Inspection on 28/06/07 for Nickleby Lodge (Welcome House)

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nickleby Lodge (Welcome House) 22/06/06

Nickleby Lodge (Welcome House) 22/02/06

Nickleby Lodge (Welcome House) 29/11/05

Nickleby Lodge (Welcome House) 16/06/04

Nickleby Lodge (Welcome House) 23/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Nickleby Lodge (Welcome House) 32 The Close Rochester Kent ME1 1SD Lead Inspector Joseph Harris Key Unannounced Inspection 28th June 2007 10:00 Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nickleby Lodge (Welcome House) Address 32 The Close Rochester Kent ME1 1SD 01634 843372 01634 827481 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) Dr Toqeer Aslam Tina May-Boughton Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2006 Brief Description of the Service: Nickleby Lodge (the Home) is registered to provide accommodation and personal care services for up to 10 adults (service users), who have difficulties with managing aspects of their mental health. The premises are a three-storey property which has been modernised and adapted for its present use. There is provision for six of the service users to have their own bedroom. The remaining four people are accommodated in two shared occupancy bedrooms. All of the bedrooms have a private wash hand basin. The property is located in a quiet residential street and it is within normal walking distance of various shops. The Home is owned and operated by Welcome House. This is a private company which operates a number of similar residential care services in the general area. The Responsible Individual is Dr Aslam. The Registered Provider supplies information to prospective service users through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure which outlines the principal features of the facilities and services available in the Home. Also, the Registered Provider ensures that a copy of the most recent Inspection Report from the Commission is available for reference in the Home if requested. The Registered Provider has informed the Commission that the current fee it charges for residence in Nickleby Lodge is £560.00 per week. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection process culminated in a site visit to the home on 28th June2007. During the course of the visit discussions were held with a number of the residents, staff and a visiting representative of the organisation. The registered manager was not present. A tour of the premises was undertaken and a range of documents were examined relating to staff, service users and the running of the home. The annual quality assurance assessment was also received prior to the commencement of the visit providing information about the home, improvements made and future plans for the development of the service. What the service does well: What has improved since the last inspection? What they could do better: 5 requirements and 7 recommendations have been issued as a result of this inspection process. The main issues surround the development of clear and detailed care plans and risk assessments for all service users and the need to clearly identify limitations and restrictions on freedom and choice where imposed for the wellbeing of an individual. The home needs to improve the core foundation training for all staff. Recruitment records also must adequately address any gaps and anomalies in newly appointed staff’s employment histories. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 6 Amongst the recommendations are issues addressing additional training in medication, adult protection and service specific training for the staff and registered manager. It is also advised that the in-house assessment pro-forma is reviewed and updated to include a greater focus on mental health and social issues. The activity planner could also be reviewed for each resident to provide a more meaningful tool to assist in the planning of resident’s time. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 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 Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. Prospective service users needs are assessed prior to moving in, although this process needs to be strengthened. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one new admission since the last inspection. There was evidence on file to demonstrate that the home had received sufficient information from the care management team and through the Care Programme Approach (CPA) process to make an adequate assessment of needs prior to the resident moving in. The organisation also has an in-house assessment tool, which could be further developed and would benefit from being used in conjunction with information received from professionals. Refer to recommendation 1. However, following the receipt of assessment information and the resident moving into the home, the registered manager had not developed a care plan based on the assessed needs or addressed the perceived risks within a risk management plan. Similarly, any potential restrictions or limitations had not been clearly identified within the home’s information. Refer to requirement 1. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is poor. Service users cannot be sure that their individual needs will be set out within a plan of care or that their personal goals will be reflected. Perceived risks are not adequately managed. Limitations and restrictions of choice are not clearly identified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 3 service user files were examined during the course of the inspection. In one case the home had not developed a plan of care for a resident who had been admitted over a month previously. There was sufficient information within CPA documentation to develop the plan addressing specific areas of need and support, which could then be further developed as the staff in the home ‘get to know’ the individual. The other individual plans were examined for residents who have lived in the home for longer periods of time. These plans were not informative and provided little constructive guidance for staff to be able to Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 10 meet needs consistently. There was no evidence of plans being updated in line with changing needs. In one case, a specific incident occurred that should have prompted a detailed plan to be developed, which had not been done. In general, the plans viewed were vague and ambiguous and in some cases taken directly from CPA documentation. Refer to requirement 1. Residents spoken to stated that they are able to choose how they spend their days and are free to come and go from the house as they wish, being able to make decisions affecting their day-to-day lives. The home has information available about advocacy services and other self-help groups and some of the staff have a good local knowledge in this respect. The home does not take an appointee role with regard to resident finances and where service users require assistance in this matter appointees are independent of the service. Restrictions and limitations with regard to individual’s freedom and choice are, it was reported, agreed with health and social care professionals and residents. However, these are not clearly identified within the care planning process or adequately documented. Therefore service users cannot be sure that they are applied consistently. Any restrictions or limitations need to be clearly documented and assessed with regard to finances, going out unescorted, access to cigarettes and similarly related issues. Additionally, one service user is subject to a Supervision Order, but there is no reference to this and the restrictions implied within the care notes or plan. Refer to requirement 2. Risk management plans were examined for three service users, which in one case had not been completed and in the other circumstances did not provide a robust assessment of the perceived risks or management guidance. There was little evidence that risk management plans are developed in response to changing needs and risks, which was particularly apparent in relation to an incident that had occurred for one service user. Refer to requirement 3. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. Service users have a lifestyle that suits their individual needs with appropriate leisure activities, community access and diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home generally achieves an appropriate balance with regard to leisure activities and meaningful occupation. A number of the residents in the home are now of an older age and state that they are happy to spend time in and around the house or access the nearby towns as they wish. Each resident has an activities calendar, which provides an outline of activities for each week. These are somewhat limited and focus mainly on household chores/routines or ‘free time’. It is suggested that the calendars, if to be used effectively, concentrate more on individual activities and are more personalised. Refer to recommendation 2. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 12 Residents stated that they access the local towns regularly on their own. The organisation has made slight adjustments to the staffing rota to ensure that there is time available each day, including weekends, so that residents can go out with support if required. It was reported that visitors are welcomed into the home and are free to visit at any reasonable times. Restrictions are only placed on visiting the home in the best interests of the service users, which is an action that has been taken by the registered manager in one circumstance. Service users are encouraged to participate in the daily routines of the home in a much more positive fashion. There is evidence that residents now assist with cooking and making drinks on a daily basis, rotas have been introduced for laundry use, washing up, cleaning and other household chores with the agreement of service users. It was reported that some residents choose not to participate in these activities, which they are free to do. Residents are provided with a key to house and their bedrooms. The home provides a healthy and balanced diet and menus are developed in conjunction with the service users embracing personal choices. An alternative meal is supplied at all meal times should a resident not want the main option. There were adequate stocks of food in the home including fresh fruit and vegetables. Residents stated that the quality of food is good and that mealtimes are relaxed with people being able to choose when and where to eat. It was reported that special diets are catered for including those required for cultural or religious reasons. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. Personal support is provided appropriately, although care planning in this area could be improved. Healthcare needs are met including appropriate management of medications. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users choose when they wish to get up and go to bed and routines are flexible for each individual with regard to personal choice. The majority of service users only require prompting or encouragement in respect of personal support and it was reported that the staff in the home do not provide assistance with personal care on an intimate level. Nevertheless, the registered manager, in relation to care planning and guidance for support in this area, needs to develop service user’s individual plans in greater depth to ensure a consistent approach from staff. Refer to requirement 1. The home maintains healthcare records for each service user and letters of appointment are retained. However, the recording of visits and input from healthcare professionals are somewhat disorganised and, in some Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 14 circumstances, lacked clarity of the issues being addressed and the outcomes of any appointments. The home encourages professionals to make entries in the service user files, but in addition to this the staff in the home should ensure that adequate information is entered. The system for recording health visits and consultations would benefit from being streamlined to improve the tracking of information. Refer to recommendation 3. Medication issues are appropriately managed in the home. Policies and procedures are in place and administration charts were up to date. Storage facilities are adequate for the needs of the home. Controlled drugs are safely stored and records in relation to these well managed. Staff receive some instruction regarding medication issues, although staff need to complete more detailed training in this regard through an accredited training provider. Refer to recommendation 4. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. Service users views are listened to and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an adequate complaints procedure in place, which is appropriately distributed and displayed. Service users stated that they feel comfortable making their concerns known to the manager and staff and that they feel that their issues are taken seriously. The home retains a record of complaints made. It was reported that there have been no complaints since the last inspection. Appropriate policies and procedures are in place relating to the awareness, recording and reporting of abuse. Staff spoken to about this issue demonstrated a good awareness of the processes should they suspect any form of abuse. Staff have received in-house training regarding adult protection issues, but there are plans in place to provide all staff with more detailed training in this regard with a manager in the organisation currently working towards a trained trainer qualification. Refer to recommendation 5. It was reported that there have been no adult protection concerns raised since the last inspection. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. Service users benefit from a comfortable and homely environment that is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated that the home is well-maintained, comfortable and suitable for the needs of the service users. There is a good range of communal space, including a dedicated smoking room and a large lounge/diner. There is a domestic style kitchen and separate domestic laundry. There is a small quiet room with a private telephone on the first floor. A number of bedrooms were viewed, which have been personalised and are suitable for the individual needs of each service user. There are 6 single rooms and 2 double rooms in the home. There are a suitable number of toilets and bathrooms conveniently located throughout the house. There is a large blockpaved area with space for parking and garden furniture to the rear and side of Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 17 the home, which contains a small flowerbed and a number of potted plants. It is reported that parking is generally restricted to the front of the building. On inspection the home was clean and hygienic throughout. All hazardous substances were appropriately stored and policies and procedures are in place for the control of infection and universal precautions. It was reported that the home meets the requirements of the environmental health and fire departments. The organisation has put into place a programme of redecoration for a number of the bedrooms and, in general the home appears well decorated, furbished and maintained. