Care Home: Clova House

Similar services:

• Townley Road, 2-3
• Foxley Lane (121a)
• Tudor Lodge
• Stacey Street Nursing Home
• Delrose House Ltd
• Clovelly House Residential Home Ltd
• Abbey Road [53]
• Cherry Tree House

What the care home does well The needs of prospective residents were assessed and people were offered opportunities to visit the service prior to moving in for a trial period. Residents were encouraged and supported to take part in activities in the community and at home. What has improved since the last inspection? Six requirements were issued in the previous inspection report; five of these requirements have been met. The service demonstrated that refrigerated food items are now marked clearly for date of opening and date of disposal, and prescribed medications no longer required were being returned to the pharmacist. The premises were free from any offensive odours and the kitchen was kept clean and hygienic. Staff were offered training regarding mental health care needs. What the care home could do better: We have repeated a requirement regarding the need for the environment to be improved upon. Issues of concern were noted at this inspection in regard to the management of medication, safe staff recruitment and the service`s understanding of residents` general health care needs. First aid equipment must be checked to ensure that it is in date. Key inspection report Care homes for adults (18-65 years) Name: Address: Clova House 97-99 Clova Road Forest Gate London E7 9AG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sarah Greaves     Date: 1 0 0 7 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Adults (18-65 years) Page 2 of 26 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 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 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. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 26 Information about the care home Name of care home: Address: Clova House 97-99 Clova Road Forest Gate London E7 9AG 02082817413 02082817452 clovahouse@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Simiks Care Limited Name of registered manager (if applicable) Ms Annette Ajufo Type of registration: Number of places registered: care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Clova House is a care home for adults with mental health care and support needs and is privately owned. The service is registered with the Commission for Social Care Inspection to provide care and accommodation for to up to eleven people between the ages of eighteen and sixty-five. The premises are situated in a residential area of Forest Gate in Newham, close to public transport and other community amenities. Parking on the road is not restricted. 11 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 26 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: This service has been assessed as being adequate. This unannounced key inspection was conducted by one inspector over two days. We gathered information through speaking to residents, staff and the registered manager, as well as reading care plans, checking the storage and administration of medication, and touring the premises. We also looked at policies and procedures and checked records maintained within the care home (such as complaints log, accidents and incidents book, health and safety checks and staff files). The service was sent an Annual Quality Assurance Assessment to complete prior to this inspection, which provided additional information about the service. Care Homes for Adults (18-65 years) Page 5 of 26 What the care home does well: What has improved since the last inspection? 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. Care Homes for Adults (18-65 years) Page 6 of 26 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 7 of 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service demonstrated that prospective residents (and their supporters) received suitable assessments and information about the service. Evidence: We read the care plan for a resident that had moved into Clova House since the last key inspection. It was noted that the service has attained a multi-disciplinary assessment of the persons needs and conducted its own assessment prior to admission. Prospective residents were offered opportunities to visit the service prior to moving in; this was clearly evidenced through speaking to residents and checking relevant documentation such as care plans and the services diary. Residents were provided with a contract which stated terms and conditions. We noted that there needed to be clearer information provided to residents in regard to financial arrangements for purchasing replacement bed linen. Care Homes for Adults (18-65 years) Page 8 of 26 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. The accuracy and quality of the care planning (inclusive of risk assessments) needed to be improved upon. Evidence: We viewed a randomly selected sample of the care plans. Care Plan 1: This care plan was for a resident that temporarily required a wheelchair following discharge from hospital. We noted issues of concern regarding the discharge of this resident back to a care home that did not offer a suitable and safe environment (for example, not all of the staff had valid training in moving and handling). It was noted that the registered manager had raised concerns with the hospital prior to the discharge; however, the Commission was not informed of any concerns. A care plan to address the management of diabetes stated that blood sugar levels must be monitored every week however the documentation demonstrated that the community psychiatric nurse was undertaking these checks once a month. The care Care Homes for Adults (18-65 years) Page 9 of 26 Evidence: plan needed to be changed in order to accurately reflect the care provided. There appeared to be further confusion with a statement within the most recent Care Planning Approach meeting in February 2009 that stated a need to undertake blood sugar level testing