Inspection on 15/06/09 for Ashleigh Court

This is the latest available inspection report for this service, carried out on 15th June 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashleigh Court 18/07/07

Ashleigh Court 12/09/06

Ashleigh Court 15/11/05

Ashleigh Court 17/06/05

Ashleigh Court 04/01/05

Ashleigh Court 03/08/04

Ashleigh Court 12/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for older people Name: Address: Ashleigh Court 20 Fountain Road Edgbaston Birmingham B17 8LN     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: Kulwant Ghuman     Date: 1 6 0 6 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 Older People Page 2 of 29 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 Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Ashleigh Court 20 Fountain Road Edgbaston Birmingham B17 8LN 01214201118 01214201118 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Shanti Odedra,Mr Sunil Odedra care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 17 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 17 Date of last inspection Brief description of the care home Ashleigh Court is a care home providing care and accommodation for 17 older people. The home is located in a residential street that leads onto the Hagley Road at the point that borders on the edges of the Edgbaston and Ladywood areas of Birmingham. Hagley Road is an arterial road into Birmingham and to Stourbridge and Kidderminster in the opposite direction. It is therefore well served by a bus service on this road. The home is sited in a large Victorian building. There is limited parking space at the Care Homes for Older People Page 4 of 29 Over 65 17 0 Brief description of the care home front of the property but the road is reasonably quiet and some on the road parking is available. There is no front garden but there is a small garden at the rear of the property. The home has both single and shared rooms over the three floors most of which have en suite facilities. There is a passenger lift that gives access to these floors. Most of the en-suites would have difficulty accommodating the needs of a wheelchair user, the front of the house has steps and so does the rear garden. The home has two sitting areas, one that looks over the rear gardens. There are assisted bathing or showering facilities on each floor. The service user guide did not give details of the range of fees in the home. The reader should refer to the home for information about the fees and any additional costs. Care Homes for Older People Page 5 of 29 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 Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection to this home was carried out on 18th June 2008. This inspection was carried out over two days during June 2009 and the home did not know that we were going to visit. The focus of inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last key inspection. This included notifications received from the home. These are reports about things that have happened in the home that they have to let us know about by law, and an Annual Quality Assurance Assessment (AQAA). Care Homes for Older People Page 6 of 29 This is a document that provides information about the home and how they think that it meets the needs of people living there. Two of the people living in the home were case tracked. This involves establishing individuals experiences of living in the care home by meeting them, observing the care they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked around some areas of the home. A sample of care, staff and health and safety records were looked at. Where people who use the service were able to comment on the care they receive their views have been included in this report. We took 5 Have your Say surveys with us for the people who use the service, 5 for staff and 5 for relatives. We received three completed surveys from staff and two from relatives. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? The home has been decorated throughout in subtle colours that make the home fresh and airy. The refurbishment plan is ongoing and issues are being addressed making the environment pleasant for people to live in. There was regular supervision of staff in the early months of their employment after they had been employed in the home. This meant that their practices were monitored ensuring that the people living in the home were safe. Care Homes for Older People Page 8 of 29 People were not employed in the home until all the relevant checks were in place. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 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 and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. 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 them 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. The assessment process ensured that the needs of the people admitted to the home could be met. People were provided with information about the home and what it costs to live there. Evidence: There was a service user guide in place. It had been updated in April 2009 and was available in large print. It provided nearly all the information required to help people decide if the home would be suitable for them. The service user guide needed to include the range of fees charged in the home so that people could decide whether the fees would be acceptable to them. The service user guide refers the reader to the CSCI(Commission for Social Care Inspection) in the event that they wish to raise any concerns with us. The CSCI has been superseded by CQC (Care Quality Commission) and this should be reflected in the guide. The service user guide also indicated that three bedrooms did not have a wash hand basin fitted but we were told that this had been addressed but not updated in the guide. The inspection report with the service Care Homes for Older People Page 11 of 29 Evidence: user guide was not the most recent. The manager should ensure that the most recent report is available so people have up to date information about the home. The admission process for two people was looked at. This showed that the home facilitated visits to the home, gathered information from the placing authorities and carried out their own assessment of need to ensure that the home could meet their needs. The pre admission assessment included information about the individuals history, medical and personal care needs. This information was used to write up a care plan and the individual or their representative was involved in the process. Individuals were provided with a contract or terms and conditions of residence that told the individual of the fees to be paid. Care Homes for Older People Page 12 of 29 Health and personal care 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 health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they 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. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them 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. There were care plans and risk assessments in place however, on some occasions the needs of the people living in the home were not being adequately monitored or planned for. The management of medicines in the home could be improved. Evidence: We case tracked two of the people living in the home. This means that we look at how well their care is documented, speak to staff about the care provided and observe interactions during the day. We also looked more briefly at the care being given to a third person living in the home. Everyone of the people whose care we looked at had a care plan that detailed the care that they needed, how much they were able to do for themselves and how assistance was to be provided. For example, for one individual the care plan stated able to do own personal hygiene, give flannel soaped, towel to cover private areas. This showed that the staff encouraged individuals to maintain independence and respected their privacy. Care Homes for Older People Page 13 of 29 Evidence: The care plans covered a variety of areas including personal hygiene, mobility, nutrition, mental health and hobbies. There were risk assessments in place for moving and handling, challenging behaviours, tissue viability and nutrition enabling the staff to know how to safely assist the people living in the home. There was evidence to show that the people living in the home had regular contact with GPs, chiropodists and opticians and specialist professionals such as the advanced nurse practitioner, hospitals, and diabetes nurse specialists. The people living in the home had regular reviews about their health. The advanced nurse practitioner was visiting the home at the time of the inspection and there appeared to be a good relationship with the home. The home asked the nurse to see someone who the staff had some concerns about and the nurse was able to do this. The home monitored the weights of the people living in the home and a record was maintained. We looked at the records for the people we were case tracking. We noted from the records of one person that over the past two months the individual had lost about 8 pounds in weight. There was no evidence that this had been picked up by the staff and referred to the manager so that it could be raised with medical professionals. The individual did a lot of walking, this was a symptom of their medical condition, and this would inevitably use a lot of calories. The home needed to ensure that the individual was referred for investigation regarding the weight loss and that practices were put in place to ensure that the individuals calorie intake was also increased and records of the actual amounts they were eating recorded. The home had recently admitted someone to the home that was not an older person. The purpose of the admission was to help the placing authority to carry out an assessment of the individuals level of confusion. Although the care plan included some good detail it was not evident from this how the staff were to record or assess the individuals level of confusion. The home had admitted a person who had some specific dietary needs. The homes care plan indicated that the individual liked English food and so Halal meals were not needed, however, the social work care plan stated Halal food only. It was observed from the food records and conversations with staff that the individual was eating non Halal meals. There was a lack of understanding of what Halal food was and which Care Homes for Older People Page 14 of 29 Evidence: meats were not permitted. The home needed to ensure that people with specific needs were not admitted to the home unless the home had sufficient information and guidance to enable their needs to be met. We looked at how the home managed the administration of medicines. The home used a monitored dosage system for the management of most of the medicines in the home. This means that the pharmacist puts the tablets into a blister pack from which the staff administer the medicines. The system was generally well managed although two issues were identified. Firstly, there was a medicine that needed to be stored in a cupboard that was suitable for controlled medicines. When giving out this medicine the staff needed to ensure that there were two staff signatures to show that the second member of staff had checked that the balances of the medicines were correct before and after giving the medicine. Although the pharmacist should also have brought this to the homes attention the manager and staff administering the medicines should also have identified that it was a controlled medicine and needed to be handled differently as they have undertaken safe handling medicines training. The second issue was identified during an audit of some boxed medicines. The amount of medicine received into the home was not recorded on the MAR chart. This meant that an audit could not be carried to ensure that the individual for whom the medicine had been prescribed had received their medicine. Privacy was well managed as evidenced in care plans, the availability of having keys to bedroom doors and bathrooms and toilets having appropriate locks in place. Care Homes for Older People Page 15 of 29 Daily life and social activities 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 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. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. 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. The people living in the home had some activities to keep them occupied. Friends and families were welcome in the home and the people living in the home were provided with nutritious and varied meals. The people living in the home were happy. Evidence: We looked at what people living in the home did to keep themselves occupied. The care plans that we looked at showed us that each persons interests had been recorded. There was not always a corresponding plan on how these interests were to be met. For example, one person was interested in gardening and the care plan stated that he would be encouraged to plant seeds in the garden during the summer months if the weather permitted. However, there was no evidence of what would be done at other times, for example, visiting garden centres, watching gardening programmes or being provided with gardening magazines. It was important that plans were in place to meet the identified interests to ensure that the individuals had a fulfilled life. There was a record kept of the activities carried out in the home. These included playing ball, having a sing song, watching television, listening to music, chatting, having hair brushed, have manicures and hand massages. These activities were done regularly but they could become rather repetitive. Care Homes for Older People Page 16 of 29 Evidence: There were other less frequent activities such as movement to music, outside entertainers and a garden fete. We were told that escorts are provided for people if they wanted to go shopping, visit family and friends or places of worship. The people living in the home were helped to have their religious needs met by going out to places of worship with their relatives or via the visiting priests to the home. There were evident good relationships