Inspection on 19/11/09 for Katherine House

This is the latest available inspection report for this service, carried out on 19th November 2009.

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

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

Similar services:

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Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report Care homes for older people Name: Address: Katherine House 10-12 Ebury Road Nottingham Notts NG5 1BB     The quality rating for this care home is:   two star good 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: Karmon Hawley     Date: 1 9 1 1 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 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) 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 28 Information about the care home Name of care home: Address: Katherine House 10-12 Ebury Road Nottingham Notts NG5 1BB 01159123554 01159123560 a.smith@abbeyfield.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Abbeyfield Society Name of registered manager (if applicable) Mrs Anita Smith 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: The maximum number of service users who can be accommodated is 19 The registered person may provide the following categories of service, Care home only, Code PC to service users of the following gender, either, whose primary care needs on admission to the home are within the following categories, Old Age, not falling within any other category, Code OP, Dementia, Code DE Date of last inspection Brief description of the care home Katherine House Care Home consists of two large semi-detached houses, which have been adapted and extended with a covered corridor between the two. The location of the home provides good access to local facilities, including shops, a church and public transport. Care Homes for Older People Page 4 of 28 Over 65 0 19 19 0 Brief description of the care home Care is provided in comfortable living accommodation for up to nineteen older people. All the bedrooms are single, some with en-suite facilities. There are bedrooms on the ground and first floors, with stairs and lift access to the first floor. There is car parking to the front of the home and a well-planned, attractive courtyard garden with seating areas to the rear. Fees range from £404 to £406.28 dependent on the level of care needed. The fees do not cover items, such as toiletries, hairdressing, chiropodist, newspapers or holidays. The certificate of registration was on display and was up to date and the latest report and service user guides are available on request. 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: two star good 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 focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people living at the home and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One regulatory inspector conducted the unannounced visit over 1 day, including the lunchtime period. A review of all the information we have received about the home from the provider and the general public since the last inspection was considered in planning this visit and this helped decide what areas were looked at. The main method of inspection we use is called case tracking which involves selecting the care plans of 3 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Care Homes for Older People Page 6 of 28 The Manager, members of staff and people who use the service were spoken with as part of this visit. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. The provider provided sent their latest Annual Quality Assurance Assessment which is a document that outlines the services development over the last year and areas where they intend to make improvements, some of the information provided in used within the main body of this report. 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: Three good practice recommendations have been made in regard to the external maintenance of the building and staffing issues. 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. People using the service are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the care home. The service does not offer intermediate care. Evidence: Before someone makes a decision to use the service, time is spent with them discussing their needs and what they expect, to ensure that the care home is the right choice for them. An assessment of their needs is also carried out by a senior member of staff to make sure that staff are able to meet peoples needs before a final decision to move in is made. Once the decision to move in has been made, people are sent a letter confirming that the staff can meet their needs. To make sure that people have the necessary equipment that they may need, this is obtained before they move into the care home. Care Homes for Older People Page 11 of 28 Evidence: Also, if applicable, the staff receive an assessment from the Local Authority, which outlines peoples needs in depth, so if need be, this can supplement the care homes assessment. Staff spoken with state that plans of care contain sufficient information to ensure that they are able to meet peoples needs. One person using the service tells us that the hospital made all the plans for them to move into the care home and although they had not been able to visit, they had spoken with a member of staff. The service does not offer 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are assured that their health, personal and social care needs are set out in a plan of care so that staff know how to support them in a way that they prefer. People using the service are treated with respect and their privacy and dignity is maintained. Evidence: So that peoples needs are met, plans of care are negotiated with them where able, to ensure that their needs are highlighted. Plans of care in place are personalised and reflect peoples individual choices and preferences. A personal profile is also available so that staff can learn more about each person and understand what has happened in their lives and what is important to them. This information can then be used when people are joining in the reminiscence sessions that take place. Plans of care are in place for peoples daily activities such as maintaining personal hygiene and nutrition, these are written in the first person and outline what