CARE HOME ADULTS 18-65
Martinmas Close Care Home 6-8 Martinmas Close Lenton Nottingham NG7 4HE Lead Inspector
Joanna Carrington Unannounced Inspection 9th May 2006 10:00 Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 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 Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 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. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Martinmas Close Care Home Address 6-8 Martinmas Close Lenton Nottingham NG7 4HE 0115 846 1443 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) www.ncha.org.uk NCHA Debbi Ann Booth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. service users shall be within category LD Date of last inspection 10th November 2005 Brief Description of the Service: Martinmass 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. The current fee for living at the home is £335 per week. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over seven hours on 2nd may 2006. This was the home’s key inspection for this financial / inspection year. The main method of inspection was called ‘case tracking’ which meant selecting four residents and tracking the support they receive through checking their records, observation of care practice and discussion with staff. Due to the limited communication of the residents living at the home the inspector did not speak directly with residents but observed staff interacting with residents. The registered manager was absent on the day of the inspection. Two residents were away on holiday. Staff records were looked at and a partial tour of the premises also took place in order to assess environmental standards. As no other information and evidence had been gathered prior to the inspection all of the key standards were assessed during the inspection. Two staff members were spoken with and the deputy manager was available for discussion and feedback throughout. What the service does well: What has improved since the last inspection?
The use of risk assessments has improved, as they are used to ultimately, minimise risk but they identify ways that residents can participate in their chosen activities safely and also justify when necessary restrictions on an individual’s liberty is imposed. For example, due to limited road safety always having to be accompanied when out in the community. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 6 Support plans identifying residents not being able to use keys and how subsequently, their privacy and security is protected have now been developed. The manager has now been registered with the Commission and is in the process of completing the National Vocational Qualification (NVQ)4 Care and Registered Managers award. This will help to assure the home is run effectively and efficiently. 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 DS0000002253.V293612.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality for this outcome area is adequate. An up to date Statement of Purpose must be available in the home, so that prospective residents and their representatives have the information they need to make an informed choice about where to live. Prospective residents’ needs are assessed before they move to the home. EVIDENCE: During the course of the inspection a copy of the home’s Statement of Purpose was requested but could not be located. A summary of the Statement of Purpose and information about the home is contained in the Service User Guide, which was available. However, a Statement of Purpose is also a requirement as this document provides detailed information on the services that are offered at the home, including staffing, emergency procedures, the range of needs that the care home is intended to meet, arrangements for residents to engage in social activities and hobbies and for maintaining contact between residents and their relatives. A requirement to supply a copy of the Statement of Purpose to the Commission has been set. A comprehensive community care assessment was seen for the resident that was admitted to the home last year and there were community care assessments on the files of all residents that were case tracked. The placing authority has recently carried out community care reviews with residents and staff, to reassess needs, to ensure the care home remains as suitable in meeting the individual needs of all residents living at the home. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality for this outcome area is adequate. With only limited progress made on the development of individualised procedures for managing and responding to one named resident’s behaviour this has the potential to place residents at significant risk. Residents are supported to make choices and decisions in their lives. The use of risk assessments has improved, both identifying when restrictions on an individuals’ liberty is necessary and promoting individuals’ quality of life. EVIDENCE: The support plans seen do provide necessary information about how to support residents in meeting their individual needs. Support plans are reviewed at least every ninety days. Relatives / representatives are consulted over residents’ support. This is essentially at review meetings but where there are any significant changes or difficulties then relatives are informed. At the last inspection it was noted that for one named resident, following some serious incidents involving other residents, this had highlighted the need to establish more individualised and detailed procedures for managing their challenging behaviour, to ensure consistency and ultimately, to protect all residents. Other specialist professionals such as Speech and Language
Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 10 therapist, psychologist and social worker have been helping out in this process. Minutes of a multi-disciplinary meeting were supplied to the Commission that indicated this. Despite this process the support plan in place is still the same one as at the last inspection. There is still not the necessary guidance to staff on how to defuse a situation. Staff spoken with demonstrated an awareness of the individual communication needs of residents and gave good examples on how they support individual residents to make choices in their everyday lives. This was reflected in the respective support plans in place for communication. Speech and Language therapists have been involved where appropriate and there is a Signs and Symbols board available for staff to refer to. For all the residents that were case tracked it was noted how there is a good use of risk assessments, which accompany relevant support plans. These range from how to promote good health, including support with medication, promoting independence, for example safety in the kitchen and also risk assessments for minimising risks associated with individuals’ chosen activities. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality for this outcome area is good. There is a commitment from staff to promote a good quality lifestyle for residents by providing activities, access to the community, good meals and promoting relationships. The rights of residents are respected and upheld. EVIDENCE: On the day of the inspection two residents were away on holiday in Skegness with staff. Two other residents were at their chosen day centres and one resident remained at the home. All of the residents can access day services and attend activities that meet their needs and chosen preferences. From discussion with staff it is apparent that the team are committed to taking residents out and accessing the community amenities even though this has been restricted given the high needs of residents and no transport. The home has recently purchased a wheelchair accessible vehicle, which now means access to the community will improve for all residents. Daily records show that residents have been out to the local pub, Indian restaurant and shopping. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 12 Staff were observed interacting with residents in a meaningful and respectful manner. There was positive interaction with one resident by playing games with picture cards. 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 the outstanding requirement to devise support plans in respect of this has now been addressed. 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. Residents are supported by their key-workers to visit family, where possible. 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. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality for this outcome area is adequate. The healthcare and personal support needs of residents are appropriately met. Medicine management has improved since the last inspection but significant work is still required to ensure the safety of residents. EVIDENCE: Correspondence on residents’ files and their daily records shows residents have regular health care and dental checks. Doctors and community nurses are accessed when needed. Specialist professionals such as psychiatrists, psychologists and speech and language therapists are worked with in order to address the physical and emotional health care needs of residents. A member of staff reported that a psychiatrist has requested that they improve monitoring one residents’ epilepsy because the chart being used was very vague. It is very important that whenever possible, staff note exactly when and where the seizure occurred, its type and how long it lasted. Residents’ weight is recorded fortnightly, which is particularly important for one resident that has a weight problem. For the residents’ case tracked there were support plans seen giving step-bystep guidance on how for example, to assist with bathing and how individuals communicate when they want or don’t want a bath etc. Staff spoken with explained how there is flexibility for when personal support is provided and
Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 14 they were able to demonstrate knowledge into how residents express when they are not happy to do something. It was identified how on one resident’s support plan for dressing it does not specify how the resident can be supported to choose what they want to wear. It is recommended that this detail be added. At the last three inspections errors have been found with medication administration and recording. Since the last inspection, the recommendation to use the services of a pharmacy that are contracted with the PCT has been followed. This means that the pharmacy provide two visits to the care home to provide training and a check of the medication system. At this inspection serious errors were again found. The quantity of medication received is still not being counted in and recorded on the Medication Administration Record (MAR). Without this, an audit trail cannot be undertaken, to ensure that medicines are being administered safely and correctly. For one drug, according to the printed MAR the number of tablets that were prescribed for the current ‘four week’ supply was 168, but already into week three that supply was still not being used. When only 26 tablets should remain up until the end of the ‘4 week’ period there are 41. This suggests at some point doses have not been given, but there is no way of working out when as the total tablets for this medication has not been counted in and signed on the MAR. There is a signing out book for when medicines are taken off the premises, which occurs for residents that go to day centre, but this information is meaningless if there is no record of the total quantity. Another drug, for the same resident 12 tablets should remain in the box when only 11 were counted. For a different resident for one of their medicines each daily dose had been signed for but one tablet still remained in its blister and another medication for this resident the typed instructions on the box were not the same as on the handwritten MAR. It is recommended that instead of using the ‘ordering book’, which serves no real purpose, instead attach a photocopy of the prescription to the MAR, as a way of checking that the instructions on the MAR correlate with the GP prescription. This is the fourth consecutive time that the medication system has been found to be unsafe. This is of serious concern therefore an immediate requirement has been set. A referral to a specialist pharmacy inspector will also be made. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality for this outcome area is adequate. There is an appropriate Complaints Procedure, which assures that residents and their relatives concerns are listened to and acted upon. There are arrangements in place for the protection of residents, but in addition to this local procedures must be adhered to at all times. EVIDENCE: The Complaints Procedure is displayed in a Signs and Symbols format in the care home and is also contained in the Martinmass Close Handbook. There have been no complaints made in the last year. The residents at Martinmass Close, due to their profound disabilities, will not be able to access the Complaints Procedure themselves. Therefore, it is recommended that relatives and representatives are reminded of this procedure and that staff should also be encouraged to assist residents in accessing the complaints procedure, so that any issues concerning residents are acted on and taken seriously. Since the last inspection an allegation was made that a resident is not being adequately protected from another resident at the care home. This allegation was received by the Commission and in accordance with the Nottinghamshire Policy and Procedures for the Protection of Vulnerable Adults, was referred to Social Services for investigation. As a result of this notification the staffing numbers were increased from two to three staff at key times, so that shadowing arrangements can be effectively in place. There have been no further notifications to the Commission during this time and staff spoken with feel that generally the situation has improved. What was identified, as part of the investigation was a misunderstanding regarding what incidents should be notified to Social Services. The registered manager believed that incidents not witnessed are not to be notified. As a result, one incident in which the resident
Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 16 had some injury was not passed onto Social Services. This should not have been the case, particularly in a situation where a resident is targeted and there is a pattern of abuse. All suspicions must be shared with Social Services, along with the Commission in accordance with Regulation 37 of the Care Home Regulations. This is set as a requirement. The manager must ensure that all incidents are monitored closely and that the shadowing arrangements are reviewed on an ongoing basis. To ensure that the shadowing arrangements are working effectively the arrangement must be clearly laid out in the relevant support plans. The information that is currently recorded did not reflect what staff described. A requirement is set in respect of this. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality for this outcome area is adequate. The home is clean and hygienic but some attention to décor is still required and also to the furniture provided, so that the environment is more comfortable and safe for residents. EVIDENCE: On a tour of the premises it was evident that the environment is kept clean. There is a cleaning rota for staff identifying daily, weekly and monthly jobs. The laundry facilities are suitable for meeting the needs of residents. The home is furnished with domestic fittings and does have a homely feel however paintwork in certain parts of the home is now looking very tired and worn. There is paint coming off the walls in the kitchen and walls are stained in the dining room / lounge area. The outside window frames to the kitchen are badly rotting, for which a requirement was set at the last inspection and is now outstanding. Staff reported that the home is getting a new sofa for the lounge. Bedrooms seen did look personalised, all decorated very differently. The chest of drawers in one resident’s bedroom has seen better days. It does not open and close properly and a small nail protruded out slightly on it, which has potential to cause harm. In accordance with the Care Home Regulations 2001 it is the responsibility of the home to provide adequate furniture, therefore this is set as a requirement.
Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality for this outcome area is adequate. Residents’ benefit from an effective and appropriately trained staff team. Recruitment practices do not ensure the protection of residents. EVIDENCE: Staff have been able to access training with the Nottinghamshire Healthcare Trust and Nottingham Community Housing Association (NCHA). This will change soon when the Nottinghamshire Healthcare Trust pull out of the partnership, with NCHA taking over the employment of staff. Training records show that staff are kept reasonably up to date with mandatory training courses and other training courses are accessed to equip staff in meeting the needs of residents. All staff except two have been on training to de-escalate and defuse challenging behaviour, other courses that have been attended are suicide awareness, autism awareness, cultural awareness, communication and sexuality and relationships. All except two staff are qualified to at least NVQ level 2 Social Care. The staff rota showed some flexibility with staffing numbers but most importantly at key times there are always three staff members on shift, essential for the shadowing arrangements discussed under Standard 23. In accordance with the Care Home Regulations, the registered manager has been obtaining copies of information that is held centrally, for staff files.
Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 19 However, out of the four staff files randomly selected one of those files did not contain references. For the most recently recruited member of staff it is not clear from their file when they commenced employment and there is no evidence that necessary checks have been carried out. Evidence of this must be supplied to the Commission. This is set as a requirement. Due to ongoing problems with staff files at Nottingham Community Housing Association partnership care homes, an additional unannounced visit was made in March 2006 to the Nottinghamshire Healthcare Trust to inspect the centrally held files. For Martinmass Close three staff files were randomly selected and showed that not all the necessary information is retained on these files including evidence that the required recruitment checks are carried out before a person commences their employment. After this visit NCHA informed the Commission that the staff files looked at were in fact not the full files, as these are held at another site, which they were unaware of. Therefore, the correct staff files were not made available at the time of inspection. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality for this outcome area is good. The quality and conduct of the home are not being adequately monitored, which does not ensure the home is run in the best interest of residents. Practice within the home promotes and protects the health, safety and welfare of residents. EVIDENCE: Since the last inspection the manager has now been registered with the Commission. The manager is in the process of completing the NVQ 4 Care and Registered Managers award. In June 2005, when quality assurance was inspected, it was explained that staff from NCHA care homes are allocated as auditors and will be responsible for auditing other NCHA homes. However, the last quality audit at the home appears to have been April 2005. NCHA Service User Satisfaction surveys have recently been circulated but not in a format that is accessible to adults with a learning disability. Surveys have not gone out to relatives or Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 21 representatives of residents, which in the case where residents have limited communication and understanding, this exercise would be worthwhile. There was evidence seen that all the necessary health and safety and fires safety tests are carried out, such as legionella and water outlet temperature and fire alarm tests. Substances hazardous to health are stored securely in accordance with COSHH regulations. The required services for gas and electricity systems have been carried out. Staff receive all the necessary health and safety and fires safety training both during induction and as refresher courses. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 X 2 X X 3 X Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 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 YA1 Regulation 4 Requirement Timescale for action 01/07/06 2. YA6 15 3. YA20 13(2) Supply an up to date Statement of Purpose, containing all information as specified in Schedule 1, to the Commission within the set timescale. Develop a detailed care plan for 09/05/06 the named resident that establishes individualised procedures for how to respond to challenging and aggressive behaviour. This is an outstanding requirement and is therefore issued as an immediate requirement. Ensure that there are adequate 09/05/06 arrangements for the recording, handling, safekeeping and safe administration and disposal of medicines received into the care home. This refers to: 1. Ensuring that the quantity of medication received in the home is recorded on the Medication Administration Record (MAR) at the start of the 4 week period and at the end. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 24 4. YA23 13, 37 5. YA24 23 6. YA26 23 2. Using a consistent recording system for administration (instead of using NCHA handwritten forms for some and not for others. 3. Only signing for tablets that are administered. 4. Ensuring instructions on the MAR correlate with instructions on the box and original prescription (recommend keeping a photocopy of the prescription). Requirements concerning medicines were set at the previous three inspections. Therefore, this is set as an immediate requirement. Ensure that any suspicion of 31/05/06 abuse (regardless of whether witnessed) is notified in accordance with the local adult protection procedures. Ensure that the premises of the 09/08/06 care home are kept in a good state of repair both externally and internally and reasonably decorated. This is an outstanding requirement from previous inspectionoriginal timescale 31/01/06 not met. Ensure all residents are provided 09/08/06 with adequate furniture and fittings. This refers mainly to the named resident’s chest of drawers. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 25 7. YA34 17, 19 8. YA34 19 9. YA39 24 Ensure references and all other records listed in Schedule 2 of the Care Home Regulations 2001 are being retained on the premises for all staff. This is an outstanding requirement from the two previous inspections, original timescale 31/07/05 not met and is therefore set as an immediate requirement. Supply evidence to the Commission that the Criminal Record Bureau and POVA First check has been carried out for the named, most recently recruited staff member by the set timescale. This is set as an immediate requirement. Implement quality assurance system, that is based on seeking the views of residents and their representatives / relatives. 09/05/06 09/05/06 30/07/06 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 YA23 Good Practice Recommendations Monitor and periodically review the ‘shadowing’ arrangement in place for one resident to ensure that this is the most effective way of managing this residents behaviour, without impacting on providing for and meeting the needs of all other residents. Martinmas Close Care Home DS0000002253.V293612.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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