Inspection on 25/11/09 for Cambridge Manor Care Home

This is the latest available inspection report for this service, carried out on 25th November 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report Care homes for older people Name: Address: Cambridge Manor Care Home Cambridge Manor Care Home 33 Milton Road Cambridge CB4 1UZ     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: Don Traylen     Date: 2 5 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 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 30 Information about the care home Name of care home: Address: Cambridge Manor Care Home Cambridge Manor Care Home 33 Milton Road Cambridge CB4 1UZ 01223-363904 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Rockley Dene Homes Ltd Name of registered manager (if applicable) Mrs Doris Bater Type of registration: Number of places registered: care home 88 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only - Care Home with Nursing - Code N To service users of the following gender: Either Whose primary needs on admission are within the following categories - Old age, not falling within any other category - Code OP Dementia, not falling within any other category - Code DE Mental Disorder, not falling within any other category - Code MD The maximum number of people who can be accommodated is 88 Date of last inspection Brief description of the care home Cambridge Manor was built in 2009 as a purpose built care home designed to accommodate 88 people. The home was registered as a care home with nursing in September 2009 to provide for eighty-eight (88) people who have needs associated Care Homes for Older People Page 4 of 30 Over 65 0 1 88 88 0 0 Brief description of the care home with old age and dementia. The home is located in the city of Cambridge and provides a spacious and comfortable environment. All rooms have full ensuite facilities. The equipment fitted in communal rooms, kitchens, bedrooms and bathrooms, is of a high specification. The entire environment of the home has been designed and built to a high standard. Fees range from £375 to £950 per week, dependent upon needs. Copies of the CQC inspection reports will be made available at the home or can be accessed on the CQC webpage. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: This key inspection was the first inspection of this care home since they became registered with the Commission on 14/09/2009. We started this inspection at 9:45 am on 5/11/2009 and finished at 18:00 hours. We spoke to several people at random throughout the inspection and to five visiting relatives. Four care staff, including a registered nurse, were asked about their training and duties. We conducted a tour of the home and made observations of care being given. We assessed three peoples care plans and checked the medication they were being administered. We looked at information the home had about safeguarding people, how people are safeguarded and the complaints process. We assessed the staff training arrangements, the records of this training and the recruitment and induction processes for new staff. The home completed an Annual Quality Assurance Assessment (AQAA) when we asked for this before the inspection. We received six of the twenty survey forms we sent to people at the home. The manager was present during the inspection and was provided with feedback of the key findings. Care Homes for Older People Page 6 of 30 Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: People living at the home told us they would like some information about the activities and events organised in the home. We asked one person about the meals and he said, there is a long gap between tea time and breakfast the next day. Three people who were spoken to at lunchtime said they did not know what food they were getting until it arrived when they could choose. Another person said she did not know of any Care Homes for Older People Page 8 of 30 residents meetings. One visiting relative commented that she thought people, were somewhat isolated; there is no chat. Care Plans must include details of nutritional intake and the times when people are repositioned or turned whilst in bed, as a preventative action against pressure ulcers developing. Medication records must be accurately maintained. The induction arrangements and the programme for new staff to be inducted must be clearly documented and implemented. Training records must be complete and accurate and developed so that all training planned, or provided, is recorded and can be measured. A quality assurance system needs to be implemented. Alternative management and administration arrangements could be made so that the manager does not have to answer the main entrance door and respond to telephones and to people making requests for assistance on their call alarms, without support. Although the home has complied with building regulations the manager should seek the approval of Cambridgeshire Fire Service whether the bedrooms doors should be fitted with self closing mechanisms to prevent the spread of fire and smoke. 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 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them 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. People are assured their needs are assessed before they decide to move into the home. Evidence: The home has produced appropriate written information in their Statement of Purpose and Service User Guide about the home, its facilities and care service, including the fees they charge. There were additional leaflets available at the home about about topics of care such as, Nutritional Therapy, Dementia Care, Activities & Relaxation. People are given the opportunity to visit the home before they decide whether to move there. The home provides nursing care and residential, or non-nursing care. We saw that two peoples records showed they had been assessed by Primary Care Trust (PCT) Care Managers, prior to moving into the home and for some other people when they had been discharged from hospital. The home had also undertaken assessments and Care Homes for Older People Page 11 of 30 Evidence: arranged to visit people in their homes when private contracts for care had been agreed. Care Homes for Older People Page 12 of 30 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. Peoples care is only partly assured. Care planning and record keeping is adequately provided. Evidence: Care plans for four people were read. One persons care plan was being reviewed by a visiting Community Psychiatric Nurse (CPN) on the day of the inspection. We saw this person was funded by the local authority for Nursing care, related to her Dementia needs and