Inspection on 29/04/10 for Chaston House

This is the latest available inspection report for this service, carried out on 29th April 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 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 29/06/2010.

Key inspection report Care homes for older people Name: Address: Chaston House 11 Acacia Road London London W3 6HD     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: Clare Henderson-Roe     Date: 2 9 0 4 2 0 1 0 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 28 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) © 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 Older People Page 3 of 28 Information about the care home Name of care home: Address: Chaston House 11 Acacia Road London London W3 6HD 02089923208 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Patricia Evelyn Leatham Name of registered manager (if applicable) Ms Susan Jeannette Coombes Type of registration: Number of places registered: care home 11 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: 11 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 - Code OP Date of last inspection Brief description of the care home Chaston House provides accommodation with personal care for eleven older people. It is located in a large, semi-detached house on a quiet residential road. It is within a mile of Acton High Street and is close to public transport links. Acton Main Line Station is within walking distance and there are local shops and a park close by. The Registered Provider is Mrs Patricia Leatham and there is a Registered Manager. Care Homes for Older People Page 4 of 28 Over 65 11 0 Brief description of the care home There are seven single and two double bedrooms are situated over three floors. There is a stair lift between the ground and first floors, and residents accommodated in the second floor must be fully mobile. There is a lounge/dining room on the ground floor, plus a small sitting room on the second floor that is currently used as the sleep-in room for the second member of night staff. There is a kichen, laundry room and staff toilet situated on the ground floor. There is a pleasant garden to the rear. Toilet and bath facilities are available on each floor. The fees range from £440 to £485 per week. Care Homes for Older People Page 5 of 28 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 was an unannounced inspection carried out as part of the regulatory process. A total of 7.5 hours were spent on the inspection process. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. Several residents and 2 staff were spoken with as part of the inspection process. The CQC Annual Quality Assurance Assessment (AQAA) document completed by the home, plus CQC surveys from residents and staff have also been used to inform this report. Care Homes for Older People Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: Documentation which provides information about the care and services the home offers needs to be kept fully up to date so that the information is accurate and current. All staff need to be clear about the category of registration for the home and to ensure Care Homes for Older People Page 7 of 28 referrals are not accepted for prospective residents who do not fall within that category. Care plans must be formulated for all residents promptly following admission so that all the needs of the resident and how they are to be met are clearly identified. All receipts and administration of medications must be recorded and correction fluid must never be used on medication documentation. It is good practice for 2 staff to check and sign hand written entries on the medication administration record charts. There must be a clear record to show the meals partaken by residents, plus the food supply should enable the weekly menu to be accurately followed. Consideration should be given to increasing the amount of fresh food produce used. Staff have received training in safeguarding adults, and the importance of ensuring that all staff are clear on all aspects of potential reportable safeguarding scenarios was discussed. The home is in need of redecoration and refurbishment, and action had been commenced to identify the areas in need of work. A redecoration and refurbishment plan to cover this work, with timescales for completion is to be drawn up and followed. It is acknowledged that a new roof had been recently completed. Increased diligence is needed to ensure all areas of the home are kept free of malodours at all times. Staff employment records were mainly up to date, however the importance of following up any verbal references to obtain written references was discussed. Whilst the home is implementing good practice by including staff and residents in weekly fire drills and training, the need for unannounced drills for all staff was also discussed, to ensure they have the experience to react appropriately at any time in the event of fire. Several of the shortfalls identified at the time of inspection had occurred during the temporary absence of the manager, and the need to provide effective management cover for the home at all times was highlighted by these findings. 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 8 of 28 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 9 of 28 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 service user guide did not fully reflect the change in ownership, thus information provided was not up to date. Prospective residents are assessed prior to admission and encouraged to visit the home, so they can make an informed decision about living in the home. The manager is now clear regarding the homes registration status, thus residents who fall outside this category will not be admitted to the home. Evidence: Copies of the service user guide are in each residents bedroom. The first page had been amended to reflect details of the new owner, however other sections had not so some information was out of date. Also, the last survey information included in the service user guide was for 2008, again under the previous owners, and the manager said that a resident satisfaction survey would be carried out by the new owner. The home has a pre-admission assessment document and the manager carries out an assessment of prospective permanent residents prior to their admission to the home. Care Homes for Older People Page 10 of 28 Evidence: For placements by social services to include short term respite placements, a copy of the social services resident assessment is obtained. We viewed one completed preadmission assessment and this provided a clear picture of the residents needs, to include reference to healthcare input. We discussed the registration of the home, and the manager appeared unsure as to whether she could admit people with a diagnosis of dementia. The home is registered to offer