Care Home: The Dean Neurological Rehabilitation Centre

What the care home does well The service recognises that a comprehensive assessment of peoples needs is required prior to admission. This is because peoples needs are often very complex and the service must be confident that all arrangements are in place to meet these as soon as the person arrives. These assessments are carried out by suitably qualified staff and often involve a multidisciplinary team approach. People are consulted about their care and how this is to be delivered. If the service user is unable to contribute to this process then an appropriate representative is supported to do this. Some decisions are complex and the service is good at involving relevant health care professionals so that these can be made in the person`s `best interest`. Support is given to service users to socialise and participate in a daily life that is of their choice, as far as is practicable within the constraints of their disability. People are supported to make choices and have their preferences met. The purpose built environment is contributory in helping people to have their preferences and particular choices met in a safe manner. The service provides opportunities for people to take part in organised activities and this is helped by having a dedicated area for people to use. People say that the staff generally are very caring but the therapy team is highly praised and clearly offers a good service which makes differences to peoples lives. Again the dedicated areas and equipment available helps to make this possible. The service provides good access to specialist heath care professionals, which helps to ensure peoples health care needs are met. Safe working practices are in place to include all appropriate safety checks to ensure peoples overall health and safety. What has improved since the last inspection? This is the service`s first Key Inspection since opening in March 2009. The AQAA tells us that ongoing improvements are being made to the service. What the care home could do better: Some areas of care planning were weak and did not always give staff adequate guidance. Care planning must be more individualised and cover the areas that have been discussed in this report. This will help protect people from inconsistent or poor practices resulting from insufficient guidelines. In some instances records pertaining to peoples care or planned observations had not been maintained. In these cases the service were unable to demonstrate that sufficient care had been afforded to the individual. There was evidence of staff managing challenging behaviour in ways that were restrictive and, which in one case had resulted in a physical intervention. Staff lacked training in this and risk assessments and care plans were giving inadequate guidance to staff. This shortfall must be addressed to safeguard people from potential harm and abuse. Some of the practices used by staff indicate that further training is also required on related abuse resulting from poorly managed challenging behaviour. The service needs to continue developing its plans for people to access colleges and day centres so that equal opportunities are available to people living in the unit. A more appropriate vehicle would also help more people to get out. The current practice of starting enteral feeds in public rooms needs reviewing. The service must be confident that peoples privacy and dignity is being maintained at all times. Questionnaires returned to us indicate that the majority of the people in the unit are aware of how to make a complaint, but some indicated they were not clear. The procedure is not displayed within the unit and should be for visitors or people who have lost their initial information on this, to read. This is also shows a willingness for the service to be open and transparent. How staff training needs are organised must improve. The current system has resulted in staff not receiving an important training that is required to safeguard people. It was identified as a need some months ago by staff and evidence shows that incorrect action has been taken due to a lack of staff awareness. If immediate staff are having problems sourcing this training then the Registered Provider also has a responsibility to ensure it is provided. Evidence would suggest that although staff are managing to meet peoples care needs, that they are doing this under some pressure and that other areas are suffering because of this. We have made a recommendation around this in the report. Some areas of required audit are not being carried out such as the Registered Provider`s responsibilities under Regulation 26 of the Care Home Regulations 2001. Despite other audits being in place shortfalls have been identified in areas that robust auditing should effectively rectify. The Registered Manager has particular responsibility to ensure the service complies with the Care Home Regulations 2001. Key inspection report Care homes for adults (18-65 years) Name: Address: The Dean Neurological Rehabilitation Centre Tewkesbury Road Longford Gloucester Gloucestershire GL2 9WH     The quality rating for this care home is:   one star adequate 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: Janice Patrick1     Date: 1 5 1 2 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 41 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 41 Information about the care home Name of care home: Address: The Dean Neurological Rehabilitation Centre Tewkesbury Road Longford Gloucester Gloucestershire GL2 9WH 0 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ramsay Health Care UK Operations Limited Name of registered manager (if applicable) Ms Janet Hamnett Type of registration: Number of places registered: care home 60 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Additional conditions: The maximum number of people who can be accommodated is 60. The registered person may provide the following category of service: Care home with nursing - Code N. Date of last inspection Brief description of the care home This unit opened in March 2009 to provide care and support to people of all ages who have needs resulting from complex neurological conditions. Although attached to a local private hospital it is registered as a Care Home and people either live in the unit permanantly, receive respite care or visit on a daily basis for therapy. People are supported within a purpose built unit which contains specialised equipment and appropriate space to meet their needs. Personal care and health care needs are met by a twenty four hour care team that comprises of care assistants and qualified Care Homes for Adults (18-65 years) Page 4 of 41 Over 65 Brief description of the care home nurses. Therapy treatments and additional support is delivered by the units own qualified therapists. General Practitioners work closely with the unit to provide medical support as it is required and the unit has its own Consultant in Neurological Medicine. As well as providing day to day care staff also assist in slow stream rehabilitation. The basic room rate is one thousand and twenty five pounds per week, however fees maybe lower or higher than this and depend on each individuals needs and circumstances. These can be discussed on an individual basis with the service. Care Homes for Adults (18-65 years) Page 5 of 41 