had recently been moved to Cambridge Manor from another care home. The room she occupied was not within a Dementia nursing part of the home, although the manager was fully aware of her needs and the type of care she had been assessed as needing. This persons mental health and welfare was stated to have significantly improved since she moved to Cambridge Manor, according to the CPN. Comments made by this persons relatives to the CPN also acknowledged this improvement and said her care is good and they were pleased with the care being provided. Her care plan included an element for Mental Capacity under which was recorded, no problem. This comment did not qualify her capacity. The CPN stated this person does not have capacity for many things and that the care plan did not adequately explain or Care Homes for Older People Page 13 of 30 Evidence: indicate this. The home uses the resources of their organisations qualified Nutritional Therapist Nurse. One person who was very weak and had moved into the home from hospital was confined to bed. Staff knew his care needs and described these to us. They told us that his GP visits twice weekly and that his family visit every day. We spoke to two members of his family who were visiting on the day of inspection. We also spoke to the nurse in charge of his care. Observing him in bed suggested he should be repositioned, or turned frequently to prevent skin pressure build-up. Staff explained to us they were doing this. In the nurses office there was a list of people who must be turned whilst in bed, to prevent any pressure ulcer developing. He was included in this list. His charts were read and these did not indicate the frequency for repositioning, although they had been completed approximately every two to three hours to show that he had been repositioned in bed. His care plan did not refer to the seriousness of his medical condition and did not include a written plan to meet his needs for maintaining skin and relieving pressure areas. The care plan did not state the need to, or a plan to record his diet or food intake. His plan was erroneous in that it stated he is wheelchair bound. All of his care was being given in bed. His mental health needs that had been recorded in his care plan were totally inappropriate; they related to mood disturbances; twenty minute discussions and other measures, which were blame orientated, and unnecessary. When these were pointed out to the manager she agreed they were unnecessary and would be removed. His daughter-in-law told us his appetite is very small and he could eat only small amounts. Records of his fluid intake and food charts were seen. These showed that on 18/11/2009 only five entries for fluids were counted and on 22/11/2009 showed a lot more entries. Fluid charts for the 23/11/2009 shows only entries during the night time and no entries for the day time. His care plan stated, high protein diet, although it was not evident if this had been provided. There was no available plan to record any night time checks on this persons very fragile health. Another persons charts for recording her position, either in her chair or in bed, had not been recorded regularly, or consistently. The charts did not indicate whether she was in bed, or seated in her wheelchair and had not been recorded for 31/10/2009 & 01/11/2009. We saw another person who needed to be cared for in bed. She was frail and had been assessed by the home on 12/10/2009 and by the NHS on 07/10/2009 and moved to the home on the 15/10/2009. It was clear from seeing her that some of her needs would be associated with skin pressure care. The turn charts kept for her showed two entries on the 22/11/09 at 3pm & 7.20pm. There were no other records Care Homes for Older People Page 14 of 30 Evidence: available relating to her being turned. There had been the involvement of a Physiotherapist, a referral to a dietitian and various visits by her GP. A continence advisors assessment had been carried out. Risk assessments undertaken included, Waterlow and Must assessment tools that revealed high risks of the potential for pressure ulcers and of malnutrition. A moving and handling assessment had been carried out. The nurse in charge told us that this person was moved, or turned every two hours. There was a nutritional record for the 24th and 25/11/2009. There were no charts at all kept to record the fluid she had consumed. The turn charts relating to peoples skin care and pressure care, were kept in one folder in the nurses office and nobody had a turn chart left in their room for staff to contemporaneously record the turns, or changes of position. Medicines were store in a locked cabinet in a suitably temperature controlled room. Controlled medication was stored in a secure cabinet, within this room. The controlled drugs for one person showed these had been accurately recorded and administered. The medication of non controlled drugs for the same person showed there was an unexplained amount of three missing tablets. Another medication prescribed for the same person was checked and found to be accurately recorded and accounted for. Medication for another person showed her medication record and amounts were accurate. Care Homes for Older People Page 15 of 30 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. People are assured their family contacts are encouraged and facilitated by the home. Evidence: Various comments were made by people and their relatives that reflected on respect and dignity afforded them and the activity within the home: One person told us that she had difficulty understanding the spoken English of the night staff. Another relative told us that weekend staff are different and communication in English is an issue. The daughter of one person who was paying privately for his care and had lived at the home for only a short time, told us she felt there was a lack of attention to people, staff do not engage and dont seem to encourage independence. One person living at the home said staff were polite, but there was a gap between tea and breakfast time. He was asked what he does each day and he replied there is a Wesleyan minister and physical exercises, but he was uncertain if there was any information about any activities. We saw a programme of organised activities that had been posted on to a notice board near to a dining room. Several people told us they got enough meals and food to eat and were satisfied with the food provided. We observed lunch being served in the dining room on the first floor. Two people were awaiting their meal. People were asked what choice of two Care Homes for Older People Page 16 of 30 Evidence: they would like. The meal was served