Inspection on 07/08/09 for Thurston House

This inspection was carried out on 7th August 2009.

CQC 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 CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thurston House 11/08/08

Thurston House 22/08/07

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

Key inspection report CARE HOME ADULTS 18-65 Thurston House 90 High Street Newport Pagnell Buckinghamshire MK16 8EH Lead Inspector Joan Browne Key Unannounced Inspection 7th August 2009 10:30 Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thurston House Address 90 High Street Newport Pagnell Buckinghamshire MK16 8EH 01908 617173 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) thurstonhouse11@yahoo.co.uk www.minstercaregroup.co.uk Minster Pathways Ltd Manager post vacant Care Home 7 Category(ies) of Learning disability (0) registration, with number of places Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 7. Date of last inspection 25th February 2009 Brief Description of the Service: Thurston House is a large end of terrace property with garden in Newport Pagnell. It is conveniently located for the amenities of the town centre; shops, cafes and pubs being just a few minutes walk away. The nearest rail stations are Milton Keynes or Wolverton. The area is well served by buses. Bus links to Milton Keynes are good. During office hours short-term car parking is available in marked bays almost immediately outside the house or in a car park across the road. During office hours long-term car parking is available in a designated area of the same car park. The home provides accommodation, care and support on a variable term basis for up to seven people with learning difficulties. The home is an older style three -storey house. It does not have a lift. It is not suitable for a wheelchair user. All bedrooms are single and have en-suite (WC, hand basin and shower) facilities - two of the bedrooms have a bath in addition to the shower. The service is staffed over 24 hours- usually four care staff during the day and two care staff at night. The home works closely with local health and social services providers to meet people’s needs. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This unannounced key inspection was conducted by Joan Browne on 7 August 2009 and covered all of the key National Minimum Standards for Care Homes for Adults (18-65). The inspection lasted for approximately seven hours commencing at 10:30 am and concluding at 17:30 pm. The last key inspection of the service took place on the 11 August 2008. Prior to the inspection a detailed self assessment questionnaire was sent to the manager for completion and surveys were sent to a selection of people living at the home, staff and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the home’s manager, the local area manager, staff, some people who use the service and examination of some of the home’s required records, observation of practice and a tour of the premises. Feedback on the inspection findings and areas needing improvement was given to the local area manager and the home’s manager at the end of the inspection. Three requirements were made. We (the Commission) would like to thank all the people who use the service and staff who made the visit so productive and pleasant on the day. What the service does well: What has improved since the last inspection? The care plan documentation has improved and plans are more personalised detailing the level of support that people require and how they wished to be supported. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 6 The home ensures that opened packets of food and sauces are labelled and dated to ensure that food is eaten within the use by recommended date. Maintenance and refurbishment work in the home has been carried out which means that people live in a home that is kept in a good state of repair to promote their safety. The home has appointed a manager which means that people using the service and staff can benefit from a clear sense of direction and leadership. What they could do better: 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 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. Thurston House DS0000069649.V377278.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 Thurston House DS0000069649.V377278.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People who use the 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 home’s admission practice is not consistent which means that people’s needs may not be always identified and fully met. EVIDENCE: The home’s statement of purpose and service user’s guide were examined. We found that the guide detailed what prospective people using the service can expect. Some minor amendments to the document were needed such as the name of the manager and the Commission’s details. Two people responded to the Commission’s survey one person said that they had received enough information about the home before deciding it was the right place to move in to. The second person said that they did not receive enough information about the home. Since the last key inspection the home has had one new admission. The person was admitted in an emergency. There was no evidence seen to verify that a pre-admission assessment was undertaken by the home’s staff. However, a copy of the care management assessment and a positive physical intervention plan was seen. We were told that staff were following the physical intervention Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 9 plan to ensure that care was provided appropriately as a care plan had not been developed. The home’s staff were waiting to develop the care plan in a multi-disciplinary forum with the social worker. This practice is not ideal and the home is required to review its emergency admission procedure to ensure that people admitted in an emergency have a care plan in place within a reasonable time detailing how identified needs should be met. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Care plans outlined people’s likes and dislikes. Risk assessments identified how any potential and actual risks should be managed ensuring that individuals’ diverse needs are met and independence is promoted. EVIDENCE: The AQAA informed that all care plans had been reviewed. Three care plans were examined and they were clear and easy to follow and written in a personalised manner detailing how identified needs, goals and aspirations would be met. Wherever possible the plans were signed by individuals to confirm their involvement and agreement in the process. The risk assessments seen identified potential and actual risks detailing how these risks would be managed. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 11 The staff team support and encourage people to make decisions about their lives. For example, each person has a weekly activity programme which was flexible and subject to changes if required. From discussions with people using the service and staff members it was evident that individuals were provided with the appropriate support to make decisions about their lives when required. Staff that responded to the Commission’s survey said that they were given up to date information about people’s needs. The home ensures that information on advocacy service is made available to people using the service and their relatives if required. We were told that two persons were managing their finances with limited support from staff. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people are able to participate in activities which meet their diverse needs and their dignity and rights are respected in their daily life. EVIDENCE: The AQAA informed that people were being supported to access the local and wider community. Three persons were attending a day centre and a fourth person was receiving outreach support from staff at the day centre. There were no individuals in paid employment or undertaking further education or vocational studies. Staff spoken to confirmed that they support individuals with leisure activities such as outings to the local leisure centre, cinema and local pub. Some people Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 13 were able to go out independently. The home has its own transport, which makes it easier for people to be transported. Staff spoken to said that family members and friends were welcome to visit at any time. Their involvement in daily routines and activities is encouraged with individuals’ agreement. The home’s daily routine promotes independence and people were able to rise and retire whenever they wish. The level of support required by individuals varied. It was noted that some individuals required a high level of supervision and support with their daily living activity. Meals are planned with people using the service and cooked by staff. We were told that on weekday’s cereals, toasts and fruit juices are provided for breakfast. A cooked breakfast is provided on Saturdays and Sundays. A light meal of individuals’ choice is provided at lunchtime and dinner is served in the evening. We observed some individuals helping themselves to snacks and drinks. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 &20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a system in place to ensure that people receive support with their personal and health care needs in the way they prefer which is sensitive to their race, age, and disability. EVIDENCE: The AQAA indicated that people using the service are given privacy with their personal care and wherever possible a staff member of the same gender provides personal care. We were told that individuals are able to make a choice of where they would like their personal care to take place. For example, they can choose to have a shower in their room or use the communal bathroom if they wish to have a bath. Wherever possible individuals are encouraged to do as much of their own personal care as they can with staff using verbal prompts if necessary. People’s attire was clean and tidy with attention to detail. People spoken to confirmed that they choose what clothes they wish to wear and their appearance reflected their personality. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 15 People using the service were registered with a local general practitioner. The AQAA informed that staff support individuals to make and attend health appointments. A record is maintained of health care checks undertaken by individuals. The home uses a monitored dose medication system. There were no individuals assessed as capable to self-medicate. No unexplained gaps were noted on the medication administration record (MAR) sheets examined. We found some inconsistency in staff’s recording practice. For example, two hand written entries on the MAR sheets were not countersigned by a second staff member. It is advised that hand written entries must be checked and countersigned by a second staff member to minimise the risk of error when transcribing. There was no one in the home on the day of the inspection that had been prescribed for controlled medication. At the last inspection the home was required to have an appropriate controlled drug cupboard to comply with current regulations. It was noted that the cupboard was delivered on the day of the site visit. We were told that the home had reviewed its PRN (give when necessary) medication policy and there was now a protocol in place for staff to follow to ensure that PRN medication is administered safely. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the 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 home has a complaints procedure in place to ensure that people using the service or their representative are able to express their concerns. Improvement is needed to ensure that the home has an action plan in place detailing what lessons have been learnt from any safeguarding investigation outcome in order to improve the service delivery. EVIDENCE: The home has a complaints procedure which is accessible to people using the service, staff and relatives. Individuals who responded to the Commission’s survey said that they knew how to make a complaint. The home’s complaints record folder reflected that within the last twelve months the home had received one complaint which was appropriately investigated. The home has procedures in place for responding to suspicion or evidence of abuse or neglect to ensure people’s safety and protection. Staff spoken to during the site visit were able to demonstrate the action to be taken if they suspected or witnessed any incident of abuse. Training records reflected that staff had undertaken training in the safeguarding of vulnerable adults and the area manager said that further updated training was being arranged. The Commission was notified of a safeguarding referral by Social Services who takes the lead and investigates such incidents. The outcome of the investigation was not clear. The area manager said that she had not been officially notified of the conclusion of the investigation. There was no action Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 17 plan in place detailing what lessons the home had learnt in order to improve its service and to support staff to restore their confidence which appeared to be affected as a result of the investigation. The manager is advised to obtain a full disclosure of the investigation and to put an action plan in place detailing what lessons had been learnt and what mechanisms have been put in place to support staff. The home has systems in place to ensure that people’s money is appropriately maintained in line with its policies and procedures. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Maintenance issues in the home have been addressed which means that people who use the service live in an environment that is safe and promotes their privacy, dignity and independence. EVIDENCE: The home is a large end of terrace house situated in Newport Pagnell town centre. It is conveniently located for the amenities of the town. Bus connections to Milton Keynes are good. Car parking facilities are available nearby. The nearest rail stations are Milton Keynes and Wolverton. The accommodation is over four floors- cellar, ground, first and second floor. The home does not have a lift and it is not conveniently set out for a wheelchair user. There are gardens to the rear and side of the house, which are appropriately maintained. Entries to areas of the home are controlled by staff through coded locks. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 19 The ground floor accommodation is comprised of the lobby (which includes a small quiet area), hallway, living room dining room, kitchen and two bedrooms. The cellar, which is locked when not in use, accommodates the laundry, freezers and storage areas. Bedrooms are situated on all floors and have en- suite facilities with wash hand basins, WC, baths or showers. The bedrooms seen during this inspection were satisfactorily furnished and decorated according to the wishes of the people using the service reflecting his or her interests. The AQAA informed that the home had been refurbished. Floor coverings in communal areas and the laundry area had been replaced, radiators had been fitted with covers, kitchen cupboard doors had been replaced, walls in the corridors and bedrooms had been repainted and rotten window frames replaced. Standards of cleanliness in the home were satisfactory and the home was free from offensive odours. People who responded to the Commission’s survey said that the home was ‘always’ or ‘usually’ fresh and clean. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Shortfalls in the home’s recruitment procedure and inconsistent supervision practice need to be addressed. This is to ensure that people are looked after by staff that have been appropriately recruited, supervised and trained. EVIDENCE: The present staffing of the home provides for four care staff in the morning, four care staff in the afternoon and two care staff at night. The manger said that the staffing levels were considered satisfactory to enable staff to support individuals with activities in the community while maintaining support to those who wish to stay at home. On the day of the visit there was three staff on duty because a member of staff had phoned in sick. We observed staff interacting with people using the service in a kind and respectful manner. Those individuals spoken to said that they felt safe and well supported. Staff spoken to said that they encourage people to see the home as their own. Information in the AQAA reflected the following: “staff are recruited in the correct manner with an interview 2 references and do not start without a police Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 21 check in place.” We found the statement not to be accurate. We looked at three staff recruitment files and in one file only one reference was seen. In a second file we noted that the staff member had commenced employment with a PoVA first check. There was no written evidence to verify that a named and experienced person was appointed to supervise the staff member until the full criminal record bureau disclosure had been obtained. A requirement is made to ensure that the home’s recruitment procedure is adequately implemented. Although the service recognises the importance of training and tries to ensure that mandatory training is provided and updated for all staff there were some gaps in the training programme. The manager was aware of the gaps in the training programme and plans to address them. Staff spoken to said that they receive supervision. Records seen reflected that the practice was inconsistent with infrequent individual sessions. A requirement is made to ensure that a structured supervision framework is implemented. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the 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 home needs to ensure that the fire panel record is consistently maintained. This is to ensure that the safety of people using the service and staff is promoted. EVIDENCE: The home has employed a new manager who took up employment in April 2009. The manager holds the National Vocational Qualification (NVQ) at level 3 in health and social care and a B-Tec national certificate in health studies which is equivalent to a level 4 NVQ qualification. He has five years experience working in the care sector. Two of these years have been in a supervisory capacity. He intends to pursue the registered manager’s awards training and apply for registration with the Care Quality Commission. Staff spoken to said that the manager was supportive and approachable. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 23 The home seeks the views of people using the service, staff, relatives and health and social care professionals at six-monthly intervals. We were told that the data of the recent survey was being analysed. All sections of the AQAA were not fully completed. There were areas where more supporting evidence would have been useful to illustrate what the service had done in the last year or how it was planning to improve. The fire panel record was examined and found not to be up to date and well maintained. For example, there were significant gaps noted in the weekly checks. The home is required to ensure that the record is appropriately maintained. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Version 5.2 Page 25 Thurston House DS0000069649.V377278.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 Requirement The home must ensure that two references are obtained for staff members before they commence employment. A named and experienced member of staff must be appointed to supervise staff members commencing employment with a PoVA first check. This is to ensure that there is a clear audit of the process by which staff are recruited. The home must have a supervision framework in place. This is to ensure that staff working at the care home are appropriately supervised. The home must ensure that the fire alarm record is appropriately maintained. This is to ensure that records are kept up to date to promote people using the service and staff safety. Timescale for action 25/09/09 2. YA36 18(2) 25/09/09 3. YA42 17 Schedule 4 (14) 25/09/09 Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Thurston House DS0000069649.V377278.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!