Care Home: Eva Court Support Services

What the care home does well Residents said they felt they were well supported and liked the home. The relative confirmed this. The Social Worker felt the home worked well with residents and had made some progress in areas of rehabilitation and social integration. The standard of accommodation, both individual bedrooms, and communal space is very pleasant. Residents benefit from en-suite bedrooms. All communal areas were well equipped. The home was clean and tidy. What has improved since the last inspection? This is not applicable to this home as it is the first key inspection since registration September 2009 . What the care home could do better: Medications need to be improved upon and several immediate requirements were made. The areas identified in this report, under medications must be addressed including appropriate storage cupboards for Controlled Drugs and all medication information must be accurate. The pharmacy inspector has been asked to follow up the medication issues on a separate pharmacy inspection. Records for risk assessments need to be more robust in content. Complaints records also need to be developed . The recruitment of staff must continue to ensure a consistent staff team is employed. Staff recruitment needs to be robust to ensure that staff are employed safely. Staff training must be developed as should staff supervision systems. Immediate requirements were made regarding staff personnel files, certification for electrical inspection and legionella confirmation. Quality assurance methods must be further developed to ensure input from all parties on development of the service. Key inspection report Care homes for adults (18-65 years) Name: Address: Eva Court Support Services 2 Edwin Hall Place London London SE13 6RN     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: Rosemary Blenkinsopp     Date: 0 4 0 1 2 0 1 0 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 31 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) 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 Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Eva Court Support Services 2 Edwin Hall Place London London SE13 6RN Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Vernett Maureen Brown Type of registration: Number of places registered: care home 3 Ms Vernett Maureen Brown Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence past or present drug dependence mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is 3 The registered Person may provide the following category/ies of service only: Care Home Only: Code- PC To service users of the following gender:Either whose primary care needs on admission to the home are within the following categories: mental disorder excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home The home is three bedded service dealing with those residents who fall in the catagory mental disorder. The home is domestic in style located in what was the old Hither Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 0 0 0 0 3 Brief description of the care home Green hospital site. On this site there are a number of residential dwellings and other services such as a GP centre. Residents can be of either gender. The home itself is set over three levels accessed by stairs. The main entrance is on the ground floor, bedrooms and communal areas on the first floor with the staff office and a bathroom on the top floor. Bedrooms are large and airy with ensuite facilities. Fees range between £ 850.00 per week up to £1100.00 per week . Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The inspection was conducted over a two day period and two inspectors attended on the second day. The assistant manager, Ms Harris facilitated the site visits, and staff on duty were involved with the inspection process. Periods of observation were undertaken in the communal areas. All of the key standards for younger adults were inspected during the site visits. Prior to the inspection the manager had not completed the AQAA as this service was only registered September 2009, no comment cards were received. During the visit we met with all of the residents and one relative. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated Care Homes for Adults (18-65 years) Page 6 of 31 into this report. A selection of documents were inspected including care plans, staff personnel files as well as health and safety records. Feedback was provided to Ms Harris at the end of the second day of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. Care Homes for Adults (18-65 years) Page 7 of 31 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 8 of 31 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 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admission procedures and the Statement of Purpose provide information from which a decision on placement can be made. Evidence: The home was registered September 2009 and has three female residents. The residents are under the category mental disorder for which the home is registered. Each resident is subject to after care under the Care Programme Approach (CPA) . The Statement Purpose refers to residents who have learning disability as a category they can admit. This reference must be removed as it is outside of the category for which the home are registered. Assessment information was sampled and it included an assessment conducted by the manager of the service Vernett Brown. This contained some good information and covered the activities of daily living. In addition there was a referral form from the Social Worker which outlined the residents needs, although was limited in some parts with tick boxes used and no other information. Reports from the Mental Health Team Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: and Occupational Therapist involved withe residents were also on file. Previous reviews and management meetings were retained. It was evident that a resident had been previously on a Section of the Mental Health Act 1983, and it was unclear when it was rescinded. The home is reminded that they are not registered to take patients who are detained under the Mental Health Act. Another file was sampled and of similar content. The contract and service agreement from the funding authority was on file. We were unable to locate the letters that confirmed, following the assessment, the home was able to meet the residents needs. Evidence of trail visit prior to admission were also absent. Care Homes for Adults (18-65 years) Page 11 of 31 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. Care plans reflect the residents needs and provide staff with information on which to address care and support. Risk assessments are limited and do not provide enough safeguards to either reduce or eliminate the risk . Evidence: The care plans for the