fortnightly and when required. It is acknowledged that the medical advice from February 2009 might have been subsequently changed by a medical/nursing professional; however, this needs to be clearly recorded so that care home staff fully understand the precise care needs of residents. There appeared to be a distinct pattern in the ambiguity of care plans to address general health care needs. For example, a care plan stated that the identified need of the resident was to maintain a healthy life style, and the interventions were to encourage X to eat and to discourage X from drinking a lot of caffeine. There was no information in the care plan as to how that might be achieved; for example, we would have expected to read about the provision of decaffeinated beverages and herbal teas and coffees, or perhaps a statement that this had been attempted, was not successful and different strategies were now being employed. There was evidence of the care home monitoring and recording residents weights but it was isolated from any kind of measurable context; for example, taking a monthly weight is only meaningful if the care plan states a persons height and calculates their body mass index in order to establish if they could be at risk through being underweight or overweight. The body mass index should then be discussed with a doctor or nurse for an individualised professional opinion, taking into account factors such as levels of physical activity. We found that the residents care plans for their mental health support needs were written in conjunction with external assessments and reviews, such as social workers reviews and Care Planning Approach meetings. The care plans appeared to accurately reflect the objectives identified by external professionals. Through speaking to the residents and looking at relevant documentation, we found that the service supported people to make decisions about their own lives. For example, one of the residents was taking adult education classes that were clearly improving this persons confidence, self-esteem and life skills. The service conducted regular residents meetings and individual key-working sessions. We were concerned to find that the service had not effectively advocated on behalf of a resident with mobility issues, as previously discussed in this report. Care Homes for Adults (18-65 years) Page 10 of 26 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. Residents are supported to take part in fulfilling activities. Minor improvements are needed for the recording on activities schedules and menus. Evidence: Through reading two care plans, speaking to residents and gathering information from the registered manager, we found that the service encouraged people to pursue meaningful activities. It was noted that some of the residents chose not to have any kind of structured activity programme, which was subject to discussions at Care Planning Approach meetings. We found that residents celebrated birthdays, were visited by family members and friends or made visits, and went to the cinema, church, community groups and swimming. Some of the residents were involved in activities at home, such as playing musical instruments, playing pool and participating in cookery sessions. The service maintained a schedule of monthly activities although we found that it needed to be altered to evidence any amendments; for example, a listed Care Homes for Adults (18-65 years) Page 11 of 26 Evidence: activity was a visit to a museum but upon discussion with the registered manager we found that it was cancelled due to lack of interest. Another activity on the schedule was bowling (arranged by an external organisation); however, only one resident attended this. We would not consider that there is any problem in maintaining these activities on the schedule, but there should be a recorded note to accurately reflect the outcome. The menus needed some tweaking in order to provide an accurate record of food provided, for example, the menu stated lamb steak and potatoes, grilled fish and chips and stir fry lamb with egg noodles; there is no mention of any vegetables at any of these meals. The registered manager needs to be aware of the Care Homes Regulations, which state the need for comprehensive menus so that any persons (for example, doctor or dietician) can establish a judgement regarding the level of nutrition. We were pleased to observe that some residents were participating in food preparation and cooking. Issues in regard to the safety of food storage have been commented on within this report (refer to Conduct and Management of the Home). Care Homes for Adults (18-65 years) Page 12 of 26 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. Improvements are needed for the service to both understand and safely meet the health care and medication needs of individuals. Evidence: Via discussion with the registered manager and through looking at a sample of the care plans, it was noted that residents were ordinarily self-caring in regard to personal care. Some of the residents might require varying degrees of verbal encouragement and prompting to take a shower or purchase new clothes. As previously commented upon in this report we discovered the services failure to holistically address the needs of a person with temporarily reduced mobility; for example, there were no professionally assessed arrangements in place to support this person to safely have a bath or shower. The care plans identified a sometimes-confused approach to understanding the health care needs of individuals and a failure to access the appropriate medical/nursing/ allied health care expertise within the community. We checked the storage and administration of medication within the care home. It was Care Homes for Adults (18-65 years) Page 13 of 26 Evidence: noted that the service was using its own non-standard codes on the medication administration charts, rather than the codes provided by the dispensing pharmacy. For example, the medication administration chart clearly stated