Inspection on 24/11/05 for Mallard House

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mallard House 13/02/08

Mallard House 08/05/06

Mallard House 22/07/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mallard House Dunthorne Way Grange Farm Milton Keynes Bucks MK8 1ZZ Lead Inspector Gill Wooldridge Unannounced Inspection 24th November 2005 10.00 Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 Adults 18-65. 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. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mallard House Address Dunthorne Way Grange Farm Milton Keynes Bucks MK8 1ZZ 01908 520022 01908 024533 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) P J Care Limited Mrs Agatha G Coetzee Care Home 55 Category(ies) of Dementia (55) registration, with number of places Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 26 Service Users with cognitive impairment 29 Service Users with early onset Dementia Date of last inspection 22nd July 2005 Brief Description of the Service: Mallard House is a 55 bedded nursing home on two floors which has been purpose built to provide accommodation for adults over 18 years of age with early onset dementia and acquired brain injury. The home is registered and the owner is an established provider of care in Buckinghamshire. The home is situated close to the centre of Milton Keynes and is close to public transport links. The home has its own transport which facilitates access to the community for residents. Support from a team of health professionals has been established within the local community and those employed in the home. The staff team is developing to support the residents and care and nursing staff have an ongoing programme of training to support resident care. The garden is in the process of being completed. The addition of pictures and an increase in residents belongings as their numbers increase should ensure the environment developes a homely feel. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 10am until approximately 4.30 pm on 24th November 2005. The inspection was carried out by two inspectors, Joan Browne and Gill Wooldridge. The inspection consisted of a tour of the home, five care plans were studied and the care of residents tracked. Residents and staff were spoken to and lunch was observed. Medication records and staff personnel files were also studied. The owner, clinical managers and staff made contributions to the process of inspection and did not appear phased by the inspection process. The development of the service was discussed. It is noted that the home is developing its systems which are supported by an enthusiastic staff team. What the service does well: What has improved since the last inspection? The addition of pictures and residents belongings have added to the homeliness of the environment. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 6 The staff team have started to gel, the owner acknowledges that there is still some work to be done in this area. Some care plans have improved. Residents and staff appear more comfortable in their new environment. A clear emphasis on activities takes place to support residents social needs. The manager and owner have made some alterations to the seating arrangements which has facilitated an improvement in the meal times. 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. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed at this inspection. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Care plans are in place for all residents and are supported by a planned process of assessment. However, some inconsistencies noted may effect the service delivery. Generally residents are encouraged to make decisions however, the decision making process needs to be supported by residents or their representatives signatures. Risk assessments are generally in place. However, some further detail will further support residents in maintaining their independence and ensure perceived restrictions of liberty are recorded and reviewed. EVIDENCE: Five care plans were studied and the residents’ care was tracked. Care plans covered areas such as personal care, nutrition, incontinence, diabetes and social activity. The care plans studied showed some good recording practice and well thought through care. However, the quality of the care plan was noted to be dependent on the authors. It is a requirement that the manager ensures that all care plans contain the relevant information and that all sections are completed for Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 10 example, under one heading ‘spiritual needs’, it was written ‘ not expressed’ this does not indicate that staff have tried to find out from family or if the resident was able to express his spiritual needs or that staff had asked again. All care plans must be written legibly and with a positive slant, staff’s approach must be included to ensure that a new member of staff could work effectively with residents. A quality audit system would facilitate this process. This must be supported by ongoing training for staff in care planning, recording practice and include care plans giving clear detail relating to residents medical conditions, such as diabetes. The care plan regarding diabetes should clearly describe what is the normal range of blood sugars for the individual. This will assist any new nurses assessment of any given situation. A more detailed list of symptoms relating to the resident’s condition such as symptoms regarding hyper/hypo glycaemia will assist any new carer to raise any concerns with the trained nurse. It is acknowledged that staff were recording residents blood sugar levels regularly and the clinical manager described regular review and consultation with the diabetic specialist nurse. However, from records studied it was not evident that residents with diabetes were having their blood pressure taken every month as recommended at the last inspection. All care plans must contain the information as identified during the assessment. It is acknowledged that for one resident with high blood pressure staff are recording three times a week All temperatures, pulses and respiration (TPR’s) should be recorded regularly dependent on the residents assessed needs. It was noted that this practice varies in those records seen. Residents weights were recorded however, there were inconsistencies in the records seen. In one instance, staff weighed a resident weekly although his care plan advised two weekly and then there was no record since the 6/11/05. Not all care plans confirmed resident’s likes and dislikes. However, nurses and the chef confirmed that the kitchen staff are aware of residents preferences. One care plan did indicate very clearly the resident’s preferences. Examples of good practice included clearly described approaches to residents and step by step instructions which would facilitate good care if the reader was a newly appointed staff member for example, ‘approach calmly but with confidence’ It was evident that residents had been involved in the care planning process and their requests were seen in some documentation. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 11 Residents’ preference for male or female staff to provide personal care was noted on the care plans. This is noted as good practice. Care plans relating to the care of residents’ skin indicated that nurses should seek advice from the tissue viability nurse. However the evaluation of a small pressure area did not indicate that this area had healed as described by the nurse in charge. It was noted from the care plans seen that re assessment of the care plans had occurred on a weekly basis in the first few weeks of admission, this is acknowledged as good practice. Any perceived restriction of liberty should be documented fully in consultation with residents and their representative and reviewed in a multi disciplinarily process on a quarterly basis for example, where relatives have been asked to hold residents cigarettes. Not all residents who smoke had an appropriate care plan. As described earlier, the risk assessments are supported by ongoing support from the occupational therapist, physiotherapist and dietician. Records seen supported the staff statement of detailed assessments being carried out. The home is also supported by a neuro-psychiatrist. A psychologist, physiotherapist and occupational therapists are employed by the organisation. One resident’s behaviour was supported by a behavioural chart. It was not evident in the care plan how staff should support the resident during this time. This must be supported by a formal agreement with clear guidelines for the staff. The white boards of daily information in two of the lounges downstairs were difficult to read, staff are reminded to print these clearly to support residents orientation. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 & 17 Residents are presented with opportunities to access leisure activities both inhouse and in the wider community. Further choice and opportunities should be developed which should ensure all residents social needs are met. Mallards House promotes flexible visiting which enables residents to maintain contact with family and friends. Residents are encouraged to discuss their meal preferences with the chef which should promote independence and choice. EVIDENCE: Activities described by residents included small group activities including crafts, playing dominoes, playing Scrabble, walks into town, trips to the library and ten pin bowling. During the inspection a group of residents had been for a walk and a group had been ten-pin bowling. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 13 The Television was on in the lounge with one resident enjoying watching the programme. The home has its own transport which facilitates activities. Residents were seen to have a number of videos in their rooms and magazines to encourage their interests. Many bedrooms indicated the residents’ interests and many bedrooms viewed form the corridor looked more homely with residents having their personal possessions including photographs of family members. The owner described gym and golf as being enjoyed by a number of residents. Care plans relating to social activity were seen and indicated residents’ preferences. The lunchtime meal was observed. With a choice of main course, all portions were large. The tables were laid attractively which added to the ambience. Some of the practice observed at this lunchtime was sensitive and discrete, staff were seen to be sat next to residents and taking time and encouraging residents to respond. The responses from some residents included smiles and positive eye contact. Staff were heard to offer residents choices. The manager must ensure that a nurse manages the meal times process to ensure that the good practice seen is consistent. Observed practice did not always indicate that the new staff team were working as a cohesively and supporting the residents consistently. When the senior nurse was present there was a focus, however, she was not present during the whole meal time. It is strongly recommended that the management review the process of disposal of food after meals to ensure less institutional practice. Relatives are encouraged to visit and commented favourably regarding the service especially commenting on the high staffing levels. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Staff’s observed practice should demonstrate that residents’ physical and emotional needs are met. Medication procedures are in place however; good recording practice and a further quality audit system need to be in place to protect residents. EVIDENCE: It was noted that all personal care was carried out in bathrooms and bedrooms which helped to maintain residents’ privacy and dignity. Preference of a female or male staff member to carry out personal care was indicated in care plans seen. There was some evidence of resident distress during the inspection which appeared to impact on other residents. Some staff handled this well but some did not appear to communicate with each other or ask for help. However, a nurse’s presence in the communal areas might ensure that the level of distress is kept to a minimum and support the staff team to manage any potential difficulty. It is important that the staff approach to any resident in distress is part of the care plan. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 15 Staff practice regarding the administration of medication was observed at this inspection. One staff member who was giving a resident medication did not speak to the resident during this time and was stood over him. This practice must be reviewed. This was discussed with the nurse in charge. Medication Administration Records (MAR) sheets were viewed. On the whole staff recording practice was satisfactory with some improvement in the upstairs unit noted. However, there was one gap noted and downstairs staff had scribbled over an entry. The senior nurse stated that a member of staff who had recently received her PIN number from the NMC and had recently arrived from Poland had administered this medication. The owner had explained earlier that she had given instruction that this member of staff was not to administer medication until they had been deemed to be competent. The owner assured the inspector that she would investigate this matter. It is strongly recommended that two trained nurses should sign and date any course of medication that has been completed or medication discontinued by the GP. Trained nurses must be reminded of their accountability relating to the Nursing and Midwives Council (NMC) Code of Conduct. Records must be kept of these discussions for inspection purposes. A more frequent quality audit of (MAR) sheets will ensure that errors are kept to a minimum. Since the inspection the owner has developed an audit system. It is strongly recommended that the manager develop individual PRN management plans for the medication of any resident which may be perceived as controlling behaviour or having a sedative effect. It is strongly recommended that a clear protocol supports care plans relating to residents needs regarding medical conditions such as diabetes and epilepsy. As described earlier in the report the multi disciplinarily approach to resident care can only benefit residents. It was noted that the occupational therapist and psychologist, employed by the home, were working with a resident to re establish his skills. Discussions take place every Monday to ensure the team are all working for the benefit of the residents and the owner described this communication as vital to the care of residents. Medication storage must be reviewed as discussed during the inspection. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There is a complaints procedure which should ensure that relatives and residents are listened to. Policies and procedures are in place which should ensure that residents are protected from abuse. EVIDENCE: The complaints folder was perused and the owner confirmed that the home had not received any complaints since the last inspection. It is strongly recommended that the manager record any verbal concerns and issues that relatives and residents raise and that these are recorded and actioned as appropriate. From discussions with residents it was evident that they are listened to and their views are that the care is good. Staff were able to identify that they would report any potential or actual abuse. Staff stated that shouting at a resident was unacceptable. Policies and procedures are in place to support staff practice. This should ensure residents are protected from abuse. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The environment has been designed to ensure that residents reside in an environment that meets their care and comfort needs. The addition of pictures should facilitate a more homely feel as has the completion of the garden. Standards of cleanliness in the home are good which should ensure that residents live in a clean home. EVIDENCE: The home was clean and tidy with no odour of incontinence. However, the home still has a slight clinical feel. Pictures and residents belongings in their rooms have added to the ambience. The home has adequate storage space which ensures that equipment is stored appropriately. The kitchenettes and bathrooms were clean and tidy. Staff were observed to generally maintain good hygiene practice. However on one occasion the clinical manager addressed a practice issue regarding the wearing of gloves inappropriately. Staff described hand washing as a key to infection control. Staff were seen to wear gloves, aprons and hats to aid infection control and pedal bins also aid this process. Some residents’ bedrooms indicated their personality, interests Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 18 and hobbies and some residents had been encouraged to bring items of furniture into the home. Some residents have a key to their own bedroom. The gardens have been designed to support residents’ needs and there has been considerable progress in this area. It is acknowledged that as resident numbers continue to increase and they continue to bring into the home their belongings it will add to the homely feel. It is strongly recommended that the responsible individual purchase an air conditioning unit for the nurses station to aid temperature control. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 34 Recruitment procedures must be more robust to ensure that residents are appropriately protected. The high staffing levels, a continuing emphasis on appropriate staff training and on the job supervision should benefit residents’ care. EVIDENCE: Staff rotas indicate that staffing levels are adequate to meet residents’ needs. The manager described ongoing recruitment to coincide with the increase in resident numbers. Staffing numbers during the inspection appeared to meet residents’ needs. Relatives confirmed that in their opinion staffing levels were excellent. The owner acknowledges that the team is new and that ongoing training and support is the key to building an effective staff team. Staff confirmed there is planned training for care and nursing staff in working with residents with dementia and acquired brain injury, this should ensure residents’ needs are met. Staff spoken to described clearly their roles and senior staff were aware of their accountability. Newer staff appeared to need some further direction, it is acknowledged that they may have been shadowing more experienced staff but ongoing support and clear leadership are essential to ensure the high standards the owner and manager expect and constantly strive to maintain. It Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 20 is strongly recommended that senior nurses are asked to be seen to support residents and junior staff during meal times and have a presence in communal areas. Trained nurses clearly