residents were inspected. At the first site visit there was only one resident who had a care plan in place, two residents were without them although there was the CPA care plans for reference. Without comprehensive care plans staff will be unable to address the care in a consistent manner, which is important with this type of resident. The two care plans were available for the second site visit . The care plans were to a reasonably good standard and included an activities sheet, daily events records and had risk assessments in place. The care plans are generated using the information Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: received through the CPA records. Where possible the resident should be involved in developing the care plan and sign to that effect along with the person writing it. Care plans must be kept under review and reflect changes in the residents condition. There must be a photograph on file of each resident in the service. Descriptions and other relevant information is recommended in the event that a residents should go missing. There was a form which gave an overview of the identified risks and other specific information on the individuals known risks. The information was limited and did not contain enough to either reduce or eliminate the risks, some of which would make the resident very vulnerable. It is essential when there are people who smoke in the home and have limited abilities, to have robust risk assessments not only for that individual but the risks they may encounter living in the home and in the local community. Staff in the home had evoked some safeguards for one resident who was unable to go out unaccompanied. We observed that this was the case and records to support this were in place, although other risks had little supporting documentation. One resident has little in the way of finance, the home are working with the members of the multi disciplinary team to try to get more funds for her. All other residents have their own money, non is retained in the home. Care Homes for Adults (18-65 years) Page 13 of 31 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 participate in leisure and social activities appropriate to their needs and abilities. Evidence: The home offers a good selection of entertainment equipment, with a large TV, music, games, magazines etc - all of which residents have access to. Residents are free to spend time where they want to and were seen to come and go . During the two site visits residents were engaged in some activities with staff support. One resident was taken out by staff members on a number of occasions. Staff showed patience and were caring when dealing with her, although at times she was agitated and abusive. During the first site visit there was a visiting Social Worker in conducting a review. Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: She was satisfied with the service and felt the home worked towards meeting individuals goals including those which form part of rehabilitation and daily living skills. On the second site visit we met one relative who visits daily. He told us that he spends long periods of time in the home. He usually spends time in the residents own bedroom here they watch television. They have a kettle and can make their own drinks. Both we pleased with the home and the support they provided. Visiting is flexible to maximize family contact . We were advised that one resident has just been accepted into an activities programme which the home have worked to wards for some time. Several residents spent periods of time at home during the Christmas period. Another residents spends much of her time in bed and staff need to ensure that she has sufficient stimulation in her day and that active rehabilitation programmes are in place to maximise her abilities. There was discussion about smoking - the home is a no smoking area, although there was evidence that one resident was smoking in their bedroom. Ms Harris said it was hard to stop unless you were observing the resident continually in which case, appropriate and robust risk assessments need to be developed to address the issue. The kitchen is well equipped and has a good lay out for those residents who take part in cookery sessions. The fridge and freezer were well stocked, fresh fruit and snacks were available. Drinks can be made at any time. Residents can choose what they eat and staff assist, or sometimes prepare the meals for them. Most residents eat individually not as a group. Foods were stored correctly and fridge temperatures recorded. Care Homes for Adults (18-65 years) Page 15 of 31 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. Health care is accessed through the community provision,which is appropriate for this type of resident. The systems for recording,administration and storage of medications introduce an element of risk to residents. Evidence: The residents currently in the service are all female and there was discussion about gender care issues when personal care is being delivered. This has not been a deliberate move on the part of the home, it is simply that female residents were referred. Residents in the main need support and guidance as opposed to actual assistance with care although this may change with illness. It was evident that residents spent time as they wished one resident was still in bed mid afternoon, however some residents need active rehabilitation and structure to their day, so this may not be conducive to their long term wellbeing. Residents are supported to attend health care provision in the community to enable Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: rehabilitation and integration. Residents have their own GPs and all have care coordinates as they are on Care Programme Approach (CPA) aftercare The home has the Mulberry House policies, and these cover medications, however they need adapting to reflect the local situation. Staff training and updates in medication also need to be addressed. Medications were inspected and several issues were identified. There is a metal cabinet, not attached to the wall, in the top floor office for medication storage. There is no separate Controlled Drug cabinet, and as the home was registered September 09, all new premises are required to have one. The medication storage and records were unsatisfactory. The medication administration sheets were incomplete and without residents allergies or photographs. The information on the actual medications was limited and hand transcribed although without two staff signatures to confirm the accuracy of the record. In addition there was a system for the self administration of methadone by one resident, which needs to be fully risk assessed and have a supporting care plan in place. Immediate requirements were left as follows: Medication storage must ensure that all