with the friends and relatives of the people living in the home and there were seen to be a regular stream of visitors to the home during the inspection and they were made welcome. We were able to observe the evening meal in the home and the meal was found to be nutritious and well presented. People were able to have choices of sandwiches and a hot choice. There was a four week rolling menu in place that showed that there were choices available at all meal times. The menus did not show the vegetables that were being provided at mealtimes and at tea times it generally stated assorted sandwiches. The records should show which vegetables and what type of sandwiches are being provided so that the variety of food available is shown. The people living in the home appeared to enjoy their meals. There was information available in the home for particular diets such as diabetic or low fat diets. As stated earlier, the manager needed to ensure that the specific cultural, dietary needs of individuals needs were assessed and planned for. Care Homes for Older People Page 17 of 29 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. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. 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 people living in the home were able to raise concerns and be confident that they would be listened to. The people living in the home could be confident that the home were taking steps to ensure that they were safeguarded from harm. Evidence: People living in the home were able to raise issues in meetings held for them with staff and there was information available in the home and in the service user guide about raising concerns. There was evidence to show that any complaints or adult protection issues raised had been taken seriously and addressed in a timely manner. The training matrix showed that the majority of staff had attended adult protection training however there were some new staff and night staff who needed to undertake this training. There were financial procedures in place that ensured that the people living in the home were not put at risk of financial abuse. Care Homes for Older People Page 18 of 29 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, 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. 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 environment was suitable for the people living in the home and generally provided a homely environment. Not all adaptations in the home were in working order meaning that some people could not easily summon assistance. There was an odour in some bedrooms so that the environment was not pleasant for the occupants of those rooms. Evidence: Accommodation is provided over three floors. At the time of this inspection the home was generally clean. There were several communal areas in the home including garden, conservatory, dining room and lounge. They were all comfortable and homely. The garden had had two patio areas developed and ramp installed making it more accessible to the people living in the home. There were a number of shared bedrooms in the home. The bedrooms seen had privacy screening available where needed to promote the dignity of the occupants of the rooms. The rooms varied in size. Some were not large enough to have two chairs but this did not appear to be causing any problems. Some of the bedrooms had en suite facilities consisting of a wash hand basin and Care Homes for Older People Page 19 of 29 Evidence: toilet. Where there was no en suite facilties bedrooms included commodes if they were required. The bedrooms were individualised with personal belongings of the occupants. Some people had brought small pieces of furniture with them to make their rooms more personalised and homely. Some bedrooms had televisions and radios in them so that the occupants could spend leisure time in there listening to music or watching television programmes. We were told that all but one of the bedrooms had been redecorated with input from the people living in the home, new furniture had been bought for bedrooms and the dining room and several bedrooms, the hallway and conservatory had been redecorated. The home had adaptations available to help people with restricted mobility. These included passenger lift, ramp in the garden, emergency call system, assisted bath and walk in shower. The emergency call system was an old system and in some rooms the system was moved around between the en suite facility and the bedroom. We were told that some faulty units had been delivered to the home and these were waiting to bereturned to the supplier for replacement. In one bedroom the system had been put on the shelves and would have been inaccessible to the occupant. Since the inspection the call points have all been replaced. As stated earlier the home was generally clean and fresh however, there was an odour in two of the bedrooms and this needed to be addressed to make it a pleasant environment. The laundry housed the necessary equipment. Red alginate bags were used in the home to manage the movement of soiled laundry within the home. There were a variety of bathing facilities available in the home including walk in shower, medic bath and bath with hoist seat. The hoist seat was not working at the time of the inspection. Care Homes for Older People Page 20 of 29 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 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 to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. 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 were sufficient numbers of staff on duty throughout the day to meet the needs of the people living in the home. Not all staff had undertaken the required training to ensure that they had the necessary skills and knowledge to provide care safely. Evidence: The managers hour were in addition to the care staff hours leaving her with time to undertake management duties The staffing rota showed that there were generally three care staff on duty throughout the day. There were two staff on duty during the night and there were additional catering and domestic staff on duty. The rota should show when catering and domestic staff are undertaking a care role. At the time of this inspection some the care staff were undertaking long shifts working 8am to 9pm. This was due to some staff being unavailable for duty due to maternity, sick and emergency leave. This situation is acceptable on a short term basis but will eventually lead to the staff group becoming tired. It is acknowledged that these staff do receive a number of breaks throughout the working day. The catering and domestic staff were undertaking some care shifts and the manager was interviewing for additional catering and domestic staff. Care Homes for Older People Page 21 of 29 Evidence: The training matrix showed that training in first aid and manual handling had been undertaken by the staff since the last inspection. Food hygiene and infection control training was being planned. This will ensure that the staff have up to date knowledge and skills to care for the people living in the home. The manager needed to ensure that all