Inspection on 28/01/10 for Gatehouse Cottages Care Home

This inspection was carried out on 28th January 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gatehouse Cottages Care Home 29/09/09

Gatehouse Cottages Care Home 18/01/08

Gatehouse Cottages Care Home 18/01/07

Gatehouse Cottages Care Home 27/06/06

Gatehouse Cottages Care Home 01/12/05

Gatehouse Cottages Care Home 10/06/05

Gatehouse Cottages Care Home 20/12/04

Gatehouse Cottages Care Home 29/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 16/05/2010.

Random inspection report Care homes for adults (18-65 years) Name: Address: Gatehouse Cottages Care Home Stallingborough Road Immingham Grimsby North East Lincs DN41 8BP one star adequate service 29/09/2009 The quality rating for this care home is: The rating was made on: 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 review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Jane Lyons Date: 2 8 0 1 2 0 1 0 Information about the care home Name of care home: Address: Gatehouse Cottages Care Home Stallingborough Road Immingham Grimsby North East Lincs DN41 8BP 01469574010 01469574005 gatehouse.cottages@craegmoor.co.uk www.craegmoor.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Keith Laurence Bush Type of registration: Number of places registered: Conditions of registration: Category(ies) : Health & Care Services (UK) Ltd care home 27 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Conditions of registration: 27 20 The maximum number of service users who can be accommodated is: 27 The registered person may provide the following category of service only: Care Home with Nursing, Code N. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following category: Learning Disability, Code LD, maximum number of places 27 Physical Disability, Code PD, maximum number of places 20 Date of last inspection 2 9 0 9 2 0 0 9 Care Homes for Adults (18-65 years) Page 2 of 20 Brief description of the care home Gatehouse is a care home for adults with a learning disability aged between 18 and 65. It provides care support for up to 27 people, some have complex needs. Gatehouse Cottages is in the country and is a few miles from Imminham. It is in a quiet area with only one other house nearby. You can get to the care home by bus or by the care homes own mini- bus. Rooms are in 3 buildings. No one has their own toilet and bathroom. 2 of the rooms are shared bedrooms. The care home has many things that people can use to support them in their daily life. There is space to park in front of the care home.There is a private garden behind the home and a large sensory garden. When this report was written, it cost from 500 pounds and 1185 pounds a week to live there. If people want extra services like hairdressing and private care for their feet, they could pay a bit more. Care Homes for Adults (18-65 years) Page 3 of 20 What we found: We undertook this random inspection to check if the registered provider had complied with the requirements we made at the last full key inspection on the 29th September 2009. Some of these requirements remain outstanding, due to this we are following our enforcement procedures and further action will be taken. Choice of home. There have been no new admissions to the home since the last key inspection and the local placing authority have continued to suspended admissions until improvements with the homes action plan in relation to previous safeguarding investigations have been fully addressed. From checks of care files we found evidence that all the assessments seen had been reviewed and updated. The records contain more detailed information about peoples current needs and also a lot of person centred information about how people choose to have their care. One individual with complex needs had recently been admitted to hospital for treatment, there was no evidence that the home had carried out a reassessment prior to discharge, however the manager told us of difficulties he had experienced in arranging this assessment, he is aware of the importance of reassessment visits to ensure that the home can continue to meet individuals needs. The manager could not show us any evidence that statement of terms and conditions/ contracts had been formulated and agreed. At the previous inspection a recommendation had been made with regard to this matter, as this has not been addressed a requirement will be made in this report. Individual Needs and Choices. Evidence from case files we looked at showed that the staff have worked hard with rewriting and updating the majority of care plans and risk assessments, however there were some inconsistencies found in the review and updating of these records. We saw that the care records had been rewritten using the same format, many of these documents replicated the previous documents in place. Other care records had been updated. Many of the care files were seen to be muddled and contained a lot of old information, which could be archived. At the last inspection people who reside in The Lodge had told us of budgetary limitations put in place around the purchase of coffee, the manager confirmed that these limitations were not now in place, we saw that peoples care plans to support the management of finances had been updated but their finance record sheets had not. Another care file seen for an individual who had recently been discharged from hospital had no care plan in place to support a new area of need. The files seen in the main facility showed that the majority of care plans had been rewritten 11th and 13th December. There were no evaluation records in place to support that they had been reviewed within the month timescale. A small number of care plans Care Homes for Adults (18-65 years) Page 4 of 20 had been rewritten and updated prior to the last inspection, there was little evidence that these plans had been evaluated in line with the timescales identified. Although the majority of daily records did not evidence any significant changes, the lack of formal review means that staff are not consistently and formally reviewing individuals needs and ensuring that the care plans are kept up to date to meet peoples current needs. The risk assessments seen in the majority of the files had been rewritten and updated in line with the care plans. Review dates had been recorded for monthly