Inspection on 12/05/09 for Church Farm Nursing Home

This is the latest available inspection report for this service, carried out on 12th May 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Church Farm Nursing Home 22/01/07

Church Farm Nursing Home 24/01/06

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Key inspection report Care homes for older people Name: Address: Church Farm Nursing Home Church Lane Cotgrave Nottingham NG12 3HR     The quality rating for this care home is:   three star excellent 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: Rebecca Shewan     Date: 1 2 0 5 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 27 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 27 Information about the care home Name of care home: Address: Church Farm Nursing Home Church Lane Cotgrave Nottingham NG12 3HR 01159894595 01159894345 cfnursinghome@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Church Farm Nursing Home Ltd care home 44 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users who can be accommodated is 44. 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 care needs on admission to the home are within the following category Dementia Code DE Date of last inspection Brief description of the care home Church Farm nursing home cares for forty-four residents in a recently extended and previously converted period building in the heart of Cotgrave. It is close to the village centre shops and bus routes to Nottingham city centre. The home is registered to provide nursing and non-nursing care. A maximum of three people who require palliative care can also be accommodated. There are both single and shared bedrooms. Two of the three bathrooms have adaptations. The home has an attractive garden to the front and an enclosed courtyard to the side and centre of the main building, which is level and is freely used by residents. All areas of the home are accessible through ramps and a passenger lift. Care Homes for Older People Page 4 of 27 Over 65 0 44 Brief description of the care home The range of fees for the service is 467 (GBP) - 831 (GBP) per week and are fully inclusive, including hairdressing and chiropody. Potential new residents find out about the service via the internet (the homes website, CQC reports) by word of mouth, contacting the home directly, placing authorities and from care professionals. Care Homes for Older People Page 5 of 27 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: three star excellent 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 unannounced inspection took place during the morning and afternoon of the 12th May 2009. The homes Annual Quality Assurance Assessment (AQAA), incident reports and previous inspection reports, held by the Care Quality Commission, were read before the inspection. The inspection of the home took eight hours. Records such as care plans, staff files and medication records were also viewed. Thirty eight service users (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Registered Manager, Deputy Manager a Cook, two Activity Coordinators and three residents were spoken with. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents records and documents. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: There were no requirements made as a result of this inspection. Recommendations for good practice were made in that the pre admission assessment pro forma should be updated to identify the date of the assessment and where it was conducted. Record entries should be written in black or blue pen and errors should not be Care Homes for Older People Page 7 of 27 corrected with the use of white correction fluid. The Complaints Policy is in need of updating to reflect that the Care Quality Commission can be contacted at any time during the event of a complaint and not after all internal processes have been conducted. 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 27 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 27 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 home has good processes in place for assessing potential new residents, with services being offered to only those residents whose needs can be met. Evidence: Either the homes Registered Manager or Deputy Manager carries out pre admission assessments. Copies of care management assessments from the placing authority are obtained, where these exist. The Registered Manager addresses any issues, which are highlighted within this assessment. Documented records are maintained of all correspondence with the placing authority. Records inspected showed that preadmission assessments are carried out on all new and potential residents. Documentation relating to the most recent admissions to home were viewed and found to have been conducted with the involvement of the resident and/or their representatives (where applicable). It was observed that pre admission assessment records need to be further developed to clearly identify the date of the assessment and the place where the assessment was conducted. Therefore a Recommendation has Care Homes for Older People Page 10 of 27 Evidence: been made. Intermediate care is not provided by this home. Care Homes for Older People Page 11 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are offered a good provision of health care, psychological and personal support by the home. All care is administered in way that protects residents privacy and dignity. Medication procedures ensure that medication are stored and administered safely. Evidence: Care plans (including risk assessments) were sampled and it was evidenced that they were comprehensive, detailed in content and covered all aspects of residents needs. Care plans are generated after a two assessment and review process, which allows for a settling in period of the resident and any changes in needs or behaviours associated with being in a new environment. They are written to allow the assessor to gain a good overview of individuals medical, mental health, social and personal care needs and provide the assessor with a clear