is important to each person and the support that they require to ensure that their needs Care Homes for Older People Page 13 of 28 Evidence: are met. To ensure that staff have the necessary information to support people appropriately, information is in place within plans of care in regard to complex needs such as expressing sexuality, dementia care and diabetes. Whilst the information in regard to sexuality and dementia is in depth and covers the specialist assistance and support that people may need, care plans in regard to diabetes only contain basic information. This issue was discussed with the manager who will develop these further to ensure that all the necessary information is in place. In depth risk assessments are in place in respect of all identified needs such as falls, manual handling and mobility to ensure that risks are managed and reduced and people remain safe. There is evidence of both plans of care and risk assessments being reviewed and updated as required so that people receive continuity of care. Staff spoken with tell us that they have access to the care plans and that sufficient information is made available for them to be able to support people appropriately. Staff are also able to discuss peoples individual care and specialist needs outlining the support that they offer to ensure that their needs are met. People using the service tell us that their needs are met and that the staff assist and support them as needed. So that peoples medical needs are met, we can see within peoples plans of care that they are supported to access specialist services such as the district nurse, psychogeriatican and doctor as needed. Also the equipment necessary for ensuring peoples skin is kept free from sores is obtained via the district nurse if needed. Staff tell us that there is enough equipment in place within the care home and they can also discuss how they ensure that people maintain healthy skin; people are able to see the GP or district nurse if needed, there is enough equipment in place and the district nurse supplies beds and mattresses. People using the service confirm that they can see the doctor when needed; we can see the doctor if we need to and they visit us here. Staff who administer medication have been trained to do so, to ensure that people using the service are protected by the medication practices in place. On examining medication records we can see that people receive their medication as prescribed and if this is not administered for any reason this is documented to ensure that this can be monitored. As good practice, handwritten entries are usually signed by two members Care Homes for Older People Page 14 of 28 Evidence: of staff to ensure that these have been checked as correct. When peoples plans of care are negotiated, their ability to manage and administer medication is also assessed. Following this an agreement is put into place should people want the staff to administer their medication. One person using the service tells us that the staff look after their medication and that they are happy with this arrangement. To ensure that people using the service are treated with respect and their privacy and dignity are maintained, a member of staff is the Dignity Champion and they attend regular meetings so that they are up to date with good practice. We can see that staff treat people using the service with respect at all times and when supporting them with care, their privacy is maintained. Staff and people using the service maintain good relationships and we can see that staff are genuinely compassionate and caring. Staff spoken with are able to discuss how they maintain peoples privacy and dignity; we shut doors and curtains and ensure people look respectable, you should treat them as you would want to be treated yourself. People all have their own personalities and are different, even though some people have dementia, they are different, the most important thing is to make sure people are looked after, clean and respected and that their dignity is upheld, its a matter of being here for them and looking after their needs, and we are offering people choices, making sure that care is individualised, closing doors and respecting privacy, a high standard of care is offered. People using the service tell us that staff are kind and caring at all times. Care Homes for Older People Page 15 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. People are supported to live a life of their choosing which meets their expectations and maintain contacts with people that are important to them. Evidence: Staff have formed an activities committee, which people using the service and their relatives are welcome to participate in if they wish so that they can be involved in planning activities. Activities such as cooking, reminiscence, manicures and massage, dog patting sessions, pot planting, musical morning and board games are on offer. Each person using the service has an individual activity plan in their care plan, which highlights which activities that they have participated in. We can see that people generally participate in something everyday. Staff feel that there are sufficient activities on offer to occupy people using the service and that people may spend their time as they wish; people can go out into the community if they want to but many chose not to do so, people enjoy the activities but it does sometimes depend upon their mood, there is enough to occupy people, one person goes out to church and the Nun also visits here to see people who are Roman Catholic, and the routine is flexible, people can do what they want to do. Care Homes for Older People Page 16 of 28 Evidence: People using the service tell us that they are settled living at the care home and they enjoy the activities on offer; there are activities available but we just tend to occupy ourselves and are quite happy doing so, we can spend our time as we want, I have made friends here, I enjoy reading the newspaper and keeping up to date with whats going on, I am happy and settled here, it is better than where I was before, it is a nice home, it is comfortable. I play games with the staff and I enjoy watching TV. So that people are supported in meeting their religious needs a volunteer visits the care home and supports this and peoples personal ministers and a nun also