Care Home: Sherwood Court

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What the care home does well Staff worked well with the residents and understood how their needs were to be met. The manager is working well to improve the systems and paperwork in the home.There is a driver at the home who supports the residents to go out into the local community. What has improved since the last inspection? New furniture, carpets and redecoration has been carried out at the home.The garden has been improved.The kitchen has been decorated.The home have now got lockable gates to improve the safety of the people who live at the home.There are various activities on offer in the home.A choice of healthy food is available. What the care home could do better: The heating system should be effective in supplying aBoilercomfortable temperature to all areas of the home, as on the day of this inspection two bedrooms were very cold without any heating being provided.All care records should be kept up to date and reviewed on a regular basis.Meal times should be reviewed to ensure that residents have a choice about where and who they take their meals with. Medication procedures must be reviewed to ensure that all residents are safeguarded in light of the recent errors that have occurred. The Quality Assurance process should include all aspects of the service to ensure the best service is provided for those who live at Sherwood Court.Staff must be provided with Mental Capacity Act, Deprivation of Liberty safeguards and safeguarding training to ensure that they have a clear understanding of procedures to follow. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Sherwood Court The Common Hatfield Hertfordshire AL10 0NX The quality rating for this care home is: one star adequate service 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: Julia Bradshaw Date: 1 8 1 2 2 0 0 9 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 Inspection report CSCI Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2010) 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. www.cqc.org.uk Internet address Information about the care home Name of care home: Address: Sherwood Court The Common Hatfield Hertfordshire AL10 0NX 01707262405 01707259563 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) : Caretech Community Services Ltd care home 8 Number of places (if applicable): Under 65 Over 65 8 8 8 8 learning disability physical disability Additional conditions: Date of last inspection A bit about the care home Sherwood Court is a residential care home for eight service users with learning and physical disabilities. The Provider is CareTech Community Service Limited. The building, a bungalow, is situated in the town of Hatfield. It is within walking distance of the supermarket, local shops, and public transport. There is a small parking area in the front of the building. There is a lounge, dining room, laundry and kitchen. Shared bathroom and toilet facilities are nearby. There is a garden area to the rear and a patio overlooking the lounge. For up to date information on the fees contact should be made with the manager. Information about the service can be requested from the manager. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This was the first inspection carried out by the Care Quality Commission. We looked at how it felt for people living at the service. We looked at the information that we received from the service including the Annual Quality Assurance Assessment (AQAA) this gave us information from the manager and how the home was meeting the needs of the people who live at the home. It also provided us with some information on staffing levels and the name of the social service work teams involved in the home. We looked at care records. We looked at the care that was being provided by the staff. We talked to the residents and staff at the home. We looked around the home. Information booklets and a copy of the most recent inspection report should be available in the office or the reception area of the home. What the care home does well Staff worked well with the residents and understood how their needs were to be met. The manager is working well to improve the systems and paperwork in the home. There is a driver at the home who supports the residents to go out into the local community. What has got better from the last inspection New furniture, carpets and redecoration has been carried out at the home. The garden has been improved. The kitchen has been decorated. The home have now got lockable gates to improve the safety of the people who live at the home. There are various activities on offer in the home. A choice of healthy food is available. What the care home could do better The heating system should be effective in supplying a Boiler comfortable temperature to all areas of the home, as on the day of this inspection two bedrooms were very cold without any heating being provided. All care records should be kept up to date and reviewed on a regular basis. Meal times should be reviewed to ensure that residents have a choice about where and who they take their meals with. Medication procedures must be reviewed to ensure that all residents are safeguarded in light of the recent errors that have occurred. The Quality Assurance process should include all aspects of the service to ensure the best service is provided for those who live at Sherwood Court. Staff must be provided with Mental Capacity Act, Deprivation of Liberty safeguards and safeguarding training to ensure that they have a clear understanding of procedures to follow. 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 Julia Bradshaw CQC East Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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.cqc.org.uk. You can get printed copies from enquiries@cqc.org.