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Inspection on 07/06/05 for Martinmass Close Care Home

Also see our care home review for Martinmass Close Care Home for more information

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff at the home value the links and communication they have with the day services that residents attend. This is good practice in ensuring that the needs of residents are being met consistently and in order to identify and support residents with any problems they may have. Staff enable individuals` to maintain relationships with family and for one resident who has recently moved to the home, this is his first experience living away from his mum. The home has worked closely with the social worker in supporting both the resident and his mum to adapt to the situation. Staff work as a team in developing care plans and planning support and care plans are reviewed monthly with multi-disciplinary reviews every 6 months. The manager was described as being approachable. There is an effective and committed staff team and with different roles assigned to staff such as health and safety and gardening this uses the different skill mix and interests of staff in a positive way, something of which the residents will ultimately benefit from.

What has improved since the last inspection?

Many of the issues / concerns identified at the last inspection have now been or are in the process of being addressed. The service user guide has been amended to include how to contact the Commission for Social Care Inspection. Before the new resident moved into the home his compatibility with the other residents was given serious consideration, especially as the current residents have lived at the home for a number of years with no changes to their group. Following an incident where confidentiality was breached it was recommended, for the assurance of relatives that a copy of the confidentiality policy was sent out to them. Letters have gone out to relatives enclosing copies of the confidentiality policy and also where applicable with copies of amended care plans for consultation. Instructions on medication administration records are much clearer for residents who may have medication given on a `when required` basis.

What the care home could do better:

The manager is still not registered with the Commission for Social Care Inspection. This is an offence for which the manager could be prosecuted. As this was identified at two previous inspections this has now been identified as a serious concern which must be addressed immediately. In relation to this the manager has not yet been enrolled onto a level 4 National Vocational Qualification (NVQ) care and managers award, which without a professional qualification this is the qualification required to be manager of the home. There has been a drug error since the last inspection. This should have been notified to the Commission. What needs to be notified to the Commission for Social Care Inspection was discussed and two main areas that needed clarifying were medication errors and adult protection. There still needs to be more evidence of consultation with relatives and representatives on care plans. Implementing a system of quality assurance that involves residents and relatives is still not yet implemented but it was reported that staff will soon be attending a course on the Quality Tree, which is the Nottinghamshire tool for quality assurance which central to this is involving residents in the process. For the protection of all residents it is important that certain staff records are kept at the home. There are copies of references on files for new staff but this must apply to all staff.

