Inspection on 11/05/09 for Martin House

This is the latest available inspection report for this service, carried out on 11th May 2009.

CQC found this care home to be providing an Good 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

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Martin House 1 Swift Road Southall Middlesex UB2 4RP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Clare Henderson-Roe     Date: 1 2 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 30 Information about the care home Name of care home: Address: Martin House 1 Swift Road Southall Middlesex UB2 4RP 02083073300 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): marnie.reed@servitehouses.org.uk Servite Houses Name of registered manager (if applicable) Marnie Brillantes Reed Type of registration: Number of places registered: 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: 75 The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission are within the following categories: Old age, not falling within any other category - Code OP (Maximum number of places: 45) Dementia - Code DE (Maximum number of places: 30) Date of last inspection Brief description of the care home The home has been purpose built to meet the National Minimum Standards for Older People. It is situated in a residential area of Southall, and is easily accessed via public transport. There are shops and a Post Office within walking distance to the home. The home comprises of 5 units, each of which can accommodate 15 residents. All bedrooms are single with en suite toilet, wash hand basin and shower facilities. Each Care Homes for Older People Page 4 of 30 care home 75 Over 65 0 45 30 0 Brief description of the care home unit has a communal sitting/dining area with a kitchen area plus a separate quiet room and activities room. Two of the units are registered to provide dementia care and three units are registered to provide general care. Each unit is individually staffed. The home accommodates residents placed by the Borough of Ealing. The following information regarding fees has been provided by Servite Houses: Martin House was developed under the Governments Private Finance Initiative and capital costs are met in this way. Ealing Council pays a unitary charge, which covers all the services the council receives from Ealing Care Alliance. It covers the costs of care and the provision of facilities management services to the day care service and accommodation. It is not possible to separate these out to identify how much each residential care and nursing care placement costs. The fee payable to the council by residents who fund themselves in full is £526.00 per week for residential care. The fee payable to the council by residents who fund themselves in full is £651.00 per week for nursing care. Deducted from that will be the free nursing care amount of £125.00 (high) and £83.00 (medium and low) 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: 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: This was an unannounced inspection carried out as part of the regulatory process. A total of 23 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. Residents, staff and visitors on each unit were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents have also been used to inform this report. It must be noted that it is not always possible to ascertain the views of residents living with the experience of dementia. Care Homes for Older People Page 6 of 30 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: Although there has been an overall improvement in the medication management for the home, shortfalls in the recording of receipts on one unit were noted, plus work is still ongoing to address the issues with clinical room temperatures. Servite Houses have a comprehensive induction training, however staff are not always undertaking this on commencing their employment. In addition, shortfalls were noted in the Care Homes for Older People Page 8 of 30 training and updates in some health and safety topics, although it is acknowledged that more sessions have been booked in certain topics. Professional development training for the nursing staff is also lacking, and work needs to be continued to ensure training and development needs are being addressed. 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 set out 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information in the Statement of Purpose and Service User Guide was not up to date, thus did not provide current information. Prospective residents are fully assessed prior to admission, thus the home ensures that they are able to meet each residents individual needs. Evidence: We viewed the Statement of Purpose and Service User Guide, which were available in residents bedrooms. We noted that some of the information was out of date, and in addition not all the information required under Schedule 1 of the Care Homes Regulations 2001 was included. The Manager said that this would be addressed. We viewed pre-admission assessments on all 5 units. These had been well completed and gave a detailed picture of the residents needs. In addition to this the home also Care Homes for Older People Page 11 of 30 Evidence: obtains copies of the Social Services resident assessment prior to assessing each prospective resident. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service user plans were up to date, personalised and complete, thus providing staff with the information required to care effectively for each resident. Overall medications were being well managed, however minor shortfalls identified in the management of medications could place residents at risk. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs discussed, recorded and met. Evidence: We sampled the service user plans on each unit. Overall these had been well completed and provided a clear picture of each resident, their needs and how these are to be met. Risk assessments for falls had been carried out and monitoring forms are in place so that any falls can be audited. Monthly reviews of the service user plans had been carried out. There was some evidence of input from residents and their representatives involvement in the formulation and review of the service user plans, however this work needs to be progressed so that this is carried out for all residents. Care Homes for Older People Page 13 of 30 Evidence: We noted that there were improvements in the signing and dating of documentation by staff, with more attention to this still needed. We viewed wound care documentation and found that it was comprehensive, clearly identifying the dressing regime in place and the progress of each wound. Pressure relieving equipment had also been identified in the service user plan and pressure sore risk assessments had been completed. Pain assessments were in place and there was evidence of input from the tissue viability nurse. Moving and handling assessments had been carried out and documentation identified the equipment to be used for moving each resident. Nutritional assessments had been completed and residents are weighed monthly. If an issue arises referrals can be made to the dietician. Primary Care Trust continence assessments are carried out for all residents with continence care needs. Care plans for continence care needs were in place, and the need to look at developing a continence care assessment specific for use in the home was discussed with the Manager. Bedrail risk assessments had been carried out and consents for their use were in place. There was evidence of input from healthcare professionals to include GP, dietician, optician, district nurse, chiropodist and tissue viability nurse. We met with the GP for the home and he visits twice a week. Residents spoken with confirmed that their healthcare needs were being met. We sampled medication management and records on all 5 units. With the exception of one unit, all receipts, carried forward balances, administration and disposal had been recorded. Where medication had been omitted or refused the correct coding had been used to identify this, with a clear explanation of the reason for omission. For residents who go on leave from the home, a form is completed to clearly identify the exact amount of each medication being taken from the home and what is brought back when they return from leave. Any handwritten entries on the medication administration record (MAR) had been signed for by 2 staff. For residents on warfarin therapy the records were clear and the instructions following the most recent blood test had been followed. For residents who required their medications to be crushed, an agreement had been reached with the GP and a consent signed for this. Single use lancing devices were available for use when monitoring blood glucose levels. Care plans for the management of diabetes had been formulated, and clearly showed the care for each individual. On the personal care units, the district nurses are still managing the drawing up of insulin, and do a weeks supply each time. The residents are not able to choose the actual syringe to be used, and therefore this practice contravenes current good practice guidance. This has been discussed with the Operations Manager who will conduct further discussions with Ealing Primary Care Trust. For residents on oxygen therapy clear signage and care plans were in place. For medications with very specific administration instructions, these had been recorded on the MAR. Controlled drugs were being correctly stored, however the need for all staff to use their full signature Care Homes for Older People Page 14 of 30 Evidence: when signing the controlled drugs register was discussed. There is an ongoing problem with the temperature in the rooms where medications are stored and Servite Houses are aware of this issue. We were informed that 3 types of fans had been trialled but did not prove effective in keeping the room temperatures consistently below 25 degrees centigrade. Staff were seen caring for residents in a gentle and professional manner, exhibiting much patience and skill especially when caring with residents with dementia. Interaction between residents and staff was good and there was a happy and content atmosphere in each unit. Residents spoken with expressed their satisfaction with the care they are given and were dressed to reflect individuality and cultural preferences. Residents can have their own telephone, either mobile or land line. Personal clothing is discreetly labelled, and the home has purchased small identification buttons so that all personal items can be labelled when received into the home. Several of the bedrooms had been personalised and there was a very homely feel throughout. There was good teamwork on each of the units and the staff are to be commended for the high standard of individualised care they provide. Since the last inspection there has been an improvement in the ascertaining of the wishes of residents and their families in respect of health deterioration and end of life care wishes. The Operations Manager reported that a training programme is being planned with the palliative care nurse for the home, and should commence in the near future. We noted that staff had not received training in palliative care, and the Operations Manager has confirmed that this is being organised with the palliative care nurse for Ealing Primary Care Trust. Care Homes for Older People Page 15 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activity provision for the home is excellent, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents right to independent representation is respected. The food provision in the home is very good, offering variety and choice, with residents choices being respected. Evidence: The home has a full time activities co-ordinator. There is a comprehensive activities programme for the month and in addition several entertainments, parties and outings are planned. Staff were seen participating in activities with the residents, and it was clear that activities are seen as part of the daily routine, as opposed to an added extra. Care plans were in place for each resident in respect of their hobbies and interests. The activities co-ordinator had contacted several of the local places of worship, and the home now has regular services provided by the Church of England and the Baptist Church, plus input from the Roman Catholic Church. In addition, religious activities for the Asian residents also take place, and visits to the local Temple and Gurdwaras had been arranged. There is an activities room on each unit and one Care Homes for Older People Page 16 of 30 Evidence: room is now for reminiscence, with pictures of times gone by and famous people on