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. The training of the staff team needs to be improved and recruitment practices tightened. There are adequate numbers of staff on duty, although this needs to be kept under review. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a staff team of 4 carers excluding the registered manager, all of which are relatively recently appointed. The registered manager has worked in the home for a number of years. Since the last inspection 3 out of the 4 care staff have been newly appointed at Nickleby Lodge. Currently 1 staff member has achieved an NVQ level 2 and two other staff are working this qualification. Refer to recommendation 6. In discussion with staff, however, it was apparent that they had developed a good knowledge of the resident group and the needs of the home in a relatively short space of time. Both staff spoken to had positive attitudes towards the service users and were observed to interact in an enabling and thoughtful manner. Service users all commented that they ‘get on well’ with the staff members. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 19 Staff rotas have recently been reorganised to ensure that there are at least 2 staff on duty at times during each day, allowing for some flexibility for residents to receive support and ensuring that staff do not work excessively long hours alone. The staffing hours meet minimum requirements, although they do not exceed these. It is advised that staffing levels continue to be very closely monitored to ensure that the needs of all service users can be met at all times. Three staff personnel files were examined, which demonstrated some weaknesses in the recruitment process. This was particularly apposite with regard to completed application forms and employment histories. A full and complete list of employment/unemployment needs to be provided for all newly appointed staff. Where a gap or an anomaly in the employment history is discovered the registered manager/organisation must take steps to address this and provide evidence that these issues have been fully explored and resolved. Refer to requirement 4. Two written references, proof of identity and evidence of CRB and POVA checks were on file for all staff including other relevant information. The organisation needs to improve the level of training provided to staff in respect of mandatory training and other service specific issues. The home has been providing certificated training in all mandatory topics using BVS induction videos. Whilst this training demonstrates a level of competency including completed questionnaires, it is not intended to replace in-depth courses provided by qualified trainers. As a result, combined with the induction programme, the home does provide a good foundation for staff competency, but does not meet requirements for further training in core skills and knowledge such as fire safety, food hygiene and first aid amongst others. The organisation has provided trained trainer courses for some managers from other homes in manual handling and adult protection. These trainers plan to provide training in these topics in the near future, it was reported. Additional training requirements are also advised as a result of this inspection process including care planning and risk assessment training, medication and mental health awareness training. Refer to requirement 5 and recommendation 7. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. The home is reasonably well run, although some management training needs have been identified. Quality monitoring and health and safety systems are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was not present at the time of the inspection due to planned leave. She has managed the home for a number of years and staff state that they feel well supported by her. However, a number of shortfalls have been noted through the course of the inspection process, particularly surrounding documentation and care planning. These may highlight some Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 21 additional training needs for the registered manager as a number of these issues have been raised through previous inspections. The organisation has worked to improve quality assurance processes, having recently completed a series of questionnaires for service users and staff and then collated the information within a quality report. The operations manager has also responded to advice in respect of improvements to the monthly monitoring visit format, which has also improved. There is evidence of improvement in the environment. However, there is a note of concern that a number of the shortfalls identified through this and previous inspections have not been addressed through the organisation’s own processes, to which particular attention should be paid. All health and safety information in respect of environmental health risk assessments, servicing and safety certificates, fire log records and accident reports was seen to be up to date and satisfactory. The home, as previously identified, does have shortfalls in the provision of mandatory training and safe working practices. Refer to requirement 5. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 2 X Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 YA2 Regulation 14, 15(1)(2) Requirement To ensure care plans are developed for all service users providing clear and consistent guidance to meet individual needs and personal goals. To ensure all restrictions and limitations are clearly documented with appropriate guidance and clarifications of the reason for this. To ensure evidence of liaison with professionals and the service user is documented. To ensure detailed and clear risk management plans are developed for each service users and changing needs/concerns are adequately risk managed. (Previous requirement not met. Timescale extended from 01/01/07) To ensure that all gaps and anomalies in the employment histories of newly appointed staff are thoroughly resolved and evidence provided. To ensure that all staff receive appropriate core training in all mandatory topics. Timescale for action 01/08/07 2. YA7 12(3), Schedule 3 01/08/07 3. YA9 13(4) 01/08/07 4. YA34 19 01/08/07 5. YA35 18(1)(c) 01/09/07 Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA2 YA12 YA19 YA20 YA23 YA32 YA35 Good Practice Recommendations The home should continue to develop the in-house preadmission needs assessment to fully address mental health and social needs in greater depth. To review the use of activity planners including more personalised and a wider range of activities. To review the process for recording healthcare visits and consultations ensuring clear information for the reason and outcomes from the input. Staff to undertake accredited training covering medication issues. To ensure that all staff receive appropriate training in adult protection issues. To ensure that the home achieves at least 50 of staff with NVQ level 2 or above. To provide staff and the Registered Manager with additional training with particular regard to care planning and risk assessment and mental health awareness. Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nickleby Lodge (Welcome House) DS0000028989.V338966.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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