staff had undertaken mandatory training, and the required updates, to ensure that the people living in the home were safe in their care. The recruitment files for three staff were looked at. They showed that people did not start working at the home until all the recruitment checks were in place. The manager needed to ensure that if any issues came up on the checks a risk assessment was put in place to show that the issue had been considered. One of the three files showed that the individual had completed a suitable induction within the required timescales however the other two had not. The manager needed to ensure that this issue was monitored more closely to ensure that the individuals completed the inductions to show that they were safe to be left to work unsupervised. It was pleasing to note that new starters received regular supervision to monitor their practices ensuring that the people living in the home were supported appropriately and safely. During the inspection one of the emergency call systems was activated but the staff did not respond promptly. Staff should respond quickly as this could leave someone at a potential risk in the home. Care Homes for Older People Page 22 of 29 Management and administration 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 led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate 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. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. 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 continued to make improvements but systems needed to be in place to ensure that the manager could monitor the way in which the people living in the home were being supported. Evidence: The management and staff team continued to improve the service the home provides. The open and inclusive atmosphere was evident in the home as staff were encouraged to develop their skills. There were staff meetings and meetings for the people living in the home. This ensured that staff had the opportunity to discuss issues such as infection control, moving and handling and issues in respect of caring for individuals. The people living in the home had the opportunity to discuss if they were unhappy about anything and meals they would like in the home. Some steps had been taken to gather the views people had about the way the service Care Homes for Older People Page 23 of 29 Evidence: was run however the results had not yet been collated to form a report showing where the home had done well and the areas where improvements were needed. The manager needed to ensure she was monitoring the actions of staff for example, the provision of halal meals, the administration of some medicines and ensuring that staff undertake the required training. The records for the management of expenditures made on behalf of the people living in the home were good. We were told that the manager was doing the fire training however, to ensure that the correct information was being passed on it was important that she undertook the fire marshalls training. Records showed us that the equipment was generally well maintained however, during the inspection it was noted that the hoist for the bath was not working and the emergency call system was not accessible from beds and in the en suite facilities. Care Homes for Older People Page 24 of 29 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 Older People Page 25 of 29 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 14 The registered person must ensure that specific cultural and dietary needs are assessed and planned for in sufficient detail for the staff to know how to meet them. This will ensure that the needs of the people living in the home are met in a person centred way. 31/07/2009 2 8 13 The registered person must ensure that the weights of the people living in the home are monitored and referred to the appropriate professionals for advice. This will ensure that the people living in the home receive the care they need in a timely manner. 31/07/2009 3 9 13 The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal 31/07/2009 Care Homes for Older People Page 26 of 29 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 of medicines received into the care home This will ensure that medicines received into the home are handled appropriately. 4 22 23 The registered person must ensure that the emergency call system is available to the people living in their bedrooms and en suites at all times. This will ensure that the people living in the home can be assured that they can summon assistance when they need it. 5 28 12 Staff must respond to the emergency call system quickly. This will ensure that the people living in the home get assistance quickly. 6 38 23 The person providing fire training must be competent to do so. This will ensure that the staff receive training in line with recent good practice and legislation. 31/07/2009 31/07/2009 31/07/2009 Care Homes for Older People Page 27 of 29 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 1 The service user guide should be updated to include the fees and most recent inspection report so that people can make an informed decision about whether the home is suitable for them. The manager should ensure that the care plans show how the aims are to be achieved. This will ensure that the aims of the care plan are acheived in a person centred way. The manager should ensure that the records enable an assessment to be made as to whether individuals are receiving the required nutrition. This will ensure that the nutritional needs of the people living in the home are met. The manager should ensure the cultural dietary needs of the people living in the home are met so that their beliefs and customs are maintained. The registered person must ensure that all the equipment in the home is kept in good working order. This will ensure that the people living in the home have all the equipment they need to meet their needs. The registered person should take steps to address the odour in the bedrooms when it arises to ensure that there is a pleasant environment. The manager should ensure that the staff do no twork excessively long hours for a prolonged period as it could lead to fatigue and put the people living in the home at risk of not having their needs met safely. The rota should show when ancilliary staff are undertaking a caring role. This will ensure that it can be determined what role all staff are undertaking. The manager should ensure that their is a risk assessment in place where any issues are raised on employment checks to show that the individuals are suitable for working at the home. The manager should ensure that actions are taken to ensure that new staff complete their induction within the required timescales. The manager should ensure that systems are in place to ensure that she can monitor the actions of the staff to monitor that they work in line with current good practice guidelines. Page 28 of 29 2 7 3 8 4 15 5 21 6 26 7 27 8 27 9 29 10 30 11 31 Care Homes for Older People Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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