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Inspection on 22/06/09 for Great Western Road, Flat 3, 22-24

Also see our care home review for Great Western Road, Flat 3, 22-24 for more information

This inspection was carried out on 22nd June 2009.

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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff have a good rapport with residents and demonstrate a kind and caring attitude. Staff help residents to carry out activities in the home that they enjoy. Residents can choose when they get up in the morning and when they go to bed. They are also involved in the choice of meals. Care planning documentation is person centred and reflects the likes and dislikes of the people who live here.

What has improved since the last inspection?

Overall the recording of medication has improved, however some issues remain which are outlined in the report. Medication audits now take place to check the amount of medication that should be in the home. Registered Provider audits are taking place more frequently. The lounge area now has new laminate wood flooring. There is now a more person-centred approach.Great Western Road, Flat 3, 22-24DS0000010877.V375631.R01.S.docVersion 5.2

What the care home could do better:

Areas needing improvement were discussed with the Service Manager at the time of inspection. The recording of information needs to improve, especially in regard to health care and potential safeguarding issues. The safeguarding procedures need to be clearer at the home and all staff need to be aware of them, also staff training in this area needs to be up-to-date for all staff. The staff training log needs to be kept up to date at the home and staff supervision needs to take place more frequently.

Key inspection report CARE HOME ADULTS 18-65 Great Western Road, Flat 3, 22-24 22-24 Great Western Road London W9 3NN Lead Inspector Sharon Newman Key Unannounced Inspection 29th June 2009 09:00 Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Western Road, Flat 3, 22-24 Address 22-24 Great Western Road London W9 3NN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7289 5041 020 8964 5507 The Westminster Society for People with Learning Disabilities Christine Quantock Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 11th August 2008 Date of last inspection Brief Description of the Service: Flat 3 is a purpose built, wheelchair accessible, first floor flat providing accommodation and care for men and women with a learning disability. The home can accommodate up to six service users. The property is owned and maintained by Paddington Church Housing Association, and the care is provided by the Westminster Society for People with Learning Disability, a voluntary organisation. The home is located in a residential area of Westbourne Park, close to shops and transport links. The home is part of a small residential block that includes a second registered care home and six flats for people with a learning disability who are living independently. Each person living in the home has his or her own bedroom. Communal areas, bathrooms and toilets are shared. The current weekly fee for the home varies from £1,101 - £1,660, with no additional charges. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. As part of the inspection of this service we visited the home on 22nd June 2009 and time was spent talking to staff, residents and viewing paperwork. During the inspection a number of records and documentation were checked including care planning information, medication administration records, health and safety documentation, and quality assurance documentation. We also looked at the premises. The service manager completed an Annual Quality Assurance Assessment (AQAA) which is a self assessment of the service. At the time of the inspection four residents were living at the home. What the service does well: What has improved since the last inspection? Overall the recording of medication has improved, however some issues remain which are outlined in the report. Medication audits now take place to check the amount of medication that should be in the home. Registered Provider audits are taking place more frequently. The lounge area now has new laminate wood flooring. There is now a more person-centred approach. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 6 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have their needs assessed and kept under review to ensure relevant care is provided. EVIDENCE: The service manager told us that two prospective residents are currently being assessed to see if life at this home would suit them. One has already visited the home to meet staff and other residents. The information in the two residents care plans we looked at showed that individuals receive full assessments prior to coming to live at the home. The local authority re-assesses the needs of the people living at the service to ensure the care plans match their current needs. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans are person centred and residents are involved in the planning of their care. Residents are encouraged to make decisions about their lives. Residents are supported to take risks through the care planning and risk assessments process. EVIDENCE: The service manager tells us in the AQAA that “we have changed the format of the care plans in order to make all care plans accessible to people.” The care plans seen were person centred and contained pictures and photographs to make it easier for the people who live here to understand them. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 10 Each person has two files, one containing health information and the other with a wealth of information about the individual’s daily needs, likes, dislikes and aspirations. Some information relating to two incidents recorded (on regulation 37 forms) for one service user and one incident recorded for another individual regarding moving and handling were discussed with the Service Manager as they contained potential safeguarding/unexplained injury issues and it was unclear how these had been followed up. We were informed that the incident regarding moving and handling had resulted in the moving and handling trainer coming out to assess this area at the home. However, issues had been highlighted at this visit (such as staff using an underarm hold) and there was no evidence of follow-up. It was also undated. Please refer to the Concerns, Complaints and Protection section of this report. The risk assessments relating to these individuals were detailed but had not been updated following the above incidents - this must be addressed. One (regulation 37) form reporting an issue contained two different dates so that it looked like the report had not been made until a month after it took place. The Service Manager reported that this was a mistake; however more attention needs to be paid to the recording of information. In one file a report was seen with the name of a different individual on the front page, the service manager reported that this was wrong and it did relate to the individual that the file belonged to and not the name indicated. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a range of activities although more external (outside) activities should be offered. Residents rights are respected and their opinions are valued. Residents are involved in choosing their meals. EVIDENCE: Regular residents meetings are held to enable them to air their views about the home. The AQAA confirms that “weekly house meetings” are held. Also residents “participate in a satisfaction survey” to gain information about their views of life at the home. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 12 The Service Manager tells us in the AQAA that “two outside therapists provide reflexology and music sessions on a monthly basis.” A resident told us that they enjoyed living at the home and they had attended a recent meeting at the home. They also said that they had enjoyed baking cakes the day before. They also reported that they regularly attend church services. Although many activities are offered within the home and some local community activities take place such as shopping - thought should be given to offering more community activities in other areas. The AQAA reflects this and states “we could be offering more a variety of activities in the community outside of the local area.” The Service Manager told us that they are looking into this. We saw staff talking to staff in a caring manner, showing respect and offering them choices about what they wished to do. Residents were involved in choosing the new flooring for the lounge area of the home and choosing the curtains for their bedrooms. The AQAA tells us that “the link worker system has recently changed so that “everyone has an allocated person and to ensure continuity of support at all times.” There is a menu folder which contains colour photographs of different types of food and this helps those who live here to decide what they would like to eat. A residents told us that they “liked the food.” The Service Manager told us that they have recently purchased a slow cooker so that staff can spend more time with the residents. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents have access to a range of health and social care support. Information relating to health care needs is not always fully recorded and it is sometimes unclear what action has been taken. Issues with medication have not yet been fully resolved and action must be taken to ensure that residents are not put at risk. EVIDENCE: We saw evidence in the care plans to show that a range of professionals are involved in the care of the people who live here. This includes GP’s, District Nurses, psychologists, psychiatrists, speech therapists, physiotherapists, occupational therapist and Social Workers. A District Nurse was observed to be visiting the home on the day of the inspection. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 14 The AQAA tells us that “everyone is supported to attend regular health appointments in areas appropriate to their needs.” We saw evidence that where issues have been identified, best practice meetings are held with the residents and health and social care professionals to discuss the options available. An action plan is then put into place. Information in the AQAA told us “the team is more aware of the need and importance of monitoring food/fluid intake……” However, we found the information recorded on the fluid charts to be variable. Overall, there has been an improvement but one chart was found where not fluids had been recorded and another where 400mls had been recorded at 9am and 400mls at 12pm – in a 24 hour period. The Service Manager reported that she would look into this. The AQAA tells us that “same gender support with personal care is provided for intimate personal care wherever possible.” Tracking hoists have been installed in the home to help with the moving and handling of residents. Overall medication recording and administration appear to have improved. However, one topical cream was not signed for on one occasion and where a person was highlighted to have a specific allergy this had not been indicated on their medication administration record. A course of medication counted for one resident was found to be correct. The Service Manager reported that there had been some specific issues regarding medication recording and administration that the service is addressing. She reported that some measures have already been put into place. For example a medication audit is carried out weekly. We discussed that the issue relating to non-administration and poor recording must be fully addressed and she said that she will liaise with the appropriate department within the organisation to ensure that this is resolved to ensure that those living at the home are not placed at risk. The Service Manager also told us in her AQAA that “the team could be better aware if side effects of medications.” Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a clear complaints procedure which is available in a format which is easier for the residents to understand. The recording of information in relation to potential health care and safeguarding issues is unclear. Incidents are not always fully logged. EVIDENCE: A complaints log is kept at the home and gives details about the action taken. The service manager reported that there have not been any complaints at the home since the last inspection visit. The service has a clear complaints procedure which is available in a format which is easier for the residents to understand. The Service Manager stated in the AQAA that “people are supported to make complaints via tenants meetings and through contact with the support and management team, as well as in day services and other agencies.” Some good practice was seen regarding safeguarding issues and we saw that where an issue had been highlighted with a resident, reviews had been held Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 16 with the relevant health and social care professionals and an action plan drawn up. However, we also saw evidence where no clear action or follow–up could be seen following potential safeguarding issues. Written information relating to the action taken was not available. The manager reported that where incidents of unexplained bruising/potential safeguarding issues occur the Regulation 37 form that is sent to us (CQC) is copied and sent to the Local Authority. We discussed that a more robust referral system directly to the Local Authority needs to be in place – if only to ask for advice. Also, in discussion with the service manager it became apparent that the pathway for referrals to the Local Authority Safeguarding team appeared unclear. There is a clear need to clarify this process. It would be good practice to have a clear referral chart/Local Authority Safeguarding referral (SOVA) Guide on the wall for all staff to follow From the training records available at the home it shows that not all staff at the home are up-to-date with training in the area of safeguarding. This needs to be put in place to ensure that residents are not placed at risk. At least two incidents that had been logged on Regulation 37 forms had not been logged into the incident book. All incidents must be logged her with clear details of the action taken. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a homely, light and airy atmosphere and it home continues to be accessible to wheelchair users and provide specialist equipment to meet the needs of the current residents. The home is clean and hygienic. EVIDENCE: This service is a purpose built, wheelchair accessible, first floor flat. There is a passenger lift up to this level. It is light and airy with a large lounge area and a communal kitchen that has space for three large tables. Each individual has his or her own bedroom. The communal areas, bathrooms and toilets are shared. One resident told us that they liked their bedroom and those seen looked comfortable and well-personalised with pictures and possessions. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 18 There is a wheelchair accessible toilet, an assisted bathroom and an assisted shower room for residents use. Tracking hoists have been installed in the flat to support residents who require assistance with their mobility. The home was clean and hygienic at the time of our visit. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have a good rapport with residents Not all staff are up-to-date with training in mandatory areas including moving and handling. Staff one to one supervision needs to increase in frequency. EVIDENCE: Staff were observed to have a good rapport with residents and to treat them with respect. Staffing numbers seemed appropriate for the number of residents (4) on the day of inspection and the staff indicated on the rota were on duty. The manager told us that currently a minimum of two staff are on duty in the morning and two in the afternoon. The Service Manager is also on duty. There Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 20 are two assistant managers in addition to the Service Manager. Three waking night staff are currently employed by the service. A record is kept of staff one-to-one supervision; however from the evidence available we saw that not all staff are receiving enough sessions. We discussed that the frequency of this supervision needs to be increased to help to ensure that staff receive the support they need to develop their roles. Staff appraisals need to be carried out for all staff as this is currently not taking place. The Service Manager reported that she is aware of this and it will be addressed. It is also reflected in the AQAA that there is a need for increased supervision and for appraisals to be carried out. From the evidence we saw during the inspection it appeared that not all staff were up to date with training in areas such as moving and handling, first aid, SOVA and food hygiene. The service must ensure that it keeps an up-to-date register of staff training to ensure that all staff are up-to-date in mandatory areas. We were unable to view the staff recruitment information at this inspection visit as it is kept at the head office. We spoke to a representative from human resources during the visit and they sent email confirmation of the criminal record checks (CRB) and reference checks for a new staff member. However it would be good practise for a form to be kept at the home with details of staff members pre-employment checks. Staff meetings are held monthly to enable staff to keep up to date with developments at the organisation and to air their views. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current (covering) service manager has the relevant experience to run this service. However a manager needs to register with the Care Quality Commission. This service has a quality assurance programme and seeks the opinions of residents and other interested parties regarding the running of the home. The health and safety of the residents is promoted at the home. EVIDENCE: Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 22 The Service Manager tells us in the AQAA that “the care manager of the home resigned from her post in February, the management of the home is overseen by a service manager.” She told us that a new manager has been recruited but has not started yet. The home needs to ensure that any new manager is registered with the CQC. Although there have been improvements in some areas which is good, there are still areas within the home that need to improve. Much of this relates to the recording of information and this is where staff training is needed and ongoing audit of care plans, health records and medication records must take place. Evidence was seen that the service manager carries out Regulation 26 visits which are audits of the service. This helps to identify strengths at the home and areas that need improvements. Quality assurance audits are carried out at the home to help to ensure that the views of the people who live here are taken into consideration regarding the running of the home. Health and safety checks such as gas safety, five yearly electrical installations and portable appliance testing were up-to-date. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 2 X 3 X 2 3 X Version 5.2 Page 24 Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13 Requirement Managers and staff must make sure that risk taking assessments are reviewed regularly and especially when a person’s support needs change, to make sure that service users are cared for safely. The information in service users fluid charts must be accurate and fully completed, Medication records must be fully completed. All staff must be up-to-date with training in the safeguarding of vulnerable adults. The procedures for referral to the Local Authority must be clear. The Society must ensure that all incidents are fully recorded in the log book with details of the action taken. The Society must make sure that a copy of staff recruitment information including CRB Disclosure details is kept in the home for inspection. Steps must be taken to ensure that staff training records are DS0000010877.V375631.R01.S.doc Timescale for action 01/08/09 2 3 4 YA19 YA20 YA23 13 13 (2) 13 01/07/09 01/07/09 01/09/09 5 YA23 13 01/07/09 6 YA34 19 01/09/09 7 YA35 17 01/08/09 Great Western Road, Flat 3, 22-24 Version 5.2 Page 25 kept up-to-date and reflect the training undertaken by staff. Previous timescale of 01/10/08 not met. The frequency of staff supervision must increase to at least six times a year for fulltime staff. Appraisals must take place for all staff. A manager must be employed for the home and must register with the Care Quality Commission. The standards of record keeping in the home must be improved to ensure that they are accurate and up-to-date. Previous timescale of 01/10/08 not met. 8 YA36 18 (2) 01/10/09 9 YA37 9 01/12/09 10 YA41 17 01/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 26 Care Quality Commission South East PO BOX 1250 Newcastle upon Tyne NE99 5AL National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. Great Western Road, Flat 3, 22-24 DS0000010877.V375631.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!