Care Home: Tapton Grove Nursing Home

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What the care home does well The home has a strong and well established team who are approachable appear to be respected by residents and staff alike. We observed warm and jovial banter between staff and residents. The Expert By Experience felt there was an open culture at the home and a relaxed and homely atmosphere in the home. It was considered to be a home where there was a sense of inclusion and equality for residents. One resident took on the responsibility of escorting the Expert by Experience around the home and introducing them to other residents. Residents gave us positive views of living at the home and the support they received from staff saying it was the `best home ever` and `very clean`. The home does all it can to support residents through periods of acute mental health problems to avoid hospital admissions unless it is absolutely necessary. This is supported by close working relationships with Community Mental Health Teams. The home has over 90% of care staff hold or are working towards NVQ 2 or above in Health & Social Care. There are also a strong team of mental health trained nurses to provide care for residents. What has improved since the last inspection? The home has good links with psychiatric services and where possible residents are being encouraged to use community based services. A restrictor has been fitted to the smoking room window to prevent the risk of falls. Staff are now completing a skill based induction pack when they commence work at the home. What the care home could do better: Whilst no complaints were formally recorded the files we looked at indicated that some had been received and dealt with appropriately these had not been recognised and recorded as complaints. The majority of staff had received training in safeguarding adults however a few gaps on the training matrix indicated that a few staff had not yet received formal training. For some staff moving and handling training was also due. The building is large and we found areas that were in need of redecoration and general refurbishment including carpets and curtains. The home has yet to fully incorporate mental capacity assessments into residents staff files. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Tapton Grove Nursing Home Grove Road Brimington Chesterfield Derbyshire S43 1QH     The quality rating for this care home is:   two star good 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: Bridgette Hill     Date: 1 0 0 6 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. 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. 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. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Tapton Grove Nursing Home Grove Road Brimington Chesterfield Derbyshire S43 1QH 01246274178 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) : kellygartland@sunhealthcare.org Sun Healthcare Limited care home 47 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home 10 37 Tapton Grove provides nursing and personal care for up to 47 persons of both sexes, which includes up to 10 persons with dementia and 37 persons with mental disorder (excluding dementia and learning disabilities). There are separate nursing and care staff groups for each category with centralised hotel services (with satellite kitchens provided to each unit) and an overall registered manager. Service users with dementia are accommodated separately to those with a mental disorder. The home is located approximately 1.5 miles from Chesterfield town centre with a secluded setting approximately a half-mile from the nearest bus route. Details of room sizes are given in the statement of purpose for the home. There is level access to garden areas for service users. Good relationships and Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home networks are establishing with outside health care professionals with regard to the specialist health care needs of those service users accommodated. The range of fees charged at the home is £490.04 - £1400.00 per week. Extra charges were made for chiropody, hairdressing, toiletries and some trips. Local authorities funded the majority of service users in the home. Care Homes for Adults (18-65 years) Page 5 of 30 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: This inspection was an unannounced one. The purpose of this inspection was to assess all key standards and compliance to previously listed requirements. The Inspector was accompanied for part of the Inspection by an Expert by experience Rita Hodkin. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Various records including care planning records were examined the findings are recorded in the body of this report. Discussions were held with residents, relatives, staff and visiting professionals during the visit. Care Homes for Adults (18-65 years) Page 6 of 30 An Annual Quality Assurance Assessment was completed by the Manager of the home prior to the visit and where relevant the content has been included in the body of this report. Surveys were also sent to residents, Relatives and staff. Where these were returned these have also been considered and included as part of the evidence when assessing the home. The Manager Pat Willey was on duty during the inspection and we also spoke to the Deputy Managers during our visit. 