Inspection on 21/01/09 for Mappleton House

This inspection was carried out on 21st January 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mappleton House 10/06/09

Mappleton House 23/05/07

Mappleton House 17/01/07

Mappleton House 11/08/06

Mappleton House 23/08/05

Mappleton House 21/02/05

Mappleton House 05/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Mappleton House Mappleton House 9B Chestnut Grove Mapperley Park Nottingham NG3 5AD     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Meryl Bailey     Date: 2 1 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 32 Information about the care home Name of care home: Address: Mappleton House 9B Chestnut Grove Mappleton House Mapperley Park Nottingham NG3 5AD 01159623714 01159623714 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mappleton House Care Homes Ltd care home 9 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 9 Mappleton House Care Homes Limited is registered to provide accommodation and personal care for persons of both sexes whose primary care needs fall within the following category :- Learning Disability (LD) 9 Date of last inspection Brief description of the care home The date of the last inspection of this service was 23 May 2007. Mappleton House Care Homes is a care home providing long-term personal care and accommodation for 9 younger adults who have a learning disability. The home is located in a residential area, north of Nottingham city centre and close to shops, pubs, the post office and other amenities. Mappleton House Care Homes comprises of two houses and a bungalow each with three single bedrooms. Unrestricted parking is available on the road. Information about the service is provided on request at Mappleton House. The fees for the service range from £900 - £3,000 per week depending on needs. There are additional charges for hairdressing, chiropody and toiletries. Care Homes for Adults (18-65 years) Page 4 of 32 Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Commission for Social Care Inspection is on outcomes for people and their views on the service provided. This process considers the providers capacity to meet regulatory requirements and minimum standards of practice and it focuses on aspects of service provision that need further development. We reviewed all of the information we have received about the home since the last report of our key inspection in May 2007. Managers of homes are now required to complete a document called an Annual Quality Assurance Assessment (AQAA) to identify from their own quality monitoring what the service does well and what they need to improve. The AQAA was returned in June 2008 and was used to plan the visit and to support judgements made in this report. Care Homes for Adults (18-65 years) Page 6 of 32 We did the inspection visit with one inspector. It was unannounced and took place on one day during the daytime. The main method of inspection we use is called case tracking which involves us choosing a sample of people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. We looked at three peoples records. The people living at the home have needs relating to communication and our assessment of their views has been through observations and some limited direct responses. We had discussions with three support staff working there as well as the acting manager. A partial tour of the premises was made and this included some of the bedrooms as well as communal areas and facilities. We also looked at a sample of staff records to find out if checks were carried out before they started working at the home and if they were appropriately supervised and trained. What the care home does well: What has improved since the last inspection? What they could do better: Produce an up to date and accurate Statement of Purpose and supply a copy to the Commission. This is so that clear information is available about the service. Amend the Service User Guide (Residents Guide) to give accurate information and ensure it is available in appropriate formats. This is so that people have access to clear information about the service. File away papers that are no longer relevant so that staff can follow clear support plans. Plan and facilitate regular activities outside the home. This is so that people have opportunities to engage in a wider range of activities. Provide an annual holiday or appropriate day trips for each person living in the home. Promote healthy eating individually with people. Put a system in place to ensure staff fully maintain the Medicine Administration Record Sheets. Staff must follow instructions for administering all medicines. This is so that all people living in the home always receive their medicines at the correct times and safely as prescribed by a doctor. Provide clear information in the Complaints Procedure. This is so that people know who will respond to their concerns. Also, they need to make the Complaints Procedure Care Homes for Adults (18-65 years) Page 8 of 32 appropriate to the needs of people living in the home. This is to give everyone an opportunity to understand how to make a complaint. Ensure all floor coverings are clean and replaced where necessary. This is so that people live in a clean and well maintained home. Thoroughly clean all showers and provide ventilation. This is so that people benefit from hygienic bathing facilities. They should also make everyone aware when laundry facilities are not available. Carry out a full training needs assessment and provide a full training and development plan. This is so that all staff receive training appropriate to the work they they perform. The acting manager must make a full application to the Commission to be assessed for registration. This is so that the acting manager can demonstrate her fitness to manage the home for the benefit of people that live there. Review the quality assurance system so that there is a regular system to gain and act on the views of people living in the home and their representatives. All records must be maintained, up to date and available for inspection and this includes staffing records. This is so that the service provided can be monitored to ensure the safety and wellbeing of people living in the home. Reassess all potential risks to people in the environment and take appropriate actions to reduce or eliminate these risks. This is so that sufficient action is take to keep people safe at all times. 