described the care of residents though this detail was not always evident in the care plans. Three staff personnel files were studied. Prospective employees fill in an application form and the home requests two references, only one reference was seen on one staff file. This was discussed fully with the owner and systems were described to ensure that the second reference is in place within a short time of the member of staff starting their employment. It is a requirement of the report that the manager and responsible individual ensures that all staff have two references before they commence their employment. CRB’s and POVA First checks were seen on all staff files viewed. Work permits were in place where appropriate as was a health declaration and job offer with terms and conditions. The care and nursing staff are supported by a team of health professionals who discuss residents’ care and involve the training department to ensure residents’ needs are met. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Health and safety information was examined throughout the registration process and during this inspection which indicates that residents health, safety and welfare is promoted and protected. The manager must develop clear audit systems to support the service delivery ensuring residents and relatives’ views are encouraged. Residents benefit from a well run home. EVIDENCE: The manager was on annual leave and the inspection was facilitated by the owner. The inspectors comments were taken on board and the owner acknowledged any shortfalls. A large number of health and safety documents were studied during the registration process along with fire officers and environmental health officers reports, which supported the process. A recent food safety inspection has Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 22 been carried out with recommendations being actioned. Health and safety records viewed were satisfactorily and included fire safety records which indicated that the fire panel is checked weekly and that the fire safety equipment was last checked on the 18/10/05. The hot water temperatures are checked monthly and were seen to be within the required range. The lift certificate was issued on the 7/7/05. PAT testing was up to date and hoists were checked on the 11/11/05. Emergency lighting checks are carried out regularly. The owner acknowledged that there is work to be done on the home’s audit systems but strides have been made since the inspection which will need to cover all areas of residents’ care. The responsible individual must send copies of the reports of monthly visits made in accordance with Regulation 26 to the Commission. The manager was on annual leave during the week of this inspection. It is acknowledged that her and the owner’s high standards ensure that residents receive an effective service. Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mallard House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000063734.V268548.R02.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15 (b) Requirement The manager must ensure that all care plans are reflective of residents needs and ensure an overall standard of care plans. This must be supported by ongoing training for staff in care planning and good recording practice. The manager must ensure that any perceived restriction of liberty or concern as detailed in the care plans are discussed in a multi disciplinarily forum with the resident and their representative to ensure that the risk is acceptable to all and to ensure that documentation supports the home in their duty of care. Review should be quarterly and the home must maintain records for inspection purposes. The manager must ensure that staff who administer medication and record medication on MAR sheets have been properly trained and competency checked. The MAR sheets must be audited DS0000063734.V268548.R02.S.doc Timescale for action 31/01/06 2 YA7 13 (4) 30/09/06 3 YA20 13 (2) 31/03/06 Mallard House Version 5.0 Page 25 regularly and discussions with staff about their accountability should ensure staff follow the homes medication policy. Records must be maintained for inspection purposes. 4 YA20 13 (2) The storage of medication must 31/03/06 be reviewed to ensure residents and visitors are safe. In the interim a thorough risk assessment must be in place by the 31/12/05. The manager and responsible 31/03/05 individual must ensure that 2 appropriate references are sought for perspective employees including the prospective employees previous employer. The responsible individual must 31/12/05 send copies of the reports of monthly visits made in accordance with Regulation 26 to the Commission. 5 YA34 19 Schedule 2&4 6 YA39 26 Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 26 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 YA6 Good Practice Recommendations It is recommended that the manager develop a quality audit system to ensure documents interrelate including assessments care plans and risk assessments and consultation with residents relatives and care managers supports the process. It is recommended that blood pressure is taken monthly and recorded for all residents with diabetes. All temperatures, pulses and respiration (TPR’s) should be recorded regularly. All residents weights should be recorded regularly. It is strongly recommended that a clear protocol supports care plans relating to residents needs relating to medical conditions such as diabetes and epilepsy. The manager should develop individual PRN management plans for residents for medications that may be perceived as controlling behaviour or having a sedative effect. 4 YA17 It is strongly recommended that the manager review the meal time process further. It is strongly recommender that the manager reviews the disposal of food after meals. It is strongly recommended that the responsible individual purchase an air conditioning unit for the nurses station to aid temperature control. It is strongly recommended that further quality audits be developed to support gaining clients and relatives views. 2 YA19 3 YA20 5 OP25 6 YA39 Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Mallard House DS0000063734.V268548.R02.S.doc Version 5.0 Page 28 - 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. 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