CARE HOME ADULTS 18-65 Martinmas Close Care Home 6-8 Martinmas Close Lenton Nottingham NG7 4HE Lead Inspector Joanna Carrington Unannounced 07/06/05 10.00am 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 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 Stationary 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. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Martinmas Close Care Home Address 6-8 Martinmas Close Lenton Nottingham NG7 4HE 0115 8461443 0115 8461443 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) NCHA Ms Stephanie Hurd CRH 5 Category(ies) of LD registration, with number of places Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22/03/05 Brief Description of the Service: Martinmas Close Care Home provides care and support for up to five adults with a learning disability. It is situated in a residential area of Lenton close to a range of public amenities and within easy reach of Nottingham City centre. All five bedrooms are on the first floor and are single rooms; 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. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6.5 hours on the 7th June 2005. It was the home’s first unannounced inspection for this financial / inspection year. Due to people who live at this home having communication needs and limited understanding the inspector was not equipped to be able to speak with the residents during the inspection. Any judgements in this report are from observation, speaking with staff and reading residents records and documents. A tour of the premises took place and staff records were also looked at during the inspection. Two members of staff were spoken with and the manager was available for discussion throughout the inspection. What the service does well: What has improved since the last inspection? Many of the issues / concerns identified at the last inspection have now been or are in the process of being addressed. The service user guide has been amended to include how to contact the Commission for Social Care Inspection. Before the new resident moved into the home his compatibility with the other residents was given serious consideration, especially as the current residents Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 6 have lived at the home for a number of years with no changes to their group. Following an incident where confidentiality was breached it was recommended, for the assurance of relatives that a copy of the confidentiality policy was sent out to them. Letters have gone out to relatives enclosing copies of the confidentiality policy and also where applicable with copies of amended care plans for consultation. Instructions on medication administration records are much clearer for residents who may have medication given on a ‘when required’ basis. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 Some progress has been made on ensuring that residents and their representatives have enough information about the home. Prospective residents do not move to the home until their needs have been assessed. EVIDENCE: The service user guide and Martinmas Close Handbook now contain enough information on the Complaints Procedure including how to contact the Commission for Social Care Inspection (CSCI). Since the last inspection there has been a new admission to the home. A copy of the resident’s extended community care assessment was available on file. This along with a copy of the care plan from a residential home where short breaks had been provided are forming the basis for the care plans being developed by staff at Martinmas Close. It was explained by the manager how part of their own assessment was to read through the social worker’s assessment and to meet the prospective resident in order to ascertain their compatibility with the people already living in the home. This was seen to be an important element of the assessment process particularly as the existing residents had been together for years with no changes. One resident will soon be leaving Martinmas Close to move onto Supported Living. This move has been postponed due to delays in obtaining the property. However, there has already been some interest in this resident’s room. The Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 9 manager explained how so far the referrals received have been for people that both the manager and staff do not feel are appropriate to the current resident group in terms of their vulnerability. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 10 Although existing care plans are thorough to assure that the needs of residents can be met, some evidence of consultation is still required. For the protection of all residents some prioritisation is necessary with the development of care plans for the new resident. Relatives and representatives now have the necessary information to assure them that confidential information is handled appropriately and sensitively. EVIDENCE: Care plans identify individual needs and provide comprehensive information about how to support residents in meeting these needs. A care plan for attending to one resident’s oral hygiene has now been updated, as identified at the last inspection, which refers to the acceptable measures staff can take in cleaning his teeth. The care plan identifies the preferences of the resident. A member of staff spoken with said that she offers to clean the resident’s teeth while he is in the bath as this is when he is most relaxed, which is exactly what is stated in the care plan. Identified as a requirement at the last inspection this care plan has been shared with the appropriate relative so that any disagreement can be recorded. On the other residents’ files seen there is currently no evidence of consultation with relatives or representatives. The manager explained how letters have Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 11 gone out to relevant people about this and the aim is to obtain signatures with a date next time they visit the home in order to indicate that they have read and agree / disagree with the care plans. Consultation will then take place and be evidenced at residents’ reviews. For the new resident care plans are in the process of being developed, with involvement of the social worker. However, there is not yet a care plan for how to manage his frequent challenging behaviour, despite several incident reports already. Both members of staff spoken with explained a similar approach with what to do in this situation. To ensure consistency there needs to be a clearly structured strategy in place. This is a care plan that is urgently required and takes priority over other care plans in order to ensure that all residents feel safe and to help this resident adapt to his current environment. Rather than accessing care plans on the computer hard copies were seen on the day of the inspection. Although having hard copies are not compulsory this is currently necessary at this home to aid the consultation process and so that staff can update records while still being able to supervise residents. Staff spoken with mentioned how having only one computer in a small and tucked away office restricts access to electronic care plans. On a tour of the premises this confirmed that the office only accommodates comfortably one person at a time. If information was not held on a hard copy then how could there be any form of consultation? It is recommended that some consideration be taken on further provision of equipment to enable staff to use the electronic system more efficiently. Following the recommendation at the last inspection relatives and representatives have now been given copies of the confidentiality policy in order to provide some reassurance regarding expectations of staff and when information needs to be shared. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 and 16 Staff are committed to providing fulfilling and community-based activities but this is restricted by the home not having its own vehicle. Staff enable residents to maintain relationships with friends and family. In order to fully recognise the rights and responsibilities of residents these need to be referred to within care plans. EVIDENCE: It was evident from talking with staff that taking residents out and supporting them to access the community is seen as an important part of their role. There are care plans for community-based activities identifying what individuals enjoy doing and any activities participated in such as going to the pub or going to town on the bus are recorded. Some residents were on a holiday in Derbyshire in a rented cottage. Staff spoken with do feel that because the home does not have its own transport this means that accessing the community is restricted. With one resident needing two to one support and an intensive supervision programme for two residents this also stops there being any spontaneity. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 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. Visits by friends and relatives are recorded within the implementation section of care plans and a member of staff reported that relatives visit the home regularly and are made to feel welcome. One resident is supported by his key-worker to visit his father every month. The new resident attends Barncroft Day Service, which is where he went before he moved to Martinmas Close. This is to provide some continuity and to ensure there is contact with people he already knows. Staff have also supported the mother of the new resident as it is has been a difficult time for her given that until now she has always lived with and supported her son. Through observation and talking to staff it is apparent that staff respect and promote the rights of residents. Staff were observed interacting with residents and not exclusively with each other. On one of the files seen any household chores this resident has been involved in have been recorded. However, it is recommended that there is a care plan on each residents’ file specifically for domestic skills, which promotes residents’ responsibilities and their right to have some involvement in the home. The manager explained how one of the resident’s communicates with staff when she wants the lockable facility in her bedroom to be locked / unlocked and there is a care plan for this arrangement. None of the residents at the home have the ability to use a key, which means that rooms are left unlocked. To demonstrate full consideration has been given to the privacy of residents and also to ensure the security of their belongings a care plan / risk assessment is required. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 Progress has been made in ensuring that residents receive personal support in the way that is preferred and required. The manager must ensure that medication errors do not continue so to be assured that the medication system is safe. EVIDENCE: On the resident’s files seen there were detailed care plans on how to provide personal support highlighting individuals preferences such as gender and having a shower or a bath and how individual resident’s communicate when they want a shower etc. Staff spoken with explained how there is flexibility for when personal support is provided and they were able to demonstrate knowledge into how residents express when they are not happy to do something. At the last inspection a requirement was set to develop the care plan for a resident who will often refuse support with having his teeth cleaned. The care plan now gives clear step by step instructions on what to do and also indicates what is likely to be the most successful approach. The care plan also makes reference to the resident’s right to refuse and that under no such circumstance shall the individual be forced. The instructions for ‘when required’ (PRN) medication are now clearer, which was set as a requirement at the last inspection. However, medication Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 15 administration records seen this time showed that there have been a couple of recent errors. It is important that when medication has been administered this is recorded in the right box otherwise on first glance of the record it looks as if that particular dose was not given. The other error was in fact when a dose had been missed. The appropriate action was followed when the error was found and the manager was informed immediately and this error has been addressed with the relevant member of staff. It is recommended that the procedure following a drug error is displayed within the file to ensure that necessary action is taken in case another error occurred. This incident was not notified to the Commission for Social Inspection when it should have been, in accordance with Regulation 37 of the Care Home Regulations 2001. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 There has been significant progress in safeguarding residents from abuse. EVIDENCE: There has been a history between two of the residents in which one resident severely picked on another resident resulting in frequent and abusive incidents. The only successful strategy for protecting this resident has been to implement a protection plan whereby staff shadow and supervise both residents while they continue to live together. This arrangement is therefore still in place but the victim is now waiting to move into Supported Living, which is a positive step forward. Specialist professionals were called upon so that a multi-disciplinary approach was taken in finding ways to protect this resident. The manager and staff spoken with are now familiar with the Nottinghamshire adult protection procedures and know that violent incidents between residents must be notified to the Adult Protection Unit. All staff receive adult protection training as part of their induction and LDAF (Learning Disability Award Framework) training and in addition to this the manager is aiming for all staff to eventually attend the NCPVA (Nottinghamshire Committee for the Protection of Vulnerable Adults) training in the local policy and procedures. The manager was not aware that all notifications to the Adult Protection Unit must also be notified to the Commission for Social Care Inspection (CSCI), in accordance with Regulation 37 of the Care Home Regulations 2001 so that CSCI can oversee the protection of residents from abuse. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 17 Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 and 30 Residents’ can choose to bring their own furniture or it is provided by the home, taking into account individuals’ personal preferences and taste. All staff are responsible for ensuring that residents live in a clean, tidy and hygienic environment. EVIDENCE: The concern was raised at the previous inspection that there is an expectation that residents purchase their own furniture when they move to the home. The manager and deputy manager explained that this has never been the case but may have appeared so as the bedroom inspected appeared very empty, prior to the new resident moving in. This was so that they could have some say in what furniture was purchased by the home. It was reiterated to the manager during the inspection that under no circumstances are residents expected to bring their own furniture. The bedrooms seen did have different furniture and were well personalised. On a tour of the premises the environment appeared clean and tidy. There is a detailed cleaning list for daily, weekly and monthly jobs which, when completed are signed off by staff. This ensures that essential cleaning tasks Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 19 are completed and that the responsibility is shared fairly between all staff. There are laundry facilities appropriate to meeting the needs of residents. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 34 Residents are supported by an effective staff team. Residents will be fully protected the home’s recruitment practices once copies of references are held on all staff files. EVIDENCE: There are always a minimum of two members of staff on shift and there are times when there are more, but currently this is mainly in order to carry out the ‘protection plan’ for one vulnerable resident who is soon moving on to Supported Living. The manager explained how this arrangement has ran on the normal complement of staff so staffing levels should not change at all when this resident leaves. Due to difficulties with recruiting new staff there are times when a care agency is called upon to cover some shifts but usually it is the same worker who is familiar to the residents and the service. The skills and interests of staff are utilised well at the home with staff being assigned different responsibilities such as health and safety, quality assurance and communication. This contributes to the overall efficiency of the home, which the residents will ultimately benefit from. In accordance with Schedule 2 of the Care Homes Regulations the manager is now taking copies of references for new staff and on the staff files seen these did contain proof of identification and evidence of police checks. The manager Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 21 did explain, however that she has not yet managed to get copies of references for all staff. This is required. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 Registration to be manager and training in this role are required for the current manager to enable her to run the home well. Some progress has been made with the implementation of a quality assurance system. Practice within the home promotes and protects the health, safety and welfare of residents. EVIDENCE: The manager has still not applied for registration with the Commission for Social Care Inspection as manager of the home even though she has been in post since September 2004. Given that this has been a requirement at two previous inspections this is now an immediate requirement and a matter of serious concern. The manager has applied to do her National Vocational Qualification level 4 Care and Managers Award but is yet to be enrolled on a course because of issues around funding. It is recommended that this is resolved as a matter of urgency so that this training can commence. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 23 Periodic surveys of residents and families’ views are undertaken via keyworkers. A member of staff has now been assigned the role of quality auditor. This entails visiting and auditing other NCHA homes and a ‘quality auditor’ from another home will visit Martinmas Close. The manager reports that this will soon be implemented following training on the ‘Quality Tree’, a Nottinghamshire tool for obtaining the views of adults with a learning disability. There are environmental risk assessments in place and there was evidence seen that all the necessary health and safety and fire safety tests, servicing of equipment and recording of water (for the prevention of Legionella) and fridge / freezer temperatures (for the promotion of food hygiene) are all up to date. Staff receive all of the necessary health and safety and fire safety training both during induction and as refresher courses. Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x 2 3 3 2 x Standard No 31 32 33 34 35 36 Score x x 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Martinmas Close Care Home Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 1 x 2 x x 3 x C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 25 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 6 Regulation 15(1) Requirement Devise a care plan on how to effectively manage the challenging behaviour of the new resident. Ensure that consultation with service users relatives and / or represenatives is obtained and evidenced following reviews and any identified changes to support. Ensure that there are risk assessments / care plans in place outlining why service users do not have keys and measures in place for respecting privacy and for the security of service users belongings. Ensure that there are adequate systems in place for the recording and safe administration of medicines. Ensure that medication errors that adversely affect the safety and welfare of any resident are notified to the Commission for Social Care Inspection. Ensure that any incidents of adult protection are notified to the Commission for Social Care Inspection. Ensure that a copy or original Timescale for action 30/06/05 2. 6 15(1)(2) 31/07/05 3. 16 12(4)(a) 31/07/05 4. 20 13(2) 30/06/05 5. 20 37 30/06/05 6. 23 37 30/06/05 7. 34 19 31/07/05 Page 26 Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Schedule 2 8. 37 8 and 11(1) of Part II of the Care Standards Act 200 references and all other records listed in Schedule 2 of the Care Home Regulations 2001 are held on the premises, for all staff. Ensure that the manager applies for registration. As this was set as a requirement at the two previous inspections this is now an immediate requirement. immediate 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 6 Good Practice Recommendations To consider the facilities and equipment required within the home to enable staff to use the electronice SURE system efficiently, without having the need to make hard copies. It is recommended that the home has its own vehicle in order to enable staff to support residents to access the community and its facilities. It is recommended that there is a specific care plan for domestic skills for each resident. It is recommended that a copy of the procedure to follow in case of a drug error is displayed in the medication file. It is recommended that the manager starts the NVQ Level 4 as soon as possible. 2. 3. 4. 5. 13 16 20 37 Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Edgeley House Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Martinmas Close Care Home C53 C03 S2253 Martinmas close V232787 070605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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