medications are safely stored and storage complies with appropriate legislation. Full risk assessments, care plans and supporting documentation must be in place for those residents who are self medicating. Medication records must be fully completed. One agency staff to whom we spoke said that she did administer medications . We checked this with Ms Harris who confirmed that agency staff did administer medications after instruction from her during their induction session. It is essential that all staff who administer medications are trained and safe to do so. It is particularly important with this type of resident, who may need a combination of drugs some of which may have side effects. If staff are unaware of what drugs they are administering, and the possible side effects, this will be detrimental to residents. Ms Harris confirmed verbally to us that she will stop agency staff doing medications and Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: will once new staff have been appointed arrange for training on medications. The pharmacist has been asked to visit to monitor compliance with the requirements. Care Homes for Adults (18-65 years) Page 18 of 31 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. Complaints information is adequate although needs to be further developed to ensure residents are protected. Staff had sufficient knowledge of dealing with suspected abuse to afford protection to residents living in the home. Evidence: The home has a Service User Guide which includes information on how to make a complaint. The home has a set of the Mulberry House polices and procedures which provide good information on whistle blowing, dealing with abuse, bullying, harassment etc although as stated previously, need to be adapted for use in this home. It also has policies and procedures for dealing with complaints . This will also need to be amended to reflect the local situation. The CQC has been advised of no complaints relating to this service. We were advised that there have been no complaints raised since the service opened September 2009. The home needs to develop a complaints log to record any complaints. All information relating to complaints must be retained and securely stored including the investigation of such. The two care assistants both knew what to do in the event of suspected abuse and Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: were aware of the term whistle blowing and how to deal with this. They both said that they had received instruction on this through the agency. In the office there was further information on whistle blowing. One resident is subject to Deprivation of Liberty restriction under the Mental Capacity Act 2005, which means they are unable to go out unaccompanied. The home had managed this process with support from the Multi Disciplinary Team who felt is necessary to protect the resident. Once the home has permanent staff then whistle blowing and abuse need to be included in induction and regular refreshers organized there after. Care Homes for Adults (18-65 years) Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a good standard of accommodation for residents living there . Evidence: The home is located in what was the old Hither Green Hospital. This site is now a residential facility with other amenities located in it . The home is a newly built house domestic in style and well presented. There are several flights of stairs which means all residents must be mobile to live there. All areas were clean, tidy and hazard free. Each bedroom has an en suite facility and the bedrooms seen were large and airy. They were personalised and to a good standard. All bedrooms have a lock to the door and lockable storage space is provided. Communal ares comprise of a large kitchen /dining area. The kitchen was well equipped spacious and a pleasant area to spend time in. This is important as the residents in this home require rehabilitation and cooking may be one.such area. There is a separate sitting area, this too was very comfortable and well equipped. A large TV, magazines, books and games were all available for use. There are two Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: communal bathrooms one on each of the first and second floors. Neither of these bathrooms had locks to the and this needs to be rectified to ensure resident have privacy when bathing. It was noted in one bedroom that the window restrictor was not applied. All windows first floor and above need to have these applied and it is important in this type of setting. On the top floor is the staff office. This too is a large spacious area. This where the staff do their sleeping in. Amenities are provide such as TV, kettle etc t for staff. Care Homes for Adults (18-65 years) Page 22 of 31 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. There are insufficient staff employed to ensure consistent care is provided. Recruitment procedures introduce an element of risk to residents and more training needs to be provided to ensure staff are competent to undertake their work. Evidence: We met with all staff who were on duty during the two days of the inspection. All staff we met, with the exception of Ms Harris and her sister Ms Brown, were agency staff. We were advised that the home is recruiting fill time staff at the moment. Ms Harris is the assistant manager and Ms Brown was acting in an administration role on the second site visit. The two other staff were working as care assistants. We were advised that there are five staff employed, two of which are in the process of being purchased by the home from the agency. One the first day of the inspection the staff personnel files were not available for viewing and an immediate requirement was left regarding this as follows: The recruitment files for all those staff employed need to be available for inspection 7/1/2010. One the second site visit 7/1/2010, there was one permanent staff file available and two other staff files had only the information obtained from the agency. The file of the Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: permanent staff member was limited with only one reference, which had very little written on it. There was no evidence of terms and conditions, job descriptions, contracts or other employment records. Criminal Record Bureaus checks are retained in separate sealed envelopes and these are done through an umbrella organization, who are also the agency who supply the staff. There was no evidence of POVA checks. In this file the induction record was absent. We were shown standard contracts, terms and conditions, and job descriptions which we were advised were issued although as this person was a family member it was not retained. In the file of the agency staff there was better information in respect of recruitment although this was all done when they