that if a resident refused medication staff should record the code A and if staff could not observe a resident taking their medication because the person was staying overnight with a relative then the code entered needed to be D, however, we found that staff were using R to indicate medication refused and L for social leave. We spoke to the registered manager regarding this inappropriate and potentially dangerous practice; the registered manager stated that dispensing pharmacist had given their approval. We contacted a regional pharmacist inspector during the course of this inspection in order to discuss this claim and were advised that the practice needed to cease immediately, in order to protect residents from risk. The British National Formulary (BNF -medication guide book) stored in the medication room was out of date, although an up-to-date version was obtained during the course of the inspection. The registered manager stated that the new copy would be kept in the office to prevent it from going missing (there was a notice displayed stating that staff should check the BNF in the main office); however, we felt that staff should have immediate access to important information about medication at the point that they were dispensing the medication. This concern was also discussed with the regional pharmacist inspector, who advised that the current BNF must be kept in the medication room. We advised that residents should be encouraged to safely store topically applied creams such as E45 or sudocrem within their bedrooms (for example, within a drawer or cabinet) as we observed a tube of E45 placed in a prominent position within an unlocked bedroom. The registered manager appeared reluctant to initially accept the inspectors advice, stating that E45 was a preparation that could be purchased over the counter (as well as being available via prescription) and was for the treatment of general dry skin conditions. Following some discussion and advice sought from the regional pharmacist inspector, it is now understood that this is a good practice to follow with any type of medicated cream, lotion or topical application as some treatments could cause allergic reactions if inappropriately picked up and used by other persons. We found medication that had been dispensed in April 2009 but was no longer being used by the resident; the registered manager stated that a social worker was collecting the medication for disposal as the local pharmacy could not take the medication (as it was dispensed by another pharmacy in North London). We have advised that the information on medication administration records regarding whether an individual is known to have allergies or not should be written in a bolder and noticeable style, in accordance to established good practice within care homes. It was noted that staff had recorded on a medication chart that a resident had not Care Homes for Adults (18-65 years) Page 14 of 26 Evidence: received medication at the care home on a certain date as they were at a relatives house; however, other documentation evidenced this date to be wrong. We checked the contents of the first aid box in the kitchen and found that half of the contents had expired; the registered manager stated that a member of staff that was first aid qualified regularly checked the equipment. Care Homes for Adults (18-65 years) Page 15 of 26 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. Although policies and procedures, and staff training are in place, further work is needed to promote staff knowledge and understanding of their role in protecting vulnerable adults. Evidence: At the time of this inspection there was one complaint, which was being investigated by the registered manager. There were no other significant complaints recorded since the previous key inspection. The service produced a satisfactorily written Safeguarding Adults policy and staff had received training in May 2009. As previously identified in this report, we have raised concerns regarding the services failure to properly identify and address the safety and welfare of a resident with an inappropriate hospital discharge. This has identified the need for further training for the registered manager and staff. Care Homes for Adults (18-65 years) Page 16 of 26 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service lacked a welcoming, homely and well-maintained ambience. Evidence: The service occupies an ordinary domestic property in a residential street. The following observations were made during this inspection: A notice was displayed on a communal notice board apologising to residents for the inconvenience caused by the repairs and refurbishments. The notice was not dated and gave no details regarding the programme of works. The first aid box in the kitchen was hanging off the wall and needed a second nail to secure it. We were unable to see out of some of the windows due to the accumulated dust and dirt; we were informed that a quote for window cleaning had been sought. We opened a cupboard door and found tins of paint; this should be kept in a locked area. There was a chipped and broken piece of furniture in a communal lounge; we were informed that this was awaiting a booked removal. The communal areas lacked homely touches; for example there was a grey notice board in the lounge and a plastic bin with a liner (not usual equipment within a lounge). The stairs creaked as we walked on them, and the lino in one of the bathrooms was bubbling up. A few of the bathrooms had incomplete taps with bits missing. The rear garden evidenced that residents were undertaking gardening projects (growing flowers Care Homes for Adults (18-65 years) Page 17 of 26 Evidence: and vegetables); however, we were concerned to find that there were two broken paving stones left lying in the garden that we could lift up. There was a very noticeable collection of cigarette butts in the front garden. We commented upon this during the inspection and a member of staff cleared it up. Care Homes for Adults (18-65 