overview of the residents current needs, limitations and required assistance. Therefore the previous inspection recommendation that care plans should be more specific about residents individual strengths and needs, and be aimed at a member of staff who has no prior knowledge of the resident, rather than assuming that they will know them well has been met. Documentation Care Homes for Older People Page 12 of 27 Evidence: also detailed managing triggers to challenging behaviours, any restraint required to ensure the residents safety and any issues that may result in Deprivation of Liberties. Daily records are maintained and are reflective of the care plan. It was observed that some entries into care plans and daily records were written in red pen or had been changed by means of white correction fluid. Therefore a recommendation has been made. Care plans and risk assessments are reviewed on a monthly basis and are updated to accurately reflect any change in needs. Care plans include reference to equality and diversity and clearly addresses any needs identified in the strands of diversity, which are: gender (including gender identity), age, race, religion or belief, and disability. Residents are registered with a GP from a local surgery. Any residents wishing to retain their own GP on admission would be supported to do. Weekly GP reviews of some or all residents are conducted within the home. A Continence Assessor attends the home as needed and is accessed via the GP or directly by the staff of the home. The Registered Manager reported that on a recent visit to the home, the Continence Assessor commended the home on its ability to manage continence and using continence products effectively. Domiciliary opticians attend the home and private appointments to local opticians are also supported. Dentist treatment is arranged via private and/or NHS surgeries. There are both types of surgeries available locally. Home dental visits are also conducted as required. Access to audiology is sourced via the Rope Walk (a hearing centre based in Nottingham city centre). The home has a Chiropodist who attends the home every six weeks and as required. The service has established good links with the Mental Health Team and are able to access the Consultant Psycho Geriatrician and the Community Psychiatric Nurse. The Emergency Mental Health Team are contactable at anytime. The local police are aware of the service and they maintain good communication with each other. The service has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Medication Administration Record (MAR) sheets were viewed and it was evidenced that these provided a clear audit trail for all medications administered or omitted. Controlled medication records were audited and found to be correct. All controlled drugs are stored and recorded in the appropriate manner. It was observed that daily medication fridge temperatures are maintained consistently. Staff were observed providing personal support to residents in such a way that promoted and protected their privacy and dignity. It was observed that residents Care Homes for Older People Page 13 of 27 Evidence: bedroom doors were knocked before staff entered them and that residents were called by their preferred choice of address. Staff are fully committed in supporting individuals to lead purposeful and fulfilling lives, with as much or as little assistance required by the resident. Teams of staff care for residents, each team consists of a designated Manager (either the Registered Manager or Deputy Manager), two Senior Carers and ten Care Assistants. Each resident has a designated Key Worker. Staff currently wear uniforms that reflect their role; Dark Blue for trained staff, navy stripes for senior staff and white or lilac for Care Assistants. Domestic staff wear pale blue and Activities Coordinators wear red. The management of the service are currently in the process of considering how uniforms can be changed, in order to promote a more homely feel for residents and promote the beliefs of Dementia Awareness and Dementia Care Mapping. Care Homes for Older People Page 14 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to enjoy a full and stimulating programme of activities to choose from. The home provides a wide range of social, cultural and recreational facilities and supported to develop their life skills. A wide variety of meals and specialist diets are provided for residents, with residents choice and wishes being respected in relation to food choice and times of eating meals. Evidence: There are six Activity Coordinators employed by the service, residents therefore benefit from having activities provided seven days a week. Residents are consulted on a 1 to 1 basis regarding their social and leisure interests. Each individuals care plan contains a life plan, which details their life, occupation, relations and hobbies/interests etc throughout their lives. The content of life plans are considered and activities are organised around the individuals preference and previous interests. Although there is a published list of activities in place, these may be changed due to residents requests and behaviours being taken into account. Records are maintained of all activities conducted. Activities include: 1 to 1 sessions, arts and crafts, ball and board games, reminiscence, Visiting entertainers (Birdie man who plays an accordion and sings, Care Homes for Older People Page 15 of 27 Evidence: country and Western singer, soul singer and musicals), movement lessons, film afternoons, prize bingo, biscuit and cake decorating, chocolate fountain exotic fruit tasting sessions, aromatherapy sessions and doll therapy. All residents birthdays are celebrated. Throughout the home there are rummage boxes which contain items that can be handled by residents and encourage them to feel the texture and prompt memories about what they are, whether they had one as a child etc. The Registered Manager reported that he had achieved basic user status in Dementia Care Mapping, whilst the Deputy Manager and other staff