Inspection on 16/12/09 for Dorothy House

This is the latest available inspection report for this service, carried out on 16th December 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dorothy House 16/01/08

Dorothy House 11/07/07

Dorothy House 15/01/07

Dorothy House 21/08/06

Dorothy House 19/10/05

Dorothy House 23/06/05

Dorothy House 22/02/05

Dorothy House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for older people Name: Address: Dorothy House 186 Dodworth Road Barnsley South Yorkshire S70 6PD     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: Janis Robinson     Date: 1 6 1 2 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 31 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 31 Information about the care home Name of care home: Address: Dorothy House 186 Dodworth Road Barnsley South Yorkshire S70 6PD 01226249535 F/P01226249535 azaryounis@aol.com None Mr Azar Younis Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Evelyn Phillips Type of registration: Number of places registered: care home 16 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: 16 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 category: Old Age, not falling within any other category, Code OP - maximum number of places 61 Date of last inspection Brief description of the care home Dorothy House is registered to provide personal care and support to a maximum of sixteen older people. It is situated on the main road from the M1 motorway to Barnsley town centre. The home is an extended bungalow that stands well back from the main road at the top of a driveway. The home shares the grounds with its sister home, The Firs. The gardens are landscaped and there is adequate car parking space. The home is accessible to persons using walking frames or wheelchairs. There are small bedrooms Care Homes for Older People Page 4 of 31 Over 65 16 0 1 7 1 1 2 0 0 8 Brief description of the care home to the front of the property and larger bedrooms to the rear of the property. There is a communal lounge dining room and a small quiet lounge. There is a small patio area leading from the lounge. Written information about the home is available from the home. Current fees range from £356.77 to £386.20 per week. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is one star. This means that people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Janis Robinson, regulation inspector. A visit to the home took place between 9am and 4pm on the 16th of December 2009. The manager was present during this visit. Prior to the visit the manager submitted an Annual Quality Assurance Assessment (AQAA), which detailed what the home was doing well and any plans for improvement in the next twelve months. Information from the AQAA is included in this report. Questionnaires regarding the quality of care and support provided were sent to people Care Homes for Older People Page 6 of 31 living in the home and staff. Completed questionnaires were returned by six members of staff and eight people living at the home. Two people were assisted by relatives to complete their questionnaires. On the day of the visit staff were observed interacting with people that lived at the home. A partial inspection of the premises was undertaken and records relating to care and the running of the home were checked. Six people living at the home and three relatives were spoken with about their experiences of the care provided. Care staff and the cook were spoken with about their roles and experience of working at the home. The manager was spoken with about the running of the home. Verbal feedback was given to the manager, Evelyn Phillips and owner, Mr. Younis, at the end of this visit. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? The manager had met all of the requirements and recommendations made at the last inspection, where it was in her power to do so. The daily records completed by staff contained sufficient detail so that peoples health Care Homes for Older People Page 8 of 31 and well being was reported on. Entries were dated and signed so that they could be monitored. Written signs detailing the date and menu had been enlarged so that they were easier to read. Increased monitoring of financial recods had been put into place to safeguard peoplesl interests. Staff were observed using footplates on wheelchairs to minimise the risk of accidents. A fire risk assessment had been completed. This was up to date and ensured people were protected. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Care Homes for Older People Page 9 of 31 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 10 of 31 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 11 of 31 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. Information about the home was provided to people so that they could make an informed choice. Some minor amendments would ensure the information was fully up to date. Peoples needs were assessed prior to moving into the home to make sure these could be met. Evidence: A statement of purpose and service user guide were in place and seen by us. Copies of the service user guide were seen in peoples bedrooms, which meant that they had access to this information. The guide contained details about all aspects of the home so that people could make informed choices. However, some information was out of date. The guide did not reflect the current management of the home, or give correct contact details about how to contact us. This meant that people did not have access to full information to uphold their rights. In their surveys, when asked if they had been provided with enough information about the home to help them decide to move in, all eight respondents said Yes. Care Homes for Older People Page 12 of 31 Evidence: The manager stated that she carried out needs assessments for each person prior to their admission to the home, so that their needs could be identified. The manager would visit the person in their own home, or hospital, to carry out the assessment. The manager said that wherever possible, relatives would be involved in the assessment process so that full information was gathered. Copies