Inspection on 29/04/09 for Newhaven Community Care Ltd (Phoenix House)

This inspection was carried out on 29th April 2009.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newhaven Community Care Ltd... 19/06/08

Newhaven Community Care Ltd... 20/12/07

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Newhaven Community Care Ltd (Phoenix House) 124 Crowstone Road Westcliff on Sea Essex SS0 8LQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sarah Axam     Date: 2 9 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Newhaven Community Care Ltd (Phoenix House) 124 Crowstone Road Westcliff on Sea Essex SS0 8LQ 01702337057 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : newhaven_manager@communitycaregroup.co.u k Newhaven Community Care Ltd care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 6 The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary needs on admission to the home are within the following categories: Learning disability - Code LD - maximum number of places 6. Date of last inspection Brief description of the care home Phoenix House is a care home providing personal care and accommodation for up to six residents who have a learning disability. The home is a three storey detached house situated in a residential area and is close to all local amenities. There are six bedrooms for residents within the home and it has a large lounge overlooking the rear garden and an adjacent dining area. Additionally there are two other lounge areas for residents use. The home has a rear garden which residents are able to access. Two mini buses are available to transport the residents to their activities and to college. Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home The weekly fee charged to residents is currently £1853.00. Additional, charges incurred by residents relate to chiropody, transport, holidays, personal toiletries, hairdressing and some leisure pursuits. There is a Statement of Purpose and Service Users Guide readily available within the home. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The unannounced site visit took seven and a half hours to complete and was carried out as part of the annual inspection programme for this service. This visit was conducted with assistance from the manager. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. The last key inspection for this home was held on the 19th June 2009. Five staff and one resident were spoken with during the site inspection. We looked at all the information that we had received, or asked for, or what the service has told us about things that had happened in the service since the last inspection. Prior to this site visit, CQC (Care Quality Commission) sent out surveys to all interested Care Homes for Adults (18-65 years) Page 6 of 32 parties, however whilst writing this report none have been returned to us. Additionally the manager was sent an (AQAA) Annual Quality Assurance Assessment form by us (CQC). This is a self assessment required by law, that asked how well the home is meeting the needs of the people who live at Phoenix House and the homes own quality assurance results of July 2008 were used as part of this process. All information obtained was triangulated and reviewed against the commissions key lines for regulatory activity. This helps us to use the information to make judgements about the outcomes for the people who use this service in a consistent and fair way. What the care home does well: What has improved since the last inspection? What they could do better: Incorporating residents or their representatives views and agreements within the care plan could be improved upon. Information in general needs to be in a format that is understood by the individual, such as, using makaton symbols, photographs or reference aides specific to that individual. This will allow individuals to be a part of the care they receive and what kind of support they choose to have from staff. A ramp would allow people to have safe access independent of staff to the back garden and would reduce the possibilities of falls. Staff ratios still need to be further improved upon. Additionally consideration to further senior support, since the deputy post at the home, has recently made void by the manager and provider should be addressed. This would ensure that this better protects the residents by supplying staff with greater shift leader support. The home needs to give better information around safeguarding, complaints, concerns and quality assurance feedback to all interested parties and to make this freely available within the home. The current service user guide and statement of purpose has the wrong contact information and organisational name for CQC. This needs to be corrected so as people have the proper information given to them. The outstanding repeat requirements and recommendations from the last inspection need addressing. Care Homes for Adults (18-65 years) Page 8 of 32 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clear and comprehensive assessment process assures people that their needs could be met prior to moving in their home. Evidence: The manager told us in the Annual Quality Assurance Assessment that there is a statement of purpose and residents guide, which provides information about the home to help people decide if they would be happy there. The manager told us that should a person enquire about a place in the home they would be provided with information and the persons family or advocate would be given an assessment to complete with details of the prospective residents needs. A copy of the social services or local authority needs assessment would also be obtained. The manager said that people are invited to visit the home before they move in and once they do a contract would be agreed. We saw that there is a current service user guide and statement of purpose in place. One persons information that had just recently moved into the home, showed us that these documents had not been given and this person confirmed to us that they did not Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: receive any information prior to moving in. When we visited the home we looked at the way in which a persons needs would be assessed. We saw that the assessment covered details of the persons physical and health needs as well as the support the individual required to maintain personal and oral hygiene, communication, next of kin, GP, contacts, diet, behaviour, social, spiritual leisure, educational, mobility, the level of support and a weekly activity plans. Care Homes for Adults (18-65 years) Page 12 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be assured that they will have the opportunities for personal development and build upon their daily living skills so that they are able to lead a lifestyle that they choose. Evidence: The manager told us in the Annual Quality Assurance Assessment that each person had a care plan, which was reviewed at least every twelve months or more often where this was appropriate. They told us that emphasis was put on enabling residents to make decisions and choices about their daily lives including what meals they eat and what clothes they wear etc. Residents who completed surveys, with the assistance of staff, indicated that they could make choices and do what they wished to do during the day and evening. When we visited we looked at care plans for four of the residents living in the home. We saw that staff recorded long term and short term goals for residents. However goals set in care plans did not reflect fully what the individual wanted to achieve and there was little evidence that the plans and goal setting had Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: been carried out with residents, even those who were more independent and capable. For example, Within information held within peoples files it showed us that some attempt had been made to include them by writing down their opinion, more often than not it was written from the staffs point of view. Additionally sometimes they lacked appropriate risk assessments and vital information needed (information used if someone needed urgent medical attention and was taken into hospital, missing persons profile and medication self administration guidelines or risk assessment) to keep all people safe best as possible. Each person is provided with a personal care and support plan. The support plan clearly outlines activities, information, support needed and risk assessments for this area. We saw this by looking in four peoples information and speaking with one of the residents who live at Phoenix House and looking at their weekly activities chart. Care Homes for Adults (18-65 years) Page 14 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that their identified needs will be met appropriately and that they will be able to live the lifestyle they choose. Evidence: The manager told us in the Annual Quality Assurance Assessment that residents are supported to develop skills and to participate in activities of their choice both in and outside of the home. We saw that all residents had a plan of care which described their choices for the activities they wish to participate in. One of the residents who was more capable of living a more independent lifestyle attended college one day per week to learn skills to improve living skills. They also accessed activities such as clubs and pubs within the local community. Information showed us that all of the four residents have planned Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: activities both in the home and outside within the community. One resident told us I use the local cinema, theatre and evening clubs. Another person said I am currently looking for employment and my key worker is helping me do this. The manager told us that all residents have access to the homes vehicle, local taxi service, buses and trains, so that they could enjoy more outings outside of the home. We looked at the arrangements for supporting residents with choosing and preparing food and meals. We saw that staff supported resident in buying and preparing food and that there was a planned menu, which reflected residents likes and dislikes. Each resident had a care plan which described the support the individual needed. Staff told us that one resident could read the menu and the others were supported in choosing meals through the use of picture cards. Care Homes for Adults (18-65 years) Page 16 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good care plans give staff the necessary information to provide good care outcomes for all people. Evidence: The manager told us in the Annual Quality Assurance Assessment that the health and personal care needs of all residents are met and that staff are trained to administer medicines safely. Residents completed surveys with assistance of staff and said that they staff treat them well and act on what they say. When we visited the service we saw in peoples information that they have good access to all other health professionals such as GPs, consultants, nurses and social workers. However looking within the recording of the outcomes of all appointments, some written daily notes or summaries, did not clearly show us that these issues are picked up on, or action taken within an acceptable time scale. There was information recorded about how medication is managed, for instance, the correct receipt, recording, storage and handling, administration and disposal of Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: medications. Four of the staff confirmed to us that they knew procedures well and were aware of individual need. Looking through all residents records it revealed to us that one resident who self administered some medication did not have any medication risk assessment or guidelines for staff to follow. The manager assured us, that this practice issue would be picked up on quickly and resolved immediately. The manager told us that all staff who administers medication had up-to-date training and this was seen in their personal files. Care Homes for Adults (18-65 years) Page 18 