on a plate and presented to people rather than any choices being given about proportions or portions. One person asked the care assistant what the food was. She was given a choice of two meals of pork chops and pasta, or braised lamb. Her discussion with the carer about how tender the braised lamb was, did not address her questions and concern about not being able to eat the meat. Tables were neatly laid with cloths, cutlery and flowers and jugs of drinks and were inviting. Some people were observed being assisted and encouraged to eat whilst others managed independently. We saw one person being assisted to eat in bed. She was spoken to respectfully and with kindness by the care assistant who was attending to her. We saw that a number of relatives visited people during the inspection and we spoke to some of the family and friends. We spoke to five relatives who told us they were very regular visitors. Care Homes for Older People Page 17 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not explicitly assured they are safe, or informed how the home are protecting them. Evidence: The homes complaints policy and process was clearly explained in the Statement of Purpose. A leaflet is available at the home welcoming, your comments, compliments or complaints and asking for these to be placed in the post box in the reception area. The home had a satisfactory complaints policy. People we spoke to told us they would speak to the manager, whom they knew, should they wish to complain. There have not been any safeguarding concerns or allegations raised in connection with Cambridge Manor. We asked staff what they knew about safeguarding people. One member of staff told us she would refer any suspicion of abuse to the manager and expected the manager to inform the local authority Safeguarding contact. She was asked if she knew where to report abuse to if she had to. She replied that she did not know where any telephone numbers or contacts or information of where she could report abuse to the Local Authority or the Police, if it were necessary. Three other staff were spoken to and asked about reporting abuse they each stated they would inform the manager or their line manager and were not aware of how to report an allegation of harm directly to the local authority or to the Police, should this ever be necessary. On the day of the inspection, safeguarding training was being provided by an external Care Homes for Older People Page 18 of 30 Evidence: agency for staff employed by the home. The written information provided by this training company was read. A list of contacts with telephone numbers was included in this written material, but the list did not include the Cambridgeshire County Council safeguarding contact, or a suitable local Police contact. The home has a policy relating to safeguarding. There was information kept in a file about safeguarding. It included information about the new Independent Safeguarding Authority. However, we did not see any information about Cambridgeshire County Councils published guidelines for safeguarding people. There was no noticeable material informing people how the service is safeguarding them. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured the home provides high quality accommodation and suitable equipment for nursing and residential care needs. Evidence: The owners have created a purpose built care home of hotel style and high quality accommodation. The environment is new, modern, comfortable and spacious. All bedrooms are large and have full ensuite facilities. There are sufficient numbers of additional bathrooms fitted with specialist baths. Dining rooms and lounges or sitting rooms are numerous as are the small kitchen units on each floor. There are some double rooms for couples wishing to share, or to live together. There are plenty of private areas for people to use. The home is on four floors, including the basement. Everything was modern and bright. A call alarm system is fitted to all rooms and linked to numerous screens in the home. These calls are able to be monitored at specific terminals. The outdoor area was undergoing completion and landscaping. The owners have created a care home of hotel style and high quality accommodation. Doors to the communal dining and sitting rooms and the double doors at regular intervals along corridors, were fitted with self closing mechanisms to prevent the Care Homes for Older People Page 20 of 30 Evidence: spread of fire and smoke. None of the bedroom doors had a self/swift closing device fitted as a precaution against fire. We saw many bedroom doors held open by chairs. The manager told us that a sprinkler system was fitted and was sure that the Fire and Rescue service had been involved with the planning of the building. The manager was asked to consult with the local Fire and Rescue Service for their approval that it complies with current legislation under the Fire and Safety Order. We subsequently contacted Cambridgeshire Fire and Rescue Service and made a referral to them regarding this matter. A requirement relating to this matter has been made under the Management & Administration group of outcomes for National Minimum Standards, 31-38. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent 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. People are not completely assured staff receive appropriate training. Evidence: On the day of inspection the home employed eight permanent nurses and six bank (reserve or additional staff) nurses; nineteen care staff and three bank care workers; a cook, kitchen assistants, domestic staff, one administrator and a manager. The manager stated she was in the process of recruiting more care staff. We assessed the recruitment records and the process used to employ two care staff. The staff records were presented neatly in folders. One persons record included two references, a POVA First check (Protection of Vulnerable Adults list) and a Criminal Records Bureau (CRB) disclosure. The other person transfered to Cambridge Manor from another care home that the providers own. Her references were from that care home and a new CRB disclosure had been obtained. We looked at the induction arrangements for the above two staff. There was no induction record for one care worker who had been offered work on 01/09/2009, and started employment soon afterwards. The other member of staff, who is a nurse had commenced the Skills for Care Common Induction Standards and completed this over 10 days. Tick boxes had been scored over four different days to show this. We spoke to one other care worker who had commenced employment when the home opened Care Homes for Older People Page 22 of 30 