Inspection on 13/10/09 for Lucerne House (21-23)

This inspection was carried out on 13th October 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 but made no statutory requirements on the home.

Other inspections for this house

Lucerne House (21-23) 22/04/08

Lucerne House (21-23) 23/05/07

Lucerne House (21-23) 08/05/06

Lucerne House (21-23) 10/02/06

Lucerne House (21-23) 01/11/05

Lucerne House (21-23) 10/03/05

Lucerne House (21-23) 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Lucerne House (21-23) 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB     The quality rating for this care home is:   one star adequate 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: James Pitts     Date: 1 3 1 0 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 35 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 35 Information about the care home Name of care home: Address: Lucerne House (21-23) 21-23 Lucerne Road Thornton Heath Croydon Surrey CR7 7BB 02082399547 02082391151 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Wayne Wallen,Mrs Naomi Wallen care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home 21 and 23 Lucerne Road were two terraced houses, which have been joined by means of walkways on the ground and first floors. Having applied two years ago to run the two establishments as one home, the Registered Providers are registered as a single home accommodating up to a maximum of six adults with learning disabilities. At the time of inspection the home had one vacancy as a service user moved out earlier this year. The home is close to the town centre and accessible public transport. 2 3 0 4 2 0 0 9 6 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 35 Brief description of the care home Care Homes for Adults (18-65 years) Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is one star. This means that people who use the service experience adeqaute quality outcomes. Two inspectors undertook this unannounced inspection. One site visit was made but the manager was not available and records were seen to be disorganised. A further visit was therefore made. The site visits lasted a total of four hours. During the site visit records relating to staffing and care provision were examined. We undertook a brief tour of the premises. We were able to speak with people that live in the home. We received an Annual Quality Assurance Assessment (AQAA) from the service. We also used information held regarding any concerns or notifications. Care Homes for Adults (18-65 years) Page 6 of 35 What the care home does well: What has improved since the last inspection? 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. Care Homes for Adults (18-65 years) Page 7 of 35 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 8 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who chose to live at Lucerne House need to be confident that their needs will be appropriately assessed prior to them moving in. The information contained in assessments is basic and requires reviewing to make sure that current needs are known. Evidence: We were told during the site visit that there have been no new admissions since last key inspection in April 2009. Assessments completed prior to the current individuals moving into the home were not available for inspection. We saw an accommodation and service agreement which included the room to be occupied. The document was not dated and did not include the fees, the registered person told us this was because local authorities are paying for individuals care. These documents have not been signed by the registered person or the person using the service. The agreement should be updated to reflect the changes to the registration authority and the contact address. Care Homes for Adults (18-65 years) Page 9 of 35 Evidence: The Statement of Purpose and Service User Guide have been updated to reflect the reduction in bed numbers. However, information on the new regulatory authority, the Care Quality Commission is needed in both documents. We discussed our findings with the manager and recommended that assessments on the people living in the home are reviewed, to evidence what their needs are now. This would make sure that the assessment is a live document and reflects progression in a persons care. Information from the assessment must also be carried forward into the care plan. Care Homes for Adults (18-65 years) Page 10 of 35 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvement has been made in making sure that individuals care plans lead from the assessment and identify how needs should be met, but this needs to be consistent. Care is needed to make sure that risk assessments give information on how a person is to be protected from harm. Evidence of formal reviews of plans by placing authorities is needed to demonstrate that peoples plans are live documents. Staff must make sure that the language used in support plans does not label an individual. Detail is needed in plans to inform staff how needs can be met. Evidence: The AQAA states: At Lucerne house we have a system in place to do daily reports and a summary at the end of the week. So the monitoring of service user needs and choices are more consistent. We looked at care plans and found that people had been involved in the plans development. We saw that people have signed their care plans. Individuals we spoke Care Homes for Adults (18-65 years) Page 11 of 35 Evidence: with confirmed they are involved in reviews and planning for their future. We noted that the service has developed some person centred plans for individuals which are quite detailed. One persons care plan was not clear about the communication support they needed and this must be made more clear and describe how the service is meeting this need. One person told us they had been involved in developing their care plan and where a restriction was noted, they were aware of the reasons why. The service needs to be clear why this restriction is in place and have details from the GP to confirm this. Case files contained a sheet with individuals likes and dislikes, showing at a glance the food, drink and activities they prefer and those they do not like. Care must be taken when completing these to be factual and describe a behaviour rather than label it as bad habits. Also some sheets required updating to reflect changes in need. A persons religion was recorded in case files. At the time of the site visit there were no specific