or three monthly intervals depending on the level of risk identified. Few of the risk assessments seen had been reviewed in line with the monthly dates. There was an incident on the 23/01/10 where an individual had left the building. The risk assessment had not been reviewed following this incident, nor had the individuals care plan been reviewed to ensure any changes to the current care support in place were needed to protect this person. Another example we saw was one persons pressure damage risk assessment identified very high risk, this assessment had been reviewed on the 10/12/2009, however this individuals daily records detailed red areas and soreness observed to sacral areas, the risk assessment had not been reviewed within the month timescale. A failure to update peoples care plans and risk assessments to meet their current needs could result in them being put at risk of harm. These requirements have not been met and a warning letter will be sent. We saw good evidence that more detailed communication plans had been put in place, plans seen detailed how the individual communicated, what certain communications and behaviours mean and how staff could communicate. Improvements were seen with the quality of person centered planning in place. Training records showed that twenty five staff had accessed a course on person centred planning. Staff spoken with told us that they considered the training had been beneficial however they were not clear about further developing the plans given some of the peoples very complex needs. We noted that person centred plans are currently being developed for some people at the service through day services, these are good examples which the staff can use to assist them in further developing their own plans. We also saw good evidence that supplementary records such as food and fluid charts were being properly completed which ensures that people are being monitored closely and any problems could be followed up. We looked at a number of behaviour management plans for individuals in the service who at times demonstrate behaviours which are challenging to themselves or others. We found that they had been updated and the ones examined generally gave staff information on possible causes of the behaviour, what triggers to look out for, how to prevent occurrences and direction on how to manage situations. One behaviour management plan recently updated does not reflect guidance received by other professionals involved, this is covered in detail in the section relating to Health. Records show that formal annual care reviews have been held for individuals in the service where the care manager, the individual where possible, the relatives and named nurse/ manager of the service have met and discussed all aspects of the individuals current needs. The manager has developed a programme to ensure all individuals have their care formally reviewed six monthly. The manager has given this programme to the lead care manager from the local placing authority and intends to liaise further to enable their attendance where possible. Care Homes for Adults (18-65 years) Page 5 of 20 Lifestyle. We saw evidence that the majority of care plans to support peoples social needs had been reviewed and updated. However the plan seen for one individual with very complex needs did not describe their current support in this area, and activity records for this individual were very minimal. Most of the individuals have detailed activity programmes in place which describe the type of activities they enjoy at different times of the day. Activity records to support this programme showed many gaps. Observation during the day in the main facility evidenced that many peoples programmes were not being followed and there was little activity or social support provided, for example two individuals were taken to the day centre and one individual was taken out to the shops, the majority of individuals spent their time in the sitting room with the T.V. on or spending time in the dining room or around the staff desk in the hall. Few people were observed to be taking part in any meaningful activity. Staff spoken to said that many activities outside the home did not take place due to the shortage of drivers. There was no evidence that the transport arrangements at the home had improved and this limited peoples access to the local community.One individual has a swimming session detailed on the activity programme twice a week, we saw records to support that this took place once weekly, staff told us that the second session often did not take place due to the shortage of drivers. There were few records to support that the majority of people who reside in the main facility regularly accessed the community.This requirement has not been met and a warning letter will be sent. There was no evidence that people residing in the Lodge had received any support regarding their budgetary education, not all their financial care records had been updated. Improvements have been made towards providing people with holidays, people who reside in all areas of the home are being supported to choose where they would like to go and a number of holidays have been booked. We observed breakfast and lunch meal times in the main facility and there was good evidence that improvements had been made towards providing people with individualised support. We saw that people took their meals at times to suit them and support was provided by the staff member allocated to support their care that day. Training records show that eleven staff had attended a course on eating and drinking with respect and dignity on the 28/10/2009. There was little evidence that improvements had been made to the choice of meals provided at breakfast time. We observed that all the people were given either Weetabix or Readybrek and one person had the choice of toast. We observed staff support during this meal, we observed staff ask people very closed questions to ascertain choice such as Do you want weetabix? Staff told us that other cereals are provided, however when we looked in the kitchen store cupboard, these were not available. People who use the service must be provided with a variety of meal choices at breakfast to suit their preference and dietary needs. At the previous inspection a recommendation had been made with