Inspection on 20/05/08 for Home Close

This inspection was carried out on 20th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Home Close 25/05/07

Home Close 05/06/06

Home Close 07/12/05

Home Close 17/05/05

Home Close 22/11/04

Home Close 25/05/04

Home Close 08/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Home Close Cow Lane Fulbourn Cambridgeshire CB1 5HB Lead Inspector Lesley Richardson Unannounced Inspection 20th May 2008 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Home Close Address Cow Lane Fulbourn Cambridgeshire CB1 5HB 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) 01223 880233 01223 881728 Home Close Ltd Nicola Malthouse-Hobbs Care Home 68 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (68) of places Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated at any one time who require nursing care must not exceed 42. One named person in the category DE(E) Date of last inspection 25th May 2007 Brief Description of the Service: Home Close is a purpose built home situated in grounds in a quiet lane close to the centre of the village of Fulbourn. Accommodation is arranged in flats, and each flat has a kitchenette and lounge area. There is a large communal lounge/dining room on the ground floor. Individual accommodation is on two floors with the upper floor being accessed by a passenger lift or stairs. The home provides care for older people with both social and nursing care needs. There is a day centre on site and the home has ambulance bus transport available for outings. An extension was built and this was registered with CSCI in January 2007. This increased the number of places they can provide by 20 to 68 people, of which, a maximum of 42 can also have nursing needs. The home is situated approximately 1 mile away from the centre of Fulbourn and 5 miles from the centre of Cambridge. There are local shops, pubs and a post-office in Fulbourn, and a full range of shopping and entertainment facilities in Cambridge. Fees for the service range from £595.00 to £740.00 a week. Extras are charged for additional items such as chiropody and hairdressing. Copies of the latest CSCI inspection report are available in the manager’s office or at the reception desk for people wishing to read them. Home Close DS0000015159.V364961.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. This was a key inspection of this service and it took place over _ hours and __ minutes as an unannounced visit to the premises. It was spent talking to the manager and staff working in the home, talking to people who live there and observing the interaction between them and the staff, and examining records and documents. Two requirements from the last inspection have been met and two requirements have not been met. There have been no more requirements and one recommendation made as a result of this inspection. Information obtained from the Annual Quality Assurance Assessment and from returned surveys was also used in this report. Ten surveys each were returned from people who live at the home, and two each were returned from visitors to the home and staff members. What the service does well: Staff are polite and respectful to people living at the home. They take their time and don’t hurry people. Comments we received about the home and staff who work there include, “On days that I visit my mother she is always clean and well dressed” and “Staff friendly, pleasant to deal with”. An assessment is obtained before people go to live at the home to make sure staff there are able to care for them. Everyone we spoke to and received surveys from said there is enough information provided about the home, and one person said, “The information I have is accurate”. Every person living at the home has a care plan to show staff what they need to do to help that person. The plans are written to show what people can still do for themselves and tell staff members what they need to do for that person. Care plans are not written for everything and this is talked about more in the section about what they could do better. Care plans are looked at regularly to make sure they are accurate and risk assessments are also completed to show how risks can be reduced or made safer. People have access to health care professionals, such as opticians, chiropodists, GPs and community nurses. There is a very dedicated activities co-ordinator at the home who makes sure there is always something for people to do, if they want to. She is well liked and respected by people at the home. People living at the home are able to Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 6 choose what they do during the day, and this includes staying in their room if they want. The home helps people keep in touch with their relatives, and one visitor said, “The staff are very good at taking the telephone to our Mum”. Meals are appetising and people we spoke to said they like them and they are happy with the choice. One person returning a survey said the meals had, “more variety and much improved” and a visitor said, “my mother is not a good eater but the home do have very good meals”. Staff members help people to eat, if this is needed, and they do this with respect and consideration for the person they are helping. The home is clean, tidy and smells pleasant. Regular maintenance and servicing checks are carried out and it is a safe place for people to live. Complaints are dealt with properly and everyone we received information from said they know how to and who to make a complaint to or talk to if they had any concerns. People who live at the home said they feel safe living there. The manager is a registered nurse and has other qualifications in management and dementia care. She has been working at the home since December 2005. Records are kept to show money kept by the home on behalf of people living there. This means that there is information to show when money is spent and what it is spent on, so that people can feel safe in having the home take care of it. There are enough staff at the home to be able to give people the care they need. Everyone living at the home who returned a survey