Inspection on 25/05/10 for Chy Byghan

This is the latest available inspection report for this service, carried out on 25th May 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chy Byghan 23/09/08

Chy Byghan 22/04/08

Chy Byghan 07/06/07

Chy Byghan 05/06/06

Chy Byghan 08/02/06

Chy Byghan 20/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/07/2010.

Key inspection report Care homes for older people Name: Address: Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX     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: Michael Dennis     Date: 2 5 0 5 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: Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX 01736871459 01736871423 rosemarydeane@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Jacqueline Brown,Mrs Rosemary Ann Deane Name of registered manager (if applicable) Mrs Rosemary Ann Deane Type of registration: Number of places registered: care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Chy Byghan is a registered care home providing accommodation and personal care for up to nineteen older people. Up to six of the residents may require care because they experience confusion. The home also provides day care for up to three older people. The home is detached and is located in the village of Sennan, approximately 11 miles from Penzance. It is situated slightly off the main road and has car parking for approximately 6-7 vehicles. The building consists of two storeys, with most of the accommodation provided on the ground floor. Several of the residents bedrooms have French doors that open directly onto an outside patio. All the bedrooms currently have Care Homes for Older People Page 4 of 28 Over 65 6 19 0 0 Brief description of the care home single occupancy but two rooms can be shared if required. The home provides a comfortable sun lounge, a smaller second lounge and a well-decorated, spacious dining room. The registered providers live adjacent to the care home and one provider is the registered manager. One of the providers, Mrs Deane, plays an active role in running the home on a day-to-day basis. 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 inspection was carried out on 25th.May 2010 by two inspectors. We received six surveys from residents, or representatives of the people that live there. The comments received in these surveys were all extremely positive. We also received ten surveys from staff members. Again all the comments were positive and it is obvious that staff enjoy working at Chy Byghan. The inspectors met with the registered provider, Mrs Deane, staff, and residents, examined documentation (including surveys) and toured the premises. This home provides individualised care that the people that live there clearly appreciate. The overall rating of an adequate service reflects the requirements and recommendations made. We recognise the improvements made since the last inspection. There were no direct concerns about the actual care provided. Care Homes for Older People Page 6 of 28 The issues identified in this report were discussed in detail with the registered provider, Mrs Deane. Concerns remain regarding some of the recording practices and updating of policy documents. These are detailed in the body of this report. We carried out this inspection over a cumulative period of approximately seven hours. We spoke with residents, the registered manager and staff. We looked round the home including the rooms of the people that live there. We inspected the homes documentation. Although the overall rating for this home has remained at adequate, it is recognised that there has been improvements since the last inspection. Further improvements and continued commitment are now needed to progress the home forward towards a good rating. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: The home could improve its Statement of Purpose and Service User Guide (combined document), by presenting it in alternative formats. More can be done to ensure care plans give clear direction to staff. More could be done to involve residents in their care plans and to ensure forms are properly completed and planned interventions carried out consistently. Life histories, likes and dislikes would enhance the quality of recording. The registered providers should continue with and expand the use of quality assurance questionnaires, publishing a summary of the findings and any action taken as a result. More evidence is required to substantiate the training delivered to staff and indicate forward training plans. Evidence of regular staff supervision needs improvement. The complaints procedure requires updating to include the current contact details of the Care Quality Commission and the Department of Social Care and Support. Photographs of staff should be attached to their file to improve identity checks. Surnames of staff to be added to the duty rota to enable clear identification. We recommend that the pharmacist is contacted for advice on the provision of medication security cabinets in order to fully comply with the Royal Pharmaceutical Guidelines. Hand written entries made to the medication administration records should be accompanied by two signatures. Care Homes for Older People Page 8 of 28 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 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 10 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 home does provide residents with the information they need. Prospective residents are assessed prior to admission. Evidence: There is a Statement of Purpose and Service User Guide, but this combined document is not dated. This information is provided to residents or prospective residents and is present in every bedroom. Discussion took place with the Mrs Deane as to how this could be improved (e.g. alternative formats: audio/video, and the inclusion of a summary of the findings from quality assurance surveys). The care documentation for the most recent admissions