Inspection on 26/04/10 for Heath Lodge

This is the latest available inspection report for this service, carried out on 26th April 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heath Lodge 29/01/09

Heath Lodge 22/01/08

Heath Lodge 11/07/06

Heath Lodge 31/10/05

Heath Lodge 05/07/05

Heath Lodge 29/09/04

Heath Lodge 13/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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: Heath Lodge St Georges Avenue Weybridge Surrey KT13 0DA     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: Lesley Garrett     Date: 2 6 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © 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 30 Information about the care home Name of care home: Address: Heath Lodge St Georges Avenue Weybridge Surrey KT13 0DA 01932854680 01932851792 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.surreyresthomesltd.co.uk Surrey Rest Homes Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 26. The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) Date of last inspection Brief description of the care home Heath Lodge is a registered care home for up to 26 older people. It is one of four homes owned by Surrey Rest Homes Ltd. The home is a large detached house with a purpose built extension, set in a large garden in a residential road close to Weybridge railway station and town. The accommodation is on two floors with a chair lift that falls short of the last few steps to the ground floor. The home has single and double rooms, Care Homes for Older People Page 4 of 30 Over 65 0 26 26 0 2 9 0 1 2 0 0 9 Brief description of the care home some with en-suite facilities. There is a garden to the rear of the premises and parking to the front of the building. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection of the care home was an unannounced Key Inspection. Mrs Lesley Garrett, Regulation Inspector and Mrs Rosemarie James Local Area Manager, carried out the inspection and the unregistered manager and the registered manager from another home within the group represented the service. We arrived at the service at 09:45 and were in the home for five hours. It was a thorough look at how well the home is performing. It took into account information provided by the home and any information that CQC has received about the service. In January 2010 we completed an Annual Service Review (ASR) for the home. We indicated in this report that we would bring the key inspection for the service forward following information that had been gathered for that review and knowledge we had about the service. We asked to meet with the registered provider for Surrey Rest Homes and we met with Dr Prasad during the day. He spoke with Mrs James and she was able to explain some of the concerns we had concerning this service. Care Homes for Older People Page 6 of 30 CQC had been supplied with an AQAA (Annual Quality Assurance Assessment) and this document was used to assist with the inspection. This document was supplied in time for us to use for the ASR in January and therefore it was not a year old so could be used to assist with this key inspection. We spent time talking and observing some of the people using the service and speaking with some staff members. We looked at how well the service was meeting the key national minimum standards and complying with the regulations and have in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes care plans, risk assessments and daily records, training records and the homes safeguarding and complaints policies and procedures. From the evidence seen by us and comments received we consider that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Eight requirements were made following this key inspection and can be viewed in detail at the end of this report:The statement of purpose and service user guide to be kept under regular review and updated when necessary. The risk assessments contained within the care plans at the home must have clear instructions available to staff so that they can understand the scoring system used. The complaints policy should contain the correct information, be kept under review and updated when necessary. Safeguarding procedures at the home should be strengthened to ensure staff refer all safeguarding incidents promptly to the appropriate authority. All parts of the care home should be well decorated and in a good state of repair with good evidence of a refurbishment programme that is put into practise by the management team. The infection control and cleaning procedures at the home to improve and action to be taken when shortfalls are identified. Training in the home for staff should be strengthened to meet the needs of the people who use the service and be appropriate to the work they are to perform. Care Homes for Older People Page 8 of 30 Management arrangements within the home need to be strengthened and for the current person in charge to become registered with CQC. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to use the service do not benefit from up to date information regarding the home. Evidence: We sampled the service user guide and statement of purpose. Both documents were found to contain information that was out of date and they had not been reviewed since December 2008 and January 2009 respectively. The manager told us that head office had accidentally deleted the documents from the computer so they needed to be typed again. Later in the afternoon these documents were supplied to us and they now contained the correct details for who was now managing the home and the correct contact details for those people that may wish to make a complaint. The person in charge told us that all prospective people wishing to use the service now benefit from a pre-admission assessment. Two people now carry out this assessment. At the moment it is the person in charge and the manager from another home but in Care Homes for Older People Page 11 of 30 Evidence: the future it will be the manager and senior carer. The document has recently been reviewed and allows the person who carries out the assessment to make the decision about the needs of the person they are assessing. The person in charge said they could make an informed choice about admitting this person to the home. The procedure for admitting people to the home was not followed during the Christmas period and this is now subject of a safeguarding adult investigation. The home does not accommodate people who require intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The risk assessments that are used in the home need to be strengthened to ensure that staff have the information they require to care adequately and to protect the people using the service. Evidence: Two folders of people using the service were sampled and they both contained a variety of care plans and risk assessments. It was observed that the risk assessments that were in place were, for example; regarding falls, skin integrity, mental health assessment, moving and handling and behaviour. Following each assessment a scoring system