personal care (previously known as residential care) to older people. They are not registered for any specialist categories, for example dementia or mental health care. The manager said that she was now clear on this matter and would ensure that they do not admit any residents that the home is not registered to care for. It is acknowledged that the majority of staff have undertaken dementia care training, to provide them with the skills and knowledge to care for residents who may develop dementia whilst living at the home. Care Homes for Older People Page 11 of 28 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. Care plans were not in place for all residents, and this could place them at risk of not having their needs fully identified and met. The healthcare needs of each resident are identified and met, thus helping them to maintain optimum health. Shortfalls were found with some of the medication records, and this needs to be addressed to ensure all medication records are accurate and up to date. Staff were seen caring for residents in a gentle manner, respecting their privacy and dignity. Evidence: We viewed 4 service user plans. For 2 residents a comprehensive care plan had been formulated, identifying all their needs and how these are to be met. Monthly review documents were in place and evidenced that reviews had been carried out with input from the resident. For 2 residents a full care plan had not been formulated, and the monthly review document only had been used, which did not identify all the needs and provide a full plan of care. This was discussed with the manager who said that she would ensure care plans are in place for all residents. The home has a risk assessment document that lists several areas of risk to include those expected when caring for residents with mental health and dementia care needs. This was discussed with the Care Homes for Older People Page 12 of 28 Evidence: manager as part of ensuring residents with diagnoses outside the homes registration category are not admitted to the home. The completed risk assessment documents viewed did identify the individual risks to each resident and recorded how these will be managed to minimise each risk, to include the risk of falls. We recommended adding a section for the risk of developing pressure sores, so that this is also highlighted. The manager explained that the GP is informed if there are any concerns about a residents skin condition. Separate assessments for moving & handling had been carried out. Continence assessments are carried out by the district nurses and continence products are supplied to those residents who need. There was evidence of input from healthcare professionals to include GP, district nurse and chiropodist. The manager said that residents are referred promptly to the GP if they are unwell and that the GP will refer residents for any specialist input, for example, the dietician. We sampled the medication records and management. The majority of medications are supplied in dosette boxes, which have been pre-filled by the dispensing chemist and are delivered to the home weekly with a 7 day supply. Some medications are supplied in boxes to cover 28 days. Several gaps were noted in the receipts for medications for both the weekly and monthly medication deliveries on the medication administration record (MAR) charts in use. With 1 exception, staff had signed for all administration of medications on the MAR charts. Medications for disposal are returned to the dispensing pharmacist and a clear record of this is maintained and signed by a member of staff and by the pharmacist on collection. We did an audit of 6 boxed medications and 2 dosette boxes and the stocks were correct in line with the number of tablets signed for. The manager has developed a self-medicating form for residents who can apply their own creams such as aqueous cream and E45 cream, and the resident signs this to say they are able to do so. The manager explained that all prescription only creams are kept securely and signed for by the staff who apply them. Correction fluid had been used on 2 MAR charts viewed and this is unacceptable. Hand written entries seen on the MAR charts had not been signed and we discussed the good practice of 2 staff checking each entry and both signing for it. The manager said that she would speak with the staff about all the shortfalls identified with the medication management. Staff were seen caring for residents in a gentle manner, respecting their privacy and dignity, and there was good communication between staff and residents. Residents looked well cared for and were dressed to reflect individuality. Residents spoken with said that they are happy at the home and there was a good atmosphere. Call bells were responded to promptly. We viewed 3 bedrooms and these had been Care Homes for Older People Page 13 of 28 Evidence: personalised. Care Homes for Older People Page 14 of 28 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 home has an activities programme and work is ongoing to provide more activities to meet residents interests. The home has an open visiting policy, thus encouraging residents to maintain good contact with relatives and friends. Information about advocacy services is available, respecting the residents right to independent representation. The food provision at the home is satisfactory, however increased fresh food products and better attention to providing the menu choices available would enhance the food provision at the home. Evidence: The manager explained that the activities board was in the process of being updated, and showed us notices of activities that had taken place. There is a list of the activities to take place each month, and we discussed having a more comprehensive weekly activities programme to reflect the actual activities taking place each day. The home receives input from Garden Buddies which is a charity run scheme and they have planted seeds and plants in the garden and encourage the residents to participate also. Information from the AQAA states that the staff go through the daily newspaper and discuss current affairs with residents so they are kept informed of life outside the home. It also lists various parties and outings that have taken place to include a spring tea party, halloween and bonfire night parties, theatre trips and monthly pub Care Homes for Older People Page 15 of 28 Evidence: lunch outings. Staff have also been trained to lead seated excercise sessions with the residents, and one was taking place at the time of inspection, with residents enjoying taking part. The manager said that the home has an open visiting policy and visiting is encouraged. There were no visitors present during the inspection, so we were not able to speak with any. The manager said that she does have contact with an advocacy service, and that she