Care Home: Hartfield House

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What the care home does well There is a committed manager and staff team who have worked at the service for varying periods of time. Findings from this inspection indicate that the service is run in the best interests of the people who use the service and that they are at the forefront of any planning and decisions made. The atmosphere is relaxed and comfortable, and we observed positive interactions between the people who use the service and the staff. What has improved since the last inspection? At the previous inspection there had been nine areas where the service had to improve. The service has taken action on all of these, which represents a positive response to the findings of the previous inspection. In particular, improvements have been made to the reviewing of peoples care, environment and staff records. What the care home could do better: Areas where the home could be doing better are highlighted in the report and were discussed with the area manager during the inspection. These include improvements to the information in support plans, medication recording and risk management planning.Hartfield HouseDS0000070866.V378580.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Hartfield House 170 Roehampton Lane London SW15 4EU Lead Inspector Louise Phillips Key Unannounced Inspection 17th November 2009 12:00p Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 1 Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 2 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. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 3 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 Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Name of service Hartfield House Address 170 Roehampton Lane London SW15 4EU 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) 020 8780 0057 m.saddler@southsidepartnership.org.uk www.southsidepartnership.org.uk Southside Partnership Manager post vacant Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 5 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories 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: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 18 16th December 2008 Date of last inspection Brief Description of the Service: Hartfield House is a care home providing respite/ rota and emergency care for up to eighteen people with a learning disability, five of whom may also have a physical disability. Accommodation is provided in single bedrooms, double bedrooms and two semi-independent flat-lets. Since September 2007, the service has been owned and managed by Southside Partnership, having been previously run by Wandsworth Council. Hartfield House is located close to shops, pubs and other amenities. It has good access to public transport. A limited number of parking spaces are available outside the home. At the time of this inspection the weekly charge for respite/ rota care and emergency care is £1086.63 per week. Additional charges are made for some outings. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star – good service. This means the people who use this service experience good quality outcomes. This inspection took place over two days and included a visit to the service by a Regulation Inspector. We did the inspection over two days, as on the second day we met with the area manager and she enabled us to access the staff records. When we visited we spoke to the people who work at the home and the area manager, as the manager was on leave. We also looked at records, observed what was going on and looked at the environment. Surveys were received back from four people who use the service, and these are referred to in the report. What the service does well: What has improved since the last inspection? What they could do better: Areas where the home could be doing better are highlighted in the report and were discussed with the area manager during the inspection. These include improvements to the information in support plans, medication recording and risk management planning. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 7 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. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 8 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 Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 9 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 and 2 People using 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. People are provided with up-to-date information about the service. The assessment process is thorough to ensure that the service is the right place for new people to move to. EVIDENCE: There is an accessible, pictorial Service Users Guide which provides relevant information to people who use the service about what they can expect during their stay and how they can contact if they are not happy about something. Most of the people who stay at Hartfield House for respite have done so over a number of years, staying for periods of one to seven days on a rota basis, throughout the year. We looked at the care files for three people who use the service. The files contain relevant information about the referral and assessment process, along with information from relevant health and social care professionals involved with the person. Each person has had their care reviewed recently by the multi-disciplinary team. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 10 As part of the assessment process an up-to-date needs assessment is gained from the social worker involved in their care. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 11 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 and 9 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. Positive improvements continue to be made to the support planning and risk assessments to ensure a more user-focussed service. Some improvements are needed to ensure that support plans are updated following reviews of the person’s care. EVIDENCE: At the time of inspection there were seven people using the service and we were informed that six more people were due to start their respite at the service later in the week. We looked at the care files of three people who use the service. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 12 When we last visited the home a new support plan format had just been implemented at the service. This was seen to established and in use at the home. For some people the information in the support plans read as if it is the assessment of the person, and more information should be provided about their needs and the actions to be taken to support them in meeting their goals. In one person’s care files there were minutes of a person-centred meeting that took place in July 2009, where areas such as the person’s desires, wishes and plans were recorded. This information had not been used to update the support plan, and should be used to inform and develop this further, to ensure that people are receiving the support they want, and that this is evidenced. Similarly, we saw that reviews are taking place of people who use the service, and the support plans need to be updated following these, as this was not seen to always take place. Some people have ‘working guidelines’ in their files for staff to use, in areas such as where the person refuses medication, their personal care and managing their behaviour. Again, these should be used to inform the support plans. This then ensures that the support plan is a comprehensive, up-to-date record of all the support that the person needs. It is recommended that the manager audits the support planning documentation at regular intervals to ensure that each person who uses the service has a detailed support plan that is current to their needs and wishes. Risk assessments are in place for each person, and kept under regular review. They are individualised to the safety needs of each person, drawing upon the initial history of risks that have been gained through the assessment of the person. Some improvements are needed to ensure that the risk management plans following on from this detail how all risk behaviours will be managed by the service, as in the files we looked at, risk behaviours had been identified, though little information was given about how the person is supported with these. The files for some people contain a lot of information, some with numerous copies of the same document. It is recommended that the files are archived to ensure that current, up-to-date information is held, to avoid confusion. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 13 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, 14, 15, 16 and 17 People using 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. People who use the service are supported to pursue individual interests and activities both inside and outside the home. There is a relaxed atmosphere at the home which is enhanced by the positive relationships between the staff and people who use the service. EVIDENCE: At time of inspection there were seven people using the service. Some people were at the home for the day, and the staff informed us that others were out either visiting their relatives, one person was at the day centre, another at an art class, whilst the other was at college. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 14 In the surveys we received from people who use the service, they told us that the staff usually treat them well and they listen and act upon what they say. Staff spoke fondly about the people who use the service and have a good understanding of their needs. We observed genuinely caring and positive interactions between the staff and people who use the service. People who use the service told us that they are able to make decisions about what they do each day, in the evenings and at weekends. One person did say that they would like to have more trips out arranged by the service. There is a games room at the service that includes a punch bag, basketball net and a pool table. However, when we visited this was in the process of being refurbished and could not be used. The pictorial menu for the evening meal was on display at the service, and people who se the service are involved in choosing the menu for the week at the house meeting on a Tuesday evening. There is a dining room where people can enjoy their meals with other people who use the service. There is a good stock of food in the fridges, freezers and cupboards in the kitchen, to ensure that a variety of foods can be provided. Following a requirement from the last inspection, the service has taken positive steps to label opened jars and containers in the fridge. However, it was observed that cereals decanted into containers had not been labelled in the same way, and this must happen to minimise risks to people who use the service. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 15 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 and 20 People using 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. People are supported to meet their health and social care needs. Whilst improvements have been made to the medication system at the service, more thorough monitoring of this needs to take place, and areas addressed. Some improvements need to be made to the medication system at the service. EVIDENCE: The care files hold records of all healthcare appointments that people attend, and detail different guidance, where necessary, from relevant members of the multi-disciplinary team. And example of this is where the file for one person who uses the service contains a document titled ‘health service provision’, which has been completed by the community learning disability. This provides a full medical history and details how the physical needs of the person are met through relevant members of the multi-disciplinary team. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 16 Regular reviews of peoples care takes place with the involvement of the relevant health and social care professionals and the person who uses the service. We looked at the medication held for three people who use the service. This is held in bottles of Monitored Dosage Systems (MDS), dependant on the dispensing pharmacy. The medication is appropriately stored and the information on the Medication Administration Record (MAR) corresponds in most cases with that on the medication packet. However, we did find that the tube of gel prescribed for one person has a label on it that states ‘apply every 24 hours as directed by your doctor’, where another tube of the same gel says ‘use as directed by your doctor’. The MAR records that the gel is to be given PRN (as required). Similarly, in the fridge we found prescribed injection ampoules for one person, which we were informed is administered by the district nurse. There was no record of this on the MAR, or of this having being received into the home and this must be recorded. The fridge contained prescribed cream for one person who is not currently using the service, and this must be disposed of. Improvements have been made to the storing of medication in the fridge, with this now kept locked, and a daily record of the temperature of this maintained. Another improvement is that a daily medication audit had been introduced at the service, where senior staff countersign the form to state that they have checked the MAR chart and these were are in order. However the last date that this was recorded to have happened was on the 6th November 2009, with the last late shift audit on the 9th November 2009, with only the night audit kept up-to-date. Similarly we found that that despite the forms being audited, in all the MAR charts we looked at, the ‘allergies’ section had not been completed. In some cases the allergies section had been completed with allergies relating to animals/ pollen, whereas the MAR must include allergies in relation to medication. A requirement has been made for the service to address this to ensure that people are not given medication inappropriately. The PRN medication should also be written in separate section of MAR to that of regular medication, to avoid medication being administered inappropriately. The BNF (British National Formulary) in use at the home is dated September 2008, and the most up-to-date one should be in use at the service, with this being renewed at least annually. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 17 The medication policy has been reviewed recently, and is dated January 2009, and there is also an easy read medication policy, dated August 2009. PRN guidance is also provided for each medication, including what circumstances this is to be offered or administered. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 18 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 and 23 People using 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. There are appropriate procedures for addressing complaints and ensuring that risks to people using the service are minimised. EVIDENCE: Feedback from people who use the service is that they know who to talk to if they are not happy about something and most know how to raise concerns or make a complaint. The service has an appropriate complaints procedure that provides timescales in which any complaint will be acknowledged and investigated. This is also available in a more accessible format, with pictures, for the use of the people who use the service. The service keeps a log of any complaints received, including the outcome of the complaint. A record is also maintained of whether the complaint has been upheld or not. There are policies and procedures at the service regarding what to do in the event of an abuse allegation being made at the service. The staff training records indicate that most staff have received recent training in Safeguarding of Vulnerable Adults, and training is planned for those who still need to attend this. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 19 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, 25, 27 and 30 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. Improvements have been made to the environment to make the home safer and comfortable for the people who stay there. Some areas still need attention to make the environment more homely. EVIDENCE: People who use the service told us that the home is always kept fresh and clean. When we visited the environment was in the process of being cleaned and there were no malodours. At the last inspection of the home there were a number of areas in the environment that needed to be addressed to make the service more homely. The service has taken positive actions on these to enhance the environment, Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 20 including installing curtains or blinds in the bathrooms and bedrooms and replacing the flooring near the flooring on the ground floor fire exit. Exposed pipe-work in most areas was seen to have been boxed in, though we did observe that this still needed to be done in bedroom 13, and around the lower skirting board in bedroom 3. In addition, the cloakroom to the right of the entrance is in need of having a door installed, as it is unsightly, with boxes, pictures and old furniture being stored in there in a haphazard way. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 21 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 and 36 People using 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. Staff receive training relevant for their role. Appropriate recruitment checks minimise risks to people who use the service. Improvements need to be made to ensure all staff receive consistent supervision. EVIDENCE: The recruitment files for four staff were seen to contain the required information about recruitment checks, such as two references, Criminal Records Bureau check and copy of proof of identification. They also contain information regarding the staff member’s application, a copy of the records of their interview and correspondence relating to the offer of their job. We saw evidence to confirm that new staff receive an induction to working at the home, and also that they are reviewed for a period of probation. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 22 We looked at the training records for the same four staff. Records indicate that they receive mandatory training in areas such as fire safety and health and safety, as well as training in safeguarding adults, moving and handling, diabetes and administering medication. In addition to medication training, staff have also carried out a medication assessment, to assess their competency, which is positive, and should be used annually to ensure staff maintain their competency in handling medication. A number of staff are currently trained to National Vocational Qualification (NVQ) level two or three. Staff who work at Hartfield House receive one-to-one supervision from a senior member of staff. However, when we looked at the frequency of supervision that staff receive we found that this is not always consistent, with some staff receiving supervision regularly, and others infrequently. It is recommended that staff receive a minimum of six supervision sessions a year, with these spaced at regular intervals. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 23 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 and 42 People using 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 manager is competent and understands the responsibilities of their role. Findings from this inspection indicate that the service is progressing in a positive direction for the benefit of the people who use the service. Appropriate health and safety checks are carried out to minimise risks to the people who use the service. EVIDENCE: The manager has been working at the service for approximately eighteen months. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 24 Staff we spoke to said that they get very good support from the manager and area manager. They said that the improvements at the service have given them more structure to what they are doing, which enables them to look at their objectives and reasons why they are working in a certain way, and encouraging them to make positive changes around this. Regular staff meetings take place and meetings with people who use the service occur weekly, due to the nature of the service, with new people arriving weekly. The area manager told us that over the past year the service has developed a quality action group, where they meet with parents of people who use the service for suggestions, complaints and compliments about the home. Records of these meetings were seen to confirm these had taken place. The area manager said that they ensure that relatives are kept up-to-date about future plans for the service and any changes that affect them. The service carries out customer surveys or people who use the service, however, the forms we saw were not dated and it is unclear as to what happens with results of these. The service should demonstrate clearly how feedback is used to develop the service. The service holds relevant certificates and records to indicate that appropriate checks are carried out areas of health and safety, including the electrical system and gas safety. The Portable Appliance testing certificate was dated April 2008, and there was no evidence to demonstrate that this had been carried out since this time. All accidents and incidents are recorded, and the service notifies the CQC appropriately about any incidents that occur. Hot water temperatures testing is carried out at the service, though the recording of this was inconsistent, with this sometimes happening every week, and other times gaps of two weeks in between entries. This should be carried out weekly, and records maintained to evidence this. Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 25 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 3 2 3 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 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Version 5.3 Page 26 Hartfield House DS0000070866.V378580.R01.S.doc Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement When reviews of people take place, the information must be used to update the support plans to ensure support provided is relevant to the person’s needs. Risk management plans must detail how all risks assessed will be managed by the service. Foods decanted into alternative containers (eg. cereals) must be clearly labelled with the date opened, and to be disposed of. This is to ensure that people using the service are provided with suitable and nutritious food. The MAR must include allergy information in relation to medication to ensure that people are not given medication inappropriately. The Registered Persons must ensure that all medication held at the service is handled, recorded and administered appropriately. Timescale for action 31/01/10 2. YA9 13 31/01/10 3. YA17 16(2)(i) 01/12/09 4. YA20 13 01/12/09 5. YA20 13(2) 01/12/09 Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 27 6. YA25 13(4), 23 The exposed pipe-work in bedroom 13 and around the lower skirting board in bedroom 3 must be boxed in to minimise risks to people who use the service. The service must ensure that Portable Appliance Testing is carried out periodically and a certificate maintained at the home to evidence this. 31/01/10 7. YA42 23 31/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that the manager audits the support planning documentation at regular intervals to ensure that each person who uses the service has a detailed support plan that is current to their needs and wishes. The service should hold the most up-to-date BNF, and renew this at least annually, to ensure the most current reference information is available about medicines. Staff should receive a minimum of six supervision sessions a year, with these spaced at regular intervals. The service should demonstrate how the feedback received from surveys informs improvements to the service. Hot water temperatures testing should be carried out weekly, and records maintained to evidence this. 2. YA20 3. 4. 5. YA36 YA39 YA42 Hartfield House DS0000070866.V378580.R01.S.doc Version 5.3 Page 28 Care Quality Commission Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.london@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. 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