said they get the care and support they need and nine out these ten people said there are usually staff available when they are needed. What has improved since the last inspection? Two of the requirements made at the last inspection have been met. We found medication storage and administration records, and staff training had improved. We looked at the records that show medication receipt, administration and return and these are completed accurately, although staff must make sure there is a clear explanation for medication not given. The storage room for medication is now air-conditioned and provides a constant temperature within manufacturers guidance. All staff members receive required health and safety training when they first start working at the home. Refresher and updated training is also given to all staff and most staff members have received this within the required intervals. The home has a person whose role is to make sure this training is given. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. People have enough information before moving into the home, which means they are able to decide if they would like to live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eight out of ten people said they had received a contract from the home and everyone we received comments from said they had enough information before moving into the home. Assessments are completed before people move into the home and assessments by health and social care teams are also obtained to provide more information. We looked at the care records of one person who had moved into the home in the last 6 months. Although the homes own assessment had been completed there was some information that should have been looked at in more detail. This means the home is able to say whether it has the staff with the skills and experience to care for someone before they move in, but may not know everything about that person. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 10 The home does not provide accommodation specifically for intermediate care or for rehabilitation purposes. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. Care records generally provide enough information but there are not care plans written for all identified needs, which means staff do not always have guidance to adequately care for people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who commented in surveys said they get the care and support they need from staff members and during the inspection people told us care staff are nice and are polite. We saw this during the inspection and that staff knock on doors before entering rooms. One relative commented, “on days I visit my mother is always clean and well dressed”. Each person in the home has their own set of care plans that guide staff members in how to care for them. Care plans for four people were looked at as part of this inspection. They show that each person has a plan that gives staff members’ information about what they need to do to meet most of the identified needs. Risk assessments, for things like falls and moving and handling, are completed and reviewed regularly. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 12 Although care plans are well written and give staff enough information, they are not always written for all identified needs. We looked at the records of two people because the manager and staff told us they could be aggressive. One person had no care plan to tell staff the best way to manage this behaviour or what the medical specialist had advised. We talked to three staff members who all had different opinions about the amount of aggressive behaviour this person was having. This ranged from no aggressive behaviour at all, ever, to regular aggressive behaviour towards other people living at the home. There is a care plan for the other person that was written when that person started living at the home, but this has not been changed and does not show any more information about the aggression or when it may occur. Other records are kept that show the person is usually verbally aggressive towards staff and may happen more often when they are giving personal care. There is no guide to tell staff about this possibility or what they should do if it happens. We looked at another person’s plan because she had only come into the home for a short time after being in hospital. Since being in the home this person has developed diarrhoea, but there was no care plan to guide staff in how to manage this or what problems the person might be having because of it. The requirement made at the last inspection has not been met. Nine out of ten people returning surveys said they receive medical attention when they need it and comments from people at the home show this. There is information in care records to show health care professionals, such as specialist nurses, opticians and chiropodists, are contacted for advice and treatment. We looked at the care records for the person mentioned in the above paragraph to see if a doctor had been contacted for advise. The person had declined the offer to contact the local doctor when the diarrhoea first started. However, the care records do not show the person was asked again if they wanted a doctor to visit and it was 10 days before a doctor was contacted for advise about this problem. The manager said that the community psychiatric nurse visits people with a mental health diagnosis. People we spoke with during the inspection and received surveys from all said they get medical attention when the need it. Medication administration records are completed correctly, with very few entries not signed or given a key code to indicate the reason the medication was not given. One person had been started on a second medication for a health problem and staff said they had not been sure whether both medications should be given, so had temporarily stopped the first one. However, this had not been written on the MAR sheet. Medication is stored in locked trolleys, which are kept in a locked room and storage for controlled drug medication is also stored in a locked cupboard. The storage room is airconditioned and temperature checks show medication is stored at acceptable temperatures. In view of this and because MAR sheets on the whole are properly completed, the previous requirement has been met and another requirement has not been made. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. People are able to participate in meaningful activities, choose how they spend their time and are helped to keep in contact with their family. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seven out of ten people who returned surveys to us said there are activities that they can take part in. Several people told us during the inspection that they did not want to join in social activities provided in the home but that they had been asked. People were complimentary about the range of activities provided at the home, which includes both group and one to one activities. The activities coordinator is clearly very dedicated and held in high regard. She showed a good understanding of people’s needs, life experiences and the therapeutic benefits of activities. However, a number of people and one relative who completed a survey said that they sometimes miss activities, and there are never any activities for one person who is not able to get out of bed. The activities coordinator thought this may be because she is expected to take everyone wanting to take part to the activity and doing this alone has become more difficult since the expansion Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 14 of the home. There is no separate activities room so people who do not wish to join in have to either go somewhere else or sit through the activity. The manager said plans are being discussed to change an unused lounge to an activities area. One resident said they had a lack of control over their life and they no longer managed their own finances or medication. We talked to the manager about this and she told us it had already been looked at. People are able to make everyday choices about when to get up and go to bed, how to spend their days, whether that is in their own room, in the main lounge/dining area reading the paper or participating in activities. The home has an open visiting policy and people can have visitors at any time of the day. Both of the visitors returning surveys said the home helped people keep in touch and they are kept up to date with issues concerning that person. One comment from a visitor said, “the staff are very good at taking the telephone to our Mum”. A relatives meeting is held every 2 months, minutes are available and displayed in the reception area. The main meal is served at lunchtime and fresh fruit is served as part of the meal four times a week. We saw lunch being served in one flat and consisted of cauliflower cheese bake and sausage plait, followed by cheesecake. Food was served appropriately and staff were courteous and attentive and offered assistance where required. Drinks are offered throughout the meal and at other times. Most people described meals as mainly good but some felt the quantities were too large, and a comment from one relative was, “my mother is not a good eater but the home do have very good meals”. Since the last inspection the home has employed a supper chef who prepares a hot and cold alternative meal. One person said the food trolley was brought up at 4.30 and was not served until 5.00 and was sometimes cold and another person said, “the choices at supper are limited and monotonous and poorly presented”. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People know how to make complaints and concerns known and can be confident that these will be listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People returning surveys said they feel safe living at the home, they know who to speak to and how to make a complaint if they have to, and that staff listen to what they say and act on it. Although one visitor who returned a survey said complaints are only sometimes appropriately dealt with. The home has a complaints procedure and keeps a complaint log to show how they have looked at and the outcome of complaints that have been made. We were told before the inspection there have been four complaints made to the home, which were all looked at within the proper timeframe and the action taken is shown in the log. One recent complaint is currently being investigated under local safeguarding procedures. The manager confirmed that staff receive training in safeguarding (protection of vulnerable adults). All new staff complete this training as part of their induction and then receive more detailed training from an internal trainer, who has completed a train the trainer course with the local safeguarding team. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The home is clean and provides a safe environment, giving people a pleasant place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a large purpose built property situated in a suburban area in the village of Fulbourn and on the outskirts of Cambridge. People living at the home have access to a number of communal areas, including a garden at the back of the property. The general décor within the home is satisfactory, and it was clean and tidy, with no offensive smells. Everyone returning surveys said the home is usually clean and tidy and people at the home said the home is clean. The call bell was an issue for a number of residents, who stated it was loud and disturbed them at night. We heard the call bell during the inspection and they are loud and would be disturbing at night. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staffing levels and training ensures people receive the care they need, but recruitment checks have not improved and do not make sure all staff are safe to work with people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home said the majority of staff are nice, but some told us they had a better rapport with some staff. Although there were enough staff on duty to cover the care needs of residents, one person said care staff were always rushing and some people said it takes care staff a long time to answer the bell sometimes. Low staffing levels in the afternoon was a concern for several people. We visited two lounges after lunch but did not see any staff members and people sitting there said they would not see staff members again until they had a cup of tea later in the afternoon. We also spent some time in the main lounge and dining area in the afternoon, which is also next to the office where care records are kept. Five staff members were in the office writing notes with the door closed, and nine people sat in the lounge area. While it would not have been too difficult for people in this area to attract staff members’ attention, having no staff easily available in other areas of the home would be isolating for people living there. Another person commented on the heavy use of agency staff who were not familiar with their needs. The manager said there are care position vacancies Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 18 and that they use agency staff to bring staffing numbers up, but that they try to use the same agency staff so consistency is provided. We looked at four staff files; two for staff members who had recently been employed, the third was for an agency worker and the fourth staff file was for a staff member was employed from oversees and recruited through an employment agency. Satisfactory references had been obtained for all staff members, although references for one person were dated 6 months before that person had started working at the home. Dates of previous employment in two of these staff files had been written in years only, and there was no exploration of gaps in employment history in interview notes or other records in the files. The issue of exploring gaps in employment histories has been found at the last two inspection and there is still no improvement in this area. CRB checks had been applied for three staff members and PoVA 1st checks had been issued before they started working. However, the staff member employed from overseas had been employed on the basis of a police check from another country only and PoVA and CRB checks had not been applied for before that person started working at the home. This staff member had also been employed following a telephone interview only, rather than a face to face interview that allows assessment of answers to questions and the person being interviewed. The manager said all overseas staff are provided with English lessons after starting work at the home. New staff members complete an skills for care induction pack, which has common induction standards and is linked to a National Vocational Qualification (NVQ) in care. We saw completed packs in new staff members files. The home employs a person who has been trained to give training in moving and handling and he delivers most of this and other staff training. The training matrix shows not all staff have received refresher training in the last year, but training is planned throughout the year and includes specialist training. A number of staff have completed a local dementia course and further staff are enrolled on the course. 6 staff were spoken to and they confirmed that they had received training relevant to their job role. They also confirmed that they received regular supervision and attended team meetings. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is good. The home is a safe place to live and people are asked their opinion so that things they are not happy with are changed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been at the home since December 2005 and is registered with the Commission for Social Care Inspection as manager. She is a nurse registered with the Nursing and Midwifery Council and has completed the registered managers award and the ENB (English National Board) N11 qualification in dementia care. Regular residents meetings are held and we spoke to a number of people who have attended these. They told us the meetings are well attended and Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 20 minutes are available. One person said that they are not told what action has been taken when they raise concerns or suggest improvements. An annual quality assurance survey was carried out by the home in 2007, a report has been written and shows the issues that were found. Other audits are carried out at monthly (medication), quarterly (accident records) and annual (infection control) intervals by the staff or management. Money is kept by the home on behalf of people living there; access can be gained through the administrator who maintains an accounting system for credits and withdrawals. Money and records for 3 people were checked, all were correct and tallied with the written records. Information provided before the inspection shows maintenance checks and servicing of equipment and systems are carried out at the required times. We looked at maintenance records and saw that weekly and monthly checks that need to be complete are done and these are recorded to show this. Although checks of the fire safety system are carried out a recent visit by the fire safety officer has identified a number of issues and the manager said the home either already has or is working to resolve these. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement Care plans must be written for identified needs, to make sure staff have guidance about how to meet all care needs. This requirement had a timescale of 31/08/07, which has not been met. Enforcement action is now being considered. Recruitment checks must be completed before new staff start working at the home, to make sure it is safe for them to do so and to protect people living at the home. This requirement had a timescale of 05/06/06 and 31/08/07, which have not been met. Enforcement action is now being considered. Timescale for action 31/07/08 2 OP29 19(1)(a), (b) 31/07/08 Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations People living at the home should be informed of action taken to resolve issues identified during meetings with them. Home Close DS0000015159.V364961.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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