Inspection on 05/06/09 for Great Glens Facility Limited

This inspection was carried out on 5th June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Great Glens Facility Limited 24/08/07

Great Glens Facility Limited 13/06/06

Great Glens Facility Limited 10/02/06

Great Glens Facility Limited 18/01/05

Great Glens Facility Limited 26/08/04

Great Glens Facility Limited 29/01/04

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

Key inspection report Care homes for adults (18-65 years) Name: Address: Great Glens Facility Limited 149/151 Midland Road Wellingborough Northants NN8 1NB     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home 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 full review a ‘key’ inspection. Lead inspector: Ansuya Chudasama     Date: 0 5 0 6 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 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 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 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. 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 Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Great Glens Facility Limited 149/151 Midland Road Wellingborough Northants NN8 1NB 01933274570 01933224729 darrylfoulds@greatglens.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Darryl Foulds,Mr Frank Leslie Foulds care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: To accommodate 4 service users at 153a and 153b Midland Rd, Wellingborough in need of PC by reason of mental disorder, for the age of 25 years & over To accommodate18 service users at 149/151 Midland Road, Wellingborough, NN8 1NB, PC by reason of mental disorder for the age of 25 years and over Date of last inspection Brief description of the care home Great Glen is a Home providing personal care for up to twenty-two young adult residents who have long-term mental health needs and have ongoing involvement with community based psychiatric support services. Accommodation is provided in the main building on two floors, all in single bedrooms, each with an en-suite facility, and in two separate semi-detached houses next door, providing two single bedrooms each, for the more independent residents. Facilities in both properties include recreation lounges, communal living rooms on both floors, with facilities for making hot drinks. There are limited adapted facilities to cater for physical disability, although currently the category of registration is only for residents with mental health needs with no physical disability Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 22 Brief description of the care home needs. Externally, there are landscaped gardens with a large patio area. The home is situated in a relatively quiet residential street not far from the centre of Wellingborough. On the 24th of August 2007 the fees for the service provided were between six hundred and one thousand and four hundred pounds per week per person. Care Homes for Adults (18-65 years) Page 5 of 30 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: zero star poor 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 Care Quality Commission (CQC) policy and methodologies which require review of key standards for the provision of a care home for older people that takes account of the peoples views and information received about the service since the last inspection. Evidence used and judgments made within the main body of the report include information from this visit. We looked at the Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We sent out care homes surveys for staff and for the people to complete information about how the home was meeting their needs. We received the surveys back when we asked for them. The information from these documents are used in the report. Care Homes for Adults (18-65 years) Page 6 of 30 We also looked at the information from the last key inspection and the records of any other visits that we have made to the home in the last 12 months. Information we have about how the home has managed any complaints and things that have happened in the home, which are reported under notifications and are a legal requirement are also looked at. The report refers to we this is because the report is written on behalf of the Quality Care Commission. We last inspected this service on the 24th of August 07. This key inspection was carried out on the 5th of June 09. The senior support worker and the manager helped out with the inspection process. On the day of the inspection there were 22 people living at the service. 18 people were living in the main house and 4 people were living in the semi-independent houses. The home had no vacancies. During this inspection we tracked the care of two people who use this service. This involved reading their care records and also talking to them wherever possible to obtain their views on the service. We also spoke to some of the other people who live in the home. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to some of the staff who were on duty. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Information about staff recruitment must be all obtained before staff start work. This is to ensure the people are kept safe from any harm. Provide the peoples survey results in a format the people can understand. Provide a medication cupboard, which meets the Administration of Medicine in Care Homes guidance. Ensure that all the information stated in standard 6 of the National Minimum standards for adults is included in the peoples plan. This is to ensure all their needs are met. Care Homes for Adults (18-65 years) Page 8 of 30 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. Care Homes for Adults (18-65 years) Page 9 of 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The peoples needs are assessed prior to them living at the home to ensure their needs will be met by the home Evidence: The home has a statement of purpose but a service user guide was not available. The people spoken to told us that they had visited the home. One person told us that we visited the home and liked it and came to the home. It was said that the social worker got me in. Another person said it looked clean and every one was nice and friendly and the bedroom seen was nice. Other comments include I came for a visit and was able to look around to see if I liked the place. The peoples files looked at showed that there were assessment admission details of the person being admitted to the home. All the people in the home have contracts. But all the information stated in standard 5 needed to be included in the contract . This is so the people understand their terms and conditions of their stay. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: Care Homes for Adults (18-65 years) Page 12 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people have care planning documents but these needed developing further to include all information stated in the standard to meet the peoples needs. Evidence: We looked at two peoples care plans in detail and discussed their care needs with staff on duty. The staff showed that they had very good understanding of the care needs of the people. Evidence showed that these plans were being reviewed but there was no mention of the person being involved in the process. One of the new people admitted to the home told us that they had not seen their care plan. As discussed at the inspection all the information stated in the standard needs to be included in the care plan. This is so the people know how their goals and aspirations are being met by the home. The AQAA says that we are currently in the process of reviewing service user files. These will be more detailed and concise and incorporate the new care plans already being implemented. We were also told that the service could do better was to have more in-depth care planning and more detailed communication. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: A range of risk assessments are in place that enables the people to take risks as part of an independent lifestyle. However the information needed expanding and needed to include the five steps to assessing risk as discussed at the inspection. We were told the home had meetings about each person living in the home and staff discuss every thing about the person so their needs can be better met by the home. The peoples information was kept secure in the office and One person told us that they talks to staff and they know that they will not talk about what they said to other people living in the home. Care Homes for Adults (18-65 years) Page 14 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Meals served are nutritious and plentiful with a menu, which changes each week so that the people have a balanced diet with choices to meet their needs. Evidence: We were informed that the activities are carried out in the dining room. A board was displayed near the entrance of the home and had the activities displayed for the day. We were told that once a week during term time the college bring their computers to the home to do IT training with the people who wants to get involved. On Fridays there is cooking in the afternoon and this was observed. The cakes baked were delicious. On Mondays they have an exercise activity. The people also play table tennis and this was played on the day of the inspection. The people choose to do the activities that they enjoy. Art and craft sessions were said to be done in the home Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: during the holiday period. Some of the pictures done by the people are displayed around the communal areas in the home. The people told us that they go on holidays and have day trips. We were told that some of the people were going on holiday to Barcelona next October. Some people had been to Wickstead park yesterday and said that they enjoyed this. One member of staff was observed taking one of the people shopping. Some of the people went to town or visited their family. Some of the people had also joined the gym. We were told that if the home had more staff they could offer more activities to the people and be more involved in social life. The people have a small kitchen where they are able to make tea and coffee. This place is kept clean by staff supporting the people to do this.We were told that the people choose the menus on a two weekly basis. A variety of comments were received about the food that was offered to the people. One person told us that they had lived at the home for 7 years and told us I like it here and I like being with people and food is nice with choices. All the people spoken to said that the food at the home was very nice and they had choices. The people told us that they liked their bedroom, and each persons bedroom seen was individualised to their taste. Some people enjoyed spending time in their rooms as they preferred this. We were told by the people that they had chosen the colours for their room and had the layout of the room the way they wanted this. This was observed on the day of the inspection. The people say that the staff are very nice and helpful. One person told us that that they liked the people that they lived with because they were nice.We did observe that the people in the home got on well together. The people living in the semi independent houses also told us that living in the houses was more homely and they had the freedom to do what they wanted, and treated the place like their own home. Most of the people in the home maintain contact with their families and friends. We were told that staff support one person to visit their family and they enjoyed this. The home has a peoples meeting every 3 to 4 months. The manager has an open surgery for any one to discuss their concerns with them. One person told us that they enjoy having one to one session with the manager than attend a big group meeting. Care Homes for Adults (18-65 years) Page 16 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The peoples health care needs are being met by the home. Evidence: We observed staff interaction and noticed that they talked to people in a respectful manner and were careful to preserve their dignity. The people we spoke to informed us that the staff knocked on