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 peterchart Poor Adequate Good Excellent How we did our inspection: We looked at all the information that we have received about the service since its registration with the Commission in March 2009. This included the services first Annual Quality Assurance Assessment, AQAA. The AQAA is a self assessment completed each year by a service and forwarded to the Commission. It tells how well the service feels it is currently meeting peoples needs and tells us of any improvements made to the quality of the service. It also outlines any plans for the following twelve months in relation to its service provision. It also gives us some numerical information about the service. We looked at any information we have that tells us how the service has managed any complaints, concerns and any staff investigations. We have considered what the service has told us about things that have happened, these are called notifications and are a legal requirement. Care Homes for Adults (18-65 years) Page 6 of 41 We considered any relevant information from other organisations. We also considered the views of those using the service, their representatives and staff. These were collected by forwarding questionnaires to the service before our site visit. Two Inspectors then visited the service over two days. On the first day this was between the hours of 9.30am and 3pm and on the second day between 8am and 5.45pm. We looked in detail at the care of four people and inspected their care files. We observed the interactions between several other service users and staff. The arrangements for safe administration of medicines were inspected. We inspected records pertaining to staff recruitment and supervision and we asked to see staff training records. We also inspected other records pertaining to the smooth running of the service and those relating to peoples overall health and safety. We looked at the arrangements for safeguarding people from abuse. We looked at the current arrangement for the management of the service and we looked at how the service carried out its own quality assurance and how required improvements are planned and actioned. We walked around the building, spoke to several service users, members of staff and spoke to one relative. Care Homes for Adults (18-65 years) Page 7 of 41 What the care home does well: What has improved since the last inspection? What they could do better: Some areas of care planning were weak and did not always give staff adequate guidance. Care planning must be more individualised and cover the areas that have been discussed in this report. This will help protect people from inconsistent or poor practices resulting from insufficient guidelines. In some instances records pertaining to peoples care or planned observations had not been maintained. In these cases the service were unable to demonstrate that sufficient care had been afforded to the individual. There was evidence of staff managing challenging behaviour in ways that were restrictive and, which in one case had resulted Care Homes for Adults (18-65 years) Page 8 of 41 in a physical intervention. Staff lacked training in this and risk assessments and care plans were giving inadequate guidance to staff. This shortfall must be addressed to safeguard people from potential harm and abuse. Some of the practices used by staff indicate that further training is also required on related abuse resulting from poorly managed challenging behaviour. The service needs to continue developing its plans for people to access colleges and day centres so that equal opportunities are available to people living in the unit. A more appropriate vehicle would also help more people to get out. The current practice of starting enteral feeds in public rooms needs reviewing. The service must be confident that peoples privacy and dignity is being maintained at all times. Questionnaires returned to us indicate that the majority of the people in the unit are aware of how to make a complaint, but some indicated they were not clear. The procedure is not displayed within the unit and should be for visitors or people who have lost their initial information on this, to read. This is also shows a willingness for the service to be open and transparent. How staff training needs are organised must improve. The current system has resulted in staff not receiving an important training that is required to safeguard people. It was identified as a need some months ago by staff and evidence shows that incorrect action has been taken due to a lack of staff awareness. If immediate staff are having problems sourcing this training then the Registered Provider also has a responsibility to ensure it is provided. Evidence would suggest that although staff are managing to meet peoples care needs, that they are doing this under some pressure and that other areas are suffering because of this. We have made a recommendation around this in the report. Some areas of required audit are not being carried out such as the Registered Providers responsibilities under Regulation 26 of the Care Home Regulations 2001. Despite other audits being in place shortfalls have been identified in areas that robust auditing should effectively rectify. The Registered Manager has particular responsibility to ensure the service complies with the Care Home Regulations 2001. 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 9 of 41 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 41 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New people are admitted to the service after their needs have been fully assessed and the service is sure it can meet their often extremely complex needs. Evidence: We looked at the admission information for 3 people we were case tracking during this inspection. Each person had been comprehensively assessed by the home prior to admission. A copy of this assessment was backed up by supporting assessments and care plans from their placing authorities or hospital. Management described the process in place which could involve several visits to the person where they were residing and that this process would take as long as was necessary. People were encouraged to visit the home and their relatives were also welcome. People were able to choose the room they wished to have, so long as it had the necessary adaptations and equipment they needed. Robust records were kept of these visits and peoples general introduction to the home. Transition meetings and discharge meetings from hospital were also well evidenced. Care Homes for Adults (18-65 years) Page 11 of 41 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 did reflect some of the peoples assessed needs and there is some evidence that people are being supported to make choices about their lifestyles. Greater consistency in care planning will ensure that people are being supported in a consistent approach. More robust recording is required of restrictions that are in place to safeguard people from harm, see outcome four for details. Evidence: We case tracked the care of 3 people living in the home and sampled files for other people. Each person had a main file which contained a copy of their risk assessment and care management plan (RAMP). In addition to this they had a clinical file and a daily file. RAMPs had been developed from each persons assessment of needs providing a holistic