has undertaken training in deprivation of liberty safeguards (DOLS). A DOLS assessor has also visited the home and provided them with printed information. We viewed the kitchen, which was clean and tidy. Daily fridge and freezer temperatures are recorded. There is a weekly menu, however the meal choices on the menu did not tally with the meal provided at the lunchtime. Of the 4 resident meal choice records available to view, only one had been completed. We viewed the foodstocks, much of which was frozen, with salad items and potatoes being the fresh items seen. We recommend increasing the amount of fresh food products available and also there must be sufficient stocks maintained to ensure the daily menu choices can be accurately provided. The home has had a recent Environmental Health inspection and the manager said they had maintained a 3 star good rating in the scores on doors scheme for food hygiene. Policies and procedures for food hygiene and safety were on display. Care Homes for Older People Page 16 of 28 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 home has a clear complaints procedure and residents know how to raise concerns, so that any complaints can be investigated and addressed. The home has safeguarding adults procedures in place and staff have received training in this area, thus protecting residents. Evidence: The home has a clear complaints procedure and this is on display in the home. The manager said that they have not received any complaints since the new owners took over the home. The surveys completed with the residents indicate that they know who to speak to if they have any concerns and also know how to make a complaint. The home has a safeguarding adults policy and also has a copy of the Ealing safeguarding adults procedures. The manager said that all but 3 staff had attended the Ealing safeguarding adults training, and plans were in place for the last 3 staff to attend also. The CQC surveys completed by staff indicate that they know who to speak with if they have any concerns, and we discussed various scenarios with staff, who knew to report any incidents of suspected abuse. We discussed the importance of ensuring that any incidents that may occur between residents are also reported in order to ensure they are being fully protected. The manager was clear on this point and is working with her staff to ensure they fully understand all aspects of safeguarding reporting. Care Homes for Older People Page 17 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is evidence of works taking place to improve the environment, with further works being planned to redecorate and refurbish the home, to provide residents with a good standard of accommodation. Overall infection control is being managed at the home, with some further work needed to keep the home fresh and clean throughout. Evidence: We carried out a tour of the home. There was evidence of some redecoration having taken place and a new roof had also been completed, however several areas were noted to be in need of redecoration and refurbishment, for example, the second floor bathroom. The manager explained that the home had very recently had an environmental audit carried out and that once the quotations for works required are received the owner was going to do a works plan for the home. We discussed the need to ensure that a full redecoration and refurbishment plan, with timescales for completion is drawn up and followed. The garden was in need of attention, however it was explained that the scaffolding for the roof replacement had only very recently been removed and the Garden Buddies are to landscape the garden in the next couple of months, having already been involved in work in the garden. The managers office has been relocated to a building in the garden which also houses a store room where COSHH items are securely kept, plus there is a garden shed for storage of equipment and garden items. The office that was on the first floor has been converted into a bathroom, with a standard bath in it, and we discussed the need to install a Care Homes for Older People Page 18 of 28 Evidence: radiator guard prior to the bathroom being put into use. There is a laundry room with one washing machine and one tumble dryer. There is a sluice programme on the washing machine to aid with infection control. Protective clothing to include gloves and aprons were available. Overall the home was clean and tidy, however there was a malodour noted in one room, and the carpet was very marked, which needed to be addressed. The AQAA lists that the home has policies in place for infection control. Care Homes for Older People Page 19 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being appropriately staffed, thus ensuring the needs of the residents can be met at all times. Staff undertake training to provide them with the skills and knowledge to care for residents effectively. Staff recruitment processes are in place and followed, however written references need to be obtained for all staff to fully protect residents. Evidence: At the time of inspection the home was being appropriately staffed to meet the needs of the residents. A copy of the roster for the week was on display. The manager explained that there are 3 staff on duty in the morning, 2 staff in the afternoon and 1 waking and 1 sleep-in staff at night. The staff carry out cooking and cleaning duties as well as providing care. The AQAA lists that of the 12 staff, 10 have completed NVQ level 2 or above in care. This was discussed with the manager who said that all new staff commence NVQ level 2 once they have completed the induction programme. We viewed 2 sets of staff employment records. These included application forms with employment histories and reasons for leaving previous jobs, health questionnaires, photographs, CRB checks, interview records, letters of offer and contracts. In one set of records 2 written references had been obtained, to include one from the last Care Homes for Older People Page 20 of 28 Evidence: employer. In the other records viewed verbal references had been obtained and a record made by the manager. We discussed the importance of obtaining 2 written references for each prospective employee. For all new staff, the Skills for Care induction programme is completed, and examples of the workbooks were seen. In addition there was evidence that staff had carried out training in topics relevant to the needs of the residents, to include dementia care. The manager explained that the majority of the staff have signed up to do a distance learning course in equality and diversity. It was clear when talking to the manager that she is aware of the importance of providing staff with training to keep them up to date with the skills and knowledge they need to care effectively for residents within the registration category for the home. Care