display. Outings and parties are arranged, and the staff help to provide some of the entertainment for various events, which include celebrating significant days and religious festivals throughout the year. Residents clearly enjoyed joining in the activities and recounted what they had found particularly interesting to us. There is a life history document completed for each resident, and this provides a good picture of each resident. Residents and relatives are being involved in producing a more comprehensive Life Book for each resident, an example of which was viewed. This gives great detail about the person and their history, to include family photographs and events, and how the resident likes to be communicated with for maximum effectiveness. The activities co-ordinator and the staff are to be commended on the excellent level of activities provision in the home. We discussed advocacy provision for the residents. The Manager explained that each resident has a care manager and also family members to represent them when needed. In addition there is information about Age Concern and Alzheimers Society, who can provide independent advocates if required. The Manager also explained that she is setting up a family support group for the families of the residents living on the dementia care units. The home has an open visiting policy and visiting is encouraged. Overall the relatives spoken to were happy with the care provision at the home, and any points raised were fed back to the Manager. One relative praised the support they as well as their loved one received from the staff. We viewed the kitchen and it was clean and tidy, with good stocks of fresh, tinned, dry and chilled produce, to include fresh fruit and vegetables. The freezer was out of order and action was being taken to address this. In the interim daily deliveries of frozen goods were being received. The home has a 4 week menu, and picture menus are available so that residents can easily identify the meal choices on offer. In addition to the standard menu choices, further alternatives are available to residents so that their personal and cultural preferences are catered for, and these are recorded on the daily menu choice sheet. Staff were available to assist residents with their meals in a gentle and discreet manner. Mealtimes were observed and residents were enjoying their food and interacting with other residents and staff. Drinks and snacks are available throughout the 24 hour period. Residents spoken with said that they enjoyed the food provision at the home and confirmed that they are offered choices, which are respected. We sampled the lunchtime menu on the first day of inspection and the food was well presented and tasty. Care Homes for Older People Page 17 of 30 Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. Evidence: Details of the complaints procedure are available in the Statement of Purpose and Service User Guide, and are also displayed in the home. There had been 3 complaints received by the home since the last inspection. These had all been fully investigated and responded to. The home has adult protection policies and procedures in place that dovetail with the Ealing Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. The Manager reports to CQC and the Ealing Safeguarding Adults Team any incidents that she feels might require investigation under safeguarding adults procedures, and appropriate protocols are followed. Since the last inspection there have been 4 safeguarding referrals which have been reported and investigated. Care Homes for Older People Page 19 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has been built and furnished to a high standard, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. Evidence: The home has been open for one year. It is purpose built and each bedroom is single with an ensuite shower and toilet facility. Each unit has a kitchen, lounge/dining area, a quiet room and an activities room. All areas of the home are being very well maintained. All units have a key pad entry system for the security and safety of the residents. Each bedroom is furnished to a high standard and adjustable beds are available for all residents who require nursing care. At the time of the inspection snagging work was being undertaken by the building contractors to complete any repairs from the original build. There is a garden and this is being maintained. We viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. The washing machines have a sluice programme for infection control. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. We were informed that each unit has allocated domestic staff. The home was clean, fresh and bright throughout. Care Homes for Older People Page 20 of 30 Care Homes for Older People Page 21 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met. Systems for vetting and recruitment practices are in place and protect residents. Whilst there is evidence of some training taking place, delays in induction training and lack of professional development training could limit the skills and knowledge of staff, thus potentially compromising resident care. Evidence: The home has five units over three floors. Each unit can accommodate 15 residents. At the time of the inspection there were 52 residents at the home. At the time of the inspection all units were being staffed to meet the assessed needs of the residents. The manager is supported by a Head of Care and a Head of Nursing. Both posts are supernumerary. Information provided by the Manager states that 25 of care staff are qualified to NVQ in care level 2 or the equivalent. NVQ in care training has also been arranged for more care staff and Servite Houses are aware of the need to increase to a minimum of 50 of care staff with this or an equivalent qualification. We viewed 3 sets of staff employment records. A completed application form, confirmation of the healthcare questionnaires being completed plus the Criminal Care Homes for Older People Page 22 of 30 Evidence: Records Bureau reference numbers were available in the files viewed. In one instance a reference had not been obtained from the most recent employer. All the recruitment documentation plus pre-employment checks are held and carried out by head office. At a recent inspection of another Servite Houses home these issues had been identified and the Operations