Care Home: Mount Adon Park

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Mount Adon Park 49 Mount Adon Park Dulwich London SE22 0DS two star good service The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Lynne Field Date: 3 0 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. They reflect the things that people have said are important to them: 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 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 Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Mount Adon Park 49 Mount Adon Park Dulwich London SE22 0DS 02082990305 02086938675 dev@odc-csft.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Odyssey Care Solutions for Today care home 4 Number of places (if applicable): Under 65 Over 65 4 0 learning disability Additional conditions: The registered person may provide the following category 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: Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 Date of last inspection A bit about the care home Mount Adon Park provides a home for four adults with learning disabilities. It is run by Odyssey-Care solutions for today, a private who also have other homes in the area It is a three-story building that is indistinguishable from the othe buildings in a residential road near Forest Hill. The home is close to shops and transport links but is situated in an extremely hilly street which would cause difficulties for anyone with mobility problems. There are gardens front and back and on-street parking. Each resident has a single room and there are communal kitchen, living and dining areas. The fees for a place at this home are #1903.00 and these are currently paid by social services with the residents contributing #68.29 towards their food. 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: two star good 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 How we did our inspection: This is what the inspector did when they were at the care home The inspection was unannounced and was carried out on the 28th November 2008. The locum registered manager and the senior support worker was present and took part in the inspection process. The inspection included a tour of the home and we were able to check the personal files of three residents, including their care plans, risk assessments, medication records, the complaints book and other documentation relating to the residents support and health and safety. The senior support worker gave us the tour of the home and residents were happy for us to see their bedrooms. We spoke the locum registered manager and senior support worker about how the home was developing and systems that are in place to ensure the residents are given the service they want and need. During the inspection we met and spoke to all four residents and three staff as well as being able to sit in on a staff meeting. Residents came and went during the inspection and we were able to observe that the interaction between staff and residents was friendly and respectful. Residents have their own bedroom, and access to a range of homely communal areas. Appropriate professionals have been consulted and adaptations are being made to meet residents changing needs. As part of the ongoing inspection we visited the organisations head office that was facilitated by the homes service manager to check staff files and training records. What the care home does well What has got better from the last inspection The service user guide has been developed and is now in a more accessible format and communication passports have been developed and are in place. Person centered meetings are being held and outcomes from these are being acted on. Support guide lines are being kept up to date more often than before. Team meeting are held each week and safe guarding issues are high lighted and discussed at these. The organisation has worked hard to comply with the requirements left at the last inspection. What the care home could do better Some staff said they did not feel supported by management and did not receive training that met their needs and enabled them to feel confident in their tasks. Supervision had lapsed and needs to be reinstated to support staff meet the expectations of the residents. Mandatory staff training has lapsed and staff must receive training to help them support residents safely. Local Medication procedures need to be reviewed so there is a clear audit trail. The organisation need to keep CSCI informed of any incidents or changes in the home as soon as they happen. Some areas of the home need to be cleaned, refurbished and redecorated. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Lynne Field 33 Greycoat Street London SW1P 2QF 02079792000 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 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 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 . Service users and their families are provided with all the information they need to make an informed choice about where to live and whether they are being offered everything that they should be. When someone new wants to move to the service, staff assess their needs and decide whether they can meet those needs before they offer them a place. Evidence: We checked the statement of purpose and service user guide. These had been reviewed in April 2008 and were in a more accessible format in the form of pictures and written text. These could be further improved by using more pictures and or widget and a larger text with shorter more concise sentences. There were two new residents had been admitted since November 2007. We were told there is a procedure in place for the staff team to fully assess whether a new resident would fit in with residents already living in the home and whether the staff team could meet their needs before they are offered a place. Prospective residents are given the opportunity to visit and to test drive the home by coming to visit for a day, then if that was successful an overnight stay followed by weekend visits or stays. If placement is acceptable to the prospective resident, they would be able to choose the decoration of their room and bring personal possessions to personalize it and make it their own. The residents who already live in the home are asked about who they would want to share their house with. Staff said this happened with one new resident but not for the other resident who had very high needs who was Evidence: in hospital before being admitted to the home. We spoke to the service manager who said this was because the resident had lived in another of the organizations homes near by and was known to the present residents, manager and staff and they has liaised with the hospital, social worker and community nurses to try to have every thing in place before they can to live in the home. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The residents are involved in planning their care with their key worker, the registered manager, appropriate professionals and family members. Potential risks are identified and residents are supported to take risks within a risk management framework. Evidence: We looked at three residents files. Two were files of residents who had recently come to live at the home. There were copies of the social services and homes assessments on file. Care plans give a thorough description of residents individual behaviours, reactions and preferences and how the residents like to be treated. There are detailed support guidelines that describe how staff will support residents on a daily basis and help them develop their skills and enable them to achieve any identified goals. Each resident has a care plan and person centred plans are being developed. Some are written in an easy to read format. Risk assessments are on file and are reviewed and up dated every six months or before if the need arises. There were detailed guidelines and risk assessments on file on how the residents who have challenging behaviour or high needs could be managed and supported safely. We saw copies of the six weekly review and weekly key worker meetings held on residents files. Monthly summaries are done that assess how the service user has been over the period and identify work that has been done to enable them to meet identified goals. We found from speaking to staff and from documentation seen on file that residents are supported to make their own choices whenever possible and other people are Evidence: brought in to help them make choices if they do not have any family to help them. Staff and the speech therapist are working with individual residents to develop communication passports that will help with the residents communication needs. The home has residents meetings and key worker sessions to meet with resident and find out what they want and tell them about things that are happening. The home uses an advocate to help those residents who do not have family involved in their care. We saw residents have a list of in house and community activities of their choice and which they are actively encouraged and supported to partake in. We were able to observe that this is done mostly on a one to one basis. We spoke to one resident who said they did not always choose what they wanted to do but did most of the time and they were happy at the home. They said they went out often and staff helped them do this. They said one member of staff spoke to them in endearing terms and they did not like that from that person. We were able to speak to the service manager about this during the inspection and he was going to speak to the resident about this and the staff in general about the appropriate way to address residents. Another resident who had recently moved in told us they were very happy living at the home and could go out when they wanted to do. 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 engage in appropriate, enjoyable and fulfilling activities and mix with the general community. Residents are actively encouraged to keep in touch with friends and family and develop appropriate friendships. Residents rights and responsibilities are respected. Evidence: On the day of the inspection we met all four residents at various times during the day. Two residents were out at separate venues of their choice with the support of a member of staff. Staff said they would go through the activities program with the resident to make sure they understood where they were going. Decisions about what activities residents were going to take part in were made in a variety of settings. Some decisions were made at residents meetings, others were made at reviews and others individually in key worker meetings, which are held every week with residents. We were told three residents have regular contact with their relatives. One resident said they regularly met their family members and spoke to them on the phone as well. Another resident goes to their familys home for weekends. Staff said they thought it was important for residents to keep in touch with family and friends and some were more actively involved with the home than others. We were told this was their choice Evidence: but the home encouraged them to be involved as much as possible. Staff said some relatives act as advocates in decisions relating to social and health care needs of their relatives placed there while others were not able to do this. One resident does not have any known family. The staff said residents are encouraged to eat a healthy diet. Staff and the residents meet to decide what goes on each residents weekly menu and residents go out to buy that with the help and support of staff. One resident is unable to eat solid food 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Staff help residents to go to the doctors, hospitals and dentists when they need to so that residents do not get sick and are looked after properly. Residents receive personal support, in the way they prefer and their physical and emotional needs are met. Medication is handled safely but the home need to review some of its procedures to have a clear audit trail of how and when medication is dispensed, ordered, stored and recorded. Evidence: We checked three residents files and from looking at the residents files we could see each resident has a copy of their medical history, a health assessment done by the home and health action plan on file. The record of health appointments attended indicated that staff supports each resident if this is what the resident requires, to attend an appropriate range of health care appointments in line with their individual health care needs. This included the outcome of the appointment. One resident has very high health care needs and these are well documented. Specialist health care professionals, who have liaised with the staff, have supported and trained the staff of the home to ensure the resident has the support from staff in the way they need. Three residents are more able and are supported with personal care needs, as they require it. We spoke to four members of staff, including the senor support worker who has been acting up since the manager has been on extended leave. They all spoke in detail all the health care needs of residents and showed a full knowledge of how they could support residents to meet those needs. Evidence: None of the residents are able to self medicate and this was recorded in their medical risk assessment. Three of the residents medication is stored securely in a locked medication cabinet in the staff office and the fourth residents medication is kept in a locked filing cabinet in their room. The senior support worker said they planned to replace this with a proper medication cabinet. We were told all staff must to go through the homes medication training programme before they are allowed to dispense medication and two staff checks the medication when it is being dispensed. We checked two residents medication with the senior support worker including the resident whose medication was kept in their room. One resident seemed to have a large quantity of medication in stock. This should be monitored and only enough medication for the month should be ordered. The way medication was recorded on the individual charts was not clear and did not leave a clear audit trail. For example there were times when it looked as if medication had not been given and staff need to record why it was not given by using the medication codes. The home needs to audit the medication regularly and review some of the medication procedures around ordering, storage and recording the residents medication to have a clearer audit trail. There was a copy of all staff signatures that dispense medication and information about the medications in use. We noted from the list of staff training we were given, staff apart from one new member of staff had not had any medication refresher training since August 2007 or before that. Staff training needs to be reviewed and up dated. See Standard 32. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home has procedure in place that would mean that complaints are investigated and taken seriously. The residents are protected by the organizations procedures around protection of vulnerable adults. Staff are aware of their responsibilities but some staff need to have their training up dated in this area. Evidence: On the day of the inspection we were unable to find the complaints book. We were told this was because a number of files and documents had been taken away to the organizations head office to be inspected. When we visited the head office as part of the inspection we checked the complaints book and noted there had been one complaint. This was from residents relative and had been responded to appropriately. We saw a copy of the homes complaints procedure in the service users guide that we were given during the inspection. The service manager told us that the service promotes the homes complaints procedures at the service users meetings and residents are encouraged during these meetings to raise any concerns, complaints or suggestions for improvement in relation to the service they receive. The meetings also operate as a forum within which residents can discuss any problems they have in relation to communal living. Staff told us they encourage residents to raise any concerns they have with their key workers during key worker meetings. Part of the complaints procedure is residents can instigate with support from others they trust. Advocates, relatives, social workers and other professionals can also raise concerns on the residents behalf. The service manager said they take all complaints seriously and aim to deal with them promptly within the time scales. We were told they had introduced a complaints, comments and compliments book for the residents, relatives or professionals to register any comments in and they are encouraged to use it by the manager and staff. Evidence: We checked staff training records and found not all staff have attended recent training around protection of vulnerable adults. 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 is large enough but some areas have not been decorated for a while. Parts of the home are now looking shabby and grubby and would benefit from a deep clean. The home is safe and comfortable with adequate private and shared space, toilets and bathrooms. Residents bedrooms are comfortable and are decorated to reflect their personalities. Evidence: The home is a three-story building that is close to shops and transport links. It is situated in an extremely hilly street, which would cause difficulties for anyone with mobility problems. On the day of the inspection the senior support worker gave us a tour of the home. There is a large sitting room with a dining area at the front of the house. This is comfortable and well furnished. The communal kitchen is shabby and looked unhygienic. The walls, doors and surfaces looked grubby and in need of deep clean. The senior carer said this had been arranged and the it was due to be done by the day of the inspection. The carer said they would follow this up. The home would be mostly unsuitable for people with a physical disability, as there are several short flights of stairs to various landings. Each resident have their own bedroom. We were able to see two bedrooms. Each room is of an individual style and residents have brought items of furniture and personal possessions to the home that makes each room individual and homely as well as reflecting the culture and background of the residents. The residents we met were happy to show us their bedrooms and said they like their rooms. One resident has their own personal landline phone, which they use to contact their family. All the rooms were personalized with their own fixtures, fittings, and furniture. All the service users were encouraged to Evidence: clean their own rooms with support from the staff as part of their daily living skills. The bedrooms are close to the bathrooms and there is also a separate toilet. The small laundry room is on the ground floor next to the kitchen and has the appropriate equipment. We were told residents are encouraged to do their laundry with the support of the staff. There have been concerns about the stability of the building and a number of crackes are being monitored. Some areas in the home were grubby and a number of carpets in the communal areas need to be cleaned or replaced. The home has use of a mini bus and there is car parking space available at the back of the house. 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 . The recruitment records show that the procedures followed are safe, thorough and comply with the legal requirements. Mandatory and specialist staff training has been inconsistent and needs to be more robust. Having regular formal recorded supervision supports the staff to work with the residents effectively and must be recommenced. Evidence: The senior support worker, who knew the residents and home well had been asked to manager the home in the registered managers absence. During the inspection we met the registered manager from another of the organizations homes. They said they had been asked to come and support the senior support worker. They said since coming to support the support worker, they had realized the staff in the home needed more support and there were a number of issues that needed to be addressed. To do this constructively and efficiently they had asked the senior managers in the organization if they could come to manage the home on a full time basis for a period of at least three weeks in which time they hope to bring stability to the staff team. The home is not fully staffed with permanent staff. To meet the staff short fall, the home users their own bank staff or agency staff. We were told they try to have the same agency staff on a regular basis so they come to know the residents. We checked the rota and there