Inspection on 14/11/07 for Martinmass Close Care Home

This inspection was carried out on 14th November 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 4 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 11/05/07

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 14th November 2007 10:00 Martinmass Close Care Home DS0000002253.V348930.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.V348930.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.V348930.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) Debbie Booth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Martinmass Close Care Home DS0000002253.V348930.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 11th May 2007 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 two vacancies remain 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.V348930.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit, as part of the home’s key inspection took place on 14th November 2007. Inspections focus on outcomes for people that use the service. In order to do this the main method of inspection used was ‘case tracking’ which meant a resident was selected and their care was tracked through interaction with them, discussion with staff and checking their care records. The staff team was also observed communicating and engaging with residents. A sample of staff records were also looked at to make sure staff get the necessary training and that checks are carried out on staff before they start 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 users of the service or their relatives, and also from any surveys that are sent out. At the time of writing this report three residents surveys and two relative surveys had been returned. Services are now required to fill in a document called an AQAA (Annual Quality Assurance Assessment) in which the registered manager identifies from their own quality monitoring what the service does well at and what they need to improve on. The AQAA was returned before the site visit and was used to plan the site visit and to support judgements made in this report. What the service does well: There are good admission arrangements, which mean prospective residents have enough information about the home to decide to move there and their needs are assessed before they move to the home. This is to make sure the home is suitable and to make sure they are compatible with people that already live there. Residents are supported to have a good fulfilling lifestyle. They go to day centres if they choose to and there are opportunities for all residents to go on a holiday and to have regular trips out. 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 involved 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.V348930.R01.S.doc Version 5.2 Page 6 There is a complaints procedure in place for residents and their representatives to air their concerns and complaints and be assured these are 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. There are good systems in place for monitoring and reviewing the quality of the service. There are three audits per year and surveys that go out to relatives and residents. The survey is presented in a picture format so that it is more accessible to residents and there is also a DVD, which gives ideas on how to help residents use the survey and give their feedback. What has improved since the last inspection? What they could do better: The use of risk assessments must improve in order to promote the safety and independence of residents. This is an outstanding requirement from the previous inspection. Reviewing residents’ attendance at routine health approintments could be done better, in order to support residents in maintaining their general health. They must ensure all required notifications of incidents are made to the Commission. This is so that the home can be effectively regulated in how well they promote and protect residents’ health and welfare. Residents and/or their representatives must be issued with contract / terms and conditions, for signing in order to protect their rights in respect of their accommodation. Minutes of residents meetings should be presented in a way that is more accessible to residents, to support fact that these meetings are theirs to discuss what is important to them. Martinmass Close Care Home DS0000002253.V348930.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.V348930.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.V348930.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, 3 and 5 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 to make sure people have enough information to decide to live at the home and that the home will be suitable in meeting their needs, but legal rights and responsibilities in respect of their home are not protected. EVIDENCE: There have been no new admissions to the home. There was a copy of the placing authority’s community care assessment on the case tracked resident’s file. This was updated last year to ensure the home continues to meet the resident’s needs. The Statement of Purpose was reviewed and updated in May 07 and contains all the necessary information about the home and the services provided. There is an easy read occupancy agreement, which is presented with pictures but the actual license agreement on file that specifies terms and conditions of the placement is not actually signed by the resident or a representative. Martinmass Close Care Home DS0000002253.V348930.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 poor This judgement has been made using available evidence including a visit to this service. The staff team support residents to make their own choices and know how to meet residents’ needs but care planning arrangements are still not sufficient in assessing risks, which compromises residents’ safety and rights to freedom and independence. EVIDENCE: Staff members were asked about the needs and main risks for the case tracked resident and it was evident that the staff team have a good understanding of the resident’s needs, including how the resident communicates and what support is given to enable the resident to make choices. Examples were given on what the signs are if the resident is unhappy about doing something and picture cards were seen, which are used to enable communication. There are now monthly house meetings and the minutes indicate residents are consulted about different aspects of the service, for example, on trips out and future holidays. The minutes are not written in an Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 11 accessible format and are not yet displayed, which would promote the fact that these are the