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 Care Homes for Adults (18-65 years) Page 8 of 30 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. Care Homes for Adults (18-65 years) Page 9 of 30 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 10 of 30 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. Suitable systems are in place to assess residents needs and offer them the opportunity to visit the home before deciding to move in. Evidence: The Annual Quality Assurance Assessment completed by the manager told us that prior to admission a full assessment of the residents needs was undertaken, the basis of which was used to generate a care plan. We were told that all prospective residents were offered opportunity to visit the home this could be for a few hours or a longer stay over a few days or until a decision had been made as to whether the placement was suitable for them.. We looked at three care plans all of which contained a copy of the pre admission assessments. The care plans were all signed to say that the residents had been given a copy of the Statement of Purpose to tell them about the home and the complaints procedure. Consent was also signed where residents had agreed to share a room Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: Most residents were funded through Local Authorities or partly through the Free Nursing Care Scheme and where other agencies were involved staff told us they obtained copies of the information prior to admission. After admission a 72 hour care plan was put in place which was reviewed after the 72 hour period with the resident and Care manager. The home does not offer intermediate as defined by the Older persons National Minimum Standard 6. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans were in place which described the needs of residents and how these were to be met. Evidence: We examined a sample of 3 care files to assess how care was being recorded and managed. The residents had signed to say they had been involved in the care plans and the range of care plans varied according to the residents needs. Some care plans contained abbrviations however that residents may not understand. Each resident had a key worker and records told us that time was spent individually with the residents on at least a weekly basis. The identified needs recorded indicated that residents were supported through quite severe episodes of poor mental health and where possible the disruption of hospital Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: admissions was avoided through increased support being given to residents. During these periods records staff liaised closely with Psychiatrists and other professional staff. Whilst some staff had completed training on the Mental Capacity Act no formal assessment of residents had been Incorporated in the care files to examine if residents were able to generally have capacity to consent to some areas of care such as medication. The care files we looked at contained various risk assessments according to the needs of the residents. For older persons these considered tissue viability, nutrition and falls. For younger adults varying risks depending on needs were recorded. It was evident that where there some risk there were care plans to support these and staff had tried to work with residents on coping strategies to deal with situations they found difficult. One resident told the Expert by Experience that they felt well cared for and noted that the female carers helped with personal care and put the resident at ease. Male and female staff were available on all units should residents have a preferance as to who assisted them with their persoanl needs. Care Homes for Adults (18-65 years) Page 14 of 30 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. The home offers an individual approach to residents to enable them to make choices and decisions about their lives. Evidence: An Expert by Experience accompanied us at this inspection to speak with residents about what it was like to live in the home. The Expert by Experience considered that there were good relationships between staff and residents and that staff took the time to communicate well with residents. One resident told us you cant differentiate between staff and residents. The majority of residents said they were happy at the home and it was the best home ever, some particularly seemed to enjoy the grounds and the tranquillity of the setting. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: The home has a vehicle to assist residents to go out and for some trips out transport was occasionally hired. Trips out to places such Hull (the Deep), Stratford Upon Avon and Liverpool had taken place. Some residents had also enjoyed holidays accompanied by staff. One resident participated in the inspection by showing the expert by experience around the home and introducing them to other residents. Residents had varying levels of Independence and their abilities and choices were respected with some residents going out and using public transport to visit their friends and families. After the discussions with residents the expert by Experience felt it may be beneficial to residents to explore links to voluntary organisations to further broaden the community participation for residents. The Expert by Experience ate lunch with the residents. We were told the food was excellent and a choice of meal was routinely offered. The kitchen had recently been inspected by the Environmental Health Officer who assessed it as being very good and gave it a 4 star rating. Care Homes for Adults (18-65 years) Page 16 of 30 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. The home fosters good relationship with healthcare professionals to ensure the residents healthcare needs are met. Evidence: The home has close relationships with the local Mental Health Service staff and whilst some clinics are held at the home on a regular basis to review residents. Since our last visit some residents have also been encouraged and assisted to use the local outpatient service to improve their Independence. We also spoke with one resident who had attended an outpatient appointment alone who then discussed this with the staff on duty to tell them about the outcome. Systems were in place to monitor changes in residents weights unless residents declined this in which case their decisions were respected. Some changes were difficult to interpret due to weights being recorded in kilogrammes on some occasions and stones at others. Care records contained details of any visits either in the home or out of it were Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: healthcare professionals were seen. Some specialist advice had been sought where considered necessary for example for tissue viability needs. Many residents in the home smoked and sessions had also been set up a smoking cessation worker who visited the home to work with residents to enable them to cut down or stop smoking if they chose to. We looked at the storage and handling of medications