were employed by the agency not the home. We did see an induction record which was completed. The manager must ensure that all staff are subject to robust recruitment procedures. The recruitment files for all those staff employed need to be completed, with two references, POVA and CRB checks, contracts and identity checks. Good practice would indicate that essential and desirable criteria should be detailed, interview notes are kept and it maybe beneficial to do testing on literacy and numeracy. The manager must check that the prospective employee is legally entitled to work in the home. A full induction record needs to be retained and thereafter evidence of training and supervision. There was little in the way of training records although a training matrix is being produced we were advised. Ms Harris advised us that training was planned for the new year including some from Mulberry House . It is essential that staff are updated regularly on the statutory topics and have sufficient training to deal with residents in the home. The two agency staff we met with did not have photographic identity badges and had not brought any other identification with them. Both staff were asked about dealing with mental health residents and both answered questions satisfactorily. The staff duty rota showed two staff during the day and one at night sleeping in. Ms Harris had been doing sleep ins recently and these had been very busy due to a disturbed resident. In such circumstances the staffing should be reviewed. Care Homes for Adults (18-65 years) Page 24 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by an experienced individual. Health and safety is adequately addressed to make the home safe to live in. Quality assurance needs to be further developed to ensure residents have input into the development of the service. Evidence: Mrs Vernett Brown is well experienced in this type of work and has previously had nursing homes. Ms Brown is a trained nurse in the field of psychiatry. At the two site visits she was away on leave so her daughter, Ms Harris, the assistant manager, facilitated both site visits. Ms Harris was very help full during the site visits although due to lack of management experience struggled in some areas. All requests made, were fulfilled by her and she demonstrated a willingness to learn and accepted advice readily. We saw records relating to the fire risk assessment although this will need to be Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: adapted to reflect the homes operation, particularly where there are residents who have limited capacity and smoke. The gas safety certificate was current and the portable appliance testing had been conducted March 2009. The employers liability certificate was on display and current. Some of the documentation relating to health and safety issues was not available at the first site visit and could not be viewed. In particular the service certificates for the fire servicing, fire extinguishers and the fire alarm panel were not available. The 5 year electrical certificate and legionella testing certificate were also unavailable. Immediate requirements were left for these issues, and a five year electrical certificate has now been e-mailed to this office. Ms Harris confirmed water samples for legionella testing have been sent. The home has sets of policies and procedure produced through Mulberry House and these are very good tools although some will need to have local policies in place as well, including those for medication and fire. We were advised that the home retains no money for residents, all have their own bank accounts and one resident is under Court of Protection. As the home has only been registered since September 09 there was little in the way of quality assurance records although informal meetings do take place we were advised. These will need to be developed in the future to ensure that the views of those using the service are taken into consideration and acted upon. Care Homes for Adults (18-65 years) Page 26 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Adults (18-65 years) Page 27 of 31 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 1 20 13 Medication storage must 15/01/2010 ensure that all medications are safely stored and storage complies with appropriate legislation. To protect residents living in the home. 2 20 13 Full risk assessments, care 15/01/2010 plans and supporting documentation must be in place for those residents who are self medicating. Medication records must be fully completed. To protect residents living in the home. 3 28 16 Window restrictors must be in place on windows and openings first floor and above. To ensure residents are safe . 4 34 19 The recruitment files for all 14/01/2010 those staff employed need to be complete, with two references, POVA and CRB checks, contracts and identity checks. 28/02/2010 To confirm staff are safe to work in the home. Care Homes for Adults (18-65 years) Page 28 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 The Statement of Purpose 28/02/2010 must only include the category of resident that the home is registered for. To ensure accurate information is provided to prospective residents and purchasers of the service. 2 9 13 Robust risk assessments must be in place for all issues identified. To ensure residents are protected. 28/02/2010 3 20 13 Staff must have competency 28/02/2010 assessment that are recorded at regular intervals To ensure that staff who administer medications are safe to do so 4 20 13 Staff who administer medications must be safe and competent to do so. To protect residents living in the home. 28/02/2010 5 22 22 The home must develop its own policies for dealing with complaints, adult protection and whistle blowing. To ensure all persons have access to correct and accurate information. 28/02/2010 Care Homes for Adults (18-65 years) Page 29 of 31 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 6 32 18 Staff need to be provided with sufficient training to do their work. To ensure that there is a competent staff team working in the home. 31/03/2010 7 39 24 Quality assurance measures must be in place to ensure that all those who use the service are taken in to account. To offer residents opportunities in the development of the service. 30/03/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 4 Evidence that residents have ad an opportunity to sample the service should be retained including notes of any trail visits. Residents should be encouraged to have structure in their day with a varied range of activities and daily living skills. The home needs to develop a complaints log to record any complaints. Staff need to receive supervison at least six times a year . 2 3 4 18 22 36 Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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