overview of their physical, social, emotional and intellectual needs. Each RAMP had 17 possible sections relating to care plans and risks. The RAMPs we examined had been reviewed since admission and it was evident that where changes to need were being identified and RAMPs were being amended to reflect this. Some people had signed these documents. Evaluation sheets indicated that for some people Care Homes for Adults (18-65 years) Page 12 of 41 Evidence: key workers were monitoring these documents each month. Reviews had taken place with relatives and representatives of placing authorities to confirm peoples continued stay at the home. Where indicated by the RAMP, monitoring forms were being used for example for half hourly checks and monitoring tissue viability. However these records were being kept inconsistently with some records having gaps indicating checks were not being done. These inconsistencies are discussed further in outcome 4 of this report. Staff spoken with had a good understanding of peoples needs but spoke of the pressures they work under. We observed them working hard to meet peoples needs, following RAMPs and attempting to provide person centred care. People living in the home said staff were good but there were not enough of them and visitors also confirmed this view. Staff told us how they supported people when they were anxious or distressed. We looked at RAMPs describing how staff should help people when angry. Management said a number of strategies had been tried with people but at the time of our visit we found RAMPs to provide insufficient clear guidance about how staff should react in these situations. Daily notes for two people stated that when they had been angry they had been removed from the communal areas and taken to their rooms by staff where they were left with the door shut. One entry also indicated that treats had been removed and another entry said the television was switched off. We discussed the use of these strategies with the management team, the first of which is effectively a physical intervention. If this procedure is to be used then it must be discussed in a multi disciplinary forum with clear guidance about when it is to be used - usually as a last resort. This must be evidenced as being in the persons best interests to prevent harm to themselves or to others. Management confirmed that multi disciplinary meetings were held fortnightly and that a Psychologist was being appointed in the New Year. Restrictive practice such as switching off the television and removing treats are a restriction on choice and freedom and should not be used. Daily notes indicated that staff were supporting a person in line with their RAMP when anxious or distressed to leave the person and to return when they have calmed down. This appeared to be effective in this situation. Strategies were in place with agreement of the person to continue to be monitored and checked whilst providing them with space. Monitoring forms such as Antecedent, Behaviour and Consequence (ABC) records were being completed. Each person had a RAMP in place detailing their communication needs. A number of people have short term memory problems and these were noted. A white board had been put in place for one person as an aide memoir and another person had access to Care Homes for Adults (18-65 years) Page 13 of 41 Evidence: Possum providing them with environmental controls for their room. Communication aids were in place and people had access to support from a Speech and Language Therapist. Risk assessments were in place for moving and handling concerns. These were robust and provided sufficient information about how staff could minimise hazards. There were also falls and safety RAMPs indicating strategies for staff to keep people safe. Care Homes for Adults (18-65 years) Page 14 of 41 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 live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. Evidence: Care plans made reference to how peoples spiritual or cultural faith impacted on their lifestyle. People were supported to go to church or follow their spiritual beliefs. A number of people were busy preparing for Christmas during our visits helping wrap presents and make cards. Staff said that people were not attending colleges or accessing day care. They were researching opportunities for people to use the facilities at the local National Star College. This was an area still to be developed. Care Homes for Adults (18-65 years) Page 15 of 41 Evidence: The AQAA indicated that people were being encouraged to use communal facilities such as the lounges, dining rooms, craft and sensory room and therapy facilities. Gardens around the home were fully accessible to people using wheelchairs and people said they had enjoyed using the decking in the summer. We sampled activity records for two weeks in October and November. People said they had access to a range of activities within the home and also had the opportunity to go out occasionally. They had been shopping, to the pub and taken part in a quiz, bingo and baking cakes. One person said their bed had been moved into the communal area so they could join in with a game of bingo. A visitor said their relative would like to go out more often but they understood that the homes current vehicle restricted the number of people who could go out at any one time. The activities co-ordinator said that a new vehicle had been promised to the home. She was observed inviting people to join in the activity sessions which were well attended. She had an individual activity profile for each person indicating their likes, dislikes and hobbies. Another visitor said that people would benefit from more one to one time with staff and could probably benefit from having volunteers to help out. A survey from a relative said, the environment is stimulating with appropriate social interaction and activities. The activity co-ordinator said she had been in post for a few months and was still developing activities to reflect the diverse needs of people living in the home. An activity timetable was displayed advertising the weeks schedule of activities. Staff surveys indicated that there were daily and weekly trips out but that activities were needed at weekends. One survey from a person living in the home said they wished pets could stay. Visitors were observed visiting relatives and friends throughout our visit. Those spoken with said staff were always friendly and welcoming. People said they kept in touch with family and friends by telephone or email. All rooms have access to broadband. The AQAA stated, there are no restrictions on visiting and visitors who need to can stay overnight. People were observed being offered choices about activities of daily living such as what they wanted to do and where they wished to spend time. The therapy team actively encourage people to learn new skills or relearn old skills. They were observed running the breakfast club which offers people the opportunity to prepare their breakfast or giving support to carry out tasks such as buttering toast. The team said that if people were unable to come to the dining room then they would take the breakfast and equipment to them in their rooms. People and their visitors spoke highly of the therapy team. They said, the therapy is excellent, my .... has done really well since moving in, and the