Care Home: Sovereign Court

What the care home does well Staff are caring and people living in the home feel well supported. The management team are working hard to improve systems to ensure that person centred care is provided. The home is well maintained and has a homely feel. What has improved since the last inspection? The requirements made at the last key inspection to ensure hot meals are provided and to provide suitable drying facilities in the laundry have been met. Work is ongoing to ensure care plans meet peoples needs and become a working tool for staff providing care and support. Significant improvements have been made to the management of medicines in the care home since the last random inspection, and a new medication supply system has been introduced. Staff handling medication have had their competence assessed and medicine administration records (MARs) are well maintained. What the care home could do better: Staff training must be arranged to ensure a well trained workforce is available to people living in the home. Recruitment processes must be robust and inductions carried out to assess people capabilities before working unsupervised in the home. Clear guidance should be provided to staff when new systems are introduced into the home. Additional information on when medicines prescribed to be given `as required` or `as directed` should be provided in care plans and with MAR charts. Key inspection report Care homes for adults (18-65 years) Name: Address: Sovereign Court Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Allan Helmrich     Date: 2 5 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Sovereign Court Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA 01912716151 01912716151 noemail Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Jennifer Houghton care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The Home may continue to accommodate one named person over the age of 65 years in the category of mental disorder MD(E) The home may not admit any person under the age of 40, or over the age of 65, without the prior agreement of the CSCI. The home may not take any emergency admissions without the agreement of the CSCI. Date of last inspection Brief description of the care home This is a purpose-built care home that opened for persons with acquired brain injury and Huntingtons syndrome, aged between 40 and 65 years. It is a single storey building, with twelve single bedrooms, all ensuite, lounge, smoking lounge and dining room. It is situated on the outskirts of Newcastle upon Tyne, on a bus route, and fairly close to local shops. The statement of purpose and service user guide is being updated and the recent Care Homes for Adults (18-65 years) Page 4 of 31 2 7 1 1 2 0 0 8 12 Over 65 0 Brief description of the care home inspection report was available at the front entrance. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 stars. This means the people who use the service experience good quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. The inspection was arranged following a random inspection carried out on 1st October 2009 when some issues with the care provided were identified. Before the inspection we reviewed information we have received since the last key inspection on 27th November 2008. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The providers view of how well they care for people. The views of people who use the service, their relatives, staff and other Care Homes for Adults (18-65 years) Page 6 of 31 professionals. During the visit we: Talked with people who use the service, staff, the home manager, service manager, operations manager and a visitor. Looked at information about the people who use the service and how well their needs are met. Looked at other records that must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last inspection. We told the provider what we found. Surveys were provided for residents, staff and professional visitors. Five surveys were completed by people in the home, five by staff and one by a professional visitor. Information from these sources is used in the report. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 31 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides sufficient information to enable people to make an informed choice before moving into the home and collects appropriate information to limit admitting someone whose needs cannot be met. However full information is not readily available to staff to ensure individual needs are met. Evidence: When asked, the manager provided a range of information about the service. The information was clear and informative. It was also available in other formats including audio tape. Details of recent changes in the management structure are not included yet. Three of the five people who completed a survey recorded they had received sufficient information before moving in and one person could not remember. A new admission document is being trialled to provide a comprehensive statement about the individual. This is a large document that was not fully explained to the new manager before being used to obtain information relating to the newest resident. Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: When fully operational this document will provide the required information to enable a decision to be made as to if the home can provide appropriate support. Details of where and who was involved in providing pre admission information is not recorded. This is useful in determining the quality of information provided. The file included historical information provided by the local authority before admission. Some care files seen were new and information in previous files was not immediately available. This included some pre admission assessments and care plan evaluations. Staff spoken to were aware of peoples needs but not fully appraised of the new structure of care planning being brought in by management. This means people may not get the standard of care promoted in individual care files. Care Homes for Adults (18-65 years) Page 11 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New systems are being introduced and people are consulted on a daily basis as to what they choose to do but there is a lack of planning to promote and encourage new aspirations and the achievement of goals. Evidence: As mentioned previously a new system of collecting and recording information about the individual is being introduced and therefore the information available was not always fully developed. Old files have been archived and some useful information about people such as previous evaluations of their care plans has not been recorded in the files in use. Four case records were reviewed. One of these was developed by a service manager as a model for the production of other plans. The service manager stated that she had introduced the plans to the staff team. However when questioned, staff felt unsure of how they were to be used. Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: The system being introduced takes information collected as part of the admission process and uses this to inform up to seventeen standard care plans. Some of these plans were specific to individual needs but others were produced when no need had been identified. A base line assessment of people is also done, identifying the specific abilities people have relating to; using public transport, using a telephone, household tasks, etc. However, non of the plans reviewed identified a goal to be achieved by anyone. Goal plans promote independence and progression. The plans did contain assessment of risks associated with daily living. And when an issue was identified such as any support required when outside the home, a care plan is produced to ensure staff awareness. People spoken to said that they choose what to do and where to go. Staff were observed during the inspection asking people to make choices and respecting their decisions. However in a survey returned by five people who live in the home, only one person stated they decide what to do each day. Three stated they sometimes do and one stated never. Comments made were; the home could provide more outings, trips to town or meals out. More activities could be provided when plenty of staff are on. I would like to get out a bit more. I am restricted as to what I can do due to my illness. Care Homes for Adults (18-65 years) Page 13 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to live a lifestyle of their choice but more could be done to provide a better standard of activities. Evidence: The new manager is reviewing the activities provided in the home. Some information about activities is recorded but this was insufficient to establish if people are well supported in this area. One case record contained an activities sheet but this was blank. Another file contained an activities programme for each day of the week, however, the manager could not confirm that these activities had taken place. Friends and family are encouraged to visit at any time. Most people see relatives and friends regularly and some are able to go out unsupported. People spoken to said they choose what to do and they were generally content with their lifestyle. However those who need support in the community said more could be done to get them out. Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: No one currently living in the home has employment but people are supported and encouraged to assist in the home should they choose. They assist with shopping tasks, use local community facilities and local transport. Some people visit the nearby social club and one person attends a sewing club. As identified previously no one has any form of goal plan to promote fulfilling activities of their choice. Staff and people living in Sovereign Court appear to get on well and they were seen in conversation throughout the inspection. Everyone spoken to said they enjoy the meals provided in the home and those asked were aware of the menu choices. A notice board identifies the meals of the day. Meals are provided by Sovereign Lodge, a larger home for older people on the same site. However the manager said that anyone not wanting the menu choices were provided with individual meals of their choice. This was confirmed by people spoken to. People were well supported during lunchtime which was a pleasant affair enjoyed by all. Care Homes for Adults (18-65 years) Page 15 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well supported to maintain good health but staff training must be reviewed to ensure professional healthcare standards are met. Evidence: The case records in development identify that people are regularly seen by appropriate healthcare professionals. But due to the archiving of old files it was not easy for staff to ascertain when periodic health checks such as dentist and optician appointments were last attended. In the case records reviewed, health monitoring was in place. Peoples physical and mental health needs are identified and where a need is identified an action plan is produced to inform staff of the support to be given. People are regularly weighed and a set of sit on scales is available in the home to aid this action. One person using percutaneous endoscopic gastrostomy (PEG) feeding tubes is supported by staff in the home. These staff have not been assessed recently by the community nursing service to ensure they provide the correct support and the member of staff assisting on the day of inspection had not received this training at all but was shown by a previous manager of the home. Other than this people were seen to be well supported by the Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: staff team and those spoken to all praised the homes staff. A healthcare professions commented in a survey; All care staff provide individualised care and support. They act in a professional capacity and maintain high standards of care. People living in the home said; Staff look after me well. Staff keep me safe and if I need anything I just have to ask. The following information was provided by the pharmacist