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 . Information about the service is kept up to date and provided for all prospective users of this service and everyone wishing to enter the home has a full assessment of need completed. This ensures that all parties can be sure the home can meet all individual needs. Evidence: Two care plans were reviewed and evidence gained regarding the initial assessments that are carried out to access if the service can meet the needs of the person. Information is held regarding the person’s history and current needs. An assessment of each persons needs and aspiration are made before the person moves into the home. The manager completes these assessments. The service also receives and seeks external specialist support to meet the individuals needs. Whole life and care programme approach reviews occur to support people in achieving and reviewing individual needs, goals and aspirations. The admissions procedure to the service includes trial visits for the person to make an informed choice about where to live. A contract is then drawn between the service provider and the person using the service. These contracts should be signed by either the person using the service or their representative. The terms and conditions of the home are agreed in writing so that people are clear about the roles and responsibilities of all those 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Care plans are insufficient in detail to ensure that people using the service are assessed, reviewed and safe from risk. Evidence: People living at Sherwood Court have an individual care plan and an allocated key worker to support them in the service. Pen pictures are in place for each person and provide good information goals, likes and dislikes of the individual. However there is a need to ensure that all care plans are signed and dated to ensure they are active, up to date and that all relevant persons have agreed the care plan. Individual daily notes and guidelines for the people living at the service were available. People who use the service are supported within the Whole Life Review process. Ranges of risk assessments are completed within the service for necessary actions. Activities and outings enjoyed by people living at Sherwood Court determine that service users are supported to take risks as part of their lifestyle. Risk assessments are in place. However on the day of this inspection one risk assessment completed in relation to the use of bed rails was dated 4/4/07 and had not been reviewed or updated since the initial assessment. Another service users records stated that they required bed rails but there was no consent or risk assessment available to confirm the Evidence: service user or their representative had been consulted regarding this. As part of the case tracking process of two people care plans, one persons weight chart were found to be blank for the months of January, June and September 09 and the other persons bowel chart was last dated 22/08/09, although this should have been completed on a daily/weekly basis. Both these omissions could impinge on the service users health and welfare. 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 . People who use the service can feel assured that they will be offered and receive appropriate opportunities for social/leisure and community involvement. People are provided with well balanced meals to assist in healthy living. Evidence: A day care programme for each person is maintained within the individual care plan. Staff support and encourage people to maintain and develop social, emotional, communication and independent living skills. The person in charge stated that all residents attend daycare placements on a part-time basis, except for one person who currently does not have a daycare placement. Daycentres attended by people at Sherwood Court are Hornbeams, Oakmere and Briars Lane. People also have enjoyed holidays provided by the home to Blackpool in the months of October and November. The service is centrally located, and is within a short distance from shops and the local community amenities. The service seeks to reflect racial and cultural diversity of people living within this service through celebration of, and awareness of different cultures, religions and festivities. During the inspection staff and people were observed to interact equally with one another. Evidence: People are supported appropriately to take part in activities within the home. Individual needs, choices and preferences are considered. People living at Sherwood Court frequently enjoy going out for lunch and going on shopping trips. People have also recently taken part in trips to the theatre, swimming sessions, bowling and the local cinema. There were records seen on the day of this inspection to confirm that service user meetings are held regularly. The last minutes seen were dated 18/10/09 and 8/11/09. Menus were available and provided on a rolling four-week basis, which appeared well balanced and with a range of choices. Records are maintained of food consumed and offered. People are offered choices and encouraged to support in the kitchen as appropriate. However people who have difficulty in communicating their needs and choices verbally, could be further assisted with their choices, with the introduction of a pictorial menus. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Those who use the service are currently placed at risk due to the unsafe procedures in relation to the effective administration and monitoring of medication. Evidence: All personal care provided is individual to each persons needs. Assessments are completed ensuring that the method adopted is person centered which in turn should provide an holistic approach. People living at Sherwood Court are supported appropriately with aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dietitians. A detailed policy is in place to support the safe administration, storage and receipt of medicines. Staff spoken to on the day of this inspection confirmed that they had been both inducted and trained in the administration and safe keeping of medication. The service use the dossette system to dispense medication. However the MAR sheets could benefit from having a recent photograph on each individual sheet to assist staff when administering medication. Nobody within the service currently holds their own medication. The recently completed AQAA states that Medication training for staff are completed and closely supervised by the manger with audits and checks. Medication errors are reduced considerably compared to the previous year. Staff confidence has improved. However during the inspection of the medication procedures within the Evidence: home it was discovered that there have been a total of ten medication errors since October 2009. The errors included people not receiving the correct doses of medication and several omissions of prescribed medication. There must be a robust system in place that identifies errors at the earliest possible