regard to this matter, as this has not been addressed a requirement will be made in this report. Care Homes for Adults (18-65 years) Page 6 of 20 Personal and Healthcare Support. We found evidence that improvements had been made to aspects of the management of PEG feeds in the home but there were some inconsistencies in record keeping and staff hygiene practice. Storage had improved and lines and feed were stored either in a cupboard in the individuals room or in the new clinic room. A new file has been put in place to ensure that all the records are properly maintained however there was evidence that neither the new file or the care file held all the current documents. Prior to the last inspection visit, staff had received training following concerns raised regarding hygiene practices in administering PEG feeds. During this visit we observed a staff member administering PEG feed without wearing protective clothing which is not in line with the homes policy and procedure.The recording and hygiene practices remain inconsistent and may put people at risk. This requirement has not been met, a warning letter will be sent. We saw little evidence to support that peoples health and support information had been updated. Many of the files did not contain health action plans and those seen were dated from 2007/8. Hospital passport documents were in place for some of the files seen, however these were not dated to identify when they were completed. Some of the people who use the service have received support and assessments from community health care professionals, we saw written guidance from these professionals in reports and in the care records however not all the guidance had been included in the care plans nor was there evidence that the guidance was being followed by staff consistently. For example a physiotherapist had recorded in one individuals care file on the 19/01/10, directions for position changes. The care plan had not been reviewed to include this information, nor did the daily or supplementary records detail that staff were providing this support, staff spoken with were not aware of this guidance. Another individual has detailed behaviour management plans in place, however there was little information to direct staff on how to support the individual positively to prevent disruptive behaviour and they focus more on managing behaviours in response to incidents.There are detailed reports from the intensive support team and also the speech and language therapist in place to inform clearer behaviour management plans, which would provide a sound platform for reflective practice. We observed that this individual displayed behaviours during breakfast time which upset another person, the staff member did not follow the guidance provided by the community health care team and was not able to manage the situation effectively.The inspector had to request assistance from another staff member to intervene and provide appropriate support. Not ensuring that peoples health care needs are planned for may mean that care will be missed and this could have a detrimental affect on their health and wellbeing. This requirement has not been met, a warning letter will be sent. Significant improvements have been made to the storage of medications in the home. A new medication storage room has been provided and all aspects of storage appeared much more positively managed. At the last visit a Sense outreach worker raised concerns about the standards of personal care provided to an individual they visited in the service. We passed these concerns onto the manager at the end of the visit and requested that they look into the issues formally. At this visit, the manager told us he had discussed the concerns raised with the outreach worker, however there were no records to support this. A requirement will be made regarding the need to ensure complaint records are maintained to support the Care Homes for Adults (18-65 years) Page 7 of 20 investigation of the issues raised. New records to support accuracy and consistency with the recording of peoples weights had been put in place, however there were minimal records seen as the weighing scales have been broken for some weeks and are in the process of being repaired. Information received prior to the visit from a community nurse specialist confirms that one of the qualified staff has now completed a proficiency assessment with regard to phlebotomy. This means that people who use the service are able to have blood samples taken by a member of staff they know and do not have to attend the local health centre each time. This qualified member of staff is now able to carry out proficiency assessments with other qualified staff in the service to ensure more staff are competent in this area of clinical practice. Concerns, complaints and protection. We saw evidence that not all incidents in the home had been recorded and followed up and the manager and staff were still unclear about the safeguarding policy regarding their role in referral. All staff have completed safeguarding training. Failure of staff to record incidents and use the safeguarding policies and procedures could mean that there is a delay in the decision making and investigation processes. This could place individuals at risk of harm. For example the daily records for one individual detailed that they had left the building on the 23/01/10 and had been found outside at 17:30. No incident report was completed. No regulation 37 notification was completed. No referral to safeguarding was made and the persons care manager was informed during the individuals case review meeting some days later. There was no evidence that this individuals risk assessment had been reviewed or their care plan had been updated to reflect any increased monitoring or support required. It is important to note that a safeguarding investigation had taken place in February 2009 following an incident where this individual had left the building and was found some hours later. One to one support had been arranged for this individual following this incident, which was in place for approximately six months. Failure of staff to record incidents and use the safeguarding policies and procedures could mean that there is a delay in the decision making and investigation processes. This could place individuals