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 set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 32 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. Information available about who provides the service is misleading. People have been assured their needs can be met at the home. Evidence: Mappleton House Care Home Limited is a company registered with the Commission to provide care at this home. In August 2008 this company was purchased by Rushcliffe Care Limited. The Statement of Purpose and Residents Guide that were made available at the inspection do not give the above information. Both documents also give inaccurate information about a registered manager as there is currently no manager registered with the Commission. There was a copy of an old service User Guide on one persons file, but no one had an up to date copy. The Residents Guide is not in a format that people living in the home can understand. There was a note saying that an alternative format can be obtained from the Registered Manager, but we did not see any available. Otherwise these documents contained some useful information for people about the service provided. Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: No new people have moved into the home since December 2007. There are no current vacancies. There were comprehensive assessments from health and social care professionals about the needs of the last person who moved in and the acting manager had previously attended meetings with professionals and family to ensure full information was obtained in order to plan the support needed to meet the persons needs. Care Homes for Adults (18-65 years) Page 12 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support is planned and people are enabled to make some choices in their daily lives. Evidence: There were files of relevant information about each person living in the home and these each contained an individual person centred plan. Most of the plans were older versions that had been updated several times and this gave a confusing account in some cases where old information had not been archived. The acting manager showed us a copy of one plan written using a new format and said that this will be used for all people living in the home in order to provide a clear up to date plan for each person. There was information on some peoples files about how to use parallel talking and social stories to enable communication with people. We observed positive interaction between staff and individual people living there. Staff offered some choice about activities and where people wanted to be within their home. Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: There were detailed risk assessments on each file and these contained clear information about action staff needed to take to reduce risks when people were engaged in particular activities. Due to risks associated with behaviour some people had individual attention from a staff member for the greater part of the day in order to keep everyone safe. However. action was not always taken to reduce risks in the environment and this is detailed in the management section of this report. Care Homes for Adults (18-65 years) Page 14 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people benefit from attending day centres, but others would benefit from more structured activities being provided. Sufficient amounts of food are available, but healthy eating is not promoted. Evidence: Four people were at day centres and the other five were in their own houses. There were daily activity sheets as a guide to choosing individual activities within the home. A staff member was playing with a ball with one person for part of the time. Another person was involved in using the washing machine with support. The television was switched on in two houses and, in another, one person was curled up in an arm chair. None of the five left the premises during the inspection. One person continually asked to go for a walk and walked around outside in the yard with a support worker several times. Staff said that they sometimes go to parks for walks. The acting manager told Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: us that there was no one available to drive the vehicle. Since the inspection she has informed us that two staff have now been insured to drive. On the first floor, within one house, we saw a multi sensory room, but the acting manager and other staff told us that it was not often used. One person liked swimming, but the acting manager had not been able to find a suitable venue. One person had been on holiday with parents, but the acting manager told us there had been no holidays provided by the company that owns the home. Lunch was prepared by staff in each house. Staff told us some people sometimes helped by washing vegetables and setting the table. One person had eaten chips, pork steak and beans. In another house staff were cooking omelette, beans and chips. Staff told us they suggest a meal and if some people want something else they offer a choice of food by showing them what is in the freezer and cupboards. In one house we heard one person being consulted, but not the other. Likes and dislikes about food were written down in care plans, but there were no records of meals eaten. Care Homes for Adults (18-65 years) Page 16 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive support with personal care in the way that meets their individual needs and have access to health professionals, but the current handling and recording of medication puts peoples health at serious risk. Evidence: There was detailed information in individual support plans about the most effective way to support people with their personal care and this included preferences. Visits and support from health care specialists such as consultant psychiatrist, GP, Community nurses and Occupational Therapist was written down within the individual files. Medication was stored in a locked cupboard in each house. On checking some records we found there were gaps in the recording of medicine given to people. It was not possible to confirm whether or not all medication had been given as prescribed, but there was evidence that some had not been given. For example, on 12 January 2009 a quantity of eight Hyoscine 1.5mg patches were recorded by the pharmacist as issued for one person. No one had signed the record to confirm this number was received. Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: The instructions were Apply a new patch to a different area of the body every THREE days. The record showed the initials of a staff member on 14 January 2009, but was otherwise blank. A support worker claimed she had previously not known how to apply a patch, but was shown what to do on 14 January 2009. She then said she had applied a new patch on the day of the inspection (21 January 2009) and had not had time to initial the record. Another support worker checked if a patch was in place, but found none. We counted the remaining patches and found seven and no one could explain why none were applied on other days. This meant that they had not been applied every three days as prescribed. There were some other gaps and inconsistencies in other records and altogether this affected four of the nine people currently living at Mappleton House. Also supplies of 28 new medicines had not been checked and signed as received into the home. Within staffing records there was no evidence of training in handling medication. Following the inspection the company has informed the Commission that staff have been given training in the form of Medication workbooks and their competency will be monitored. Care Homes for Adults (18-65 years) Page 18 of 32 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 do not have clear information about how to complain, but procedures are followed to keep people safe. Evidence: The complaints procedure is included at the end of the new Residents Guide, but this had not yet been issued to anyone. The information directed people to write to Rushcliffe Care Ltd, but no name was given. We did not see the procedure displayed anywhere and it was not in signs and symbols format. There were records of complaints received and one of these was dated since the last inspection. There was a letter responding to the complainant, but not a full record of the complaint, investigation and outcome. So it was not clear if the complainant was satisfied. We had received one anonymous call at the Commission about another concern. The previous registered manager had investigated and responded to us appropriately. One of the staff told us that staff had received training in Safeguarding Adults last year. She demonstrated that she was was aware of reporting procedures should there be any specific concerns. We were made aware of one safeguarding concern and the acting manager told us a social worker was planning to visit to investigate. We are awaiting the outcome of this. There was evidence on the staff files seen that appropriate checks had been carried out regarding their fitness prior to commencing work. Care Homes for Adults (18-65 years) Page 19 of 32 Care Homes for Adults (18-65 years) Page 20 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people live in clean, spacious accommodation within the home, but other areas do not currently to meet peoples needs Evidence: The home is made up of two houses and a bungalow. We looked in most areas of each building, but did not see every bedroom. One house (Chestnut) was well decorated and all areas were clean. One person proudly showed us a bedroom that was spacious with an ensuite shower room. The top floor of this house was used by one person and contained a separate room and extra dressing room to meet this persons needs. A newly refurbished kitchen was available. In the other house (Oak) the kitchen and dining area needed new flooring and this was to be fitted within a few weeks. Other areas were clean and rooms had been adapted to meet individual needs and risks but action was not taken to reduce all risks (see management section of this report). The bungalow (Beech) had a level access at the entrance, which was via the kitchen and was not spacious enough to bring a wheelchair inside. One person using a wheelchair outside was able to walk through the bungalow. Staff had kept the kitchen area clean, but the conditions in the bungalow were not of the same standard as in the other buildings. The carpeting was unclean and stained in the lounge and there was Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: mould around the showers as there was no ventilation. Bedrooms were small and contained basic furniture. The acting manager told us the bungalow would be refurbished in a few weeks time. There were two washing machines, which are normally sufficient, but the acting manager told us that the machine used by Oak and Beech was not working as the repairer was waiting for a particular part. One person living at the home had not been informed it was out of order and put clothes in this washing machine, but could not complete the washing. Care Homes for Adults (18-65 years) Page 22 of 32 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. There is a sufficient number of staff to meet peoples needs but not all staff are sufficiently trained to meet peoples needs. Evidence: The staffing rota showed that there were sufficient numbers of staff so that some people had full time one to one support. We spoke to three support staff individually and found they were aware of individual needs and routines. They each told us that there were always enough staff. At night there was one staff for each house and they were able to contact each other if support were needed. We saw two staffing files that contained an application form, two references and a criminal record bureau check. Information about new staff and all staff supervision records were held at another office in Loughborough. Staff said they had recently had some useful training and were given certificates. The acting manager confirmed that half the staff attended training in Moving and Handling and Food Safety in January 2009. Training in Challenging Behaviour and Epilepsy was planned for February. There was no clear training plan, but the acting manager said that one was being devised for the whole staff team in order to identify which staff Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: needed further training. She told us that six new staff completed induction training, but records to confirm this were not at the home. As already reported, staff had not received sufficient training in medication and this affected people receiving their medication as prescribed. Care Homes for Adults (18-65 years) Page 24 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Current