years) Page 18 of 26 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 not assured that the staff that care for them will be safely recruited or adequately trained. People using 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. Evidence: The staff training records indicated some gaps in staff training. A person appointed in September 2008 had not yet undertaken first aid training, and did not have moving and handling training. A member of staff appointed in December 2008 did not have medication training or moving and handling training. The training plan for the service indicated that the following training had occurred this year; Protection of Vulnerable Adults (May 2009), Nutrition in care (May 2009) and Mental Capacity Act (June 2009). We were not clear regarding the content or quality of this training; for example, staff seemed genuinely unaware of the need to produce menus that clearly documented how the service provided a nutritionally balanced diet, there was no reference to straight-forward and commonly used systems for monitoring weight in a meaningful manner such as Body Mass Index, and a care plan addressing the over-use of caffeinated products did not identify alternatives that could be offered. Other training was planned for later in the year, including moving and handling, fire safety, challenging behaviour, quality assurance and dementia care. Care Homes for Adults (18-65 years) Page 19 of 26 Evidence: We checked upon the recruitment of two newest staff members. First recruitment file: The two references obtained were both personal references. There is a written discussion (of a telephone call) recorded by the registered manager with a person that stated they were a sales manager and was able to comment upon the candidates work performance, but there was no evidence to support the authenticity of this information. A provider of a personal reference stated that they knew the candidate as a friend yet they gave information on how the candidate dealt with residents/clients/patients/carers. There was no evidence to indicate that these comments were further investigated. Second recruitment file: The member of staff commenced work on the 20/12/08. The Protection of Vulnerable Adults check was received on 11/03/09 and the Criminal Record Bureau check was obtained on 30/03/09. All of the staff had achieved a National Vocational Qualification in Care or a recognised equivalent. Care Homes for Adults (18-65 years) Page 20 of 26 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. Improvements to the management of this service is required in order to fully meet the needs of the residents. Evidence: We found significant shortfalls in the management of this service. This report has identified the need for the service to improve in a number of key areas, including care planning, health care, medication and staff recruitment. Staff need to be provided with clear and knowledgeable guidance, which takes into account current good practice, care homes standards and legislation, and a productive working relationship with other professionals. The service evidenced that monthly -unannounced monitoring visits were being conducted. This monitoring will need to be more rigorous as issues within this report should have been picked up on and managed at an earlier stage. We did not feel that the service presently fully acted upon the needs and best interests of the residents. We checked a couple of the residents financial records; no issues of concern were Care Homes for Adults (18-65 years) Page 21 of 26 Evidence: noted in regard to how this was undertaken. A requirement was issued in the previous inspection report for the service to ensure that refrigerated items were labelled with date of opening and date for disposal. This requirement has been met; however, we found that there were several dry food items (baking powder, sodium bicarbonate, pepper corns and a packet of jelly) that had expired. A chart was being maintained in the kitchen to indicate that checks were being undertaken. As previously stated in this report we found expired first aid items. The following health and safety documents were up-to-date: fire alarms testing, portable electrical appliances testing, electrical installations and landlords gas safety. It was noted that fluid correcting liquid had been applied to the records for some of the water temperatures for February, April and May 2009. Care Homes for Adults (18-65 years) Page 22 of 26 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 24 23(2)(b) The registered manager must ensure that the premises are well maintained, in regards to decorations, furnishings and safety. This is a repeated requirement. 31/12/2009 Care Homes for Adults (18-65 years) Page 23 of 26 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 6 15 The registered manager must improve upon the quality of the care plans, in accordance to the issues identified within this report. . 31/12/2009 2 9 12 The registered manager 31/12/2009 must ensure that risk assessments are based upon sound clinical guidance . 3 20 13 The registered manager 31/10/2009 must ensure that medication practices are improved upon, with guidance/auditing as necessary from a pharmacist. . 4 34 18 The registered manager must ensure that staff are safely recruited. 31/10/2009 Care Homes for Adults (18-65 years) Page 24 of 26 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 . 5 42 13 The registered manager must ensure that (a) first aid equipment is valid (b) dry food items have not expired. . 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 31/10/2009 1 5 The service should advise (in writing) prospective and existing residents of the need to purchase replacement bed linen and the reason for this practice. Care Homes for Adults (18-65 years) Page 25 of 26 Helpline: 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. Care Homes for Adults (18-65 years) Page 26 of 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. 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!