stage in order that these can be rectified and limit the risks to people living within the service. Also discovered were a bottle of eye drops which were stored within the main medication cupboard which had the manufacturers instructions that they should be stored at below 25 degrees. The most recent recorded temperature for this cupboard was 26 degrees. The temperature records for this cupboard fluctuated from 22 degrees to 28 degrees throughout the months of October, November and December. Two bottles of lactulose were also being stored within the same cupboard, with a manufacturers instruction to be stored below 25 degrees. Therefore the medication cupboard must be relocated to an area where the temperature can be maintained and safely controlled at 25 degrees and under, for specific medication to remain effective. There was no running record for the administration of paracetamol for one person and therefore the paracetamol could not be reconciled. The manager must ensure that all staff who administer medication have been fully inducted and assessed as being competent to do so. The AQAA states that Medication errors are dealt in a swift and timely manner by the manager. On making an error staff are suspended with immediate effect until an investigation is carried out and a satisfactory action plan drawn out. The documentation was unavailable to evidence and confirm that this procedure had been followed in all ten medication errors that were discovered. 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 . People living within this service can be assured that they will be protected from abuse and any complaints about any aspect of their care are listened to and responded to, in order to ensure they are supported and protected. Evidence: The service has a detailed complaints procedure in place. A record is maintained of any complaints made detailing actions and outcomes as necessary. The recent AQQA stated that there have been four complaints received since the last inspection was carried out. The AQAA states that these have been resolved to a satisfactory conclusion for all parties concerned. There have also been two safeguarding referrals and two safeguarding investigations, which the AQAA states have also been resolved. A detailed procedure is in place to ensure that people using the service are protected from abuse and harm. Staff employed within the home must be subject to enhanced Criminal Records Bureau disclosure. The manager should endeavour to produce all documentation relating to the people living within the home should be produced in a format that can easily be understood and not just in the written word. Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The environment is adequately maintained and promotes a homely, comfortable safe space for people to live in. Evidence: Several areas of the home have been redecorated since the last inspection was carried out, including new carpets in the hallway and lounge, bedrooms have been redecorated and new bedroom furniture has been purchased. There was also new furniture in the lounge area to provide a more homely feel. The AQAA states that in the past twelve months. The front garden has been revamped. The kitchen has been refurbished and the carpets have been steam cleaned. The front gates have been repaired and are now able to be locked at night thus improving security. Everyone living at Sherwood Court has their own, single room that has been decorated to reflect their own interests, hobbies and personal style. All areas of the service were maintained to a good standard without any obvious areas requiring repair or replacement. However two bedrooms that the inspector was shown were particularly cold and the underfloor heating appeared not to be fully effective. This was feedback to the person in charge at the end of the inspection day, in order for it to be addressed immediately. Two people spoken to were quite happy to show the inspector their own rooms and confirmed that they had been involved in selecting their own colour schemes and soft furnishings. The laundry facilities are domestic in style and appear to manage the current workload effectively. Evidence: The service was clean and odour free on the day of the inspection. The cleaning is carried out by the care staff and with people assisting where possible. The communal areas of the services are decorated and furnished to an acceptable standard and there is a selection of home entertainment equipment for service user to access. However the dining room appears very small and cannot accommodate all the service users eating their meals at the same time, if they choose to do so. Therefore on the day of this inspection the staff explained that people eat their meals at two separate sittings. The manager must provide evidence to confirm that the people using this service choose to eat their meals separately within the dining room and not because the facilities do not allow everyone to sit and eat their meal together. The staff were asked this question on the day of this inspection and stated the reason why people sat separately was because there was not enough room for everyone to eat together. Fire records were checked and evidenced confirmed that these checks were being carried out effectively. The latest fire drill was carried out on the 12/11/09. The emergency lighting was last checked on the 4/12/09 and the weekly fire checks were carried out on the 19/11/09. The annual fire check was carried out on the 17/3/09. The record for the monitoring of hot water temperatures could not be located and therefore the manager must ensure that records relating to all health and safety checks must be available and monitored closely. 