management arrangements and systems do not ensure the home is run in the best interests of the people living there. The absence of some records and the lack of some action taken pose risks to the health and safety of people living in the home. Evidence: There is currently no registered manager. An acting manager was present during most of this inspection. She has submitted an incomplete application to the Commission and has therefore not yet been assessed as fit to be registered. There was no deputy manager and staff were not aware of who to contact in the absence of the acting manager. The last Annual Quality Assurance Assessment was completed by the acting manager and received at the Commission in June 2008. In the past, the provider company sent out questionnaires to relatives, representatives and professionals. This has not been done recently and there were no completed questionnaires available. The acting manager told us there were plans to use more accessible questionnaires in a format Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: suitable for the people living in the home. House meetings were held when possible to gain peoples views. There were some daily records on the files of people living in the home, but these were not all up to date. As reported earlier, the medication records were incomplete and the acting manager was unaware that people may not be receiving there medication until the inspection. Staffing records were not all available within the home as they had been removed to another office since the Rushcliffe Care Group had purchased the company. During a tour of the premises we noticed that, as a result of assessing risks, some furniture was secured to the walls, but there was a length of television aerial cable in one persons bedroom that posed a specific risk due to this persons behaviour and needs. The acting manager told us she had requested this to be removed by the handyman and it would be done two days later. This meant there would still be two nights when the cable posed a risk of accidental injury to the person concerned. We required this to be removed during this inspection and we were satisfied that this particular risk was eliminated before the end of the day. However, we also saw that none of the window openings had been restricted to prevent risks of people falling from windows and to prevent security risks. The acting manager said that these risks had not previously been assessed. Care Homes for Adults (18-65 years) Page 26 of 32 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 20 13.2 The registered person must 30/06/2007 keep accurate records all medicines received, administered and leaving the home or disposed of to ensure that there is no mishandling and that medication is received by residents as prescribed. Care Homes for Adults (18-65 years) Page 27 of 32 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 1 20 13 Put a system in place to ensure staff fully maintain the Medicine Administration Record Sheets. This is to ensure people receive their medication as prescribed. 22/01/2009 2 20 13 Staff must follow instructions 22/01/2009 for administering all medicines. This is so that all people living in the home always receive their medicines at the correct times and safely as prescribed by a doctor. 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 Amend the Service User Guide (Residents Guide) to give accurate information and ensure it is available in appropriate formats. This is so that people have access to clear information about the service. 31/03/2009 Care Homes for Adults (18-65 years) Page 28 of 32 2 1 4 Produce an up to date and accurate Statement of Purpose and supply a copy to the Commission. This is so that clear information is available about the service. 31/03/2009 3 13 16 Plan and facilitate regular activities outside the home. This is so that people have opportunities to engage in a wider range of activities. 31/03/2009 4 22 22 Make the Complaints 31/03/2009 Procedure appropriate to the needs of people living in the home. This is to give everyone an opportunity to understand how to make a complaint. 5 22 22 Provide clear information in the Complaints Procedure. This is so that people know who will respond to their concerns. 31/03/2009 6 24 23 Ensure all floor coverings are clean and replaced where necessary. This is so that people live in a clean and well maintained home. 31/03/2009 7 30 23 Thoroughly clean all showers 31/03/2009 and provide ventilation. This is so that people benefit from hygienic bathing facilities. Care Homes for Adults (18-65 years) Page 29 of 32 8 35 18 Carry out a full training needs assessment and provide a full training and development plan for the staff team. This is so that all staff receive training appropriate to the work they they perform. 31/03/2009 9 37 9 The acting manager must 31/03/2009 complete a full application to the Commission to be assessed for registration. This is so that the acting manager can demonstrate her fitness to manage the home for the benefit of people that live there. 10 41 17 All records must be maintained, up to date and available for inspection. This is so that the service provided can be monitored to ensure the safety and wellbeing of people living in the home. 31/03/2009 11 42 13 Reassess all potential risks 31/03/2009 to people in the environment and take appropriate actions to reduce or eliminate these risks. This is so that sufficient action is take to keep people safe at all times. 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 Care Homes for Adults (18-65 years) Page 30 of 32 improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 4 5 6 6 14 17 30 34 39 File away papers that are no longer relevant so that staff can follow clear support plans. Provide an annual holiday or appropriate day trips for each person living in the home. Promote healthy eating individually with people. Make people aware when laundry facilities are not available. Maintain full staffing records securely within the care home. Review the quality assurance system so that there is a regular system to gain and act on the views of people living in the home and their representatives. Restrict the openings of all windows to keep people safe. 7 42 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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. 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