therapists are magicians. Care Homes for Adults (18-65 years) Page 16 of 41 Evidence: Meals were being provided from the hospital offering a choice of hot meals and snacks. People were observed enjoying a macaroni cheese or stew for their lunch followed by jelly. They said the food is good,and that they have a healthy diet. There were drink machines around the home offering hot and cold drinks. People also had access to fresh fruit. Where people had specific dietary needs such as diabetes or a soft diet, these were noted in their Nutrition RAMPs. Where people were obese they had access to a dietician and their records indicated staff were supporting them to follow a reduced calorie diet. The Malnutrition Universal Screening Tool (MUST) was in use. A number of people were receiving nutrition through an enteral feeding tube which is positioned in the abdominal area. Care Homes for Adults (18-65 years) Page 17 of 41 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. Although the service has to manage some very complex personal and health care needs, how these are being delivered for some people may not be protecting them from unecessary risks and in some cases the persons privacy and dignity is not being maintained. Evidence: Each person had a document titled, All About Me, which indicated how they would like to be supported with their personal care needs and their likes and dislikes. This document also provided advice for staff about how to communicate with people. For some routines were very important to them and these were outlined clearly and succinctly. Peoples Physical Health RAMPs provided comprehensive information about how to support people in areas such as nail care, bathing or showering and hair care. These made reference to peoples cultural or religious beliefs and the impact this may have on how this support was delivered. Plans also indicated where people had preferences for the gender of staff providing their personal care. Surveys indicated that the care provided is appreciated and some said it was to a high standard. Where aids or equipment were being used consent for their use was evidenced. For Care Homes for Adults (18-65 years) Page 18 of 41 Evidence: instance the use of bed sides and seat belts in wheelchairs. We noted two listening devices in the lounge which were switched off during our visits. Staff explained they were used during the night to monitor people using ventilators. Consent forms should be in place to indicate the rationale for using these and peoples permission for their use. Moving and handling guidelines were explicit about the slings, sliding sheets and hoists to be used and how many staff for each procedure. Staff confirmed they had received the appropriate training. People had access to a therapy team to support them with a daily exercise regime and spoke positively to us about the effects of this. The team were enthusiastic and energetic about their work and this was reflected in the response of people living in the home to eagerly participate in their exercise programme. Comprehensive records were being kept by the team to monitor peoples progress. Appointments with social and health care professionals were recorded in peoples daily notes providing evidence of contact with their General Practitioner, Consultants and Dentist. The management team confirmed that multi disciplinary meetings with health care professionals involved in peoples care were meeting every two weeks. Clinical notes confirmed this. On the whole arrangements were in place to assess peoples risk of developing pressure ulcers and various specialised mattresses and other equipment is in use and provides pressure relief and reduces the risks of these developing. However, we did note in one persons care file, entries recording the deterioration of a pressure area and subsequent development of a pressure ulcer over a span of ten days. The last entry indicated that a pressure ulcer had developed, but there were no more entries after this to tell us what had been done about this, whether it had healed or its current state. The nurse we asked about this was not aware of the recorded observations or risk so we asked to see the pressure area with her and after seeking permission from the service user. The area was healthy and not as the record described. We therefore presumed the area had recovered but the notes did not indicate this and do not give a clear audit of care. The same person required all support to reach their drinks and food and a care plan had been devised giving staff guidance on how to meet this very basic need. We saw that a fluid intake chart had commenced. This is usually done when staff want to monitor how much fluid someone is actually taking. The fluid chart showed big gaps of time between recorded amounts, some of these gaps constituted a whole day others were shorter but still indicating the person was getting insufficient fluid. The care plan did not offer any information about whether fluids had been offered and consumed or offered and refused. When we visited the persons bedroom Care Homes for Adults (18-65 years) Page 19 of 41 Evidence: there were drinks beside the bed and they confirmed that they could not reach these without help. They also told us that sometimes they do have to wait longer than they would choose to to have help to have a drink. This persons apetite had also been poor and we were informed that the dietitian was involved when we asked if records of the persons weight were being maintained. The MUST tool was in place but had no recorded weights on it. We were informed that the dieatician would have these. If this is correct then weights should be appropriately recorded on the MUST so that when staff review the persons care plan they are able to reference these. Arrangements for the storage, administration and recording of medications were inspected. All medicines are stored in a designated room within appropriate cupboards, trolleys and fridge. The medication rounds are split and currently carried out by two nurses; trolleys were taken appropriately to each resident during the main medication rounds and locked when unattended during the actual task of administration. During our visit the medication round we witnessed started at 2.20pm and was completed at 3.15pm. Staff explained that they were late administering medications due to various care tasks overrunning earlier in the morning and that normally this medication round is completed by 2pm. The administration records showed several gaps where staff signatures should have been confirming successful administration of certain medicines. These gaps related to medicines that had been prescribed to be taken on a regular basis at set times. We spoke to a member of staff who said that it was probably now her task to follow these up but this had not been done up to this point. We later asked management, whose responsibility it was to audit the medication administration records and we were told that the Pharmacists attached to the main hospital take a lead on this. These arrangements are not adequate enough. Each nurse has responsibilities under their registration with the Nursing and Midwifery Council, NMC to ensure that service users receive their prescribed medication and that correct records are maintained. Gaps on medication records makes it unclear as to what has taken place. It means