residents’ meetings. A relative comments in their survey that the staff team “always include family in decision making, service users reviews.” What was written about residents did mainly reflect what staff members said about residents needs and how support is given, however it was not always easy to find this information because some of it was on the electronic system while other information was on the Person-Centred Plan. For example, the care plan for nutrition refers to the risk of choking but makes no reference to anything else in respect of eating and drinking. The Person Centred Plan does include in detail the resident’s food likes and dislikes. There is no cross-reference between these two documents. This was the same with communication plans. There are risk assessments that accompany relevant support plans. Some risk assessments are concerned with health and safety such as getting in and out of the bath safely while others are for chosen activities. But, like at the last inspection, not all risks are being addressed adequately. A staff member spoken with reported that the case tracked resident’s mobility seems to be deteriorating. There is a care plan for mobility, which refers to measures such as using handrails and coming downstairs on bottom but there is no accompanying falls risk assessment. An accident record was seen on the file for an accident that happened in July, in which the resident fell on the back door step but the incident is not mentioned in a review of the mobility care plan nor did the incident prompt the development of a risk assessment. A staff member explained that the resident does sometimes lash out or pull hair; not in a malicious way but a member of the public would not understand this if it happened to them. This risk is not mentioned anywhere on a care plan or risk assessment and although there is a risk assessment for getting on and off buses there is no specific risk assessment for accessing the community and ensuring the resident’s and members of the public safety. Martinmass Close Care Home DS0000002253.V348930.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 meets personal expectations and upholds their rights. EVIDENCE: All three residents were at day centre at the start of the inspection. Daily records and care plans indicate that residents attend day services that meet their needs and chosen preferences. Daily records and activity sheets show there are regular trips out and that residents can choose if they want to go or stay at home. Local events are often attended, such as firework displays, and the goose fair. All three residents have recently been on holiday. A resident showed some photos of their holiday in Spain. Spiritual and religious needs are identified in care plans and daily records show that residents that wish to go to church are supported to do so. Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 13 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. A relative commented in their survey that staff are always welcoming when she visits. Staff members were observed interacting with residents in a respectful manner. Staff spoken with demonstrated an understanding of the rights of residents and how they ensure in their day-to-day practice these rights, including privacy and dignity, are maintained. The menu records show a variety of balanced nutritious meals are offered to residents, including meat, fish and plenty of fresh vegetables and different breakfasts. Records also show that residents have choices and alternative main meals provided. Martinmass Close Care Home DS0000002253.V348930.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 good. This judgement has been made using available evidence including a visit to this service. Personal care is flexible and meets the needs and preferences of residents and improvements to medicine management mean it is now effective in promoting the safety of residents. The management of residents’ general health is not effective enough, which could lead to decline in individuals’ health. EVIDENCE: Staff members spoken with were asked about the case tracked resident’s preferences regarding their personal support, and these preferences were reflected in relevant care plans. These states “[The resident] likes to be smart… likes to spend time looking in the mirror” and “likes to use the hairdresser and have her nails painted.” Care plans and daily records show that the case tracked resident has had recent input from a speech and language therapist and has recently been discharged from a physiotherapist. There was evidence on the Health record that the resident has had an annual ‘well-woman’ check but it also states the Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 15 last dentist appointment was in October 2006. There is a care plan, which says the resident should see a dentist every six months. This plan has recently been reviewed but there is no acknowledgement as to whether or not the resident has been or is due to see the dentist. There were no records found to confirm this. Since the last key inspection the specialist pharmacist inspector has done a random inspection at the home, to follow up serious concerns with persistent problems with medicine management. A warning letter was sent to the provider in respect of this. The pharmacy inspector confirmed that improvements have been made. Medication Administration Records (MAR) were accurate with no missing signatures and handwritten MARs were completed correctly. A medication audit is completed every week, which looks at medicines and record keeping. Staff members spoken with at this inspection demonstrated a good awareness of what is important when administering medication. A staff member reported that that they do a ‘quiz’ at staff meetings to refresh them on safe practice. Competency assessments are also carried out regularly and the pharmacist provides annual training. Martinmass Close Care Home DS0000002253.V348930.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 annual quality assurance assessment and the complaints records in the home confirm that there have been no complaints made since the last key inspection. Both relatives confirm in their survey that 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 members spoken with demonstrated an awareness and understanding of abusive practices and of their responsibility to alert their line manager of all allegations of abuse or to whistle blow. The staff team know that the local Safeguarding Adults policies and procedures have recently been revised and a staff member reported that the revised procedures are discussed at staff meetings. The case tracked residents’ money was checked. Receipts are kept for all expenditure and records of transactions are accurate, and tallied with the amount held in the resident’s purse. Martinmass Close Care Home DS0000002253.V348930.