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to ensure that peoples views are listened to acted upon and support residents to be protected from abuse. Evidence: We were told in the Annual Quality Assurance Assessment that any complaints or safeguarding alerts would be dealt with openly and thoroughly. The manager told us that residents relatives are provided with information on how to complain and how their concerns would be dealt with. They also told us that staff received information about dealing with complaints and whistle blowing when they commence work at the home. The manager told us that there is a policy and procedure for dealing with complaints. She told us that the home has an open door policy where people are encouraged to come and raise any concerns they may have. She told us that as part of the corporate complaints procedure that all complaints would be investigated by her. The manager told us that most residents living in the home would not be capable of making a verbal complaint, but that they would be able to express displeasure and that staff would be able to pick up on this. We looked at care plans to see if there was any information recorded about the way in which residents express displeasure and what signs staff should look for, but there was no information recorded. The manager Care Homes for Adults (18-65 years) Page 19 of 32 Evidence: told us that there had been no formal complaints made about the service within the past twelve months. We saw that records held within the office revealed that there were two complaint systems. Looking through one of the complaint records we saw that a complaint had been received by a relative and missed by the manager due to another complaint system being used as well. Residents who completed surveys with the assistance of staff indicated that that they knew how to complain and who to speak with if they were unhappy. None of the residents indicated that they had made any complaints. One person told us I would first speak to my key worker and then the manager. One member of staff completed a survey and they told us that they knew how to deal with any concerns or complaints raised. Looking at training and speaking with four of the staff on duty showed us that, they knew procedures well and knew about reporting of any kind of abuse. All the 11 permanent staff currently employed were waiting for an update in the safe guarding training. Care Homes for Adults (18-65 years) Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean safe environment. Evidence: The manager told us in the Annual Quality Assurance Assessment that some general refurbishment had been carried out to the home. She said that home was clean, residents bedrooms were individually personalised and the home was safe. Three residents completed surveys with assistance from staff and they said that the home is always fresh and clean. We carried out a brief inspection of the premises when we visited the home and there were no apparent odours and residents rooms were all clean and well maintained. All bathrooms, showers and toilet are in good working order, clean and provide plenty of facilities for all residents to use. When we visited the service we saw that there is quite a big drop from the doorway to the patio area that you need to use to access the garden area. Looking through all residents records it revealed to us that one resident has been identified as having a mobility issue. A resident confirmed to us that their room was kept clean and that if there was any kind of a problem it was quickly rectified and that staff did consulted with them over Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: the choosing of colour schemes and furniture to be purchased for their room. Care Homes for Adults (18-65 years) Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered positive relationships by well-supported and caring staff. Evidence: The manager told us in the Annual Quality Assurance Assessment that the home did not rely on the use of temporary agency staff. He told us that staff are recruited thoroughly and trained to meet the needs of residents. Residents who completed surveys said that staff listen to them and act on what they say. Staff were recruited to work in the home. We reviewed the information for one person who had been employed at the home since the last inspection. We saw that before the person commenced work they had provided information about their previous employment and satisfactory references had been obtained. Criminal Records Bureau disclosure and PoVA First checks had been carried out. As the manager had been employed since the last inspection, we looked at the way that they had been recruited and saw that there was no application form within their file. Once staff commenced work at the home they undertook a period of induction to help familiarise themselves with policies, procedures and the needs of residents. The manager told us that they were implementing the Skills for Care Common Induction Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: Standards induction. This is a set of nationally recognised standards and helps to ensure consistency in the delivery of care and support to people who receive social care. There was information recorded about how the staff team are qualified, for example, holding certificates in, Health and Safety, Food hygiene, Safeguarding, Manual Handling, Epilepsy, and Fire safety. Two seniors and two care staff are NVQ 3 qualified. One senior is NVQ 2 qualified and one care staff is currently carrying out their NVQ 2 training. That means that out of the 11 staff 5 are currently qualified to NVQ level 2 and above. Training is on going and identified through supervisions. Four staff confirmed to us that supervisions, staff meeting and training were all regular and supported them in their roles. Records were seen of these things and issues that were discussed. When we visited the home we looked at the rota showed us, two staff consistently carried out long days on duty, completing 145 hours of