was used. There was no details on how staff were to interpret these scores and the risk assessments did not detail what actions or interventions were needed. The nurse in charge and her mentor told us that they just knew what the scores meant. This system of risk assessments does not protect the people using the service as staff are expected to interpret for themselves the interventions that are required. This does not promote the health and well being of the people using the service. The nutritional risk assessments in place did give instruction on actions to be taken according to the score used. Care Homes for Older People Page 13 of 30 Evidence: It was observed in the office that there was a poster with an explanation about how staff could use the Malnutrition Universal Screening Tool (MUST). The person in charge told us that this was only used for people who had been identified at particular risk. No training had taken place for staff to enable them to assess adequately the nutritional status of the people using the service. This does not protect the health and well being of the people using the service. A requirement regarding poor risk assessments will be made at the end of the report. The person in charge told us that the GP visits every week to see those people using the service who need a visit or who have requested one. The person in charge told us that the GP was a good support to the home and that the GP would visit the home more often if someone was unwell. The home also has the support of of the district nurses who visit those people with specific health care needs identified by the staff or GP during a visit. The person in charge told us that the GP had recently printed the notes that are available at the surgery so that staff can see the past medical history and treatment given to the people using the service. The home also has the services of a chiropodist and optician who visit regularly. The dietitian and speech and language therapist are available following a referral by the GP. On the day of inspection the district nurse was visiting the home. She told us she thought that there had been some improvement in the home in recent weeks although she did say she was not the regular nurse that visited. There are medication policies and procedures in place. The carer told us that all medications are delivered every month and are in blister packs. They are supplied by a large chain pharmacy. The person in charge told us that the medication is audited by the supplier and this had recently taken place. It was observed that the 08:00 medication round was still taking place at 10:30. The carer told us that this was for those people that had breakfast late. The medicines are stores in a trolley and cupboard and both are in the dining room. Medication training is available to staff. We sampled the records and observed that only five members of staff have received this training and this was in June 2008. The person in charge who had previously worked at the home has not received this training. It was noted in our records that during the past year there have been two recorded medication errors. During the morning it was observed that very little interactions took place between staff and people using the service. Staff were seen to be helping people to the bathroom for showers, but whilst they were seated in the lounge very little conversation took place between them. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to take part in limited social and recreational activities. The quality of the meals are good which means nutritional needs should therefore be met. Evidence: The home still does not benefit from an activity organiser and the programme of activities are organised by the members of staff. The activity programme displayed on the day of inspection had an activities programme for seven days documented and two weeks of activities were on display. It was titled week 1 and week 2. It was not clear which week they were using until the staff told us the activity planned for that day.Activities available to the people who use the service included ball games with music, reminiscence activities, sensory games and quizzes and word games. A PAT dog visits the home once a week and nail care and hand massages are available weekly. The person in charge told us the hairdresser visits every Friday. On the day of inspection most people using the service were sitting in the two lounges. In the first lounge the people were sitting in the armchairs; one person reading a newspaper and the others were not engaged with an activity. In the lounge Care Homes for Older People Page 15 of 30 Evidence: overlooking the garden the television was on in the corner but only one person looked occasionally at the screen. One staff member was available during this time helping people to their armchairs after they had finished their breakfast and personal care. There was no evidence to say that community groups or volunteers were involved with the home. On special occasions entertainers are booked to visit the home and this was organised for the Christmas festivities. The person in charge told us that relatives and friends are welcome at any time to visit. On the day of inspection the cook was in the kitchen. She was preparing pork casserole with mashed potato and frozen carrots and beans. We were told that the delivery of fresh fruit and vegetables was due that day. It was observed that the cook took into account the wishes of one person using the service as they had stated they did not want mashed potato at lunch and the cook had prepared boiled potatoes. Another was served a vegetarian alternative. The cook has a four week cycle of menus and the people using the service received the food that was planned for that day. We observed the lunchtime meal and noted that people using the service were enjoying their lunch. Tables were laid with tablecloths and napkins and drinks were readily available. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service do not have access to a current complaints policy that has been reviewed and updated and staff have not referred an incident of abuse promptly to the local authority for investigation. Evidence: The person in charge said that during the last year they had received two complaints. These had been investigated and resolved. The home has a complaints folder where any complaint received by the home is placed with outcomes of investigations documented. The complaints policy observed during this inspection had not been reviewed and updated. It referred to CSCI with an address for us in Oxford to send concerns to. The policy referred to complaints received by Avens Court which is another home within the group and also mentioned Regulations that were not CQCs regulations. The document was confusing and people using the service their relatives or friends would not know how to contact CQC if they needed to. Documentation seen on the day of inspection confirmed that staff had received training in safeguarding adults procedures and refresher training takes place every year. The home has an internal policy on safeguarding adults and this is in line with the local authoritys and the home also has a copy of that procedure. We sampled care plans as part of this inspection process and in one particular care plan we observed a body map the staff had inserted. This detailed that one person Care Homes for Older People Page 17 of 30 Evidence: using the service had unexplained bruises to both wrists. We spoke to the person in charge who told us that no Regulation 37 notification had been written and nor had this been referred to the safeguarding adults team for investigation. The person in charge was asked to do this whilst we were still at the home. The home is currently subject to an ongoing investigation under the local authoritys safeguarding adults procedures. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not benefit from a regular programme of refurbishment and infection control procedures within the home need to be improved. Evidence: We undertook a tour of the building and looked into some bedrooms and observed all of the communal areas and bathrooms. Since the last inspection it was noted that both lounge areas had been decorated and the corridors also painted. The gates at the bottom and top of the stairs were unlocked allowing people who use the service the ability to walk up the stairs to their bedrooms if they wished to do so. A stair lift is available for those people with mobility problems. We observed several bedrooms and found all but two very dull and bare of personal items. The quality of the bedlinen and pillows was poor. We found very stained pillows and one was taken to the provider for his comments. He immediately authorised a member of staff to go to the local shops to purchase twenty new pillows. The bedrooms were dusty and cobwebs were observed in one door frame between the bedroom and the en suite. Two bedrooms were mal odorous. Most bedrooms on the ground floor were noted to be dark, some headboards were loose and one wardrobe moved when touched and was not fixed to the wall. Requirements were made during the last inspection in January 2009 to improve the Care Homes for Older People Page 19 of 30 Evidence: bathing and showering facilities. The shower on the ground floor has now been decorated and a new shower fitted. It was noticed that a block of wood was at the bottom of the shower and staff told us that was to protect their feet and the rest of the bathroom from getting wet when the shower was in use. The bathroom on the ground floor is used to store the clean laundry that requires to be placed on coat hangers. This bathroom is not in general use. The hoist was working when tested but the bath was dry and staff told us that most people using the service had showers. There was only one shower room working upstairs. There was no evidence seen of a planned decorating and refurbishment programme. During the tour of the building some infection control issues were identified. In the downstairs shower room a chair from the dining room was used to sit people using the service on when they were being supported to dress following a shower. This chair did not have removable covers so if any person was incontinent this would be difficult to clean throughly. The person in charge told us that chair is never removed from the shower room. This was not a specialised piece of furniture for a bathroom and did not have non slip feet. Buckets and mops were also stored in this room. All rooms that we visited were noted to be dusty especially on the top of the wardrobes. In the dining room the aprons that staff used when servicing meals was stored on the floor in an opened packet. Staff told us this was the usual storage place. One person using the service had an opened packet of biscuits in their bedroom. These were placed on the bedside table but not in an air tight container. Some of the over the knee tables available in the bedrooms were in a poor state of repair with some of the edges chipped which would make cleaning very difficult. The home employs a domestic who works six days a week for five hours a day. This member of staff is also responsible for the laundry. Staff records sampled showed that only five members of staff have received infection control training. Two in 2008 and three in 2009, but this did not include the person employed as a domestic and laundry assistant. A requirement will be made at the end of the report regarding the environment and infection control procedures and practises. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers at the home on the day of inspection were sufficient to meet the assessed needs of the people using the service, but the training needs of the staff team should be monitored to ensure they can meet their care needs. Evidence: We sampled the homes staff rota which is written by the person in charge. On the day of our visit the home had sixteen people who use the service in the home. Their assessed needs and the staff numbers on during the day indicated that their needs could be met. The rota showed that four members of staff are on duty in the morning and four staff in the afternoon. The person in charge is always supernumerary and she has the support of a domestic and cook. Following the inspection in January 2009 a requirement was made that the home should consider the staffing numbers at night due to the assessed needs of the people using the service and the layout of the building. Staff members also have to carry out domestic chores during the night which includes ironing. The person in charge told us that staff numbers were increased for a short while but that there are now only two members of staff again. Regulation 37 notifications received by CQC showed us that this year there have been sixteen unwitnessed falls at the home. The person in charge was asked to monitor staffing levels and that the home should always be staffed to the assessed needs of the people using the service and not by the number of people in the home. Care Homes for Older People Page 21 of 30 Evidence: The person in charge told us that most of the staff at the home have a National Vocational Qualification (NVQ) at level two and above. This training is always available for carers that have completed their induction. Inductions are given to all new members of staff and this is then linked into the NVQ programme. The last inspection was in January 2009, since that time the person in charge told us that there has been no new members of staff recruited. During the last inspection we sampled two recruitment folders and these contained all of the information required. During this inspection we did not sample any more files. The person in charge told us that training at the home takes place regularly. We looked at the training records for the staff. This showed us that only four members of staff have received first aid training; one in 2009 and three in 2008. Most staff had attended both manual handling and safeguarding adults training this year. The home is registered to take those people that have a diagnosis of dementia but only three members of staff completed this training last year. Two members of staff attended health and safety training in 2008 and as mentioned previously five members of staff have medication training but this was in 2008. Regulation 37 notifications received by us this year detailed incidents of aggressive behaviour by people who use the service. No member of staff have received training in challenging behaviour. A requirement will be made at the end of the report that training in the home for staff should meet the needs of the people who use the service and be appropriate to the work they are to perform. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements at the home need to be strengthened to ensure there is a consistent approach to the running of the home for the benefit of the people who use the service and the staff team. Evidence: Heath Lodge has not had the benefit of a registered manager since 2008. Since the last inspection in January 2009 the home has had at least five people appointed to the position of manager and one that acted in a temporary role from another home within the group. This does not allow for consistent practises within the home to be established as the staff team are constantly managed by different people. During this time managers have resigned, been appointed and only worked a few days then disappeared not informing the home their intention not to work there or took up the position then resigned before taking up the appointment. The current manager has now been in post for one month and is a former team leader at the home she has a Care Homes for Older People Page 23 of 30 Evidence: NVQ level 3. She has yet to do a recognised managers award/qualification. She too had resigned prior to this appointment but decided to return to Heath Lodge. The home is currently under investigation by the local authoritys safeguarding adults team for incidents that have occurred during this unsettling period for the home. We spoke to the provider of the home who is the responsible individual and explained the importance of registering the current manager before the home begins the registration process with CQC. All adult social care establishments have begun the registration process with CQC so that by October 2010 all care homes will have completed the registration process with us. Recently Dr Prasad has been out of the country on personal family business which has left the home without a registered person to address any concerns that CQC may have. CQC were not made aware that he was out of the country and only found out following numerous calls to the head office. The home has a operations manager who only works on a Friday and is the person who carries out most of the Regulation 26 visits and also attends the safeguarding adult meetings. CQC are assured by the staff at the home that the operations manager is always available on his mobile phone and will often call in on the home at weekends.The management arrangements at the home have been erratic for the past two years and the staff team now need the stability and direction from a stable management team to address the shortfalls identified during the key inspection. The person in charge told us that the plans are to hold meetings every three months for the people who use the service and they last had a meeting six to eight weeks ago. The minutes of this meeting were not available. Surveys to seek peoples views are sent regularly. People who use the service had surveys sent in March. Their relatives or friends received surveys in February and health care professionals will be sent surveys in April. The person in charge told us that the results are then analysed and an action plan will be written for any shortfalls identified. Regulation 26 visits take place every month. The person in charge said either the operations manager carries these out or a manager from another home within the group. On a Regulation 26 visit this year it was identified that the homes linen and pillows were in a poor state but no replacements had been ordered until the visit by CQC took place and twenty new pillows were then purchased. It should be noted that Regulation visits should be unannounced yet every visit this year has taken place on a Friday following the managers meetings in head office. The AQAA identified that all necessary health and safety certificates were in place and all staff had attended fire safety training in March this year. During a tour of the Care Homes for Older People Page 24 of 30 Evidence: building it was observed that some rooms were using door wedges but no evidence of risk assessments in place to protect the people using the service in the event of a fire. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 6 The statement of purpose and service user guide must be kept under review. This allows people who wish to use the service to make an informed decision about staying at the home. 01/06/2010 2 7 15 The risk assessments contained within the care plans at the home must have clear instructions available to staff so that they can understand the scoring system used. This will ensure that the staff understand the meaning of the risk assessed scores to enable them to deliver the correct care. 01/06/2010 3 16 22 The complaints policy should 01/06/2010 contain the correct information and be kept under review and updated when necessary Care Homes for Older People Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To ensure that all people who use the service know how to make a complaint and to whom. 4 18 13 Safeguarding procedures at 01/06/2010 the home should be strengthened to ensure staff refer all safeguarding incidents promptly to the appropriate authorities. This ensures that all people who use the service are protected from abuse. 5 19 23 All parts of the care home 01/08/2010 should be well decorated and in a good state of repair with good evidence of a refurbishment programme that is put into practise by the management team. To ensure that the people who use the service live in a well maintained and comfortable home. 6 26 13 The infection control and cleaning procedures at the home to be improved and action to be taken when shortfalls are identified. For the health, comfort and well being of the people who use the service. 01/06/2010 Care Homes for Older People Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 30 18 Training in the home for 01/07/2010 staff should be strengthened to meet the needs of the people who use the service and be appropriate to the work they are to perform. To ensure that people who use the service are cared for by a staff team who have received the required training to meet their needs. 8 31 8 Management arrangements within the home need to be strengthened and for the current person in charge to become registered with CQC. This ensures that the people who use the service and staff team benefit from consistent management practises and procedures. 01/07/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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