Inspection on 11/05/07 for Martinmass Close Care Home

This inspection was carried out on 11th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Martinmass Close Care Home 13/11/08

Martinmass Close Care Home 14/11/07

Martinmass Close Care Home 09/05/06

Martinmass Close Care Home 10/11/05

Martinmass Close Care Home 07/06/05

Martinmass Close Care Home 22/03/05

Martinmass Close Care Home 09/06/04

Martinmass Close Care Home 17/03/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Martinmass Close Care Home 6-8 Martinmass Close Lenton Nottingham NG7 4HE Lead Inspector Joanna Carrington Key Unannounced Inspection 11th May 2007 10:00 Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 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 Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Martinmass Close Care Home Address 6-8 Martinmass Close Lenton Nottingham NG7 4HE 0115 844 3663 0115 978 8182 mdebbieb@ncha.org.uk www.ncha.org.uk NCHA 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) Debbi Ann Booth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. service users shall be within category LD Date of last inspection 5th September 2006 Brief Description of the Service: Martinmass Close Care Home provides care and support for up to five adults with a learning disability. At the time of this inspection there are two vacancies at the home. The home is situated in the residential area of Lenton close to a range of public amenities and within easy reach of Nottingham City centre. Four bedrooms are on the first floor and one bedroom is on the ground floor; none are en-suite. There are two shared bathrooms and downstairs a communal lounge and dining room. The physical layout of the home makes it unsuitable for people with mobility problems. Parking is available on two driveways and there is an enclosed garden to the rear of the property. Written information about the care home, including copies of inspection reports are available on request. The current fee for living at the home is £343.62 per week. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection took place over six hours on 11th May 2007. Inspections focus on outcomes for residents. In order to do this the main method of inspection used is called ‘case tracking’ which means two residents were selected and their care is tracked through discussion with them and with staff, checking their care records and observing practice. A partial tour of the premises also took place to inspect environmental standards and staff records were also looked at to make sure staff are trained and that checks were carried out on staff before they started working at the home. Information about a home that is collected before the inspection is also used to make judgements about a service. This information could include notifications, information from other professionals, and relatives and also from any surveys that are sent out. Two surveys, both from relatives were returned before the inspection as well as the pre-inspection questionnaire (PIQ), which the manager filled in and returned to the Commission before the inspection. What the service does well: The admission arrangements at the home are good because prospective residents and their relatives are supplied with enough information about the home to be able to make a decision to move there. Prospective residents’ needs are assessed before they move to the home to make sure that the home is suitable in meeting their needs and to make sure they are compatible with people that already live there. There are support plans that cover all areas of need and care plans are regularly reviewed to ensure that any changes in need and how support is to given are identified. Residents get to go to day centres if they choose to, there are opportunities for all residents to go on a holiday and meals provided are varied and healthy. Staff enable residents to maintain relationships with family and friends. Residents’ personal preferences and choices are respected when assistance with personal care is given. Specialist healthcare professionals such as dieticians and occupational therapists are called on when necessary in order to meet the needs of residents. The majority of the staff team have a qualification in social care and staff are provided with training to help them carry out their role and to meet the needs of residents. Equality and diversity training is provided to staff to help staff understand the diverse needs of residents including needs around other cultures and ethnicity which prospective residents may have. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 6 There is a complaints procedure in place for residents and their representatives to access to air their concerns and be assured their concerns will be acted on. The local safeguarding adults procedures are being following and staff are aware of their responsibilities to alert the manager of any allegation of abuse, which helps ensure residents are protected. What has improved since the last inspection? What they could do better: The décor in the upstairs bathrooms is looking tired and in need of repainting. One of the sinks is coming off the wall, which does not look nice and is unsafe. The bathrooms could be cleaner, as there was dust and cobwebs in parts. Medicine management is still not at a safe standard. Residents are at risk of not getting their medication as prescribed if any changes to how a medicine should be given are not recorded. Risk assessments could be done better by ensuring measures to minimise an identified risk are identified. These measures will promote residents’ safety and also their level of independence. Even though recruitment records are held at the central office there must be evidence in the care home that all staff have had a criminal record bureau check, including the date of issue, disclosure number and level of check. This is so that the Commission can be satisfied that these checks are being carried out for staff before they commence their employment. The health and safety of residents is not fully protected if the risk of being scolding on radiators is not assessed and evacuation procedures in the event of a fire are not completely clear. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 8 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 Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good admission arrangements in place to ensure that prospective residents can make an informed decision to move to the home and that the home is suitable in meeting their needs. EVIDENCE: There was a copy of the placing authority’s community care assessment on the files of both case tracked residents. The registered manager reported that there has been some interest in the vacancies at the home. There was evidence seen in the form of notes that the registered manager has made an initial assessment into the needs of a prospective resident. In line with Nottingham Community Housing Association policy and procedures a copy of the placing authority’s community care assessment will be obtained before confirming if the home is suitable. There is an up to date Statement of Purpose for the home, which provides important information about the services that are provided at the home. There is a brochure, which is also supplied to prospective residents and their representatives. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments address all identified areas of need however the way the system is being used means there is potential that residents’ needs are not safely or adequately met. EVIDENCE: For both case tracked residents there are support plans in place that cover all aspects of social, recreational and health and personal care needs. Support plans are reviewed at least every ninety days. Following a review of a care plan if further information on how to meet that need is required new care plans are set up because staff are not aware of how to go back to the original care plan on the system. This means that there are various care plans relating to the same need so information can get lost. The diary indicates that staff members are already booked in for training on how to make better use of the electronic system in place. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 11 For both case tracked residents there are risk assessments that accompany relevant support plans. Some risk assessments are concerned with health and safety such as minimising risk of choking and getting in and out of the bath safely while other risk assessments are to enable residents to participate in their chosen activities and to enhance their quality of life for example helping out in the kitchen and going out in the community. A case tracked resident has a risk assessment for being in the community around members of the public but it does not actually identify measures staff should take to ensure the resident’s and the public’s safety. All it states is “staff to be aware of risk”. Daily records and review notes indicate that relatives / representatives are consulted on residents’ support. Staff spoken with demonstrated an awareness of individual residents’ communication needs and picture cards were seen which are used to enable communication. There are support plans for communication but the tool “listen to me communicate” on the person-centred plans, which provides more comprehensive information on how individuals’ communicate, was not completed for either case tracked resident. There is a lack of evidence of when consultation and resident involvement takes place. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain relationships and to experience a fulfilling quality lifestyle that meet personal expectations. Residents’ rights are not fully respected if any restrictions on their rights are not acknowledged in their care plans. EVIDENCE: Two of the three residents were out at day centre during the course of the inspection. It was the other resident’s day off. Daily records and care plans indicate that residents attend day services that meet their needs and chosen preferences. The home now has a wheelchair accessible vehicle. Staff spoken with reported this has made a massive difference in terms of more flexibility and choice when accessing the community. Daily records show there are various trips out including, going out for picnics. Individuals are supported to participate in their hobbies and favourite activities, for example going carriage Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 13 riding. All three residents are going on holiday; two are going to Spain next week and were observed to be looking forward to it especially going on an aeroplane. Spiritual and religious needs are identified and daily records show that residents that wish to go to church are supported to do so. On the residents’ files seen there are care plans outlining the importance of regular contact with family and also on how individuals interact with other people living in the home. Visits by friends and relatives are recorded. Staff spoken with reported that key-workers regularly take residents to visit their families. Staff