that the nurse administering medications after the gap is unclear as to what the person has or has not received and this puts people at risk and leads to mistakes. Staff within the unit should be taking responsibility for following these gaps up immediately. We strongly suggest that frequent audits are carried out by a designated person on the unit to avoid some of the other shortfalls identified in this report. One medication record had a tick recorded as opposed to a staff signature for a controlled medication but the controlled medicines book was signed by two staff. A check of the stock balance of this medicine was therefore carried out and was found to be correct. It is highly likely that the medication had been given in this case but the records cause confusion and are incorrectly completed. Two peoples medication records showed that they had been prescribed the same medicine which is used in an emergency situation in response to Care Homes for Adults (18-65 years) Page 20 of 41 Evidence: the condition; autonomic dysreflexia. In both cases this handwritten instruction only contained the name of the medicine and an option of two doses. There was no date of entry, no signature of the person who wrote the instruction and no indication that the written instruction had been checked by a further member of staff. Any hand written instruction must have a date and two signatures and in this case it would be extremely important to have guidance on when to use the medicine and how the variable dose was to be interpreted, either at hand in the medication folder or written on the instruction itself. Within each relevant persons care file there was a description of the condition and instruction to call the emergency services. Several people received their medication via an enteral feeding tube. We witnessed the setting up of two feeds and spoke to one nurse about how she administered one persons medication via the tube. This person is not always able to allow this to take place without expressing themselves in a physical and challenging way towards staff. The nurse described the correct procedure for administering medicines via an enteral tube but also said that it was sometimes difficult to adhere to this because it was necessary to administer the medication quickly. The nurse also described situations where spillage of the medication could occur due to the service user lashing out. As well as no care plan, there was no risk assessment in place showing us how these risks could be reduced and how they were being managed. Several other people receive their medication via the same route and while they have associated care plans for receiving their nutrition via an enteral tube, these are not in place for the administration of medicines. The general process of administering medications via an enteral tube needs to be included within the care plan as this is a more complicated procedure that must be carefully followed to make sure medicines are administered effectively and safely. As this is an unlicensed method to administer medicines this issue also needs to be considered in care plans, taking into account the provisions of the Mental Capacity Act 2005 and clear authority from the doctor to administer in this way. We spoke to one member of the therapy team who is involved in multi disciplinary meetings that are held about the care of the service user who can be physically challenging. These meetings are held so that professionals involved in this persons care can discuss the persons medical care, which without the persons life would be at risk. We saw associated records for these meetings where the medication being given via the tube are regularly reviewed. These meetings were not headed best interest meetings but there was evidence that decisions were being made by a group of professionals, which were Consultant led and where family have been included. Care Homes for Adults (18-65 years) Page 21 of 41 Evidence: It was unfortunate that this persons feed was initiated in the lounge. We witnessed their agitation and the need for staff to manage this as well as locate the enteral tube which was under clothing. The process involved some readjustment of the persons clothing and their abdominal area being exposed. All of this took place in front of other service users and their visitors and compromises the persons privacy and dignity. We witnessed another feed being set up and started in the dining room and although this was a much quieter event because the person was not distressed by it; was still carried out in an area where another service user was sitting, we were sitting and where people were passing by. There were no associated care plans evident for medicines prescribed for use as required. It was confirmed by the management team that these are not devised. Care plans should be in place for such medications giving guidance to staff of the reasons and situations that would precipitate their use. It is particularly important that clear guidance is given to staff in the use of medications prescribed in this way when the medicine is designed to calm the person down. For example, where the effect of the medicine is to slow the person down or sedate them. This is so that staff can record and demonstrate that, where applicable, alternative actions were considered before such a medicine was administered. This helps to demonstrate that the medicine was given in the persons best interest and protects the service user from inappropriate administration. Medications such as some eye drops were seen stored correctly in the medication fridge but had no date of opening. By writing the date of opening it avoids use of the medicine past its recommended time. One eye drop container had lost its outer container so we were unable to ascertain whose eye drops they were. All eye drop or ointment medicines must be discarded after 28 days in use in order to prevent the risk of using contaminated products. It was confirmed that medications are stored for the appropriate length of time following a persons death. Care Homes for Adults (18-65 years) Page 22 of 41 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are arrangements in place for people to make a complaint and for any complaint received, to be investigated, although the service would help some people by making their procedure for this more prominent. There are arrangements in place to help protect people from abuse and harm but some practices require a review to ensure this is the case at all times. Evidence: Information from the service tells us that there is a Complaints Policy and that people moving into the unit and their relatives, are informed of the procedure on admission. This process was confirmed by the Registered Manager although there was no information or summary of the procedure displayed in the unit. We read the policy which predominantly covered complaints from an employees perspective. Questionnaires returned to us from people living in the unit and their relatives indicate that the majority know how to make a complaint and who to talk to if they are unhappy about something. Three out of fourteen indicated they knew how to make a complaint and one made no indication either way. We recommended at the time of this inspection that a summary of the complaint procedure be placed in a prominent place within the unit for people to be able