to the home showed that a care needs assessment had been carried out prior to admission. Mrs Deane confirmed that they also obtain assessments from external agencies if they are involved in the referral. Discussion took place with Mrs Deane as to how the homes pre-admission Care Homes for Older People Page 11 of 28 Evidence: assessment could be improved (e.g. include a personal history, and likes and dislikes). Comments received from clients or their relatives told us that they felt they were kept well informed, and had the information they needed. The home does not provide intermediate care. Care Homes for Older People Page 12 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 are in place, but these are not comprehensive and do not provide clear direction. Arrangements are in place to meet health needs. Evidence: Each resident has a care plan intended to inform the staff of the needs they have and the best way of providing the care and support they require. Some improvement is noted regarding the content of these plans but improvement can still be achieved. The care plans seen were not comprehensive and make use of generic instruction (e.g. needs assistance with washing and dressing) rather than stating what assistance is needed). Care plans do not show that the client is routinely involved in care plan reviews. We found that the care plans included information resulting from the pre admission assessments, mobility transfers, dressing and washing, eating preferences, continence, skin care, sensory ability, orientation, communication, anxiety, risk of harm, memory and support within the social environment. Monthly reviews occur, risk assessments, manual handling assessments, weight charts and contact with G.Ps. There is a lifeline record of significant events which is seen as a positive inclusion. The Care Homes for Older People Page 13 of 28 Evidence: current medication that residents are in receipt of should be recorded on the care plans. The documentation of each persons life story will also enhance the quality of knowledge about the person and lead to greater understanding and aid communication. Records were in the main dated and signed but more consistency is required. Evidence that residents are involved in the review of care plans is needed. We observed staff on several occasions interacting with residents, they came across as kind, conscientious and efficient. The people we spoke with had no complaints about the way they were treated and were extremely happy to be living in the home. The records indicate that District Nurses and General Practitioners regularly visit different residents. Residents spoken with were complimentary of the staff and care provided. Comments received from staff and residents included All staff show great care, patience, and skill Everyone is looked after well, first class The food is great We found that staff administering medicines had received training and been assessed as competent to administer the medicines. We inspected the Medication Administration Records and these were found to be correct. In some cases hand written entries were evident. In such cases these should be accompanied with two signatures to ensure the person making the entry has done so correctly. There was a record of receipt and disposal of medicines. We recommend that a fax is received from the pharmacist when changes to medication is made. There were no Controlled Drugs on the premises at the time of the inspection. We looked at the medication storage facilities and found them to be safe and secure. They do not fully comply to the Royal Pharmaceutical Guidelines. It is recommended that you contact your pharmacist for advice with regard to purchasing the required storage facility. The current CD storage facility should only be used to store medicines and not other items, such as residents money. 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. Residents are able to participate in a range of social and recreational opportunities at the care home and in the local community. A varied and nutritious menu is in place that reflects the residents needs, preferences and choices. Evidence: Residents confirmed that staff are helpful and assist them in maintaining their social life, sometimes established before admission to the home. People said that tea is brought to them in their room around 8am and breakfast is at 9am. The residents we spoke to thought this was agreeable. People can choose what time they retire to bed. Several of the residents go to church regularly with friends who collect them from the home and a Methodist Lay Preacher visits the home monthly with an organ player, a service is given in the dining room for anyone who would like to attend. A chiropodist visits monthly. Fingernails are manicured by the staff and the ladies can have their nails painted if they ask. A hairdresser visits the home once a fortnight. Care Homes for Older People Page 15 of 28 Evidence: Mrs Deane buys a daily paper for the residents and if they request other papers or magazines the residents order and pay for them themselves. Sennen has three communal buses that are used for outings by residents. Mrs Deane has passed a test to enable her to drive one of the buses and does occasionally take residents out on trips. Every Wednesday several of the residents are taken to the First & Last pub for a meal with the local lunch club. The bus driver calls at the home on a Tuesday morning for anyone who would like to go to the farmers market. One resident said that if she wanted to go shopping then it would be arranged. Residents said that their privacy is respected and people do knock before entering their rooms. There is an activity board displaying planned activities. A musician visits occasionally. Games are played on a Sunday afternoon. Quizzes are often organised by the staff. Mrs Deane has discussions with residents, they talk about the past and what they would like to do in the future (outings, etc). One resident said that they enjoy this time as it gets them talking together. There is a collection of videos and we were told that they frequently enjoy watching old films. There is a portable telephone available to residents and two people have their own telephone. The visitors book near the entrance shows frequent and regular visitors to the home, and Mrs Deane confirmed that there is open visiting. Residents said that visitors were always welcomed and well received by the staff. Residents look after their own finances or have a relative doing so for them. Mrs Deane confirmed that the registered providers are not appointees for anyone at the home. The registered providers do hold some money securely on site for residents. Mrs Deane confirmed this is transferred to individual accounts if it accumulates. There are appropriate individual records and receipts kept. There is a 4-week rolling menu, which is adjusted with the seasons. The menu shows the choices available. There are two cooks, one working 4 days/week the other 3 days/week, however a vacancy occurs for one of the cooks at present, soon to be filled. The main cook confirmed that alternatives are available. The kitchen uses a mix of fresh and frozen vegetables, and fresh herbs are grown outside for use in cooking. Homemade cakes are provided at tea every day. The kitchen was seen to be clean and orderly and we were advised that it had been inspected by an Environmental Health Care Homes for Older People Page 16 of 28 Evidence: Officer fairly recently. The cook confirmed that the home adheres to a kitchen cleaning schedule. We observed staff during lunch, some residents needed help with their meal and a member of staff was there to assist those who were not able to cope. A menu is shown to residents for the meals to be served the following day. One resident said that if someone does not like certain food then an alternative is offered. Everything is cooked on the premises and was well presented. Most of the residents cleared their plates. We were told that fresh fruit is available if requested. The residents have their own individually named napkin rings. The dining room was light and pleasantly furnished with patio doors on to a courtyard containing a fishpond, potted plants and seating. Care Homes for Older People Page 17 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. Residents said they would feel able to make any concerns known. Residents are protected by staff who have received relevant training in safeguarding. Evidence: The homes complaints procedure is displayed discreetly in every residents room and is included in the homes Service User Guide. Mrs Deane undertook to review the contact details for the Care Quality Commission (CQC) and the Department for Adult Care Support (DACS). The Commission has received no complaints since the last inspection. A comments/complaints book has been installed near the entrance. Comments from relatives and residents told us that people did know how to make a complaint, and were confident in the registered providers response. Most of the staff have received safeguarding training. There is an appropriate safeguarding procedure giving staff clear direction as to what to do in the event of an allegation of abuse. Mrs Deane undertook to include the contact details for the Department for Adult Care Support (DACS). Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is clean and hygienic and provides comfortable facilities for the residents. Evidence: We conducted a tour of the premises and found them to be clean and tidy. The property is detached and has sea views on two aspects. The majority of the accommodation is located on the ground floor and this includes the two sitting rooms and the dinning room. Two of the bedrooms are located on the first floor with a bathroom and toilet within a close proximity. The stairs or a stair-lift access these rooms. A bathroom is also located on the first floor. Bathroom and toilets are also situated throughout the ground floor and within a reasonable distance from residents bedrooms and the communal areas. Some of the bedrooms are also provided with en-suite facilities. The residents bedrooms are well proportioned and many of the residents have personalised their rooms. Most of the rooms are very light, some with amazing sea views. Several have a balcony with seating and potted plants and some have a patio door enabling the resident to sit in privacy outside their room. They are painted in pastel shades and the Care Homes for Older People Page 19 of 28 Evidence: residents have adapted them to their own personal needs. Several of the rooms have large fitted cupboards, giving them plenty of storage space. There was a television in each of the rooms that we saw. The rooms viewed had a sink with a bathroom directly outside. One had a sink and toilet and a heated towel rail for warm dry towels at all times. A laundry is also provided on site that is suitably equipped. The laundry was seen to be clean, but care needs to be taken to keep clean and dirty laundry separate. Gloves and similar protective equipment are in this area. Mrs Deane confirmed that the home uses red sacks for fouled laundry. The laundry has domestic-style drying and washing machines. A range of disability equipment is provided at the home to assist residents to maintain their independence and also to promote their safety. In addition individual residents are provided with disability equipment where this is required and following an appropriate specialist assessment. Following a recommendation made at the last inspection a room has been identified to be a dedicated office for the manager. Mrs.Deane is now in the process of setting up this facility. Care Homes for Older People Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers are just sufficient to meet the needs of the residents, but the numbers do not currently allow for sufficient managerial time. Residents needs are