religious needs for individuals. It is recommended that people are asked if their needs have changed with regard to spiritual matters at reviews. This will evidence that individuals are able to make choices. Where placing authorities do not come and review the needs of people using the service, the service must show that they have contacted and tried to make arrangements for these reviews to take place. We examined risk assessments that included the risks for the individual and how staff should work with them to minimise risk. Where risk assessments say the person is vulnerable and this is assessed as a high risk, more information about how staff should protect the person should be included. Care is needed to make sure that care plans are dated and the goals set are realistic. We noted that one person had completed a good description of themselves in their plan, detailing their likes and dislikes and what they were interested in doing. Information on how a person communicates needs to be detailed. This will make sure that if an individuals first language is not English, then it is clear what measures are in place to aid understanding. Care Homes for Adults (18-65 years) Page 12 of 35 Evidence: Care Homes for Adults (18-65 years) Page 13 of 35 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. Individuals are able to make choice about how they spend their day. Contact with significant others is maintained. Mealtimes are flexible and the menu reflects peoples preferences. Evidence: People who live in the home told us they go out, see friends and can have visitors. We saw some people go out for lunch locally during our visit. The staff said that they cook meals and support individuals to make snacks and hot drinks. None of the people who currently live in the home have developed sufficient skill to prepare meals. Food items were seen to be stored correctly and safely. There was fresh fruit and vegetables available. Care Homes for Adults (18-65 years) Page 14 of 35 Evidence: Care plans had information on individuals dietary likes and dislikes. People who live in the home are able to be involved in discussions about what meals they would like. Care Homes for Adults (18-65 years) Page 15 of 35 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their health and personal care needs will be met in a way that respected their privacy and dignity. There must be a clear audit trail of medications into and out of the home to make sure that there is evidence of individuals receiving all there required treatment. Evidence: During our first brief visit there were no medication records available for the previous five days. It was stressed that spare copies must be available at all times. On the second visit, we noted that copies of blank medication records had been obtained. We are disappointed that this was not actioned at the time of the previous inspection when a requirement was made. The provider has stated in their improvement plan that photocopies were available. When we examined the medications within the home we found that there was no clear audit trail. Medications were not recorded when they were received into the home. We noted that Care Homes for Adults (18-65 years) Page 16 of 35 Evidence: doses and frequencies of medications were not identified on the Medication Administration Record (MAR). We saw that medications had been administered but not signed for. We do not consider that people that live in the home have not received their medications. They were able to confirm that they had had their medicine. The home must make sure that there is a clear audit trail of all medications into and out of the home. Guidance is available on the CQC website and the medication policy must reflect the guidance issued by the Royal Pharmaceutical Society. There was evidence in the care plans of individuals attending appointments at the hospital and doctors surgery. None of the people that we spoke with raised any concerns about their healthcare needs not being met. They said that their personal care was given in a way that protected their privacy and dignity. Care Homes for Adults (18-65 years) Page 17 of 35 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to voice their concerns and can be confident that these will be acted upon. Safeguarding procedures generally make sure that individuals are protected, however care is needed to make sure that no-one is deprived of their liberty and risk assessments demonstrate how people are protected from harm. Evidence: The homes AQAA states: Each service user feel at home and also visitors has commented on the atmosphere of the home and friendliness of the staff. The manager reported that they had not received any concerns or complaints. We discussed whether residents meetings were occurring. The manager said that at present this was not happening, as people that live in the home tend to approach her or a member of staff directly if they have anything they want to talk about. It is recommended that these interactions are recorded to evidence that peoples views are listened to and acted upon if needed. When we looked at risk assessments we found that more detail on how vulnerable people are protected by the service is needed. The risk assessments also need to be dated. At the time of the site visit no one living in the home had their liberty denied. Care Homes for Adults (18-65 years) Page 18 of 35 Evidence: However, one person has limits on their cigarette smoking for health reasons, but this has not been fully documented. We stressed the importance of making sure that situations that could be thought of as depriving an individual of their liberty are accurately recorded and reviewed. This will make sure that the home can evidence when agreement has been reached with the person that uses the service. We observed that the individual had no concerns about the situation and had insight into why this needed to be in place. The manager stated that she would be accessing training on Deprivation of Liberty during the next year. There have been no Safeguarding investigations since the previous inspection. Care Homes for Adults (18-65 years) Page 19 of 35 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. People live who live in Lucerne House benefit from a homely environment. They are able to bring their own possessions and decorate their rooms as they want to. The home is generally clean and tidy, but care is needed to make sure all areas are maintained. Evidence: People who live in Lucerne House said they liked their rooms and had all they needed. Each person has their own bedroom and we saw that these were arranged how the individual wanted the room to be. People had their own possessions in the room, such as televisions, freeview boxes, books , posters and DVDs. As people are over eighteen some chose to have posters and DVDs which are not suitable for individuals under eighteen years of age. The manager said that if any children visited the home, then care would be taken to make sure that they did not enter private rooms. Individuals are able to use a communal lounge, dining room and kitchen. generally the home was clean and tidy. However, small areas of routine maintenance is needed. The bathroom needs to be cleaned thoroughly, as the grouting on the tiles and the seal on the bath were dirty. The kitchen requires some tiles to be replaced and the grouting and silicone seals to be cleaned or re-done. Also, care is needed to make sure the Care Homes for Adults (18-65 years) Page 20 of 35 Evidence: flooring is kept clean, particularly around the edges. The kitchen is small but there is adequate room for a member of staff and individual to work side by side. Adequate laundry facilities are in place. The dining room is large enough to accommodate all people if they chose to have a meal together. Care Homes for Adults (18-65 years) Page 21 of 35 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. People need to be confident that they are supported by suitable recruited and trained staff. Staff need to be aware of the role in meeting an individuals needs. Essential checks must be carried out prior to a person commencing employment in the home. Evidence: Lucerne House is a small family run home. The manager reported that there is always a member of staff on call, as well as one person on sleep in duty overnight. We noted that staffing was flexible according to the needs of the people that live in the home. When we examined staff files we found that some improvements are needed to make sure that individuals are protected from harm and are supported by competent staff. Staff files did not consistently contain a full application form that included details of the employees past employment history. Two references were not always present on file. There was some evidence of previous training, but no information was available on planned training for the future. Members of staff had attending training on manual handling, health and safety at work, person centred planning and food hygiene. There was no evidence of refresher Care Homes for Adults (18-65 years) Page 22 of 35 Evidence: courses for mandatory training such as moving and handling and fire safety. Individuals had obtained NVQ qualifications. The job description contained in the file was limited in scope. It contained bullet points of what the role entailed, such as: phone calls, making appointments and record keeping. More detailed information would benefit both staff and the people that live in the home by clarifying how needs are to be met. Care is needed to make sure that there is a safe recruitment practise at the home and all necessary information is gathered prior to a person starting work. There needs to be evidence of ongoing training to demonstrate that staff are suitably skilled and competent to carry out their role. Care Homes for Adults (18-65 years) Page 23 of 35 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that live in the home need to be confident that it is run in their best interests. The manager must make sure that all necessary risk assessments and quality assurance systems are in place. Documentation relating to the running of the home must be maintained and accurate. Evidence: At the previous inspection earlier this year we were concerned about the running of the home. The manager needs to make sure that when an improvement plan is submitted timescales are realistic. Also, she needs to make sure that action points are completed. The improvement plan submitted stated that there will be updated training, risks assessment reviews, meetings for care and care plan reviews, contracts reviewed for service users, trial periods of stay for individuals who may want to live at the home, a full referral and assessment process for cases within the business and medication record sheets being readily available. We have concerns that not all these points have been actioned, as evidenced in this report. The manager must be proactive in her Care Homes for Adults (18-65 years) Page 24 of 35 Evidence: approach to the running of the home and make sure that documentation is completed and accurate. We do not have any concerns regarding the outcomes for people that live in the home, but documentary evidence is needed to support the care given. The manager reported that they had quality assurance systems, but this has not been implemented. There were records of fire drills and fire alarm testing that had been recorded. We noted that the five yearly periodic inspection report for an electrical installation was overdue. This must be carried out as a matter of priority. Gas safety checks had been undertaken and there was evidence of Portable Appliance Testing carried out this year. A general risk assessment was carried out on the home in March 2008. This needs to be reviewed to make sure that the health and safety of individuals is protected. Care Homes for Adults (18-65 years) Page 25 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 2 14 The registered person must ensure that full referral and assessment procedures are followed in all cases. To safeguard the wellbeing of those referred to the service as well as the people who already use it. 24/07/2009 2 5 5 The registered person must 24/07/2009 ensure that all people who live at the home are provided with a written contract that outlines the agreed type and level of service that they will be provided with. To ensure that the service maintains transparency in the agreed way in which facilities, care and support is provided. 3 9 13 The registered person must 24/07/2009 ensure that risk assessments are reviewed at least annually, or sooner if the need should arise. To eliminate any unecessary risk to those who use the service. 