to read. The services information confirmed that one complaint had been received from a relative. During this inspection we saw brief notes of the actual issues raised by the complainant. These had been initially received verbally by an external health care professional who passed them onto the service. There was evidence of the company investigating the issues, of witness Care Homes for Adults (18-65 years) Page 23 of 41 Evidence: statements being taken from staff and of a meeting held between complainant and internal and external health care professionals. There are general arrangements in place to help protect people living in the service from abuse and harm. The Registered Manager explained that residents and relatives are given a leaflet on admission explaining the issues relating to abuse and giving them guidance on what to do if they experience it, suspect or witness it. The Registered Manager told us that staff undertake a basic module on the computer when first employed on Safeguarding awareness and then receive further training on the Protection of Vulnerable Adults during their initial induction training. Unfortunately the service did not have evidence of all staff receiving this training and no certificates were being held so it was difficult for us to formally evidence this. The service had been planning to collect staff certificates and formulate a training record. We strongly recommended that the service start this as soon as possible and that an up to date training matrix is devised. Some of the practices discussed in outcome two of this report would indicate that some staff require further training on challenging behaviour and what can constitute abuse. The RAMPS, also discussed in outcome two, do not provide staff with adequate guidance on what to do and how to manage these situations, putting people at risk of abuse. The services information tells us that there is a Policy relating to Safeguarding and Abuse which we did not request to read during this inspection. Care Homes for Adults (18-65 years) Page 24 of 41 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in an environment that has been specifically adapted for their needs and which is well maintained and kept clean. Evidence: The service was originally registered with the Commission of Social Care Inspection, CSCI in March 2009 and was subject to a site inspection as part of that process to ensure it met with the National Minimum Standards and was fit for purpose in relation to the needs of the people who would be using it. During this inspection we witnessed the specific internal design and space being used by those living there. This included the ability to move wide and specialsed beds from individuals bedrooms to the communal spaces so they could be socially included despite being in bed. We were shown additional equipment to help with peoples bathing and various pieces of equipment that help to move people; this included one room with ceiling tracks for hoist use. Assessments for the use of this specialised equipment are carried out by Physiotherapists and Occupational Therapist who are members of the Therapy Team. There are policies and procedures in place to ensure good infection control is encouraged and practiced and staff receive training in this. The unit was clean and Care Homes for Adults (18-65 years) Page 25 of 41 Evidence: there were no offensive odours; we saw cleaning staff carrying out their tasks. Laundry facilities are shared with the main hospital to which the unit is attached and personal clothing is managed separately by the laundry staff. Many people in the unit are dependent on the use of a wheelchair and outside there are decked areas making it possible for these service users to enjoy the outside safely. Individual bedrooms had personal pictures and belongings on display. We saw people enjoying facilities such as televisions and telephones in their own bedrooms and people were aware of broadband connections in their rooms. The central cafe space has a hot drink machine that can be used by those living in the unit and by their visitors. We spoke to a senior member of staff who said that having a dedicated gym and sensory room meant that staff are able to provide a wide selection of therapy treatments and made their job so much easier, which ultimately benefits those requiring this. Similar comments were also made about the dedicated space for activities. The unit receives alot of natural light and clever use of bright colours in communal rooms helps to make these areas cheerful in what is essentially not a domestic style environment. Arrangements are in place for the daily and general maintenance of the unit. Guidance has been taken from the local Fire Service and alterations to some of the fire safety precautions had to made after the final build; we were told that these have been completed. Care Homes for Adults (18-65 years) Page 26 of 41 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 arrangements for organising and recording staff training are not sufficiently in place for the service to be able to properly demonstrate that staff are being provided with the training they require. Staff recruitment requires closer monitoring to ensure all criteria is met during this process. Some people may not be having their needs met in a way that they would choose because of inadequate or disorganised staffing. Evidence: Staff within the unit had clearly defined roles and were part of the nursing and care team or the therapy team. Ancillary and administrative staff also support the unit. It was difficult for us to evidence peoples induction and additional trainings as no individual training records or certificates were being held. There was a list of staff who had completed original induction trainings but this was not up to date and the Registered Manager confirmed that new staff had been provided with induction training but was unable to confirm names of individuals. A senior member of staff had just taken on the role of training co-ordinator and she explained that she had not as yet had time to generate an up to date training matrix. This person is a key member of the nursing team, responsible for other day to day management tasks as well as Care Homes for Adults (18-65 years) Page 27 of 41 Evidence: being one of the numbers on duty. The Registered Manager explained that dedicated hours are given for the training co-ordinator to organise the units training. The hours however dedicated for this on one of the days of our visit were taken up by the coordinator needing to prioritise service user needs, support more junior staff in their work and generally take the lead in organising other health related work. We were informed that the hours dedicated for this role were adequate and that the role has proved to be successful in other sister establishments. On discussing our concerns with staff relating to how challenging behaviour needs were being managed we were informed that staff had raised the need for this training, with the Registered Manager, several months ago. The Registered Manager said this was proving difficult to source. Due to the evidence in outcome two and the length of time staff have needed this training, we have made it a requirement that this be provided as soon as possible. The Registered Provider also has a responsibilty to ensure this requirement is met. The