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 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 can be confident that they will be supported by staff who have been appropriately recruited, experienced and trained to ensure their continued safety. Evidence: The rota was checked on the day of this inspection and the service demonstrated that adequate staffing is provided on both day and night shifts. There were four staff on duty providing care to the eight people using the service plus the manager, who is supernumerary. Observations during this inspection confirmed that these staffing levels were adequate in supporting people with their everyday care need. The service currently has a deputy post vacant and also several care assistant vacancies. The AQAA states that Positive and active recruitment drives to fill permanent positions. The vacant hours are currently covered by bank and agency staff. There was evidence to confirm that staff meetings are being held and minutes were seen for meetings held on the 8/12/09 and 2212/09. Staff spoken to stated that they had received epilepsy training (27/7/09) medication training (28/10/09) first aid training (27/03/09) food hygiene training (20/03/09) and moving and handling training was completed on the (19/5/09). However the manager must ensure that training in The Mental Capacity Act , Deprivation of Liberty Safeguards and Safeguarding training is also provided to all staff working within the service. Evidence: The four staff spoken to confirmed that they received supervision regularly. The recently completed AQAA states that Staff supervisions training and clearly defined line management. All policies and procedures relevant to this service were appropriately held on site. Staff files for people working at Sherwood Court were not checked as the manager was not on duty and therefore access to this confidential information was not possible. The previous inspection highlighted no concerns in this area. However the recently completed AQAA states that Newly recruited staff goes through mandatory and nonmandatory checks and training. All staff is inducted prior to their commencement of position. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The management systems must improve in order to ensure all aspects of the service are monitored and assessed ensuring that people are provided with the best possible care, safeguarded and protected from harm. Evidence: The manager ensures that supervisions and staff training are held regularly and four staff spoken to on the day of this inspection staff confirmed that they feel supported by the current manager. People are safeguarded from harm by the homes recruitment procedures, safeguarding training and the complaints procedure. The service should endeavour to provide all information that is relevant to the people living within Sherwood Court in pictorial format as currently some service user information provided is only produced in the written word and therefore restricts peoples understanding. The manager should further develop the Quality Assurance system in all areas of the service in order to ensure there is regular monitoring and reviewing to improve areas of development, with a particular focus on medication systems, where there were several errors discovered and an unclear pathway with regard to any action plan made in order to eradicate these errors re-occurring. All records inspected were secure and were up to date and held in accordance with the Data Protection act 1998 ensuring that peoples rights and best interests are safe Evidence: guarded by the homes polices and procedures. Care plans must always be signed by the service user or their representative. Risk assessments must also be created when ever a risk is identified. One file inspected did not have risk assessments in place for the use of bed rails. Another file had a risk assessment in place but this had not been reviewed since 2007. Some weight and bowel charts were incomplete and generally the recording processes must improve and be monitored more regularly. The general standard of fire checks and recording is good and fire records on the day of the inspection were up to date and recorded accurately. There are systems in place in order to ensure that everyone living, working or visiting this service are protected from cross infection. It is recommended that the service monitors the water temperatures on a daily basis, to ensure peoples health and safety is protected. The manager must ensure that all staff receive training in the following areas in order to ensure people are fully protected and staff are provided with the underpinning knowledge to provide the best possible service to people. This includes, Safeguarding training, Deprivation of Liberty Safeguards and the Mental Capacity Act. training. There was a random check of service users monies where one individual ledger proved to be inaccurate. There should be a system in place, as part of the overall Quality Assurance programme to ensure monies are audited on a regular basis in ensure discrepancies are identified at the earliest possible stage. 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 6 15 Care plans must be signed by either the service user or their representative 29/01/2010 To ensure that people using the service have consented to the content of their care plan. 2 9 13 Risk assessments must be created and reviewed in order to maintain peoples health and safety. 29/01/2010 To ensure that risks are identified and peoples safety is maintained. 3 20 13 There must be a robust system in place for the administration and monitoring of medication, in order to ensure that people are protected and their health and safety is not compromised by inadequate recording and quality 12/02/2010 assurance systems. To ensure peoples health and safety is protected at all times. 4 20 13 The medication cupboard should be relocated to an area where the temperature of this cupboard can be controlled effectively and safely. 26/02/2010 To maintain peoples health and safety. 5 37 24 The service must have an effective Quality Assurance system in place to record and monitor all standards within the home and rectify any inadequacies within the service provided. 31/03/2010 To ensure people are protected and are provided with the best possible service. 6 38 24 The manager must ensure 26/02/2010 that people are not placed at risk from inadequate recording systems within the home, including care planning, the administration of medication and risk assessments. To ensure that care plans, medication systems and 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 17 The service should endeavour to produce a pictorial type menu to assist people who are unable to communicate their choices verbally, to ensure that everyone living within the service have the opportunity to have the same degree of choice regarding the meals that they would like to have. Helpline: Telephone: 03000 616161 or Textphone : or 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 © (2010) 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. 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