Evidence: and she told us her induction had been very good. We spoke to the manager about the induction programme for nurses and care staff. We were shown an induction folder. This contained information called, Adult Social Care Induction Workbook for new Care Workers, issued by the local authority of another county. This had not been used for the two staff whose records we saw. There was a work set available from the Skill for Care Council in this folder. There was no available induction policy to read. There was no clarity about what induction programme is used by Cambridge Manor for nursing staff, or for care workers, or if the Skills for Care Common Induction Standards are adhered to. One other person had started employment on the day of inspection. She was a registered nurse and was working alongside a team leader that day. We asked her if her induction programme had been explained to her and she told us she was not sure of her induction arrangement. Some training topics are planned to be provided and watched through a linked TV system from a training room in the home where practical tasks can be demonstrated and performed to a training group and can be relayed to a wider audience in the home. These training topics can also be recorded and used in a DVD for training purposes. We observed a training session being provided to staff about safeguarding vulnerable adults. Some of the written information given to staff about the contacts where concerns can be reported, should be clarified by the manager. We asked for the training matrix analysis, or list of training arrangements for staff . This list showed staff names but not their status and there were not many subjects for training that were shown as being provided. There were very few dates shown for any training received or planned. These records were unclear evidence of what training staff had received, or was planned. We could not ascertain how many staff had achieved a National Vocational Qualification (NVQ) award in care. We discussed this with the manager and asked her to produce a clear record of the training plan for staff employed at the home. Care Homes for Older People Page 23 of 30 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. People are not assured the management and quality assurance systems are developed, or implemented. Evidence: The registered manager is a registered nurse and an experienced manager who had transferred from another care home that is owned by the registered provider. We spoke to a visiting relative, the daughter of a person who had recently moved into the home from hospital. She said she was not sure who was in charge and felt there was no sense of leadership. The manager told us there were two team leaders, or Heads of Care employed and eventually there will be three Heads of Care one employed on each floor and that one of these will become the deputy manager. Some four care staff and one nurse had received supervision. Clinical supervision is expected to be provided as support to nurses by the manager. The manager told us that supervision is yet to be developed and provided to all staff. Care Homes for Older People Page 24 of 30 Evidence: The home has encouraged people to make any complaint known to them; we saw a complaints information leaflet in the home and a record of the compliments and complaints that have been made. The records within care plans, medication charts, induction arrangements and training arrangements and achievements have already been referred to in this report and shown there are areas for improvement. The home have designed an audit tool that is based on the National Minimum Standards for Care Homes for Older People. This audit process had not yet been implemented by the manager, although she informed us that it will be used in the future. The home has ensured that reports required under the Care Homes Regulations 2001, Regulations 26 & 37, have been completed and sent to the Commission when expected. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must be reviewed 01/02/2010 to indicate the level of mental capacity where this element of need has been assessed by the home and has been included in a persons care plan. So that care plans are accurate records of how peoples needs will be met. 2 7 15 Care plans must be reviewed 01/02/2010 to show the precise details of the plan and record the food and fluid consumed when people have been assessed at nutritional risk, or at risk of developing pressure ulcers. So that care plans are accurate records of how peoples needs are being met. 3 9 13 Medication records must be accurately maintained 01/02/2010 Care Homes for Older People Page 27 of 30 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 So that people are assured their medication is safely managed. 4 30 18 A training plan must be developed for all staff employed at the home. So that people are assured that staff have the necessary skills to provide the care people need. 5 30 18 A structured Induction must be provided to all new staff. So that all new staff receive a clear and structured induction programme. 6 33 24 Effective quality assurance systems must be implemented to ensure records keeping is current and is accurate. So that all records kept by the home are accurate. 7 36 18 Arrangements must be made for all staff to be supervised regularly. So that staff are appropriately supported and managed. 8 38 23 The manager must ensure that bedroom doors are compliant with Fire Safety legislation by consulting 01/02/2010 01/02/2010 01/02/2010 01/02/2010 01/02/2010 Care Homes for Older People Page 28 of 30 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 Cambridgeshire Fire & Rescue Service. To ensure that people are suitably safe from the risks associated with fire. 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 1 7 The Statement of Purpose should inform people how the home will protect them from abuse. The care plan record or chart, relating to the food and fluid consumption for people whose needs indicate a risk of poor nutrition and pressure ulcer prevention, should be recorded contemporaneously in a record kept in the persons room. Safeguarding should be better promoted within the home and staff should be enabled to independently report an allegation of harm to the local authority or to the Police. The home should develop a specific and structured induction for qualified nurses, when nursing staff are employed by the home. The induction thta must be provided for care staff, should be based on the Skills for Care Commom Induction Standards. 3 18 4 30 5 30 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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