during our visit. Systems for recording medicines received and and returned appeared to satisfactory. The staff used appropriate codes on the records where residents had refused to take the medicines or were on leave. We observed that staff recoded the actual dose given where variable dosages were prescribed. The majority of the medicine records were well completed however a few gaps were evident where staff had not signed that they had been given. Generally the medicine records were preprinted one supplied by the pharmacist however at admission or for medication amendments part way through the monthly cycle handwritten entries were added, recording of this was signed by one staff member but not checked for accuracy by a second staff member. Some residents were being supported to self medicate through a transient programme where some residents initially administer their own medicines supervised by staff from the trolley. Care Homes for Adults (18-65 years) Page 18 of 30 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. Arrangements are in place to safeguard residents welfare and ensure that their concerns are listened to and acted upon Evidence: The annual quality assurance form told us that no complaints had been received at the home. As part of the review of care plans it was evident that some complaints had been made which had been appropriately addressed but not recorded as complaints. We established that suitable complaints procedures were in place and the care plans indicated that residents had signed to say they had received a copy of the procedure. The annual quality assurance assessment told us no safeguarding adult allegations had been made over the past 12 months and this had not changed at our visit. The home had safeguarding procedure and whistle blowing policy in place as well as a copy of Derbyshire County Councils Local procedures. We spoke to staff who said they had received training in safeguarding and showed an awareness of the whistle blowing procedure. The training planner at the home indicated that some refresher training in safeguarding was due and the majority of staff had competed safeguarding adult training. For a few staff they had no dates for training were recorded however dates for training were included in the training planner for the home and were due within the next month. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: The expert by Experience considered there to be an open and inclusive feel about the home and residents told us they had meetings at which they could air their views. Some monies were held securely on residents behalf. The balances of monies held correlated with the records. A dual system of recording with a paper and computerised record was in place. This resulted in the balance not being recorded on the paper system which was usually used by staff to give residents their money, it would not immediately apparent therefore if the balance of money was not correct. Two signatures were recorded one of which was usually the resident. Where residents had capacity they held their own monies and managed their own bank accounts. Assessments of residents ability to manage finances were seen in some care files. Care Homes for Adults (18-65 years) Page 20 of 30 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 home is a lager period building which does not fully have maintenance plans in place to ensure it is maintained as a comfortable place for residents to live. Evidence: The home is Grade 2 listed Georgian building which has been extended to provide accommodation for residents. The home is divided into two units with distinct staffing groups. The home is set with spacious tranquil grounds which appeared well tended. The seclusion of the home can make it potentially difficult to find and immediate bus routes are accessible only after a short walk. One resident told us the best thing about living here is walking around the pond in the summer. Its very nice. Residents are accommodated mainly in single rooms although some rooms are shared. Where this is the case residents have signed to say they have agreed to sharing a room. The Manager told us that plans are being explored to upgrade the present accommodation to provide all single rooms. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: The Expert by Experience found that the residents have their own rooms where they can retire to if needs be and they are all fitted with lock and key. They do tend to spend time in each others rooms and this allows for relationships that are confidential but supportive between couples. The bedrooms we viewed were all well personalised often having televisions and CD players and a range of music reflecting the residents preferences. One resident we spoke with told us they thought their room needed redecorating and it needed new curtains and curtains, we agreed that this was the case as it was somewhat tired. The home is a large building which requires ongoing maintenance. Some of this is scheduled as part of a larger plan to upgrade the home however some works are in need of completion on an ongoing basis. Th stair carpet was well worn and we were told by the Manager that quotes were being sought to replace this. We examined systems in place for managing fire safety and all systems were suitably serviced and routinely checked. Some residents smoked and dedicated facilities in and out of the home were available. Risk assessments were also in place to look at potential fire risks of residents smoking. The laundry area was fitted with 2 washers and 2 dryers. Where residents were able they undertook some of their own laundry and assessments were in place in files to establish their skill level and assess what help may be needed to improve Independence. Generally the home was found to be clean and well maintained. Dedicated cleaning staff worked every day to maintain the home. There were infection control Care Homes for Adults (18-65 years) Page 22 of 30 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. The home has a staff group who are suitably recruited and skilled to meet the needs of residents. Evidence: The home was fully staffed at the time of our visit with no vacancies. There are clear team structures in place for allocating staff to work on the different units and rotas indicated that staffing levels were kept at a constant and acceptable level. Supernumerary managerial time was also available for the Manager and Deputy managers. The home covered absences by using its own bank of agency staff who were familiar with the home and the residents. Where there had been gaps on the rota we observed that staff had covered these shifts to ensure the home was suitably staffed. From the Annual Quality Assurance Assessment we were told there were 49 care staff employed at the home of which 39 held at least NVQ (National Vocational Qualification) level 2 in care qualifications. Some staff were also working towards their NVQs (National Vocational Qualification). Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: The home employed qualified nurses for all units of the home and suitably had 10 nurses who were qualified in Mental health care. There were also 2 General trained nurses who worked on the Older persons unit. A sample of staff personnel files were examined. These confirmed that references and application forms had been completed by staff. Proofs of identity was also on file. A training file was in place which gave information on each individual staff member and an overview of what training staff had received. The home had one in house trainer in moving and handling though it was noted that some for some staff moving and handling refresher training was due. Some specific training for staff had been completed dependant on the are of they worked in for example dementia training. A skill-based induction was available and a completed recent copy was seen to indicate that staff were completing these. The Expert by Experience found that residents spoke positively about the staff at the home considered that staff did engage and listen to residents. Jovial exchanges between staff and residents were observed. One resident told us you cant differentiate between staff and residents this was considered an expression that was a real sense of equality in the home, but acknowledging the need for and use of boundaries when it was called for. The Expert by Experience told us really enjoyed the visit, finding the staff professional and very pleasant and there was a real atmosphere of homeliness and relaxation in the home. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed with established systems in place to ensure it is run in the best interests of residents. Evidence: The manager of the home has been in post in excess of 20 years, they are suitably qualified being a Registered Nurse and have achieved a recognised managerial qualification. Staff gave us positive feedback that the manager was supportive and approachable. There is a an established management structure in place with Deputy Managers working in each of the two units of the home. One has already achieved the national vocational qualification 4 in management and the other Deputy Manager is in process of completing this. We looked at how the home monitored the quality of the service and found that a range of surveys and audits are completed. These included surveys of residents, Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: visiting professionals and relatives. Feedback was found to be generally good and whilst no overall feedback was collated any issues were identified and followed up. We were told by the Manager that the Provider visited at least monthly and recorded visits were completed. At the visits the Provider spoke to staff and residents and quality checked some records at each visit. There was plans in place to develop the home to enable each resident to have their own bedroom and to generally upgrade the facilities on offer over the next year. Regular meetings for residents and staff were held where a range of items were discussed. One resident told the Expert by Experience that There are residents meetings for people to offload and to have problems addressed. The Expert by Experience considered the home was one where there was sense of equality and inclusion offered to residents. The Annual Quality Assurance Assessment and examination of records at the home indicated that all servicing checks were up to date. Systems were in place to ensure the handyman checked water temperatures and the fire alarm on a regular basis Care Homes for Adults (18-65 years) Page 26 of 30 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 27 of 30 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 20 13 Medication records must be fully completed with codes or signatures This is to ensure that a full record of treatment received is available and any reasons for omissions are recorded 31/07/2009 2 22 22 Where any type of 31/07/2009 complaints or concerns are received these must be recorded within a complaints log with details of actions taken to address them This is to ensure a clear record of complaints and the findings are kept at the home 3 23 18 Safeguarding adult training must be delivered and recorded for those staff where gaps appear for this on the training matrix 31/07/2009 Care Homes for Adults (18-65 years) Page 28 of 30 This will ensure all staff are fully aware of how to ensure residents are safeguarded from abuse 4 31 23 Ongoing maintenance and redecoration must be completed within the home This is to ensure residents live in comfortable well maintained accommodation 30/09/2009 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 6 There should be consideration given to assessing the Mental Capacity of residents and incorporating this into the care delivery plans. Where possible abbreviations should not be used to ensure that residents can be fully involved in the care planning process Where weights are monitored the unit of measurement should remain the same to ensure changes can be immediately assessed. The system used for recording monies should contain the balance of monies held in order that staff can ensure this is checked at each transaction 2 6 3 19 4 23 Care Homes for Adults (18-65 years) Page 29 of 30 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 © (2009) Commission for Social Care Inspection (CSCI). 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