at risk of harm.This requirement has not been met and a warning letter will be sent. There was no evidence that the management were auditing incident records to inform best practice. We saw numerous incident reports completed in the Studio for repetitive behaviours displayed by some of the people residing there, however records did not support staff review or any changes with support. The manager showed us a new document he had produced to support the auditing of incidents which had not yet been implemented. At the previous inspection a recommendation had been made with regard to this matter, as this has not been addressed a requirement will be made in this report. There was evidence that the status of all visitors to the service was now being checked. Environment. The manager had provided a maintenance programme with the improvement plan prior Care Homes for Adults (18-65 years) Page 8 of 20 to the inspection, during the visit we were given a more detailed decoration and refurbishment programme with timescales for completion. The work has commenced and is scheduled to continue until November 2010. During our visit we looked round all three areas of the home and improvements in some areas was seen, most areas in the Studio have now been redecorated and all exposed pipework has been boxed in. Work in the Lodge is scheduled for later this year, given the improvements needed in this area we think that the management should review the schedule to carry out this work as priority for example: the conservatory area has not been cleaned, the birds nest seen in September was still in situ and two pains of glass were missing. The recreation room remains cluttered and storage has not been properly addressed to ensure this room is fit for use. At the previous inspection a requirement was made to ensure the recreation room was fit for use, this requirement has not been met and a warning letter will be sent. The new medication storage area and new therapy room are very positive improvements to the facilities, the manager confirmed that a therapy table had been ordered and the therapy room would be utilised when fully equipped. We saw that measures to improve the standards of hygiene and control of infection had taken place in the laundry area with the provision of a hand basin, soap and paper towels. Odour management in the lounge in the main facility had been more effective, the staff told us that the carpets in the home were cleaned more regularly. All areas seen in the main facility were clean and no mal odours were apparent during the visit. Infection control measures were in place to support the care of an individual with a positive MRSA status. We consider that the measures in place were not safeguarding the individual, staff or other people in the service. The qualified staff member administering the individuals PEG feed was not wearing a plastic apron, there were no paper hand towels provided and staff were using a roll of tissue paper to dry their hands, the bin in the room had a separate lid which had to be lifted for use. The room was cluttered and untidy, there were two suction machines on the floor, the qualified nurse told us that one of them was broken but she wasnt sure which one.There are detailed and up to date policies and procedures in place to support infection control and hand hygiene, staff had not signed to demonstrate that they had read them. Staff must follow the homes infection control protocols to protect the health and wellbeing of this individual and other people who use the service. A requirement will be in made in regard to this matter. Staffing. Staff spoken to in all areas of the service raised concerns about staffing levels in place at certain times of the day. Staff in the main facility told us that they considered the levels in the morning shifts did not allow for activities to take place, due to the amount of personal care provision and support needed with meals. In the Lodge and Studio staff told us that they considered the staffing levels impacted on the frequency of visits into the community people could access and also the management of behaviours exhibited by some of the individuals.We consider that the management should review the current staffing levels in place in each of the units, in line with the dependency levels, to ensure appropriate staffing levels are maintained to support individuals current needs. A recommendation will be made in regard to this. The day before the visit, four of the care staff had attended a course on Intensive Interaction Therapy which was run by the community speech and language team. Care Homes for Adults (18-65 years) Page 9 of 20 Feedback from the therapists and from staff indicate that the training went very well, with positive outcomes for the staff and people who use the service who were involved. The community team plan to follow up the training with these staff members to check if they have had opportunities and support to continue with the therapy. The community team have agreed to roll out further training to more of the staff in the home if the outcomes remain positive. However it is important that staff are continually supported and monitored by senior and qualified staff to maintain effective communication with people who use the service, the incident at breakfast time detailed in a previous section, was exacerbated by the poor communication skills demonstrated by the staff member concerned. We saw records to support that thirty one staff had accessed a half-day course in Autism in October and November 2009. Staff told us that the course had been helpful in better understanding behaviours exhibited by people with this condition. There was no evidence that the staff have received any formal supervision sessions since the last inspection visit. The manager has arranged for senior staff to access training in February. The manager had produced a supervision programme for staff to attend supervision meetings in December and January, however none of these had taken place. Supervising staff will ensure that their work is monitored and management can be confident that individuals needs are being met as per their care plans.This requirement has not been met and a warning letter will be sent. Staff spoken to confirmed that they have had an appraisal meeting with the manager, we