their doors before entering their room. This was observed on the day of the inspection. Evidence in the care records showed that the people are offered support for their physical and emotional health needs. There were records of district nurses, general practitioner, and hospital appointments, and people have access to the opticians, dentists, and other health care professionals. The people told us that if they did not feel well, they would tell the staff and they call the doctor. It was also said that staff accompany those people who needed this support. One person said that they see the community nurse and a community psychiatric nurse also visited the home to find out how they were getting on and talked about their emotional problems. One person told us when they have a Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: headache, they tell the staff and they give them tablets to make them feel better. we were told that the staff who gave out medication had received the accredited training. We observed staff giving out medication and this was done by talking to the people. There were medication profiles for each person. The medication records looked at showed that there were no gaps recorded and these were satisfactory. The home did not have a controlled drugs cupboard and the medication was being stored in a cupboard in the office and this was not attached to the wall. Care Homes for Adults (18-65 years) Page 18 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The peoples concerns are listened by staff to ensure their needs are met. Evidence: The home has a complaints policy, and the procedures for making a complaint is recorded in the statement of Purpose. The home has not received any complaints since the last inspection. The staff spoken to informed us that they had completed the safe guarding of vulnerable adults procedures training. They had good understanding of this and understood the peoples behaviours to know if they were unhappy or not feeling well. The home has not made any referrals to the safe guarding team of social services. All the people spoken to were capable of informing staff if they had any concerns. They told us that they would tell the manager, family, staff, key worker, community psychiatric nurse if they had any concerns. One person told us that they find it easy to talk to a certain member of staff because they listen to him. Another person told us that staff do listen but I do not always get my own way, I dont expect to. Care Homes for Adults (18-65 years) Page 19 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and has a relaxing atmosphere to meet the peoples needs Evidence: A tour of the home showed that the place is clean and homely. There is no smoking in the home. The colour scheme in the home was very pleasant and provided a relaxing atmosphere. This was confirmed by the people and staff spoken to at the inspection. The bedrooms seen were indivualised to the people and those spoken to tell us that they like their rooms and some enjoyed spending time in them. Some people had bought in some of their own ornaments and furniture to make the place feel homely. This is also encouraged by the home. The laundry and the kitchen were pleasant, clean and domestic in character. The lounge had been painted and decorated with new carpet fitted. The home was waiting for the new curtains to arrive for the room. We were told that the shower room is kept locked. This was because one of the people in the home flooded them. However when a person wanted a shower, they have to ask a member of staff for the key. There are no communal toilets for the people to use downstairs. We were told that the people have to use their own toilet in their rooms. Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: Downstairs there is a small kitchen where the people are able to make tea and coffee. There is also a small quiet room and this was used by people who needed this. Up stairs there is a kitchen where the people who are able to prepare meals use this kitchen. The semi-independent house was visited. The house is in two units with one unit accommodating two women and the other unit has two men living here. The people were very proud to have achieved this stage of living. The rear garden of one of the semi-independent houses needed attention to make it pleasant for the people to use. One persons bathroom floor and radiator needed attention as discussed with staff. Care Homes for Adults (18-65 years) Page 21 of 30 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 homes recruitment procedures are not robust, so there fore the people are not being protected from potential harm. Evidence: The staff recruitment files looked at showed that one person had started employment without having their POVA first or CRB check. (see conduct and management of the home for further information) New staff undertake the skills in care induction after a few weeks of being employed at the home. However there was no recorded induction undertaken for the first day of starting work for new employees. There was also no information recorded to state how staff working on POVA first check were being supervised by the home. Staff spoken to said that they received an induction at the home when they start work. Staff spoken to informed us that they were getting supervision but this did not always happen six times per year for all staff. The home did not use agency staff and we were told that there was enough staff on duty. We were also told that the home retains a lot of their staff and this provides continuity to the people. This was observed on the day of the inspection. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: The staff say that they enjoy working at the home, and it was said that they looked after the peoples needs well. They supported the people to learn new skills. We were told that they do lots of training and have completed all the statutory training. One staff said they enjoyed coming to work and said that they all get on well as a team. The staff say that they have good training and staff meetings every 6 to 8 weeks and it was said that these were good. A staff training matrix showing all the training carried out by staff was not available but this was sent to CQC after the inspection. The AQAA states that the home has 9 permanent care staff and five staff have completed NVQ level 2 or above training in care. Care Homes for Adults (18-65 years) Page 23 of 30 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is experienced and qualified to run the home but the recruitment procedures for the home are not robust to protect the people from potential abuse. Evidence: The manager of the home has many years experience of running the home. He is a qualified Registered Mental Health Nurse (RMN). We are told that the manager has an open door policy and has a surgery where staff and the people can discuss any concerns they have. The staff tell us that the manager is good and very supportive and gives advice. The people also liked the manager and one person said that they prefer to talk to the manager on their own rather than attend the peoples meeting. The accident and incident records show that these were being recorded appropriately. The staff recruitment files were looked at in detail. All the information about staff induction and Protection Of Vulnerable Adults (POVA) first check was was not available on the day of the inspection. We were informed that this information would be sent to CQC. This was received on the 26th of June 09 when we asked for it again. Evidence Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: showed that one new staff had started work three days before their POVA first was received. The persons Criminal Record Bureau check was received weeks later. The files looked at did not have written information on how staff with POVA first check were being supervised by the home. The manager informed us that after he had reviewed the information and said it appears that on one ocassion there was a lag of three days between a member of staff starting their induction at our facility and written confirmation that they did not appear on the POVA list. We were also told that this is an unusal oversight and meetings have taken place between responsible staff that this does not occur again. We were given information about a survey carried out by the home to find out the views of the people living at the home. However there was no information to state when this was carried out and how many people had completed the questionnaires. We showed the information to one of the people to look at to find out if they understood the way the analysis was recorded. The person was unable to understand this. The analysis was not recorded in a format that the people are able to understand. There was no action plan to say how the sometimes answers were going to be actioned by the home. The information was not displayed as stated in the standard and in the service user guide. The home should also undertake surveys of staff, families, and other professionals involved with the home to find out their views on how the peoples needs are being met. The fire alarm system was being tested on a weekly basis. The emergency lighting was done on a monthly basis. We were told that fire drill practice was also happening on a regular basis and the people were involved in this process. We were told by staff that they had received fire training and food hygiene training. The Environmental Health Officer had visited in March 09 and awarded the home five stars which is very good. Care Homes for Adults (18-65 years) Page 25 of 30 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 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 The home must ensure the 03/09/2009 storing of medication is followed in line with the administration of medication in care homes guidance. This is to ensure that medication is kept safe in the home. 2 20 13 A controlled drugs cupboard must be provided in the home. This is to ensure that this is available when controlled drugs are needed to be stored in the home. 03/09/2009 3 34 19 The staff recruitment procedures must be followed. This is to protect people from receiving care by someone who may not be suitable to work in a care home. 24/07/2009 Care Homes for Adults (18-65 years) Page 27 of 30 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 4 34 19 A records must be kept to 24/07/2009 show that people on POVA first check are supervised by experienced staff This is to protect the people from any potential harm 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 1 Provide a service user guide in a format the people will understand. This will set out clear and easy to understand information for the people. Ensure all the information stated in standard 5 is included in the peoples contract. This is so the people are aware of all their rights and responsibilities. Ensure that all the information stated in standard 6 is included in the peoples care plan. This is to ensure all their needs are met. Expand the information on risk assessments and follow the five steps to assessing risk. This is to keep the people safe. Keep a record of staff induction when they first start work. This is to show that they have been given the information on fire safety, and about the home. Provide a staff training matrix with the dates the training took place. This is to show the training undertaken by all staff. Provide all staff six supervisions per year. This is to monitor their work in how they are meeting the needs of the people. Provide the peoples survey analysis in a format that is easy for the people to understand. This information needs to be displayed where the people can view this. 2 5 3 6 4 5 9 35 6 35 7 36 8 39 Care Homes for Adults (18-65 years) Page 28 of 30 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 9 10 41 42 Ensure the policies and procedures for recruitment are followed to safe guard people from any harm. Ensure that the information needed for inspection purposes is available when needed. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: 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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