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 good. This judgement has been made using available evidence including a visit to this service. The home’s décor is of a good standard and improvements to cleanliness mean that residents live in a safe, comfortable, homely and hygienic environment. EVIDENCE: On an informal tour of the premises the home was clean and smelt fresh throughout. The bathrooms were clean and have been redecorated since the last inspection. The sink in one of the bathrooms is now fixed and properly attached to the wall. Some bedrooms have also been redecorated, including the vacant ones so that they will be nice for new people that move in. There are new doors and double-glazing fitted throughout the property and laundry facilities are appropriate to the needs of residents. Some of the bedrooms also have new furniture and are decorated and personalised with chosen pictures and items, to suit their individual tastes. Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 18 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, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing arrangements have improved which help ensure residents are in safe hands at all times. EVIDENCE: There have been no new staff commence employment at the home since the last inspection. Two staff files were selected for examination. Both contain a pro-forma, which has on it information to confirm the staff member has two written references, and a criminal records bureau check, along with the date these checks were obtained. The actual references and CRB disclosure are held at a central office, where, as agreed with Nottingham Community Housing Association, an unannounced visit could take place anytime there. The Annual Quality Assurance Assessment states that the home is working towards ninety five percent of the staff team being qualified with at least National Vocational Qualification (NVQ) level 2 Social Care. There was also evidence on the two staff files that these staff members are up to date with their mandatory health and safety training such as fire safety, food hygiene and first aid. There are certificates for other courses attended, which are Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 19 relevant to meeting the needs of residents. Other courses include Equality and Diversity, Support Planning, Basic Housing Law, Legionella Awareness, PersonCentred Planning and Intensive Interaction / Communication. The registered manager is due to go on training on the Commission’s Annual Quality Assurance Assessment. Staff members spoken with reported the registered manager as being very supportive and there was evidence of supervision sessions seen on the two staff files examined. Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 20 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, 41 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and safety of residents is now better protected and good arrangements continue for monitoring and reviewing the quality of care, which helps ensure the home is managed well and run in the best interest of residents. A required notification was not made to the Commission, which means there is the risk that the home cannot be effectively regulated in protecting the welfare of its residents. EVIDENCE: Staff members spoken with were clear and consistent on the evacuation procedures in the event of a fire. Fire records show that since the last key inspection there have been two fire drills. All fire safety tests are undertaken as required by law and fire equipment has been serviced. The annual quality Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 21 assurance assessment confirms that the maintenance of gas and electrical systems is all up to date. A risk assessment for temperature control of radiators has now been added to the environmental risk assessments. Quality audits in accordance with Nottinghamshire Community Housing Association (NCHA) policy and procedures continue to be undertaken. The home has now had its three quality audits, in accordance with their procedures. 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 with completed action plans. There is also a new survey, which is presented in pictures so that it is more accessible to residents. The staff member that has been given the role of setting up implementation of the local Nottinghamshire quality assurance tool, called “The Quality Tree”, showed the work that she has done in sending out questionnaires to staff, relatives and residents and how the tool will also be used to measure how well the home is doing at upholding residents’ dignity and rights. An accident that resulted in a resident going to accident and emergency was not notified to the Commission. Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 22 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 X 5 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 3 X 3 X 2 3 X Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5(c) Requirement All residents must have a signed contract / terms and conditions with the home, in order to protect their legal rights in respect of their accommodation. There must be risk assessments for all areas of risk identified, with particular attention to the risk of falls and risks when accessing the community. This will ensure measures are in place for residents’ safety but also minimise restrictions on residents’ life and promote independence. This is an outstanding requirement from previous inspection, initial timescale 01/08/07 not met. There must be better arrangements in place for ensuring residents’ general healthcare needs are met. Otherwise, there is a risk that their general health will decline. Timescale for action 01/03/08 2 YA9 13(4) 01/02/08 3 YA19 12(1)(a) 01/02/08 4 YA41 37 All incidents requiring notification 01/12/07 to the Commission, as specified DS0000002253.V348930.R01.S.doc Version 5.2 Page 24 Martinmass Close Care Home under this regulation, must be made without delay. This is to ensure the home is effectively regulated. 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 YA7 Good Practice Recommendations Develop ways to record minutes of resident meetings in a more accessible way, so that the minutes are more meaningful to residents. Martinmass Close Care Home DS0000002253.V348930.R01.S.doc Version 5.2 Page 25 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.V348930.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!