were given a record detailing the dates that all staff had accessed an appraisal, however records of the appraisal meetings were not available as the manager confirmed he has been working on these at home.The manager told us that individual training needs had been identified and eight staff had since enrolled on NVQ level 3 courses, other courses were currently being arranged through workforce development. A recommendation will be made with regard to the manager ensuring all records are available for inspection. Conduct and management of the home. The manager has submitted his application form to be registered with the CQC. This is being processed and will enable his fitness to be the registered manager of the home to be tested. There was no evidence that further developments to the Quality Assurance programme had taken place. The Quality Assurance division of the company have carried out regular, full audits of the service since June 2009. A further audit of the service had taken place in January 2010. We were informed by the manager that the previous week, a team of managers from other services in the company had visited the home to review the care records, we saw evidence in the files we looked at that written lists had been compiled identifying what records were missing, incomplete or required updating. We did not see any evidence that staff were working through the lists. At the previous inspection we made a recommendation that aspects of the quality assurance programme should be developed,given the focus on improvement work to the management and administration systems at present this recommendation will remain. Overall there was some good evidence that the manager has been proactive in trying to address many of requirements and recommendations made at the last inspection visit in Care Homes for Adults (18-65 years) Page 10 of 20 September 2009.Compliance was seen to have been achieved in full towards seven of the requirements and towards six of the recommendations. We considered that a number of the requirements around care records and risk assessments have not been met due to an inconsistent approach towards the improvements needed. This improvement work has been delegated to the qualified staff, key workers and senior care staff ; there is confusion around who is responsible for maintaining which records, the quality of the recording remains inconsistent and there is little evidence that recordings made by the care staff are being checked by the qualified staff to ensure competency in this area. Although staff have received more training there is evidence that some staff are not consistently following policies and procedures, care plans and guidance provided by the community health team to ensure peoples health, safety and wellbeing is fully protected. However it is very positive that the home has recently been able to recruit four qualified members of staff with a learning disability qualification. There is great potential for these staff members to share their knowledge and skills working with the care staff to address the issues around care practices, communication skills and record keeping to provide the people who use the service with more person centred, progressive and consistent care. What the care home does well: What they could do better: Due to the failure of the registered provider to comply with the eight of the requirements made at the last full key inspection visit we will be commencing our enforcement Care Homes for Adults (18-65 years) Page 11 of 20 procedures and will be issuing a warning letter for those requirements still outstanding. Areas these relate to are care records, incident management, PEG feeding systems, staff supervision, activities / access to the community and the recreation room in The Lodge. The warning letter will reflect the timescales detailed in this report. The registered provider must comply with the warning letter within the timescales identified. Further visit will be made to the home to establish compliance. Other areas which require improvement are: People must have current contracts/ statements of terms and conditions in place which include the fees that are paid. This will protect peoples rights. Appropriate numbers of drivers for the existing transport must be provided or alternative transport provided to enable individuals easy access to the community. The breakfast menu in the main facility must be expanded to provide people with adequate choices to meet their dietary preferences and needs. Staff and management need to have full knowledge of the safeguarding policies and procedures and use them to alert the local authority to any incidents in the home. This will ensure that any incidents are investigated by the correct agency and any measures required to safeguard people can be put in place quickly. Incidents of behaviour which pose a challenge to an individual or other persons must be audited regularly to identify any potential triggers which would inform best practice. This will help protect people from harm. Detailed records must be in place to support the investigation and outcome management of any complaints received. This will demonstrate that the management are taking complaints seriously and that they are looking into issues properly. Safe systems must be put in place to manage infection control in the service; this will protect people. The home must be more proactive in reporting to the Commission, any incidents that affect the wellbeing of the people who use the service. This is so we can monitor the home, and how well staff are managing the incidents. 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 2. Care Homes for Adults (18-65 years) Page 12 of 20 Are there any outstanding requirements from the last inspection? Yes R No £ 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 15 Individuals care plans must 10/04/2010 be evaluated regularly and updated to reflect changes in need. Previous timescale of 10/12/09 not met. Warning letter issued. This will ensure the plans accurately reflect peoples needs and choices and provide direction for staff to meet needs consistently. 2 9 13 Individuals risk assessments 10/04/2010 must be evaluated and updated to reflect changes in need. Previous timescale of 10/12/09 not met. Warning letter issued. This will ensure potential risks to the individual have been identified and people can be supported to manage those risks. 