Manager confirmed that action has been taken to ensure all recruitment procedures now being followed include all the information required under Schedule 2 of the Care Homes Regulations 2001. Servite Houses have an induction training that includes the Skills for Care common induction standards. Staff spoken to confirmed that they had completed induction training, and also that they receive training in topics relevant to the needs of the residents. When we viewed the training matrix it was clear that not all staff had received training updates and that Registered Nurses have not had recent opportunity to undertake training to keep them up to date with current nursing good practice. We also identified that for some staff there had been significant delays in the undertaking of induction training, and in some cases little or no training had been offered. This was discussed with the Operations Manager and the Manager who are aware that work needs to be done in this area. Care Homes for Older People Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager has the skills and experience to manage the home and does so in an open and supportive manner. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Residents monies are well managed and securely stored. Overall the systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. Shortfalls should be easy to address. Evidence: The Manager is qualified to NVQ level 4 in management and care, and is currently looking to do level 5. In addition she has undertaken Dementia Care Mapping training since the last inspection. Staff spoken with said that the manager is supportive and does visit each unit to find out what is going on each day. The home has a system in place for quality assurance. The home has a monthly Key Performance Assessment, which is carried out as part of the contract with Ealing Social Care Homes for Older People Page 24 of 30 Evidence: Services, which provides a comprehensive review of all aspects of the home. Regulation 26 unannounced visits are carried out on behalf of the Registered Person and reports of these are available. Regular meetings take place for residents and relatives and a residents survey is carried out annually. There are also unit meetings for staff, plus regular meetings for each staff group are held. The Manager attends handover sessions on the units, plus communication books are in place. The AQAA submitted by the home provides information to show the progress being made in each area. The home holds personal monies on behalf of residents, and these are securely stored. An individual envelope is maintained for each person, which contains receipts and on which there is a clear record of all income and expenditure. We sampled the maintenance and servicing records and those viewed were up to date. The administrator who works with the maintenance man to ensure all areas of health and safety are kept up to date, was aware that some servicing was due and had evidence to show that this was being followed up appropriately. We discussed the frequencies for flushing the water systems in any vacant rooms in line with legionella guidance and the administor actioned this at the time of inspection. Any repairs needed are clearly recorded and updated once the repair has taken place. Fire drills are carried out frequently to include day and night drills and a record of who attends each drill is made. Risk assessments were available for all aspects of safety within the home, and the kitchen have their own risk assessments in place. The fire and health and safety risk assessments had last been reviewed and updated in September 2008, however there was no evidence that the action plans identifying the shortfalls found during both assessments had been actioned. Some staff spoken with had not completed all areas of mandatory training and updated within the required timescales. The Manager was in the process of compiling a new training matrix and said that this would better identify all aspects of training and the dates when further training must be undertaken. There was evidence that training had been booked for some health and safety topics. 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 4 The Statement of Purpose and Service User Guide must be up to date and contain all the information as detailed in Schedule 1 of the Care Homes Regulations 2001. To ensure that residents and their representatives have up to date information about the home. 14/06/2009 2 9 13 Further work must be undertaken to review the practice of supporting residents in the personal care units, where insulin is being drawn up in advance by the district nurses. In order to safeguard residents and staff. 01/06/2009 3 9 13 Entries in the controlled drugs register must be signed in full by 2 staff. 15/05/2009 Care Homes for Older People Page 27 of 30 To ensure correct procedures are being followed. 4 9 13 That receipts and carried 18/05/2009 forward balances are recorded for all medications. This ensures that there is a clear audit trail of all medication. 5 25 18 Staff must receive induction training without delay. To provide them with the skills and knowledge to carry out their jobs in an effective manner. 6 25 18 There must be evidence that 01/06/2009 training relevant to their professional development is available for registered nursing staff. To maintain their professional knowledge and skills. 7 38 23 There must be evidence that 01/06/2009 shortfalls identifed in health and safety risk assessments to include the fire risk assessment have been addressed within the timescales stipulated in the assessment. To protect residents, staff and visitors. 8 38 18 All staff must receive training and updates in health and safety topics at the intervals required under 01/07/2009 01/06/2009 Care Homes for Older People Page 28 of 30 relevant legislation and good practice guidance. To ensure health and safety practices are being correctly and effectively implemented at the home. 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 3 7 8 9 It is good practice for all service user plan documentation to be signed and dated. The home should formulate a continence assessment for inclusion in the service user plan. Training in palliative care should be arranged for all staff. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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