make it suitable for all those using the service. There had been no complaints made to or about the service since the last inspection. The manager had a file in which to record any complaints made and was aware of the procedure for responding to complaints. Staff had had some training in the recognition of, and their responsibility to report abuse. We were told in the AQAA that at times it was necessary for the home to use restraint. We were not provided with the information about which staff that had been trained to use restraint and how restraint was recoded. The training record confirmed that it was a training need. We were concerned when checking the money held by the home on behalf of the residents that when staff accompanied the resident on an activity that involved the resident eating out (which could be quiet regularly) the resident sometimes paid for the staff members refreshment. The manager told us that she believed that this was Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: acceptable, if the person could not pursue this activity without support, although the operational director did not agree and was unaware of this practise. Care Homes for Adults (18-65 years) Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises was clean and tidy and provided those people living at Brampton View with a homely place to live. Evidence: We were taken on a tour of the building by two of the people using the service. Each bedroom had been personalised and some of the people living at the home had their own items of bedroom furniture and other personal possessions. The home was clean tidy and attractively furnished throughout. As the service was on one level all the individuals rooms, and the communal areas were accessible to all, including those people that relied on mobility aids, including wheelchairs. All bedrooms were single occupancy with en-suite facilities. The quiet room that could be used for relaxation was not well heated, so was not used during the winter months. The kitchen was homely, and a resident in a wheelchair told us she could access it and use the surfaces if she wanted. The laundry facilities were off the kitchen. Care Homes for Adults (18-65 years) Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team were committed to providing care and support to the people using the service. Evidence: We looked at the files for two members of staff. We would have liked to sample more files but staff who had been most recently employed did not have files in the home. We were told that this was because the head office kept duplicate files for personal and the human resource manager had recently changed and was in the process of auditing the files. We would expect a copy of each member of staff file to be available at inspection.The files included a job description although we were aware that one of the staff files we sampled had a job description relating to night duty when that member of staff was working the day shift. The recruitment files that we sampled included all the required information. All contained fully completed application forms, appropriate references. Criminal Record Bureau (CRB) checks had been carried out on all staff, and home office paperwork was present where required. We were unable to see what training staff had undertaken during the inspection as both of the files we looked at included only one certificate as evidence of training. Following the inspection the manager faxed as through a training matrix which Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: provided evidence that six of the staff had dome some training, but the three new staff had nothing recorded. Not all of the training recorded on the matrix had been training provided by Msaada and without certificates there was no evidence as to the quality and validity of the record. The matrix included the training considered mandatory plus some specialist training. The manager told us that she was aware that there were a number of gaps in training but these had been booked for January 2009. The manager had written in the AQAA, in the section about what improvements were planned for the next 12 months ensure all staff have received all relevant training in order to provide a quality service for our users. It was apparent that staff were prepared to enrol,for training and would complete NVQs and BTECs. Staff supervision was happening but the manager was aware that it was not expected that every member of staff would have had the required six supervisions by the end of the year. For example one file showed that a member of staff had been supervised 13/02/08, 04/07/08, 27/11/08 and it was recorded the next was due 20/02/09. A three-month gap between supervisions will mean that it will never be possible for staff to have the required six sessions in a year. Care Homes for Adults (18-65 years) Page 23 of 31 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. The manager needed to review exactly how the home was running and ensure that staff were preforming in accordance with the regulations. Evidence: The manager had been appointed almost a year previously, but soon after starting work she had had problems with her work permit and had not worked again until afew weeks before the inspection. During her absence the deputy had acted up into the position and had run the home. For much of this time the home had run with only one resident. Recently new residents had joined the one resident, and the home was now full. During the inspection it became apparent that some of the tasks that the manager assumed were being completed by staff were not being recorded, for example the daily log and the fire log. The manager must spend time auditing the service to be sure that these tasks are undertaken as she has the ultimate responsibility for them. At the time of the inspection there was no formal quality assurance for the home in place. Staff met regularly with residents, and residents had the opportunity to meet Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: with advocates, but there was no process to record satisfaction. The quality manager did visit the home to carry out Regulation 26 visits and feed back to the manager any concerns. Prior to the inspection the service had been asked to complete an AQAA. In this document we require the serve to assess themselves and inform us as to what they believe they are doing well and need to improve on. We were disappointed that despite a reminder the AQAA was not returned until after the inspection. We were told that this was due to the change of the management arrangements for the home. Policies and procedures were in place and had last been reviewed 01/01/08. Staff must be fully aware of the contents of the policies and ensure that they adhere to them. The standard of record keeping needs to be improved. This includes the need to accurately record details and ensure that documents, particularly those that are a legal requirement, are completed with dates, full names etc. We sampled the health and safety logs and expected to see that routine fire checks and water checks had been carried out in accordance with the homes policy and procedures. However there was no evidence that the weekly checks of fire alarms was being undertaken. The manager told us that these were done but that staff were not correctly recoding this procedure. We reminded the manager of the saying, if it is not recorded it has not been done, and explained that there would be no evidence available to support hers and staffs word for this. We were advised that following the inspection the manager had spoken with the staff and ensured that the correct paperwork was available to record the necessary checks. Care Homes for Adults (18-65 years) Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 31 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 1 39 24 There must be a formal 01/03/2009 process to assess the quality of the service provided. To ensure that a good standard of care and support is provided that meets the needs of the residents. 2 42 12 All health and safety checks should be carries out in accordance with the home;s policy and these should be accurately recorded. To ensure the home is safe at all times 01/01/2009 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 1 5 The Statement of Purpose, 20/01/2009 and the Service Users Guide must include all the required information, and be up-todate. Consideration must be given to the format of these documents. These documents must provide the reader with clear details of what the service offers and be accessible to those using the service. Care Homes for Adults (18-65 years) Page 27 of 31 2 6 15 A daily record of the care 20/01/2009 provided and how the resident has responded must be kept. Daily records are a good source of evidence to show that care has been provided. 3 7 12 It must be apparent that people using the service have been involved in making decisions about the lives and the care they receive. To provide the evidence that the care provided is what the resident wants and requires. 20/01/2009 4 12 12 It must be more apparent how activities are chosen and how they meet the needs of the particular resident. This shows that the service is meeting the needs of the residents 01/02/2009 5 20 13 Staff must ensure that an accurate record is kept of the medication administered. It must be possible to correctly reconcile the stocks of the medication held in the home at any time. 18/12/2008 6 23 16 It must be clear what people 01/01/2009 using the service are expected to contribute towards. Care Homes for Adults (18-65 years) Page 28 of 31 This is to protect people from financial abuse. 7 32 18 The staff team must have the competencies and qualities required to meet the needs of the residents. It must be apparent which staff on duty have done a particular training i.e.medication training. 8 36 18 Staff must be regularly supervised. There must be a formal dedicated time for staff to receive supervising from a senior person. 01/02/2009 01/02/2009 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 pre-admission assessment should include details that confirm that the service has the required staff and equipment to meet the assessed needs of the person using the service. The care planning documentation should be more organised. They should be sufficient staff on duty to support residents to participate in the activities they have chosen and this should include evenings and weekends. There should be a record kept of what people eat. Staff should have a job description that is relevant to their role and defines their responsibilities All the staff files should be kept together. The manager should give consideration to becoming the registered manager. Staff should be aware of polices and procedures and should follow them at all times. Page 29 of 31 2 3 6 16 4 5 6 7 8 17 31 34 37 40 Care Homes for Adults (18-65 years) 9 41 Records should be accurately recorded. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. 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