met, but could be improved. Evidence: Shifts are arranged: 8am-2.30pm 2.30pm-9pm 9pm-8am There are usually three care staff on duty in the morning, two in the afternoon, and one at night (supported by the registered providers who live in the adjoining building and are available as needed). At the time of the inspection there were 3 care staff, cook and cleaner on duty for 16 residents. Staff carry out multiple roles (caring/cleaning/laundry). Additional staff can be provided at peak hours where required to make sure that residents have the level of care and support they require at all times. A number of residents said that they would not want to live anywhere else, and all were very complimentary about the owner, the time that she spends talking with them, listening to the suggestions they put forward for future activities, and the way that they are treated. The registered providers share on-call cover at night, covering 7 nights a week. Mrs Deane said she would also be looking at including the deputy manager in the on-call Care Homes for Older People Page 21 of 28 Evidence: rota. NVQ certificates are displayed in the entrance. The majority of staff have achieved NVQ Level 2 or above, or equivalent. There is some evidence of ongoing training but insufficient evidence of ongoing monitoring or an active program of training. We looked at recruitment records and found them to comply with employment practices. We did however note that not all staff have their photograph attached to these records. We also recommend that the duty rota includes the surname of staff rather than just the Christian name. Mrs Deane is aware of the need for new staff to undertake a National Training Organisation compliant induction programme (www.skillsforcare.org.uk). Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Comments from the people that live at Chy Byghan show that the home is run in the best interests of the residents. Evidence: Both providers are involved in the running of the care home and both provide direct care, but Mrs Deane has an active daily involvement. One of the Providers, Mrs Deane, is also the registered manager and has successfully completed the Registered Managers Award. Mrs Deane continues to make improvements, but further continued improvement is needed. The registered manager is too often working as one of the care staff. This report identifies requirements and recommendations that require the registered managers attention. It is clear that residents are regularly consulted about the quality of the service and facilities provided. From the consultations that take place the indications are that residents are satisfied. Quality assurance monitoring takes place on an informal basis Care Homes for Older People Page 23 of 28 Evidence: and therefore the evidence by way of recording, surveys and resulting analysis is not evident. The providers will assist residents to manage their personal allowances if this is required and suitable records are maintained. The records detail the transactions that have taken place and a running balance is maintained. Money and valuables are stored securely. There is insufficient evidence to indicate that staff are regularly supervised. There is sufficient and appropriate insurance cover for the service. Fire equipment and appliances at the home are monitored and maintained and staff are regularly trained. There is a comprehensive fire risk-assessment in place. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 7 14 The registered provider must 01/09/2009 review the care plans to ensure they accurately reflect the care needs of the residents, and clearly instruct staff on the interventions needed to meet those needs. The registered provider must involve the resident, wherever possible, in the development and review of their care plan. This requirement was made at the previous inspection. Care Homes for Older People Page 25 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 7 14 The registered provider must review the care plans to ensure they accurately reflect the care needs of the residents, and clearly instruct staff on the interventions needed to meet those needs. The registered provider must involve the resident, wherever possible, in the development and review of their care plan. This requirement was made at the previous inspection. In order to ensure staff are directed as to the care that must be provided. 01/09/2010 2 30 18 Evidence must be provided to indicate that staff are in receipt of relevant training to ensure they are competent to meet the needs of residents. 01/09/2010 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 To ensure the residents receive competent care 3 36 18 All staff must receive 01/08/2010 personal supervision at least six times a year To ensure staff are competent to fulfill their tasks and duties Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The home could improve its Statement of Purpose and Service User Guide (combined document), by presenting it in alternative formats. The registered providers should continue with and expand the use of quality assurance questionnaires, publishing a summary of the findings and any action taken as a result. We recommend that the pharmacist is contacted for advice on the provision of medication security cabinets in order to fully comply with the Royal Pharmaceutical Guidelines. Hand written entries made to the medication administration records should be accompanied by two signatures. The complaints procedure requires updating to include the current contact details of the Care Quality Commission and the Department of Social Care and Support. Photographs of staff should be attached to their file to improve identity checks. Surnames of staff to be added to the duty rota to enable clear identification. 2 1 3 9 4 9 5 16 6 7 29 29 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. Copyright © (2009) Care Quality Commission (CQC). 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