members were observed interacting with the resident at home, giving the resident choices and engaging with the resident in a respectful and meaningful manner. Staff spoken with explained how they ensure in their practice that they maintain residents’ right to dignity and privacy. It was noted how in one resident’s bedroom their toys and belongings are locked away. There is no mention in any care plans as to why this is necessary and what staff must do to ensure that the resident has access to their things when the resident wants them. The menu plans and the detailed records of what residents have eaten show that balanced nutritious and varied meals are offered to residents, with plenty of fresh vegetables. There are support plans for nutrition and eating and drinking, which identify the food likes and dislikes of residents and preferences regarding eating alone. Records also show that alternative meals are available to residents. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The personal care needs of residents are well met. Medicine management has improved in some respects but areas of practice are placing residents at risk of not getting the correct medication and subsequently a decline in their health. EVIDENCE: On the files of the case tracked residents there are copies of letters from agencies and specialist healthcare professionals, which indicate that specialist professionals such as psychiatrists, speech and language therapists and dieticians are worked with in order to meet the physical and emotional health care needs of residents. Relevant support plans however do not mention when outside professionals are involved in providing support and advice. There are detailed support plans for assistance with bathing and dressing, which make reference to individuals’ preferences. For example “[The resident] likes listening to a CD when goes up to bed and will get up for a drink at night” Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 15 Daily records evidence that there is flexibility with when residents go to bed and when they choose to shower or have a bath. “[The resident] had a lie in this morning” The medicine cupboard is secure and all drugs are being stored as required. Creams that are refrigerated are stored appropriately. Since the last key inspection improvements were noted at the random inspection with monitoring quantities of medication and carrying forward any remaining tablets onto current medication administration records (MAR). This improvement was still evident at this key inspection. There are weekly audits carried out by staff to make sure that drugs are being given as prescribed. According to the MAR sheets, however, three prescribed medicines are not being administered in accordance with the instructions stated on the MAR. The registered manager and staff reported difficulties in getting doctors to re-issue prescriptions with new instructions or to write down amended instructions at the appointment. In the meantime, the MAR sheets have not been manually amended or countersigned. For one of these drugs the daily records and support plan were examined to check whether a record of the amendment was made including by which doctor. No record was found. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and are assured that their complaints and any allegations of abuse are taken seriously and acted on. EVIDENCE: The Complaints Procedure is displayed in a Signs and Symbols format in the care home and is also contained in the service user guide. The pre-inspection questionnaire and the complaints records in the home confirm that there have been no complaints made since the last key inspection. All three returned surveys by relatives’ state they know how to make a complaint and who to. Since the last key inspection there have been no Safeguarding Adults investigations or allegations of abuse. Staff spoken with demonstrated an understanding of the Nottinghamshire Safeguarding Adults procedures, what constitutes abuse of vulnerable adults and of their responsibilities to alert the manager of any allegations of abuse. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to décor mean residents live in more comfortable and homely surroundings, but further attention in some areas, also with regards to cleanliness, is required. EVIDENCE: At the random inspection in September 2006 improvements to the environment meant that requirements made at the last key inspection were complied with. The lounge, dinging room and kitchen had been redecorated, there was a new sofa in the lounge and a resident’s broken bedroom furniture had been replaced. Since then double glazing and new doors have been fitted and some bedrooms have been redecorated. Bedrooms are personalised to suit individuals’ taste. The décor in the upstairs bathrooms is looking very tired and outdated and the sink in the one of the upstairs bathroom is coming away from wall. Most parts Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 18 of the home appeared clean and hygienic but the bathrooms were dusty and there were cobwebs around the ceiling. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 34 will be assessed by an additional inspection at the organisation’s headquarters. Training and support of staff help ensure residents are in safe hands and that their needs are met however poor induction arrangements compromise this. EVIDENCE: Four staff files were randomly selected; two of these were for staff that commenced employment since the last key inspection. There was evidence for three of the four staff that a satisfactory criminal records bureau (CRB) check has been obtained. For the new staff member there was no evidence, either by the use of a pro-forma or by a letter that a CRB check has been obtained. Recruitment information such as application forms, CRBs and references are held at the organisation’s main office. It has been agreed that an additional unannounced inspection will take place at the main office in order to fully satisfy the Commission that this standard is being met. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 20 The date employment commenced with the organisation is not stated on one of the staff files and there is no evidence of an induction that meets with Skills for Care common induction standards. The pre-inspection questionnaire states that eighty percent of care staff are qualified to at least National Vocational Qualification (NVQ) level 2 Social Care. Training records show that a range of courses relevant to the needs of residents and to enable staff to do their jobs are accessed. Courses include Equality and Diversity, Person-Centred Planning, Quality Assurance, supervision training, I.T skills and Protection of Vulnerable Adults. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to quality monitoring assures residents that the home will be well run and in their best interests. Residents’ health, safety and welfare are not fully protected. EVIDENCE: Fire records seen show that all the required fire alarm testing and drills are being carried out. There is an up to date fire risk assessment for the home, however it is not clear from looking at this risk assessment and from discussion with staff what the arrangements are for evacuating residents in the event of a fire. Fridge and freezer temperatures are monitored daily and substances hazardous to health were found stored securely. One of the case tracked residents has a risk assessment in place for access to the kitchen, which states there is a risk of the resident being scolded on the Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 22 radiator. There is not, however an environmental risk assessment in place for temperature control of radiators and whether or not measures should be in place such as radiator covers for the protection of all residents. Quality audits in accordance with Nottinghamshire Community Housing Association (NCHA) policy and procedures have now been undertaken. A quality auditor, a manager of another NCHA service has been out to the home to audit different aspects of the service. Areas for improvement have been identified and an action plan, still at draft stage, on how and when improvements will be made was seen. There is also a new survey, which is presented in pictures so that it is more accessible to residents. There is also a DVD accompanying it that gives suggestions on how residents can be assisted in using the survey. Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 X 3 X X 2 X Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 12 Requirement Risk assessments must identify measures to minimise risks and ensure the safety and well being of residents. Ensure that there are adequate arrangements for the recording, handling, safe administration and disposal of medicines received into the care home. This refers to: 1. Ensuring instructions on the MAR correlate with instructions on the box and original prescription. 2. Any amendments to the administration of medicines mid cycle are clearly recorded on the medication administration record, along with date of amendment and counter signature. Requirements concerning medicine management have been made at the last five inspections. This is of serious concern. If improvements are not seen then enforcement action will be considered. DS0000002253.V336656.R01.S.doc Timescale for action 01/08/07 2 YA20 13(2) 01/06/07 Martinmass Close Care Home Version 5.2 Page 25 3 YA24 16 4 YA34 17, 19 6 YA42 23 7 YA42 13 All parts of the home must be kept clean and hygienic. This is to ensure the health of residents and the control of infection. There must be a record of when staff members commenced employment and evidence in the care home that a satisfactory criminal record bureau check has been obtained for all staff and before a new staff member commences employment. This is to satisfy the Commission at the time of the inspection that this standard is being met and is in line with current CSCI guidance on criminal record bureau checks. In consultation with the fire authority make sure there are clear arrangements for the evacuation and safe placement of residents, in the event of a fire. There must be an environmental risk assessment for the risk of scalding from radiators. This is to ensure the safety of residents. 01/06/07 01/06/07 01/07/07 01/06/07 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 2 3 4 Refer to Standard YA7 YA7 YA19 Good Practice Recommendations Develop person-centred plans for individual residents, including the section on ‘how we communicate’. Develop ways to evidence consultation with residents, for example resident meetings. Add to relevant care plans when specialist healthcare professionals are involved in meeting individuals’ health care needs. Fix sink in upstairs bathroom and improve décor in upstairs bathrooms. DS0000002253.V336656.R01.S.doc Version 5.2 Page 26 YA24 Martinmass Close Care Home Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Martinmass Close Care Home DS0000002253.V336656.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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