general arrangements around staff training and the services lack of ability to adequately demonstrate that staff are being provided with the training they require must be improved. For the purpose of this report the evidence that staff are receiving adequate training is based on what we were told by the Registered Manager, the comments back from staff in their returned questionnaires; saying they generally receive adequate training and from comments from questionnaires returned by three visiting health care professionals who confirm that staff always have the appropriate skills to meet the needs of the people in the unit. Some qualified nurse personnel files contained information about specific trainings and courses that they had completed at various times of their careers that were relevant to the conditions being cared for in the unit. Particular training is provided for some staff who take a daily lead on the needs of those dependent on ventilators. We noted that most of the training being spoken about was in basic mandatory subjects. The Registered Manager explained that since the unit had opened it had experienced a fairly large turn over of staff. Staff had usually left following their induction training when they realised they were unable to cope with the very complex needs of the service users. The need for subsequent new recruitment had meant a new cycle of mandatory training. However, staff who remain must be able to demonstrate progression through training and one staff questionnaire commented that more training would be good. There were differing opinions on whether there were enough staff on duty to meet the personal and nursing needs of the people. The Registered Manager said there was Care Homes for Adults (18-65 years) Page 28 of 41 Evidence: enough and that set staff ratios can be flexible when needs dictate, but some staff were not of the same opinion during our inspection. However, six returned staff questionnaires indicating that there is always or usually enough staff on duty. Two questionnaires returned from service user representatives indicated that staff struggle to provide individualised care because there are not enough of them. Certainly we witnessed one service user wait 35 minutes to be moved up the bed because a member of staff could not locate another who was free to help, this service user said this was not unusual. The medication round was late on the day of this inspection and the supernumerary hours dedicated to the training co-ordinatior, were used up in the general management of the mornings work load. We were aware of the therapy team helping with personal care on one of the the mornings of our inspection and peoples care plans and other records are not always complete indicating that staff may be struggling to carry out all necessary tasks. The Registered Manager said she aims to have six care staff on duty and two Registered Nurses. This would increase as the numbers of service users increase. The shortfall in staff numbers on the day of this inspection was due to staff going off sick and various other shifts having to be altered in response to this over a weekend. We have recommended that the numbers of staff on duty be reviewed in conjunction with a review of how long individual peoples needs take to meet. We inspected the recruitment files of four members of staff. Two staff members files were complete with no gaps of employment, two references in place and appropriate clearances against police checks. Another members file showed unexplained gaps in employment history and only one reference. One staff members file gave very little information and it was explained that this person had been employed through an employment agency. We confirmed that all appropriate references and checks still need to be demonstrated by the service. There was evidence of some staff supervision and staff disciplinary investigations were seen in some files, demonstrating that appropriate action is taken by the service when required. Care Homes for Adults (18-65 years) Page 29 of 41 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. Generally the service is run for the benefit of those living in it but there are some areas of the running of the home that are struggling to demonstrate compliance with the Care Home Regulations. These shortfalls need addressing and managing appropriately to ensure the safety of the people using the service. Evidence: Ramsey Health Care has systems in place that are designed to monitor the quality of the service provided. Monthly audits were being carried out and electronically completed for Ramsey Health Care to monitor centrally. We were able to look at audits for record keeping, clinical governance, medicines and infection control. Where shortfalls were identified actions were highlighted with the person responsible for completing these. The exception to this are the auditing arrangements for the medication records as reported on in outcome 4 of this report. An action plan using a traffic light system indicated where there were major shortfalls. The Registered Manager said that surveys had been sent out to people in August of this year (2009) and that this process would be repeated in the new year. She said the survey was being revised to reflect the services the unit offered to people. A staff satisfaction Care Homes for Adults (18-65 years) Page 30 of 41 Evidence: survey had also been distributed and she was awaiting the outcome of this from an independent company. The Registered Manager said the unannounced visits from the provider as required by us had not yet been put in place. Regulation 26 visits must be done each month; they are one way that the Registered Provider can be sure that the service is complying with the Care Home Regulations 2001 and a requirement has been made to this affect in this report. Robust systems were in place to monitor health and safety. We examined the fire risk assessment and records confirmed that regular checks were being carried out on fire equipment and fire systems. Records were again being kept electronically providing prompts for staff to complete the necessary checks each month. These were then monitored centrally by Ramsey Health Care. The local Fire Service had completed their initial inspection of the home and were satisfied with the systems in place. A visit had been completed by Environmental Health and it was reported that they had no concerns. Records confirmed that water temperatures were being checked and recorded. Staff said that the temperature of hot food from the neighbouring hospital was checked. At the time of this inspection we were informed that staff were up to date in moving and handling training, again we were unable to evidence this through individual staff files or up to date training records. We understood the person within the unit responsible for this training required their annual update as a trainer. Questionnaires returned to us from people using the service and from their relatives speak highly of the work done within the unit and the therapy provided. One person said there are no restrictive rules and within the questionnaires received back from staff, comments generally indicated it was a happy place to work. Staff do however need to demonstrate in their planning of peoples care that the Mental Capacity Act and the Deprivation of Liberty Guidance is being considered. There are some general shortfalls highlighted within this report that the Registered Manager needs to address to ensure the service is compliant with the Care Home Regulations 2001. These would probably be rectified with more effective auditing. It was noted that the Employers Liability Insurance certificate on display had expired seven months before this inspection. We made the Registered Manager aware of this incase it was a simple case of the new certificate not being displayed as it is important Care Homes for Adults (18-65 years) Page 31 of 41 Evidence: that the Care Home has all appropriate insurances in place. Care Homes for Adults (18-65 years) Page 32 of 41 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 33 of 41 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 7 13 The Registered Persons 31/03/2010 must make sure that where physical intervention is used - which includes removing people who use a wheelchair from a room, this is evidenced as being done in the best interest. This is to safeguard people from possible abuse. 