3 14 16 People who use the service 10/04/2010 must receive support to take part in activities they choose and to maintain contact with the local community. Page 13 of 20 Care Homes for Adults (18-65 years) 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Previous timescale of 10/12/09 not met. Warning letter issued. People need opportunities to take part in activities they enjoy to meet their diverse needs. 4 19 12 Systems in the home to provide individuals with safe percutaneous enteric (PEG) feeding must be in place. Previous timescale of 26/11/09 not met. Warning letter issued. This will ensure peoples health needs are safely met. 5 19 12 Information about peoples health and support needs must be up to date and reviewed regularly, this includes health action plans and guidance provided from the community health team. Previous timescale not met. Warning letter issued. This will ensure peoples health needs are appropriately planned for and met. 6 23 13 Incidents in the home must be recorded properly with detail of action taken to reduce further risk of harm. Previous timescale of Care Homes for Adults (18-65 years) Page 14 of 20 10/04/2010 10/04/2010 10/04/2010 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 26/11/09 not met. Warning letter issued. This will ensure peoples safety. 7 24 23 Ensure the recreation room 10/04/2010 in The Lodge is fit for use by the people who live there. Previous timescale of 20/12/09 not met. Warning letter issued. This will ensure people will have adequate facilities which meet their needs. 8 36 18 Systems must be put in place to ensure that all care staff have supervision at least six times per year. Previous timescale of 10/12/2009 not met. Warning letter issued. This will ensure staff receive regular direction and support to carry out their work properly and any issues can be discussed and documented and actions planned to address any shortfalls in practice. 10/04/2010 Care Homes for Adults (18-65 years) Page 15 of 20 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, 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 5 17 People, their families and 10/04/2010 representatives should have clear and accurate information about the service at Gatehouse Cottages within their contract/ statement of terms and conditions. This must include the fees, payable by whom. This will protect peoples rights. 2 13 16 Provide appropriate numbers 10/04/2010 of suitable drivers for the existing transport or provide alternative transport to enable individuals who use the service easy access to the community. This will ensure people have appropriate access to the community to meet their lifestyle choices. 3 17 16 The breakfast menu in the main facility must be expanded to provide adequate choices. 10/04/2010 Care Homes for Adults (18-65 years) Page 16 of 20 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 This will ensure peoples individual dietary preferences and needs are met. 4 22 22 Records must be in place to 10/04/2010 support the investigation and outcome management of all complaints received. This will demonstrate that the home takes complaints seriously and that the issues are looked into properly. 5 23 13 The manager and staff team must familiarise themselves with, and use, the multiagency safeguarding of adults policies and procedures. This will ensure that the local authority, which is the lead agency for investigations of abuse, is made aware swiftly of any issues and can decide whether they need to be investigated. Appropriate use of the procedure will help to safeguard individuals and promote their wellbeing. 6 23 13 Incidents of behaviour which 10/04/2010 pose a challenge to an individual or other persons must be audited regularly to identify any potential triggers which would inform best practice. This will protect people from harm 7 30 13 Safe systems must be 10/04/2010 implemented and followed to Page 17 of 20 10/04/2010 Care Homes for Adults (18-65 years) Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 control the spread of infection in the home in accordance with the homes policies and procedures, relevant guidance and legislation. This will protect the safety of people who live and work in the service. 8 42 37 Any incident affecting the 10/04/2010 wellbeing of individuals must be reported to the Care Quality Commission. This will enable us to monitor incidents and check that the home is managing them well. 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 manager should carry out re- assessment visits to people, following hospital admission to ensure their needs can still be met at the home. Staff should continue to develop person centred plans. These need to reflect peoples real experiences, their needs, wants and aspirations and should demonstrate that they or their representatives have been involved in the development. The organisation should continue to review all of the information that is required by individuals and ensure it is produced in a format which is accessible to them. Staff should continue to develop the communication plans in place for people with complex needs. People should receive appropriate and agreed budgetary education and support within their capabilities to ensure Page 18 of 20 2 6 3 4 6 11 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations their rights and choices are upheld. 5 24 The manager should revise the redecoration and refurbishment programme for the home to make improvement works in Lodge a priority. A review of the staffing levels in the home should take place to ensure there are sufficient staff in all three areas of the service,to meet the needs of all the people living there. The homes quality assurance system should be developed to include consultation with stakeholders, that information from surveying people and interested parties is collated and a written report is produced. The manager should ensure that all records are secure and available for inspection. 6 33 7 39 8 41 Care Homes for Adults (18-65 years) Page 19 of 20 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got 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 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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