4 20 13 The registered person is 30/04/2009 required under regulation 13 (2) of the Care Standards Act 2000 to record the Page 26 of 35 Care Homes for Adults (18-65 years) Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action administration of medication at all times. In order to safeguard the health and well being of the people who use your service you must immediately ensure that medication is properly recorded whenever it is administered to any person who lives at the home. 5 35 18 Updated training must take place and be in evidence. To ensure that the care of the people who use the service is not compromised by a lack of awareness of current professional practise. 6 37 10 The registered person must 24/06/2009 improve the day to day management of the service and provide the Commission with all of the information that is required. This includes the necessity to make a proper and complete application to vary the conditions of registration. To ensure that the service is managed consistently day by day and that the needs of those who use the service are not compromised by a lack of diligent oversight. 7 39 24(3) The improvements to the 23/07/2008 quality assurance system must now be completed and a quality audit of the service 24/07/2009 Care Homes for Adults (18-65 years) Page 27 of 35 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 must be implemented. (This requirement remains out standing from the previous key standards inspections in May 2006 and May 2007) Care Homes for Adults (18-65 years) Page 28 of 35 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 1 5 The Service User Guide must 30/12/2009 contain all the information as required by the regulations and schedules. This will make sure that people who chose to live in the home have accurate and up to date information on the service provided. 2 3 14 Each person who lives in the 30/12/2009 home must have an assessment of need prior to moving into the home. This assessment must be reviewed regularly. This will make sure that individuals can be confident that their needs will be identified and routinely reviewed. 3 5 5A Each person who lives in the 30/12/2009 home must be provided with a contract that details what is included in the fees. Care Homes for Adults (18-65 years) Page 29 of 35 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 This will make sure that individuals are aware of what service they can expected to be provided for the fee. 4 6 15 Care plans should lead from assessments of identified needs. The language used in plans must not be derogatory and label individuals. Evidence of formal reviews is needed. This will make sure that individuals can be confident that the support they receive is adequately documented and followed out. 5 7 12 If there are restrictions on a persons liberty then this msut be appropriately documented. This will make sure that there is a clear process evidenced of why there are restrictions on a person. 6 8 12 Evidence of how an 30/12/2009 individuals commnication needs are to be met must be included in the care plan. 30/12/2009 30/12/2009 Care Homes for Adults (18-65 years) Page 30 of 35 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 This will make sure that there is real choice for people that live in the home. 7 9 13 Risk assessments must demonstrate how an individual is to be protected from harm This will make sure that evidence is available to demonstrate how risks to a person are minimised. 8 20 13 There must be a clear audit trail of medications into and out of the home, in line with guidance published by CQC and the Royal Pharmaceutical Society. This will make sure that individual receive medications that are prescribed correctly. 9 23 13 There must be evidence to 30/12/2009 indicate how a person is protected from harm within the risk assessments. Any potential deprivations of liberty must be documented. This will make sure that the home is able to demonstrate that there are suitable procedures in place for protecting people from 30/12/2009 30/12/2009 Care Homes for Adults (18-65 years) Page 31 of 35 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 harm, without restricting their choice. 10 31 18 Each member of staff must have a detailed job descriptions, that meets the needs of the Standard, Regulations and Schedules. This will make sure that they have clear guidance on what their job role consists of. 11 34 19 There must be a clear 30/12/2009 recruitment process in place. Appropriate checks must be made prior to a person commencing employment. Information that is required by the Regulations and Schedules must be in each employees file. This will make sure that people who live in the home can be confident that they will be protected from harm 12 35 18 There must be evidence of statutory and ongoing training for staff members. This will make sure that people are supported by trained and competent members of staff. 13 37 10 The manager must make sure that they are proactive in meeting the Standards and Regulations. 30/12/2009 30/12/2009 30/12/2009 Care Homes for Adults (18-65 years) Page 32 of 35 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 This will make sure that people can be confident that the home is run in their best interests. 14 39 24 There must be an annual quality assurance system in place. This will make sure that the home can evidence that individuals are involved in the running of the home and are able to express their views 15 41 17 Records required for the purposes of inspection and the running of the home must be up to date and accurate. This will make sure that the home can demonstrate progress and improvement in the running of the home. 16 42 23 There must be evidence of 30/12/2009 the required periodic checks being carried out, such as electrical installation checks. This will make sure that the health and safety of the home protects people from unnecessary harm. 30/12/2009 30/12/2009 Care Homes for Adults (18-65 years) Page 33 of 35 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 3 It is recommended that assessments of people that currently in the home are reviewed to make sure they reflect their current needs. It is recommended that the Statement of Purpose is updated to show the new Regulatory Authority. It is recommended that discussions held with people about any concerns they have are documented. This will make sure that the home is able to evidence that it is proactive in addressing concerns. 2 3 4 22 Care Homes for Adults (18-65 years) Page 34 of 35 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). 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. 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