Homes for Older People Page 21 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the skills to manage the home, however shortfalls in standards had occurred during her absence, highlighting the need for effective management cover at all times. The home is introducing new quality assurance systems in order to identify shortfalls and work to improve standards on an ongoing basis. Monies held on behalf of residents are managed well, thus protecting their interests. Overall health and safety is being well managed at the home and the manager is aware of areas to be updated to maintain the safety of residents, staff and visitors. Evidence: The manager has worked at the home for some years, and is now registered as the manager with CQC. She is in the process of completing NVQ level 4 in leadership and management for care services. She has undertaken training in various topics relevant to her role and to the needs of the residents, to include a 2 day train the trainers course, risk assessment training, DOLS and Mental Capacity Act training, First Aid, safeguarding adults and food hygiene. It was clear that the manager is very dedicated to her work and strives to provide a good standard of care to the residents. However, Care Homes for Older People Page 22 of 28 Evidence: several of the shortfalls identified at the time of inspection had occurred when the manager was on leave, and it is important that effective management cover be put in place to ensure that the home continues to run well when the manager is temporarily absent from the home. The home has been under new ownership for the past 3 months, and the manager said that she and the owner have discussed quality assurance processes to review and improve standards on an ongoing basis in the home, and they are in the process of introducing a system for the home. This will include Regulation 26 inspections to be carried out on behalf of the owner and audits of all aspects of the home. Staff meetings had already been commenced and residents meetings are also being planned. This will be looked at in more detail at future inspections. The home holds a small amount of money on behalf of each resident and a clear record is kept of all income and expenditure, with receipts for expenditure available. The manager said that if a resident does not have funds then she will write to the representative responsible for handling the residents personal allowance in order to request a top-up of funds. Should a resident be temporarily without funds, the home will continue to pay for items such as hairdressing and seek reimbursement. We sampled the servicing and maintenance records and those seen were up to date. The gas safety check was due and the manager said she would follow this up. The home has a COSHH policy and safety data sheets were available for COSHH products used in the home. There was evidence that staff had received training in health and safety topics. The manager explained that they have a weekly fire drill and training session that includes the residents and staff, so that everyone is kept up to date with fire drill procedures. We also discussed ensuring that unannounced fire drills are carried out and recommended contacting the local Fire Safety Officer to discuss this. The manager explained that as part of the quality assurance system to be introduced, risk assessment, health & safety audits and policy & procedure updates will be carried out, and the owner was in the process of finalising a contract with a company to carry out all such work. Risk assessments for equipment and safe working practices were available from the previous owners, however had not been updated since 2008. The manager confirmed that this is being addressed within the new quality assurance monitoring. No health and safety issues were identified during the tour of the home. Staff have undertaken training in health and safety topics and the manager kept records to ensure staff attend training and updates at the required intervals. Care Homes for Older People Page 23 of 28 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 24 of 28 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 1 5 Home information documents to include the Service User Guide must be kept up to date. So that residents have accurate details about the home and the service it provides. 01/06/2010 2 7 15 There must be a care plan in 01/06/2010 place for each resident that identifies all their needs and how these are to be met. To provide staff with clear information about the residents needs and how these are to be met. 3 9 13 All receipts and administration of medications must be recorded. To provide a clear audit trail of medications received into the home and being administered. 20/05/2010 Care Homes for Older People Page 25 of 28 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 4 9 13 Correction fluid must never be used on service user documentation to include MAR charts. The records must be permanent and clear. 20/05/2010 5 15 17 The food choice records must be completed for all meals. In order to provide a clear record of the food choices made by residents. 01/06/2010 6 19 23 A redecoration and refurbishment plan, with timescales for completion, must be drawn up to cover all areas of the home in need of attention. To provide residents with a well maintained home to live in. 01/07/2010 7 26 13 Action must be taken to eliminate malodours. To provide all residents with a pleasant environment to live in. 01/06/2010 8 29 19 Staff employment records must contain all the information required under Schedule 2 of the Care Homes Regulations 2001. This is to protect residents. 01/06/2010 Care Homes for Older People Page 26 of 28 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 9 31 12 That effective management cover be provided when the manager is on leave. To ensure the home is being effectively managed at all times. 01/07/2010 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 4 For all staff to be clear about the category of registration for the home and to ensure the home does not accept any referrals for residents who are outside the homes category of registration. For 2 staff to check and sign for all handwritten entries on the MAR charts. That more fresh food produce to include vegetables is included on the menu and that the home ensures adequate stocks of foodstuffs to fulfil the weekly menu requirements are maintained. To ensure all staff are clear and comfortable about identifying all potential safeguarding scenarios and reporting them. That unannounced fire drills be introduced in conjunction with current drills and training sessions. 2 3 9 15 4 18 5 38 Care Homes for Older People Page 27 of 28 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. © 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. 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