visit the care home. The manager tells us that staff are currently trying to establish further contacts so that this service may be expanded. So that people using the service can maintain contact with those that are important to them there are no restrictions on visiting and visitors may be received in private. People using the service confirm this to be so and tell us that their visitors are made welcome when they come to the care home. Staff tell us, people can go out with their family, or their family can visit here, there are no restrictions on visiting. A wholesome and nutritious menu is on offer to people using the service, with specialist diets catered for such as diabetic diets and choices offered at each meal time. The menu changes twice a year to suit the seasons and we can see that traditional meals are on offer throughout the year. People using the service speak highly of the food on offer; the food is nice, we have choices, the food is good and we get plenty to eat, and the food here is very nice, the cook is very good. Staff spoken with are aware of the specialist diets on offer such as diabetic diets and they are able to discuss how these are maintained and the reasons for these. 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. People using the service are protected from abuse and they feel able to raise concerns and complaints and can be confident that the manager will act on them. Evidence: So that people using the service know how to make a complaint should they feel the need to each is given a copy if the complaints policy and this is also on display in the care home. The complaints procedure is also available in large print or Braille for those who may need this. On examining the complaints file we can see that 6 complaints have been received in the last year. These are in regard to issues such as heating, communication and odour. We can see from these records available that these have all been investigated and resolved as necessary. Staff spoken with are able to discuss how they would deal with a complaint should one be received to ensure that these are dealt with and resolved. People using the service tell us that they have no complaints and that they are happy with the care received; I have no complaints, I can not fault the place, and it is a nice comfortable home, better than where I was before; the staff are very nice, helpful and friendly. Care Homes for Older People Page 18 of 28 Evidence: Staff have undertaken training in safeguarding vulnerable adults and on speaking with them they are aware of their roles and responsibilities in keeping people safe. People using the service tell us that they feel safe living at the care home and that if they have any concerns they know who to talk with; I feel safe and protected, and I know who to talk to if I have any complaint, but I feel safe and settled. The manager is currently working with the Local Authority in regard to an allegation of theft of a persons money. This is being investigated and at this time the investigation is inconclusive. Care Homes for Older People Page 19 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. People using the service live in a comfortable and homely environment. Evidence: There are two communal sitting rooms that people using the service may access as well as the dining area which offers plenty of seating and an opportunity to sit and talk with others. There is no longer a smoking room available and this is outlined within the statement of purpose so that people are aware of this before they make decision to move into the care home. For those people who live in the home at present and smoke we can see that they are able to smoke outside, however when this happens the door leading into the garden is left open, which causes a cold draft into the care home, this was discussed with the manager who will look into this issue. We can see that there is specialist equipment available for people to use such as assisted baths and shower rooms to ensure that those who need more assistance and support get this as required. On approaching the building we can see that externally some of the windows and window frames are in a poor state of repair. The manager stated that this issue was discussed at the latest budget meeting and a request for this to be addressed has Care Homes for Older People Page 20 of 28 Evidence: been submitted. As there are issues in regard to the availability of domestic staff, care staff are covering some of these shifts and recruitment is also taking place. The care home is generally clean and tidy; however during the tour of the care home we can see that some bedroom sinks and bedroom carpets need cleaning and there is a slight odour in the linking corridor. This was discussed with the manager who confirmed that recruitment is soon to take place and that she was in the process of addressing these issues. People using the service tell us that they are comfortable and settled in the care home; I have a nice room, I am comfortable and warm, and I am settled and comfortable here. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported by staff who are well trained and competent in their job role. Evidence: We can see from the staff duty rota that the manager aims to ensure sufficient staff are available to meet peoples needs at all times, nevertheless there are times when numbers may be reduces due to sickness or other reasons. Further recruitment is currently taking place to address these issues to ensure that staffing levels are maintained at all times. During the inspection, despite a reduced number of staff being available we can see that peoples needs are still met. Staff spoken with tell us that the staff team get on well together and that they work as a team, they also offer the following comments in respect of the staffing levels; there is not always enough staff due to sickness, however we do use agency when we can, and there are usually enough staff when we are fully staffed but it is difficult at the moment due to sickness, maternity leave and annual leave, we have been short this morning, it makes it hard work, the resident do not suffer though we just work harder. Care Homes for Older People Page 22 of 28 Evidence: So that new staff are aware of their roles and responsibilities on commencing employment they undertake an induction. There is evidence of these inductions taking place within staff files examined and staff spoken with confirm that these take place. 