of social workers assessments were obtained, when available. A care plan would be written from the information obtained at assessment. Three peoples files were checked. They contained a range of information about the persons health, personal and social care needs so that these could be addressed. Care Homes for Older People Page 13 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs were met so that they had good quality care provided to them. Evidence: Three peoples care plans were checked. They all contained information on personal needs and how these were to be met. The plans included sections on social history, interests, health care, communication and diet. Risk assessments were undertaken in nutrition, continence, falls and manual handling so that all risks were identified and minimised. The care plans checked had been reviewed on a monthly basis so that they remained up to date. The sections in care plans about social history and interests gave a clear and detailed picture of the person, which made the plans personal and not just a list of needs. This is commended. Staff undertook daily recordings so that information was available to all staff. These had improved since the last inspection as they gave details of the persons well being and the care provided. Peoples health was monitored and records were kept of professional visits so that all staff were aware of current health. The records showed that people had access to a Care Homes for Older People Page 14 of 31 Evidence: range of health care professionals, including GPs, Chiropodist, Opticians and District Nurses. People said that their health needs were met and they could see their doctor at any time if they needed to. Records of accidents were checked. These had been fully recorded so that safe procedures were adhered to. The manager said that she regularly monitored records of accidents to ensure full and safe procedures were followed. A policy on medication was in place. Staff that administered medication had been provided with safe medication administration training so that they were aware of safe procedures to follow. Part of a medication round was observed. Medication was administered safely and the records were signed after the senior staff had made sure medication was taken. Some medication administration records were checked. These had been fully completed and detailed when a medication had been refused or was not required. This upheld peoples safety. Some stocks of medicines were checked. These corresponded with the records. All medication containers had appropriate labels with correct details so that safe practice was adhered to. Medication was securely stored. The manager stated that a pharmacist was visiting the home the day after this inspection to audit the medication systems as part of their monitoring. All of the people spoken with said that staff respected their privacy. The staff spoken with could describe ways in which they maintained peoples privacy. Staff were observed knocking on doors before entering peoples rooms. People said that they were well cared for, comments included, The staff are very caring. They give me everything and more. Couldnt wish for better. The staff have time for you I am well looked after. I can see my doctor if I need to. Its marvellous here. One relative said; The staff are amazing, excellent care is given. Care Homes for Older People Page 15 of 31 Evidence: The interactions observed between staff and people living at the home appeared caring, patient and respectful. Staff took time to talk to people and included them in conversations. All of the staff spoken with were aware of individual peoples needs and could describe these in detail. Care Homes for Older People Page 16 of 31 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. Peoples daily life and social activities provided choice. Evidence: An activities worker was employed for ten hours each week. An activities programme was on display, which included quizzes and arts and crafts. The inspector joined part of a morning activity. The activity was well attended and people said that they enjoyed the activities provided. One person spoken with said that they chose not to join in and this was respected. Comments included, I always like to join in, its something to do. I really enjoyed the trips out. I dont like to join in but thats always okay. All of the people spoken with said that they had visitors and regular contact with family. One relative spoken with said that they could visit at any reasonable time and were always made to feel welcome. Staff appeared to have good relationships with the visitors to the home. Care Homes for Older People Page 17 of 31 Evidence: People spoken with said that they had choice. They could chose when to get up and go to bed, what to eat and how to spend their time. A varied menu was provided. People said that they enjoyed the food and could always have something different if they chose. Comments included, Theres always plenty. You can have a choice. Anything you want any time you need it. I like the food. Its very good, plenty of it. No cook was employed at the home. Care staff cooked breakfast and prepared tea and supper. The implications from this are reported on in the staffing section of this report. The owner of Dorothy House also owned a care home, The Firs, on the same site. The cook employed at The Firs would cook the main meal for people living at Dorothy House. Staff collected this in a large heated trolley. Staff said that this was sometimes difficult as the trolley was heavy and had to be maneuvered over a step. Staff were aware of peoples preferences and special diets so that these could be catered for. Fresh fruit and vegetables were available in the plentiful food stocks seen to ensure people had a healthy diet. Part of the lunch time meal was observed. The food appeared appetising and staff sat to assist people with eating if they needed this support. Care Homes for Older People Page 18 of 31 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. Policies and practices regarding complaints and safeguarding protected people. Evidence: A complaints policy was in place and information on how to make a complaint was included in the service user guide. A poster about the complaints policy was also on display in the entrance hall. However, both documents contained out of date information about our contact details should people wish to make a complaint direct to us. A record of complaints was kept. This was seen to detail the action taken in response to a complaint and the outcome. This ensured that important information was kept and complaints could be monitored. All of the people spoken with said that they could talk to staff if they had any concerns. Comments included, I can talk to staff, they would sort any worries. What have I got to worry about? If I had any they would be soon sorted. In their surveys, when asked if they could speak to someone informally if they were not happy, all eight respondents said Yes. When asked if they knew how to make a formal complaint, all eight respondents said Yes. A written policy on safeguarding adults was in place. The training records checked showed that staff had been provided with training in safeguarding. Additional training Care Homes for Older People Page 19 of 31 Evidence: had taken place a week prior to this inspection so that staff skills and knowledge was maintained. All of the people spoken with said that they felt safe living at the home. Care Homes for Older People Page 20 of 31 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. On the whole people were provided with pleasant and comfortable accommodation that met their needs. Some refurbishment would maintain standards and benefit people. Evidence: Parts of the environment were checked. Communal lounges were well decorated and appeared comfortable. Pictures and ornaments created a homely atmosphere. Suitable bathrooms and toilets were provided to meet peoples needs. Peoples bedrooms were well personalised and reflected individuals interests. People said the home was comfortable and that they were happy with the accommodation provided. Comments included, Its a home from home. Because its small it has a lovely homely feeling. In addition to the large lounge provided, a smaller lounge was available in another part of the home. However, a door from this lounge was kept open so that staff had access to the external laundry. This meant that the room was cold, and therefore restricted peoples choice of lounge space. Alternative access to the laundry would be possible if staff used a path from the front door to the back of the building. Some Care Homes for Older People Page 21 of 31 Evidence: parts of the home required attention so that good accommodation was maintained. The large lounge carpet was badly stained in one area. It is acknowledged that attempts had been made to remove marks, but these had been unsuccessful. The provider stated that a new carpet would be purchased. Two toilets had marked flooring and one shower room had damaged flooring and decoration. The provider had plans to update the shower room to a wet room so that peoples needs were better met. Care Homes for Older People Page 22 of 31 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. Lack of staffing at busy times could mean that peoples needs are not met in a timely manner. Evidence: The staff rota was checked. This showed that numbers of care staff were maintained. Two care staff were provided each morning and afternoon. Two waking night staff were provided during the night to meet peoples needs. The manager and staff said that they worked well together and managed to cover most shifts if staff were sick. The manager stated that agency staff were used only on occasions where permanent staff could not cover. The AQAA stated that in the last three months, thirteen shifts had been covered by agency staff. However, some practices regarding staffing meant that care staff were not fully available to people, which posed a potential risk. No cook was employed at the home. This meant the the two care staff on duty were responsible for cooking and clearing away breakfasts, preparing teas and suppers in the kitchen. This was routinely interrupted when people needed to go to the toilet, or needed other support. This practice reduced staff availability and meant that during this time staff numbers were not maintained. It is important to acknowledge that staff always prioritised peoples needs. In addition, no laundry person was employed. The cleaner undertook laundry duties during the week, but care staff were responsible for attending to laundry at the weekends. This also reduced staff availability. In their survey, one relative said, Care Homes for Older People Page 23 of 31 Evidence: At busy times, e.g. breakfast, dinner and tea, there is not enough staff. There is no longer any kitchen help at these times. This means that staff are responsible for preparing, serving and clearing away of meals. At the same time they are the ones that administer personal care needs. A definite hygiene concern. In their surveys, five of the six staff said that they needed more staff at busy times so that they could meet peoples needs. National Vocational Qualifications (NVQ) were provided to staff to enhance their skills. All of the ten care staff had achieved NVQ level 2 in care. This is over and above the recommended fifty percent of care staff trained to NVQ level 2 in care, and will benefit people living at the home. Three staff recruitment files were checked. Two of the files contained complete and full information to evidence that thorough procedures had been adhered to. One file did not contain a full application form, work history or references. The staff had worked at the home for a number of years, prior to the present manager. The manager had identified gaps in the file and had requested that a statement be provided from the staff member to confirm that references had been obtained and lost. The manager confirmed that she would obtain a full employment history from the staff member to make sure that all information that could be obtained was present in the file. All of the three files checked contained evidence that a Criminal