2 12 12 The Registered Persons must research opportunities for people to be involved in education or employment opportunities. This is to enable people to fulfill their wishes and aspirations. 31/03/2010 3 18 12 The Registered Person must review how and where service users are receiving their enteral feeds and medication. 01/03/2010 Care Homes for Adults (18-65 years) Page 34 of 41 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 This is so that the service can be sure that it is preserving peoples privacy and dignity at all times. 4 18 12 The Registered Person must ensure that service users receive the correct amount of support to maintain their health as independantly as possible. This is in relation to the support required by one service user to access enough fluids during a twenty four hour period and despite appropriate records being in place this could not be demonstrated fully. This is so that people who are dependent on the help of staff to access their fluid intake do not become distressed and dehydrated. 5 19 12 The Registered Person must 01/03/2010 ensure that there is proper provision in place at all times, for all service users, to ensure their health is properly monitored. This is in relation to the poor record keeping and therefore audit trail of care regarding one persons pressure ulcer. This is so that the persons 01/03/2010 Care Homes for Adults (18-65 years) Page 35 of 41 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 condition does not deterioate through lack of appropriate monitoring and care. 6 20 13 The Registered Person must 01/03/2010 put in place arrangements to make sure that containers of all eye drops and eye ointments are routinely replaced after 28 days in use as directed by the manufacturer or pharmacy. This is to help reduce the risks of infection from medicines that have become contaminated through prolonged use. The Registered Person must 01/03/2010 review medicine records and care plans for people living in the home to make sure that for any medicines prescribed with a direction when required, with a variable dose or for administration via an enteral feeding tube there is always clear, up to date and detailed written guidance for nurses about the administration procedure to follow via the enteral feeding tube or on how to reach decisions to administer medicines prescribed to use when 7 20 13 Care Homes for Adults (18-65 years) Page 36 of 41 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 required and at a particular dose, also taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure people living in the home receive the correct amounts of their medicines to meet their needs in a safe and consistent way in line with planned actions. 8 20 13 The Registered Person must make sure that all records for medicines administered to people who live in the home are always accurate, clear and complete. This is to particularly address the issues identified in the report about missing entries (gaps) in the records for medicines administered. This is to help make sure all medicines are accounted for and that people are not at risk of mistakes with medication because of incomplete or inaccurate records. 9 23 13 The Registered Persons 31/03/2010 must make arrangements to ensure that any challenging behaviour exhibited by service users is correctly assessed and managed. This 01/03/2010 Care Homes for Adults (18-65 years) Page 37 of 41 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 must be done by providing staff with appropriate and adequate guidance, training and support in this area of care. This is so that people can be fully protected from abusive or inappropriate practice. 10 34 19 The Registered Persons 01/03/2010 must ensure that all staff employed at the service have successfully completed and passed all the required recruitment criteria. In particular that gaps in employment have been discussed and explained and that two satisfactory references are on file. This is to demonstrate that all possible means have been taken to employ someone who will not pose a threat to the vulnerable people using the unit. 11 35 18 The Registered Persons must ensure that all staff receive training in the management of challenging behaviour. This is so that people being cared for are protected against inappropriate practices. 31/03/2010 Care Homes for Adults (18-65 years) Page 38 of 41 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 12 39 26 The Registered Provider 31/03/2010 must complete unannounced visits to the home each month and complete a written record. This is to provide evidence that the registered provider is monitoring the quality of the service provided. 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 2 3 6 6 6 Restrictions on choice and freedom such as removing treats or switching off the television should be reviewed. Where monitoring records are being used these should be completed as indicated in the RAMP. RAMPs describing the support for people when anxious should provide clear guidelines to establish a consistent approach by staff. Consent to use listening devices should be evidenced including the rationale for this. We recommend that a summary of the services complaints procedure be placed in a prominent place within the unit so that people living in the unit or those visiting can reference it. We recommend that any training completed in relation to Safeguarding Adults and Challenging Behaviour is recorded in each staff members employment file; to include any certificates awarded. It is recommended that a review is done of the time it takes to meet individual service user needs and the allocated numbers of staff on duty to make sure there are enough staff to meet the varying needs of the service 4 5 18 22 6 23 7 33 Care Homes for Adults (18-65 years) Page 39 of 41 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 users. 8 41 It is strongly recommended that concise records of staff trainings and certificates are kept on file in order for the service to be able to demonstrate that staff hold appropriate qualifications and have received the required trainings to enable them to carry out their tasks safely. Care Homes for Adults (18-65 years) Page 40 of 41 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. 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