58 of staff have undertaken the National Vocation Qualification (a nationally designed work and theory based qualification designed to enhance knowledge and skills in caring for people) level 2 or above. One member of staff spoken with tells us that they have completed this training. Staff files examined contain all the documentation required by law such as Criminal Record Bureau checks (a police check to see if a person has a criminal record or police caution) and identification in place. Two files however did not contain two references as required, however these are for long term members of staff who have been working at the service for over a decade, nevertheless the manager stated that she will complete character references for these people. Staff spoken with confirm that they have undertaken a Criminal Record Bureau check during their employment. We can see that if a Criminal Record Bureau check is returned listing a conviction that this is discussed with the staff member to ensure that they are suitable to work at the care home, however this information is brief despite of the action that has been taken to fully evidence this process has taken place. Staff files and the staff training matrix examined shows us that staff continue to undertake compulsory such as manual handling, fire and first aid training to ensure that they have the knowledge and skills to care for people using the service. Staff spoken with tell us that they feel supported in their training and development; I feel supported and have had enough training to do my job and to deal with any issues when I am in charge. I have completed the NVQ (National Vocational Qualification) level 3 and assessors award and I am now doing level 4. Doing the training has not changed the way in which I work as I feel that I was doing it well before this. I keep up to date with training and have completed medication training, and I feel supported in my job role and training, I gained a lot out of the dementia care training, it was fantastic, it opened my eyes and made me realise what it is all about, it made me look at the support I was offering people and what I learned I have now put into practice. The training is well worth it. People using the service spoken with tell us that they can talk with staff and that they are nice and caring and they help them when needed. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a care home that is well run and managed where they are enabled to have a say about the service delivery. Evidence: The manager tells us that she feels supported by the area manager in her job role. She remains up to date with her training and she has completed the Registered Managers Award (a work and theory based qualification designed to enhance management skills). Staff spoken with tell us, if there are any problems the manager listens and sorts them out, there are no problems with the running of the home, and we have staff meetings and supervisions, these are helpful. The manager is lovely and we all get on well with her, she listens to any concerns. One person using the service tells us that the manager is very good. Care Homes for Older People Page 24 of 28 Evidence: People using the service and their relatives are enabled to have a say about how the care home is run and managed and about how they are supported by way of reviews, meetings and questionnaires. We can see from the latest questionnaire results that people using the service and their relatives are happy with the way the care home is run and managed and the support that people receive. People feel that they can join in activities, that they can vote and that the staff are polite and respectful and maintain their privacy and dignity. Relatives feel that they are greeted in a friendly manner and get all the information that they need and questions are answered. Most people know how to make a complaint and are aware that they can see their relatives in private. Should people wish they may have their personal money kept in the care homes safe. If they do not wish to do this lockable facilities are made available and people may also have a key to lock their bedroom door. On checking peoples personal allowances we can see that there are two signatures for each transaction and where applicable receipts are available to make sure these are protected. To ensure that people using the service are protected from hazards a health and safety committee meet to discuss the health check of the building and any issues of concern so that these may be addressed. Accidents are also monitored on a monthly basis to ensure that if people are having repeated accidents that these can be assessed and actions taken to reduce these if able. We can see that accident occurring within the care home are minimal and when accidents do occur appropriate action is taking place. On examining the fire logs we can see that regular testing of the systems are taking place as required. Also to ensure that people using the service are protected in the event of a fire each has a personal risk assessment in place which enables a colour code to be added. This allows staff to know who needs assistance and the order of priority. The annual quality assurance information informs us that regular servicing and testing of systems such as the gas, electric and lift are taking place as required. During out visit we examined these certificates and all have been completed. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 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 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 19 27 Repair or make good the external windows to ensure that these are in a good state of repair. Discuss staff comments in regard to the staffing levels with them and reassure them that action is being taken to address these issues. When a Criminal Record Bureau check has been discussed with a member of staff and a risk assessment has been completed, ensure that there is sufficient evidence available to demonstrate this. 3 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). 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. Care Homes for Older People Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!