Care Home: Pauline Burnet House

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What the care home does well This service is clearly rated by both residents living their and their families. Comments we received from relatives included: ‘it gives an excellent service for my daughter. Staff always most helpful and there’s clear affection for her by all staff’. Another: ‘in general I am very happy with the service provided for my son who seems very happy as a resident’- and ‘299 The Rowans always appears a friendly and happy home’. The home’s admission procedures continue to be thorough ensuring people know that when they move in, their needs will be met. Some staff reported a high level of satisfaction in their job. One told us: ‘I have worked for Cambridgeshire Mencap for 7 years. I have found it to be a company that promotes good value’s. Training is good ensuring and residents receive their care from competent and knowledgeable staff. One staff member reported: ‘Training has always been provided and sought to meet areas of concern’. Residents told us that staff helped them in a way that they liked, that they chose what they wanted to do each day and that they enjoyed the various activities and outings that took place. Residents are involved in recruiting and Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 selecting prospective staff members giving them a real say in the people who are to support them. A local care manager told us that the service dealt well with a recent safeguarding incident concerning a member of staff’s care practices. What has improved since the last inspection? This is the first time the service has been inspected in its new structure What the care home could do better: The use of agency staff should be reduced as much as possible so that there is a stable and regular staff group and so that residents receive consistent care from staff who know them well. Only staff that administer actually administer medicine and creams should sign for them so there is an accurate and correct record of who has given residents their medication; the date on which liquid medication bottles are opened should be recorded and two people should always sign and date any handwritten additions to the printed MAR sheets so that they can be checked for accuracy. Staff should receive regular and recorded supervision at least 6 times a year so that they receive the support and feedback about their working practices to carry out their job effectively. Key inspection report CARE HOME ADULTS 18-65 Pauline Burnet House 1 Pippin Drive Chesterton Cambridgeshire CB4 1TF Lead Inspector Janie Buchanan Key Unannounced Inspection 14th July 2009 09:00 Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pauline Burnet House Address 1 Pippin Drive Chesterton Cambridgeshire CB4 1TF 01223 424946 01223 441768 burnethouse@btinternet.com 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) Cambridge Mencap Mrs Ruth Pitcher Care Home 45 Category(ies) of Learning disability (45), Physical disability (45) registration, with number of places Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 Physical Disability - Code PD The maximum number of service users who can be accommodated is: 45 7th August 2007 2. Date of last inspection Brief Description of the Service: Pauline Burnet House offer care and accommodation to 45 adults with learning and/or physical disabilities. Staff support people living in a number of properties within a short distance of each other including: 2 Cambridge Road, 299/309 The Rowans, Oaks and Cinnabar, and 361 The Rowans. Fees range from £3398-£5361 per year. CQC inspection reports about the home are available and copies can be obtained from www.cqc.org.uk. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this is 2 stars. This means people using the service experience good quality outcomes. For this inspection we (The Care Quality Commission) looked at all the information we had received about the service. This included the annual quality assurance assessment (AQAA) that was sent to us. The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also provided us with some statistical information. We also visited the service: in the morning we met the manager and talked to staff and residents at Pauline Burnet House. Later in the day, we visited 299-309 The Rowans to meet more residents and staff. Whilst at the houses we also looked at a range of the service’s paperwork including care plans, risk assessments, staff personnel files and medication. Prior to our visit we received 29 completed surveys back from residents, their families and staff asking for their opinion of the service. This is a good response and shows us that the service ensures it gives people the opportunity to comment on its performance. We also talked with 2 care managers from the learning disability partnership to gain their views about the service. One requirement and 4 recommendations have been made as a result of this inspection. What the service does well: This service is clearly rated by both residents living their and their families. Comments we received from relatives included: ‘it gives an excellent service for my daughter. Staff always most helpful and there’s clear affection for her by all staff’. Another: ‘in general I am very happy with the service provided for my son who seems very happy as a resident’- and ‘299 The Rowans always appears a friendly and happy home’. The home’s admission procedures continue to be thorough ensuring people know that when they move in, their needs will be met. Some staff reported a high level of satisfaction in their job. One told us: ‘I have worked for Cambridgeshire Mencap for 7 years. I have found it to be a company that promotes good value’s. Training is good ensuring and residents receive their care from competent and knowledgeable staff. One staff member reported: ‘Training has always been provided and sought to meet areas of concern’. Residents told us that staff helped them in a way that they liked, that they chose what they wanted to do each day and that they enjoyed the various activities and outings that took place. Residents are involved in recruiting and Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 6 selecting prospective staff members giving them a real say in the people who are to support them. A local care manager told us that the service dealt well with a recent safeguarding incident concerning a member of staff’s care practices. 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. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 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 home’s admission procedures are good ensuring that people are appropriately placed where their needs can be met EVIDENCE: The service carries out full assessments of people’s needs before they are admitted, which includes collecting information from a range of health and social care professionals, the person themselves and significant people in their life. Prospective residents also visit the home many times to give them the chance to meet other residents and to assess the facilities on offer. No new residents have been admitted since we last visited but we have good evidence from previous visits that the home meets these standards well. Residents who completed our survey told us they had visited several times before they moved in. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 9 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): 6,7,8,9, 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. Residents’ needs are well documented in their care plans ensuring staff have the information and guidance to support them well. EVIDENCE: We viewed the care plans for three residents and also sat with one resident and went through her plan with her. This resident told us that what was written was a good reflection of her needs and the information was accurate. The plans we read were comprehensive and detailed, giving staff a good understanding of residents’ needs and what they must do to meet them. The plans had been reviewed regularly with evidence that residents had participated in planning and reviewing their care. However, some of the plans were not in format that could be easily understood by the resident and more should be done to provide the information in a more accessible way (such as pictures, symbols, etc) Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 10 Residents we spoke to told us they choose what they do and one resident wrote in their survey: ‘I make most of my own decisions about things I do’. For example, on the day we visited one resident had decided not to go to his Concrete workshop that day as he was feeling too poorly. Residents are actively encouraged to participate in all aspects of life in their home. All are encouraged to undertake daily living skills such as shopping, preparing meals, cleaning and using public transport. One resident told us that she cooks twice and also cleans her room with support. Another, that he enjoyed going into town by himself. There are regular meetings with residents where they can raise issues and where they are consulted on a range of matters. We viewed some of these minutes which showed that issues such as activities, holidays, key working and the menu were discussed with residents. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15, 16 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. Residents live busy and active lives and are supported to maintain close personal relationships. EVIDENCE: On the day we visited residents we met were undertaking a range of activities; some were attending day services at places such as Rowan Wood, Hester Adrian, the Phoenix Trust, Snakehall, Farm OWL at Sawston. Others were planning to go shopping, to the park or to work placements and one resident was getting ready for a local over 60s club which she attends. Both staff and residents told us of recent trips to the seaside, Milton Fete, the zoo and an aerodrome and car boot sales. Residents we spoke to clearly enjoyed these activities. One relative told us: ‘my sister’s daily placements have been well Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 12 suited to her needs. Social activities, outings and holidays have usually been to her choice’. Residents also go on holiday every year which they help choose and plan and there are already plans afoot for some residents to go to Spain later in the summer. One resident told us that she had just returned from a terrific holiday, where the accommodation was very nice and the weather very good Although residents have access to a number of vehicles to transport them there is a lack of qualified staff that are able to drive them. One relative felt that the home should: ‘organise drivers and transport better to make the most of day care packages’ Staff support residents to develop and maintain intimate personal relationships and recently supported one resident to holiday with her boyfriend. Her boyfriend also visits the home regularly and she visits him at his home. The home organised an engagement party for another resident and their fiancé. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People 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. Residents’ health needs are monitored and supported by staff. EVIDENCE: Residents are supported by staff to access health services and records we viewed showed that they saw a range of health care professionals. They are also weighed regularly to ensure they are maintaining a healthy weight. One resident has recently been diagnosed with Parkinson’s disease and staff told us they were in regular contact with the Parkinson’s disease nurse specialist and occupational therapist for advice and support to meet his needs. A number of the residents have lived at the home for many years and are getting older: staff raised the need with us to be, as one reported; ‘better equipped for the needs of aging service users’ We checked medication storage a sample of residents’ medication administration records (MAR). These were generally very good with staff clearly recording when they gave residents their medication and at what time. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 14 However we noted the following shortfalls: some hand written additions to the printed MAR sheets had not been signed, dated or checked by a second person to ensure their accuracy; the date on which bottles of liquid medication had been opened had not been recorded and staff who actually administered creams did not sign the MAR sheets themselves, but relied on other staff to do this. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People 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. Residents’ complaints are taken seriously and they are protected by the service’s policies and procedures in relation to safeguarding vulnerable adults. EVIDENCE: Residents who completed our survey told us that they knew who to speak to if they were not happy. Relatives too told us they knew how to make a complaint and that the home responded appropriately when they did. Information about how to complain is available in a simple format around the homes for residents and their visitors to see. All staff receive training in safeguarding adults so they have an understanding of the adult protection system and the part they play should the need arise. One care manager we spoke with told us the service used to be not so good at reporting important safeguarding issues to them but things had improved considerably. There has been one incident concerning the protection of vulnerable adults in the last year. The home responded swiftly and appropriately to this by suspending the member of staff concerned whilst the case was investigated. All residents have a bank account in their own name to which two senior managers are the only signatories. We checked the bank books and cash sheets for two residents which showed us that written records of all transactions undertaken on behalf of residents were maintained, along with Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 16 appropriate receipts. Senior managers also regularly check these accounts to ensure that residents’ money is properly spent and accounted for. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People 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. Residents live in a comfortable and safe environment. EVIDENCE: We visited two of the houses; Pauline Burnet House itself and also 299/309 The Rowans. Both the properties were well maintained and clean with good facilities for the residents living there. Both houses had good sized gardens, giving residents easy access to fresh air and sunlight. At Pauline Burnet House there is a snozelem area with sensory equipment for residents to use. Two residents showed us their bedrooms which were very personalised, comfy and contained good quality fixtures and fittings. Both told us they liked their bedrooms. We saw no health and safety hazards during our visit. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 18 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, 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. EVIDENCE: The home has experienced difficulties in recruiting staff, forcing them to rely on agency staff to cover vacant shifts. This was clearly a concern for both relatives and current staff. One relative told us; ‘I appreciate the difficulties the organisation experiences but I would prefer to see more continuity of staff, residents with the types of difficulties using the service are often unhappy with too much change’. Another stated; ‘staff turnover seems to be quite highthere must b e a reason for this!’ Staff also raised this concern, telling us that more permanent members were needed, and that residents had found the changes unsettling. Despite this, residents we spoke to told us- ‘I like the staff, another reported- ‘they are not horrible they are nice, good friends’. A relative commented- ‘all staff appear to have masses of patience’. Interactions we viewed between staff and residents were mostly respectful, appropriate and enabling, with residents given genuine choice where necessary. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 19 We checked the personnel files for two recently appointed members of staff. Each contained evidence that appropriate checks and references had been obtained before the person was allowed to start working at the home, ensuring that only the right people are employed to look after vulnerable adults. However we noted that there was no evidence that one staff’s member criminal conviction had been discussed with her following its disclosure on her CRB. Some residents are involved in interviewing and recruiting prospective staff, giving them a real say in choosing the people who are to look after them. This is excellent practice. Staff who completed our surveys told us that they had received a good induction, that they received training relevant to their role (training files we checked also evidenced this) and that they received enough support from their manager and met with them to discuss how they were working. However, we checked the supervision records for a number of staff on duty which showed us that they had not been receiving it as regularly as recommended by the standards. One person had only received one supervision in 7 months. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42,43 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. Resident live in a home where their views are sought the quality of the service they receive is actively monitored. EVIDENCE: The management structure of this service has changed significantly since we last visited. Before, the service consisted of five separately registered care homes (Pauline Burnett House, Rosewood and 2 Cambridge Rd, 299-399 the Rowans, Oaks and Cinnabar, and 361 The Rowans). In place of an individual registered manager for each small home, there is now one manager for all of the separate homes. She is supported by 3 service managers each of whom have responsibility for two homes. Day to day control of each small home is provided by an assistant service manager. Staff had mixed views about this Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 21 new structure: one member told us it was working well and ensured more consistent standards across all the homes; another stated ‘I never know what is going to happen next and we’ve lost a lot of good workers as a result of all the change’. The new registered manager is a qualified social worker with a wide experience of managing a range of care services. She has an NVQ level 4 in management and has also undertaken a range of training courses relevant to her role Care managers we spoke with had no major concerns about the service, although reported that sometimes the quality varied depending on the ability of the assistant service managers. They felt that communication between them and staff was ‘improving’ and that at a number of disagreements between the staff team at Pauline Burnet House, which had adversely affected residents, had been resolved. The home checks the quality of the service it provides in a number of ways: a member of Cambridgeshire Mencap’s board of directors visits each month to check the properties and talk with staff and residents; surveys are regularly sent out to residents and their advocates asking for feedback about how the service operates and the service managers regularly undertake audits of care plans, medication records and staff files in each house to ensure high standards are being maintained. We checked a sample of records including portable appliance testing, hoist service records, fridge and freezer temperatures records, call bell testing which showed us that the home regularly checks and maintains its equipment to ensure its safety and effectiveness for residents. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 22 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 3 4 3 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 3 25 x 26 x 27 x 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 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 3 Version 5.2 Page 23 Pauline Burnet House DS0000015101.V376485.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Regulation YA20 Standard 13 (2) Requirement Only the staff that actually administer creams to residents must sign the MAR sheets. The MAR sheet must not be signed on their behalf. Timescale for action 01/09/09 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 YA20 Good Practice Recommendations Hand written additions to the printed MAR sheets should be signed and dated and checked a second person to ensure their accuracy The date on which bottles of liquid medication are opened should be recorded The use of agency staff should be reduced as much as possible so that there is a stable and regular staff group and so that residents receive consistent care from staff who know them well. Staff should receive regular and recorded supervision meetings at least 6 times a year. DS0000015101.V376485.R01.S.doc Version 5.2 Page 24 2. 3 YA20 YA33 4 YA36 Pauline Burnet House Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Pauline Burnet House DS0000015101.V376485.R01.S.doc Version 5.2 Page 25 - 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. 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