Records Bureau (CRB) check had been completed. A programme of staff induction and training was provided to staff to maintain their skills. The manager stated that a training plan was in place for the next twelve months, with one training event taking place each month. Staff spoken with confirmed that two monthly training events had already taken place. Training certificates were seen in the files checked. However, there was no written training record or programme in place so that this could be monitored. The staff spoken with confirmed that they had been provided with induction training and felt that enough training was provided. Care Homes for Older People Page 24 of 31 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. Overall the home was well managed. However, time restraints limited the manager to fulfill all of her duties. Evidence: The manager had been in post for approximately one year. She had previous experience of management in a care home. All of the people living at the home, relatives and staff made positive comments about the manager, these included, Shes good. She is approachable and listens to us. Her door is always open. Any suggestions to improve (my relatives) care have been listened to and acted upon. Care Homes for Older People Page 25 of 31 Evidence: All of the staff spoken with said that they worked well together and were a good team. The manager said, The staff are very caring and work well together. They have a good relationship with residents and give their best. Throughout this inspection the manager showed that she had identified areas for action and had prioritised these. However, time restraints had impacted on her ability to undertake all of her managerial responsibilities routinely. The manager worked Monday to Friday 8.30-4.30. From 8.30 am until 3pm each day the manager was part of the care staff rota, and was one of the two carers available to people. From 3pm to 4.30pm each day the manager was free to dedicate herself to her managers duties. This practice had serious repercussions regarding the routine management, and is reflected in the findings of this inspection. This issue was discussed with the provider during feedback. He offered assurances that the managers hours would be increased so that she could fulfill all of her duties. There was a quality assurance system in place to obtain and act upon peoples views. The manager had sent surveys to people living at the home and their representatives. The results of the surveys had been audited and the manager had made a record of these to show that they had been acted upon. However, the manager had not written a report about the results of surveys so that this was available to people. Monies were kept for some people. These were securely stored. Records of monies were maintained. Those checked detailed all spending, were signed and receipts were kept. The amounts kept tallied with the records held. The manager regularly audited peoples financial records to make sure they were in order. Records of staff supervision and talking to staff evidenced that staff were provided with supervision at relevant frequencies. This made sure staff were appropriately supported and appraised. A programme of staff training was in place. Discussions with the manager and staff showed that all staff had been provided with training in all mandatory areas, including health and safety, food hygiene, fire and moving and handling. Systems had been checked and serviced to make sure they were safe. However, one persons hoist seen was due a service on 09/03/2009 and this had not taken place. This was brought to the managers attention, who arranged for the hoist to be Care Homes for Older People Page 26 of 31 Evidence: serviced the week of this inspection. The manager confirmed that the hoist would not be used until the service had taken place. We received confirmation two days after this inspection visit that the hoist had been serviced and was in good working order. Fire extinguisher servicing was up to date. Records in the fire book showed that weekly fire alarm tests took place and a fire risk assessment had been undertaken. Regular practice drills were held so that staff knew how to respond in an emergency. Care Homes for Older People Page 27 of 31 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 28 of 31 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 19 23 The home must be well 26/02/2010 maintained. The damaged carpet in the lounge must be addressed. The damaged decoration and flooring in the shower room and toilets must be addressed. This will provide people with a pleasant and comfortable living space. 2 27 18 Sufficient numbers of staff must be provided at busy times. This will ensure peoples needs can be met. 26/02/2010 3 31 12 The manager must be provided with sufficient supernumerary hours to fulfill her managerial responsibilities. This will ensure the home is well managed and benefit people. 26/02/2010 Care Homes for Older People Page 29 of 31 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 38 13 All equipment must be routinely checked to ensure it is safe to use. This will keep people safe. 23/12/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 1 16 The statement of purpose and service user guide should be updated so that they contain correct details. The written complaints procedure should be updated to contain our correct contact details so that people have access to this information. The condition of the entrance corridor carpet should be monitored and replaced prior to further wear and tear so that good standards are maintained. Consideration should be given to using alternative access to the laundry. This would ensure that the small lounge is kept warm. A record of staff training and a written training plan should be undertaken so that this information is accessible and to monitor training. A quality assurance report should be undertaken so that relevant information is available to people. 3 19 4 19 5 30 6 33 Care Homes for Older People Page 30 of 31 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. 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