Key inspection report
Care homes for older people
Name: Address: Pines Care Home 56-57 Harlow Moor Drive Harrogate North Yorkshire HG2 0LE 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: Tony Railton
Date: 2 3 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area.
Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection.
This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People
Page 2 of 29 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 29 Information about the care home
Name of care home: Address: Pines Care Home 56-57 Harlow Moor Drive Harrogate North Yorkshire HG2 0LE 01423565633 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Queensland Care Limited care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 26 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 to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 26, Physical Disability - Code PD, maximum number of places 26 Date of last inspection Brief description of the care home The Pines is a care home offering nursing and personal care for up to 26 people. It is two converted Victorian semi-detached houses providing accommodation on four floors including the basement. Each floor is accessible by a passenger lift. There is seating to the front of the building and an outside area at the rear of the building where people may sit out. It is close to Harrogate town centre and a short walk to local shops and amenities. Care Homes for Older People
Page 4 of 29 Over 65 26 0 0 26 1 5 0 1 2 0 0 9 Brief description of the care home It is set in a quiet residential area affording nice views over the green space of Harlow Moor Drive. Information about the service is provided in the form of a brochure and `service user guide?. All prospective residents and their families are invited to look around the home before moving in. The most recent copy of the Care Quality Commission inspection report is available at the home for people to look at. Individual copies are available on request. On the 23rd December 2009 the administrator said the fees for living in the home range from £496.22 to £650.00 per week. This charge does not include personal toiletries, hairdressing, chiropody or newspapers and magazines. Care Homes for Older People Page 5 of 29 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: Following this visit to the service it has been awarded a Two Star rating which means people living in the home experience good quality outcomes. This visit started at 10.00 and ended at 14.30. During the visit there was the opportunity to speak to most people living in the home and one visiting relative. Other people spoken to include the Acting Manager, Nurses, care staff, administrators, domestic, cook and handyman. Some peoples records were seen including assessments, care plans, reviews, medical and daily records and record of activities. Some staff records were looked at and included, references, Police and POVA (Protection of Vulnerable Adult List) checks, training and supervision records. Other information considered included the Annual Quality Assurance Assessment sent to us before the visit, the service history and previous inspection visit reports. Other important information considered included Have Your Say surveys returned from Five visiting Health care Professionals, Six visiting relatives and Eight staff working in the home. Other records considered included the minutes of residents and staff meetings, record of complaints and Safeguarding Meeting, and Care Homes for Older People
Page 6 of 29 maintenance records. A tour of the premises was also undertaken.This was a very positive and enjoyable visit and lots of improvements were noted. The inspector would like to take the opportunity to thank the people living in the home, the acting manager and the staff team for hospitality and cooperation throughout the visit. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? To make sure people receive the care and support they need and require there is now more details in peoples care plans telling staff what they must do to fully meet peoples needs. The manger from the local Primary Health care Trust in a returned survey writes care management systems in the home have improved greatly, and continue to improve Staff say in the returned surveys The care plans are much better The care plans are more person centered and based on the wishes of residents. To make sure people are protected by the way medicines are dealt with the Policy and Procedure telling staff how to give medicines safely has been updated. To further Care Homes for Older People
Page 8 of 29 protect people records show those giving medicines have now been trained to do this safely. To make sure some medicines are stored correctly there is a new refrigerator in the treatment room. To make sure people remain safe records show that all staff have now had Fire Prevention Awareness training. To maintain standards of cleanliness for people living in the home more domestic staff have been employed. To make sure the Health and Safety of people living in the home is promoted and protected the home has employed a new handyman to carry out safety checks and repairs. To make sure peoples dietary needs are met the home has employed a new but very experienced cook. For the benefit and comfort of people living in the home there have been many improvements to the environment including the redecoration and refurbishment of ten bedrooms. Three bedrooms now have en-suite facilities and there are three new wet rooms. The main lounge has been redecorated and now has new furniture and curtains. The dining room has been redecorated has new curtains and dining room furniture. The three upper floor corridors have been redecorated and now have new carpets. There is now new light fittings providing better and brighter lighting for people living and working in the home. The front garden has now been landscaped and there are now flower boxes for the enjoyment of those living in the home. The Acting Manager said there is also major development work on the lower ground floor to provide additional bedrooms and a large conservatory. They said this work is due to be completed in the spring. What they could do better: There should be signatures to show people and their relatives are fully involved in the assessment and care planning process. There are not many descriptive words in the daily records and record of activities to show and reflect peoples choices and preferences or any decisions the make about how they live their daily lives. To make sure people are safe the medicines are checked regularly by the nurses and Acting Manager, however, the medicine administration system has not been checked by a Pharmacist. To protect people from any kind of abuse there is a Safeguarding Policy and Procedure for staff to follow, however, the policy does not include the Local Authority Protocols on reporting and dealing with allegations of abuse. To further protect people from any kind of abuse records show staff have Safeguarding training, however, there are some staff still to have Safeguarding training and update training. Records show the planned Safeguarding training for November 2009 was unfortunately canceled and rearranged for the new year. To keep people safe records show new staff have induction training, however, there is no evidence that the training provided meets the recommended Skills for Care or National Training Organization standards. It is acknowledged that people live in a well run and well managed home, however, the law says that care homes and nursing homes must have a Registered Manager. The Acting Manager has yet to submit an application to be registered with the Care Quality Commission. Although the views of people living in the home, and those of their relatives and Care Homes for Older People