inspector; Medicines storage within the home is secure and medication is stored within appropriate temperature limits. The ordering, receipt and disposal of medicines is well managed. Examination of medication records and practices observed during the visit suggest that people living in the home can expect to receive their prescribed medicines correctly as intended. MAR charts were fully completed with no gaps, although we noticed that a single dose of Metformin had been administered, but not recorded, the previous day. MAR charts are checked twice daily at the end of staff shifts and should identify any omissions in the administration records. All MAR charts were printed and there were no handwritten entries. There is no facility on the new MAR chart to record known allergies to medicines. One service user was prescribed Diazepam on an as required basis, but there was no guidance in the care plan to help staff decide when treatment might be appropriate, and the MAR sheet itself could not be located at the time of the visit. Another person was prescribed up to eight Macrogol sachets daily but there was no guidance on how frequently doses should be administered. Medicines with a limited use once opened were not marked with the date of opening although it is the practice in the home to replace all medication monthly. The controlled drug cupboard appears to meet safe custody regulations and records were accurate and well maintained. Regular stock checks are carried out on controlled drugs. Audit of the medication system is not regularly carried out, the last audit being done in April 2009. Regular audit helps identify any medication issues promptly and helps confirm that staff are closely following the homes medicines policy. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: The medicines policy itself should be supported with more detailed guidance on the local procedures to be followed when handling medication in the home. The competency of staff to handle medicines safely has been recently assessed and detailed records of these assessments are maintained. Care Homes for Adults (18-65 years) Page 18 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured their concerns and complaints will be taken seriously and while staff are sensitive to peoples needs further training related to the protection of vulnerable people will enhance this area of support. Evidence: Details of the homes complaints procedure is provided in the information pack given to people as they are admitted and a copy is posted in the home for the benefit of visitors. Everyone surveyed was aware of who to speak to if they have concerns or complaints. Staff spoken to were aware of the principles of safeguarding vulnerable people and support information is available in the home, but training in this area of care has not been provided to all staff and some were not aware of the homes policies and procedures related to this. Care Homes for Adults (18-65 years) Page 19 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe comfortable place that meets the needs of the people who live there. Evidence: The home provides bungalow style accommodation with some office space in the roof area. It is set in a cul-de-sac with a larger home for older people. There is ample car parking. Nearby there is a local shopping centre and transport links to the town centre. The home provides comfortable living space that is clean and reasonably well maintained. People spoken to said they enjoyed living there and those who completed a survey recorded the home is always or usually fresh and clean. Those bedrooms seen were personalised and people spoken to said they kept their rooms they way they liked. Corridors contained picture frames with photographs of happy times. People were seen using all areas of the home. There is a comfortable lounge and a small smoking lounge that is well used by the people who currently live there. The kitchen and laundry are domestic in size and some staff felt the laundry should be upgraded to provide a better facility. The temperature around the home was also easily controlled and very pleasant with the exception of the upper staff areas were Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: the temperature was uncomfortably cold throughout the day. Care Homes for Adults (18-65 years) Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home are supported by a caring staff team. But the training and induction provided by the company may not provide them with sufficient skills to understand and meet the needs of people who live in the home. Evidence: During the inspection sufficient staff were on duty to ensure the wellbeing of the people who live in the home. Management are currently reviewing training needs and outstanding training requirements are being addressed. Currently only four members of the care staff have a National Vocational Qualification (NVQ) and a further four are working towards this qualification. Most of the staff team require update training as recent problems with the in house trainer has resulted in training not being efficiently provided. Staff spoken to stated they felt supported but accepted that their training needs were not met and that some of the home systems being introduced had not been fully explained to them. Staff commented that morale id good within the staff team and that regular meetings take place where their views are listened to. Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: Three staff files of recent recruits were reviewed. Each contained information to demonstrate Criminal Records Bureau checks were obtained and references requested before employment. However two files only contained one reference and there was no information to show staff were inducted before being allowed to work without supervision. Competence should always be assessed before care staff work with vulnerable people. Care Homes for Adults (18-65 years) Page 23 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the homes systems are not yet fully developed by the management team, the home is safe and is run in the best interests of the people who live there. Evidence: The manager who was appointed in July 2009 is not yet registered with The Commission. She has worked in a senior capacity in care homes in the public sector, has a NVQ level 3 in care and is working towards a management qualification. Since the Random Inspection in October when some issues of concern were identified she has been supported to develop and improve systems in the home by a company operations manager and service manager. Much of this is work in progress and although in operation, it has not been fully introduced to the staff team. Staff spoken felt supported by management and were generally aware of the new systems being introduced but without the knowledge to use them fully. All five staff who completed a survey stated they are regularly supported by management. One person commented the new managers work closely with staff. Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: A quality monitoring system is not fully developed but managers are in attendance regularly and systems are in place to monitor standards. Regulatory visits are conducted by the service manager and reports made available in the home. The manager uses monthly and weekly checklists to ensure standards are maintained. Safe working practices are promoted. Fire checks are regularly recorded and staff instruction provided although the system does not identify the regularity of instruction of staff working at night. Maintenance certificates were available to show hoists are regularly checked, electrical appliances are safe and that gas and electrical wiring is safe. Care Homes for Adults (18-65 years) Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 18 13 Staff providing support 31/12/2009 normally carried out by the District Nursing Service must be assessed as competent periodically and have a statement to this fact in their training records. To ensure peoples healthcare needs are met. 2 20 13 Care plans must include 31/12/2009 detailed information and instructions for staff in respect of the administration and management of medicines, including the reasons to give medicines on an as and when basis and what constitutes needed for the named person. To safeguard the health and welfare of people living in the home. 3 23 12 The manager must ensure staff receive training related to the protection of 28/02/2010 Care Homes for Adults (18-65 years) Page 27 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action vulnerable people. And that they are aware of the homes supporting policies and procedures. To ensure people in the home are protected from harm. 4 34 19 The manager must ensure that the rigorous employment techniques are in place to ensure appropriate people are employed. This limits the possibility of employing unsuitable people. 5 35 18 All new staff must receive a structured induction that meets the Sector Skills Council standards. This ensures people are supported by appropriately skilled staff. 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 31/12/2009 31/12/2009 1 2 1 2 Amend the Statement of Purpose and Service User Guide to reflect changes in the management structure. Include details of where the pre admission information was obtained and who was involved in providing this information. Page 28 of 31 Care Homes for Adults (18-65 years) 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 3 2 Ensure that any new systems such as the recently upgraded pre admission documents and care planning are fully explained to staff before being made operational. Continue with the production of comprehensive individualised care plans. Ensure staff are aware of the care planning systems and include plans for those people who have goals to achieve. Provide a regular opportunity for people to be involved in their care planning and record any meetings between people and supporting staff with the decisions made. Ascertain whether people want to participate in fulfilling activities and use goal plans to support these choices. Continue the review of activities provided inside and outside the home to ensure they meet the needs of people living there. Prior to archiving records contemporaneous issues such as previous periodic appointments for dentist, optician or other healthcare appointments must be brought forward to the new files. This ensures staff awareness for future requirements. The medicines policy should be supplemented with detailed guidance to reflect local practices in the home, including the process for medication handover checks and a current British National Formulary should be provided and maintained. Regular audit of the medication system should be carried out to help confirm that staff closely follow the homes medicines policy. Supply of medicines for social leave, and any subsequent returns, should be fully recorded. The Mars should be amended to enable the recording of any known allergies to medicines. Dates of opening should be added to the containers of medicines with a limited use once opened. The pharmacy should be contacted for advice on this. Use quality assessment processes to review the standard of accommodation provided, related to those issues identified, temperature of staff areas and laundry facilities. 4 6 5 7 6 7 12 13 8 18 9 20 10 20 11 12 13 20 20 20 14 24 Care Homes for Adults (18-65 years) Page 29 of 31 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 15 16 17 32 37 39 Continue with staff development training so that the majority of staff have attained NVQ level 2 in care. The manager should make application to The Commission for registration. Ensure that staff are made fully aware of the homes systems and their involvement in them to ensure the wellbeing of all. A record showing staff receive appropriate fire instruction should be in place. Day staff instruction should be twice annually and staff working through the night, four times annually. 18 41 Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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