appeared there were enough staff on duty to meet the needs of the residents who apart from one are very able and what to be out and about. We were told the home had staff meetings each week. On the day of the inspection we were able to sit in on a scheduled staff meeting, which all staff were encouraged to attend including agency staff. During the inspection we were able to speak to two Evidence: members of staff. One said they had staff supervision but not regularly. Another member of staff said they did not feel supported and rarely had supervision. The new member of staff said they had LDAF induction training and had completed the induction units and the foundation unit plus training in health and safety issues. The organization keeps staff recruitment records at head office and a number of staff files that that would normally be kept in the home and other records we needed to check as part of the inspection had been removed to be checked by the organizations senior management team. As part of the inspection we arranged to visit the organizations head office where the staff files and other documentation was had been taken to and was being checked. We met the service manager who facilitated the visit. They told us that recruitment includes formal interview, taking up two references, CRB checks and POVA checks prior to appointment and all staff have an employment contract which include details of their terms and conditions of employment. We examined six staff files that contained recruitment details. We checked the files to assess compliance with Regulation 19 of the Care Homes Regulations 2001. We looked specifically at Schedule 2 of the Regulations, which specifies the range of documents required in respect of people working at a care home. The files had the required checks and references, including Enhanced CRB checks, two references, full work histories and verification that they are physically and mentally fit for their work. We were given a detailed copy of staff training records. Four staff had attained NVQ level 3. We found although the organisation had a good training program staff had not had the annual mandatory training up dated, such as moving and handling, medication and fire safety. Supervision records were checked and found to be spasmodic and at times not dated or signed although there were supervision agreements in place. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home is not keeping CSCI informed about events that come under Regulation 37 of The Care Homes Regulations 2001. The locum registered manager is supporting staff to give residents the care they need by dealing and working through the issues that have arisen relating to the management of the home. Evidence: On the day of the inspection we were told the manager was on long term leave until the organisation had investigated some irregularities relating to documentation in the home. This does not directly relate or affect the residents and they are not in any way have been or are at risk But CSCI were not kept informed which they need to be about the management arrangements of the home. Such an event comes under Regulation 37 of The Care Homes Regulations 2001. Regulation 37 requires the registered person to notify CSCI without delay of any allegation of misconduct by the registered person or any person who works at the care home as well as keeping us informed about any accident or incident that happens to residents or staff. When we checked on the number of accidents or incidents, we found these were not being reported to CSCI either under Regulation 37. We spoke to the service manager on the second day of the inspection, who was apologetic and immediately sent CSCI notification. We were able to speak to the locum registered manager who knew the home, residents and staff. He appeared knowledgeable and competent. and had called a staff meeting to bring all the staff together as part of a team building exercise. We were given a copy of the local business plan which said an annual survey will be Evidence: carried out in March 2009. We were shown copies of the provider monthly visits that are kept at the organisations head office. The home has a policy on health and safety and we were shown the health and safety records held in the home. Certification was in place regarding the Landlords Record of Gas Safety, Portable Electrical Appliance testing, and Certificate of Electrical Installation. Records showed that regular checks of the fire alarm call points were made and that fire drills were conducted. Staff need to attend annual mandatory health and safety refresher training, which included moving and handling, medication and fire safety. The management of the home needs to audit all staff training and ensure all training needs are met and complies with. See Standard 35. Are there any outstanding requirements from the last inspection? Yes  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 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 Description 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 Description Timescale for action 1 20 17 The registered person must keep an accurate record of all medication in the home. 29/01/2009 The home needs to have a clear audit trail from when medication comes into the home till when it is dispensed. 2 23 18 The registered person must ensure all staff attend appropriate POVA training. 27/02/2009 Not all staff have attended POVA training in the last year. 3 35 18 The registered provider must 07/03/2009 ensure staff have annual mandatory training. Staff need to have annual refresher training to support the residents safely. 4 35 18 The registered person must 07/03/2009 ensure staff have training specific to their residents needs. Staff need to be kept up to date in effective ways of supporting the residents of the home 5 36 18 The registered person must ensure the supervision of all staff is reinstated and there is a clear signed record of this. 07/02/2009 Staff need to be supported to help them provide support and care to the residents. 6 42 26 The registered person must 23/01/2009 notify CSCI without delay of any allegation of misconduct by the registered person or any person who works at the care home. CSCI must be kept informed of any change of management arrangements of the home. 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 1 Continue to review and develop the service user guide and statement of purpose to use more accessible format and less text. Staff need to be more aware of the boundaries and be sensitive and respectful of residents feelings in regard to being over familiar. 2 7 3 30 The home would benefit from the kitchen being cleaned and refurbished and other parts of the home cleaned and redecorated. Carpets in communal areas should be cleaned or replaced. Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web:www.csci.org.uk 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. - 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!