shift hours before their next one day off and then were back on duty for a long period of time again. We advised the manager that this could compromise the residents safety due to tiredness and the quality of care given. The manager told us that they intended to resolve and carry out risk assessments on this. Care Homes for Adults (18-65 years) Page 24 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management strategies of the home were stable which ensures the health, safety and welfare of all residents. Evidence: The manager told us in the Annual Quality Assurance Assessment that there was a system in place for monitoring the quality of the service, including obtaining the views of residents. She told us that regular staff and residents meetings are held to discuss and consult people on matters affecting them. When we visited the home we looked at the arrangements in place for obtaining the views of the people who live in the home, people who are important to them such as family and advocates and other people who are involved in their care. We saw that people were provided with questionnaires and that residents were asked if they were happy with their surroundings, lifestyles and opportunities available. They were also asked if staff allow them privacy, dignity, independence and choice. However it was not clear whether all residents would understand the questions in the format used in Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: the surveys and the use of pictures, photographs or other symbols may have been more appropriate. We saw that surveys completed by relatives indicated that they felt that residents were well looked after. The manager told us, contrary to the information in the Annual Quality Assurance Assessment that there were no resident meetings. All five staff spoken with told us that they felt well supported by management and that there are clear lines of accountability amongst the team. We looked at the arrangements in place for dealing with all residents finances. The systems in place at present do not protect individuals, as all senior staff are withdrawing peoples personal monies from their accounts by cash cards using pin numbers and people cannot account fully for their expenditure or withdrawals made by the staff. Care Homes for Adults (18-65 years) Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 15 (2)(d) All residents care plans need 31/12/2008 to reflect that involvement has been part of the process. 2 23 17(1)(a) All physical restraint that maybe used with an individual is record appropriately. This is a repeat requirement from the last inspection 20/12/07 20/08/2008 Care Homes for Adults (18-65 years) Page 27 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 6 The registered person shall keep under review and, where appropriate, revise the statement of purpose and the service users guide and notify the commission and service users of any revision within 28 days. This is because the statement of purpose and Service user do not have the correct details of CQC for service users and their families information. 29/08/2009 2 1 4 The registered person shall supply a copy of the statement of purpose to the commission and shall make a copy of it available on request for inspection by every service users and any representative of a service user. 29/08/2009 Care Homes for Adults (18-65 years) Page 28 of 32 This is because a new service user was not provided with a service user guide. 3 6 15 Care plans should be written 31/08/2009 in a format appropriate to the needs and abilities of the people using the service so that they are actively able to contribute. This is because residents care plans do not presently evidence involvement or views clearly. 4 7 20 That persons working at the care home do not act as an agent for the service user. This is because senior staff are with drawing finances for all residents under their care. 5 20 13 The registered person shall 01/08/2009 make arrangements for the recording, handling, safekeeping, administration and disposal of all medicines that come into the care home. This is because one of the people who administers medication for themselves does not have a current risk assessment or documentation that checks by staff go ahead. 6 22 4 The registered person within 01/08/2009 28 days after the date on which the complaint is made, or such shorter 29/08/2009 Care Homes for Adults (18-65 years) Page 29 of 32 period as may be reasonable in the circumstances, inform the person who made the complaint of the action (if any) to be taken. This is because complaints should be dealt with in a timely manner this is in relation to a complaint being received two months ago and no outcome recorded. 7 22 6 The registered person shall keep under review the statement of purpose and service users guide. This is because the complaint procedure, service users guide and statement of purpose not having the correct information or details of CQC. And that it does not include the local safeguarding names and numbers for service users and their families information. 01/08/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The registered person shall produce a copy of the service user guide that is made in a format suitable for the people for who the home is intended (e.g. appropriate languages, pictures, video, audio or explanation) All staff should be able to record appropriately and be able to demonstrate how individuals choices have been made and record instances when decisions are made by others and why. 2 7 Care Homes for Adults (18-65 years) Page 30 of 32 3 33 That there are appropriate staff numbers and senior cover. This is in relation to staff working long hours and the deputy post being void. That all staff files hold the correct documentation required. This is specifically related to one staff file lacking an application form or POVA 1st Check. That annual appraisals for all staff are carried out. 4 34 5 36 Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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