members have attended a Dementia Awareness Course, as a result the activities and other areas of service provision, will be reviewed to ensure that they offer residents appropriate stimuli and improve the lifestyle of people living in the home. Residents religious wishes are observed. Discussions with the Activities Team Leader highlighted that there were currently no arrangements in place for residents to receive Holy Communion. The Activities Team Leader is in the process of accessing this resource ands hopes that this will be in place soon. The management of the home believes in promoting an equal and diverse culture among staff and residents. Monthly themed days are arranged and staff and residents are encouraged to take part in these. This years monthly themes consist of countries, with the countries of India, Africa and Italy having already been celebrated. This months theme is China and as a result the service had been decorated with paper lanterns, Chinese murals and Chinese writing. The menu has also been revised to include Chinese meals. Outings such as trips to lunch with relatives, boat trips (Newark to Nottingham, Colwick to Nottingham), trips to the Wheatcroft and Moors garden centre are arranged, residents visit the pub over the road from the service for drinks and snacks, the home also uses their beer garden for their summer fayres. Picnics at Wollaton Park are also arranged. There are currently no day centre attendees at present. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the residents wishes. Care plans are utilised to record when a resident has received visitors. The homes menus are devised on a weekly basis. All meals are home cooked with an alternative and lighter option available for each mealtime. Mealtimes can be varied upon request and there is rolling breakfast system in place, which allows residents to have breakfast at a time of their own choosing. Meals can be taken in the residents bedroom or in one of the communal dining rooms. Medical, therapeutic or religious Care Homes for Older People Page 16 of 27 Evidence: diets are provided as needed. The teatime meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed and was unhurried, with those requiring assistance with feeding being treated patiently and encouragingly. Menus were observed and these were found to offer a good variety. Drinks and snacks are available at all times. All care staff carry dockets, onto which they record when a resident has consumed a beaker of water additional to those offered with meals. This is in line with current Dementia Awareness guidance. The Registered Manager reported that the service were commended for this at a recent Dementia training event. Care Homes for Older People Page 17 of 27 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. Residents benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect residents in the event of an allegation of abuse. Evidence: The home has an established complaints procedure in place. The current Complaint Policy in place will need revising to reflect that the Care Quality Commission can be contacted at any time during the event of a complaint and not after all internal processes have been conducted. Therefore a Recommendation has been made. The complaint file was viewed and this provided evidence that there have been no complaints received by the service within the last twelve months. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. RNs who are employed by the service, have the necessary Nursing and Midwifery Council (NMC) PIN checks conducted, these are also checked routinely on an annual basis. Staff have attended training in the Safeguarding of Vulnerable Adults within the last twelve months. This was evident from the staff files viewed. There have been no Safeguarding Alerts raised by the home in last twelve months. Care Homes for Older People Page 18 of 27 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. The physical design and layout of the home enables residents to live in a safe, wellmaintained, comfortable environment that is odour free and has all the necessary provisions to meet residents individual needs. Evidence: Having recently been extended, the size, location and layout of the home are suitable for its stated purpose. The extension has allowed for the provision of a bright sun lounge/diner, ten bedrooms with en-suite facilities (walk in shower with toilet and hand wash basin or toilet and hand wash basin only), a renovated kitchen area and an additional lounge diner, which is set off from the courtyard garden. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. People living in the home benefit from sensory stimuli and clear signage of facilities such as toilets, bathrooms and bedrooms. From the tour of the premises it was evident that all rooms were clearly signposted with both words and pictures. The service finds creative solutions to issues with the environment in ways that are not necessarily dependent upon cost. The service goes that extra mile to provide an environment that fully meets the needs of all residents and plans for the diverse needs of people that might use the service in the future. It has a wide range of up to date Care Homes for Older People Page 19 of 27 Evidence: specialist equipment and adaptations to meet the individual needs of current residents. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. Staff were observed adhering to infection control procedures. There is a daily cleaning schedule in place. The laundry has all the necessary equipment to ensure residents clothes and linen are laundered appropriately. Nottingham County Council has recently chosen the home to pilot a new scheme for laundering clothes. The scheme will entail fitting all individuals clothes with a radio frequency identification device, which can be scanned by staff. The device will store the residents name, room number and can hold other additional information such as whether they are an MRSA carrier or allergic to washing powder. The aim of the pilot is to promote the individuals dignity buy not having to label or write in their clothes. The pilot study will last for a duration of one year. Care Homes for Older People Page 20 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. Staff training is both current/ up to date and in accordance with residents needs. Recruitment processes are satisfactory and allow residents to be further safeguarded. Evidence: A competent staff team, sufficient in number, meets the residents needs. There is a staff rota in place, which details staff hours of working and staff job designations. The service is staffed so that in the morning/early afternoon there are two Registered Nurses (RNs) on duty with eight Care Assistants, early evening shifts consist of either one or two RNs and eight or nine Care Assistants. One RN and four Care Assistants cover the night duty. Additionally the service has staff to assist during the busy periods of the day such as Breakfast and teatime. The home has a permanent staff team of the Registered Manager, Deputy Manager, Permanent staff team of the Registered Manager, Deputy Manager, four Registered Mental Nurses, four Registered General Nurses, nine Senior Carers, thirty two Care Assistants, six Activity Coordinators, two Cooks and two Kitchen Assistants, two Administrators, two Laundry staff (one manager and one assistant), four Breakfast Assistants, one Teatime Assistant and six Domestic Assistants. The management of the home are committed to training staff in National Vocational Qualification (NVQ). Care Homes for Older People Page 21 of 27 Evidence: Eleven care staff are NVQ, level 2 or above, trained in care and a further thirteen are currently completing the NVQ level 2 or 3, in care training. Additionally there are two staff trained to NVQ level 2 in Food and Catering and four staff trained to NVQ level 2 or 3 in Activities. Staff recruitment files were viewed and it was evidenced that these files contain the majority of items required under the Care Homes Regulations 2001. There is a need for staff files to be further updated to include recent photographs of staff. Therefore a Recommendation has been made. The home has an Equal Opportunities policy in place and is an equal opportunities employer. There was evidence in staff files that staff who are recruited from overseas are subjected to the appropriate checks and have the necessary work permits in place prior to commencing employment. Training records were observed and it was evidenced that the staff induction training is conducted in line with Care Skills Sector guidance. Mandatory training consists of Skills for Care Induction and foundation programme, Moving and Handling, First Aid, Safeguarding Vulnerable Adults, Infection Control, Food Hygiene (for Kitchen staff) Fire Awareness, Health and Safety and medication. Additional training is also provided in Dementia Awareness, Dementia Care Mapping, Managing Challenging Behaviour/Violence and Aggression and other subjects that arise from changes in residents needs. Care Homes for Older People Page 22 of 27 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. Residents experience the benefits of a home that is well managed and administrated. The health, safety and welfare of residents and staff are protected at all times. Evidence: The Registered Manager of the home has achieved the Registered Managers Award, is a qualified Registered Mental Nurse and has a Diploma in Business and Management. He has been the Manager of the home for thirteen years and has the necessary skills, qualifications and experience to operate the service. Staff spoken with said that the Registered Manager is friendly, approachable and always takes concerns or comments raised about the service and its provisions seriously. Annual visitors questionnaires are conducted. Other stakeholder questionnaires are in place and there is a plan in place for these to also be conducted on an annual basis. Regulation 26 visits are conducted by the Registered Provider, the reports of which Care Homes for Older People Page 23 of 27 Evidence: were viewed and it was evident that these covered all aspects required by the Regulation and were conducted on a monthly basis. Regulation 37 incident reports are provided to the Commission and detailed records are maintained by the home of all accidents/incidents that occur. Staff meetings are held four weekly for the Management team, six weekly for senior staff and six to eight weekly for all teams. Minutes are maintained of all meetings held. The home does not take any responsibility for any of the residents finances. The Registered Manager confirmed that all residents have family, friends or representatives who protect their financial affairs. The homes maintenance files were viewed and in conjunction with their AQAA, these provided evidence that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. On the tour of the premises it was noted that bars of soap and unnamed bath/shaving products, deemed for communal use were in some of the homes bathroom and toilet areas. Therefore an immediate requirement was made. A second tour of the premise was conducted and it was found that all such products had been removed and stored appropriately. Care Homes for Older People Page 24 of 27 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 27 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 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 That the pre admission assessment pro forma is updated to identify the date of the assessment and where it was conducted. That record entries are written made in black or blue pen and errors are not corrected with the use of white correction fluid. That the Complaints Policy is updated to reflect that the Care Quality Commission can be contacted at any time during the event of a complaint and not after all internal processes have been conducted. That staff files are updated further to ensure they contain a recent photograph of the staff member. 2 7 3 16 4 29 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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