Page 9 of 29 visiting health care professionals is sought through satisfaction surveys, this information has yet to be collated and a report provided showing what people said about the quality of services provided or any changes made to the way the home runs as a result of their comments. 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 10 of 29 Details of our findings
Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 29 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. To make sure peoples personal and healthcare needs can be met by the service these are assessed before coming to live in the home. The home does not provide a specialist rehabilitation service. Evidence: To make sure the service can meet peoples personal and health care needs these are assessed before coming to live in the home. A sample of peoples records and in particular Prue admission assessments show people and their relatives are involved in the assessment and have a say in how they are to be cared for and supported. However, some of the assessments are not signed by them to show and demonstrate their involvement. To make sure people receive the care and support they need and require the assessments include peoples choices and preferences and social history. Records show allot of people are admitted to the home from hospital to receive nursing care. The assessments from the hospital show how peoples health care needs are to be met. A returned survey from a Primary Health care Trust Manager shows the
Care Homes for Older People Page 12 of 29 Evidence: care management documentation used by the home has improved greatly over the past twelve months which has improved services for those living in the home. The Acting Manager says although the home provides continuing care for people leaving hospital, the home does not provide a specialist service for intermediate care or rehabilitation. Care Homes for Older People Page 13 of 29 Health and personal care
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples personal and health care needs are met and they have a say in how they are cared for and supported. People are also protected by the way medicines are dealt with. Evidence: People living in the home say they are happy and feel that their care needs are being met. One visiting relative said they are very happy with the care and services provided and feels that all of their relatives care needs arecatered for. Five returned relatives surveys show they are very happy with the care and services provided. Eight returned staff surveys show all but one member of staff feel the home has improved greatly over the past twelve months as the assessments are better , the care plans are better and people living in the home are happier and have a say in how they are cared for and supported. The Acting Manager says since coming to the home twelve months ago all of the assessments and care plans have been reviewed and include more details telling staff what they need to do to meet peoples care and support needs. A returned survey from a Primary Healthcare Trust Manager agrees and says the homes assessments and care plan documentation has improved greatly. A sample of peoples
Care Homes for Older People Page 14 of 29 Evidence: records show their care and support needs are set out in their individual plan of care. The dates and signatures on the reviews show these are looked at regularly and amended if needed to reflect and show peoples changing care needs. Records show peoples choices and preferences are identified through the assessments and reflected their plan of care. However the daily records do not contain many descriptive words to show and reflect peoples choices on a day to day basis. To make sure peoples healthcare needs are fully met the records show that some people are supported by the District Nurses, Continence Advisors, General Practitioners, Opticians, Chiropodist and Tissue Viability Nurses. The Acting Manager says the home has close links and a good working relationship with Adult and Community Services Advanced Practitioner who advises the home on clinical matters relating to people living in the home. People are protected by the way medicines are dealt with as the Annual Quality Assurance Assessment shows the homes Medication Policy and Procedure has now been updated and is available for staff to follow.However, it was noted that the policy does not mention the Royal Pharmaceutical Guidance on the Administration of Medicines in Residential Care Homes. The Acting Manager said that all staff giving medicines have now been trained to do this safely. Discussion with staff and the staff training records confirmed this. A sample of peoples medicines were checked and found to be appropriately stored, administered and recorded. Part of a medicine round was observed and medicines were administered correctly and people were treated with dignity and their wishes respected. A tour of the premises also found there is a new refrigerator in the treatment room for appropriately storing some medicines. The acting manager says the medication administration system has not been checked by a Pharmacist. Care Homes for Older People Page 15 of 29 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. The lifestyle experienced matches peoples expectations and they have a choice from a varied and balanced menu. Evidence: Records and in particular the assessments show peoples likes , dislikes and choices regarding meals are identified. To make sure people have enough to eat and drink there is a nutritional assessment completed and care plans telling staff what people need by way of nutrition. The staff training records show they also have training in the Nutritional needs of older people. The minutes of the residents and relatives meetings show people have the opportunity to comment on the activities and meals provided. Five returned relatives surveys show they are happy with the quality of the food and meals provided.One visiting relative says the meals are more than adequate and their relative has a choice of menu. Discussion with the new cook found they are very experienced and provide a varied and balanced diet.For the benefit and enjoyment of people living in the home the cook says the fresh fruit, vegetables and meat are all sourced locally. People were observed having their lunchtime meal in relaxed and pleasant surroundings. Enough staff were observed to be available to assist people with their meals in a relaxed and unhurried manner. People were observed commenting on the quality of the meals provided and some observed changing their
Care Homes for Older People Page 16 of 29 Evidence: mind and having something else not on the menu. The Annual Quality Assurance Assessment says there are snacks available throughout the day and o the day of the visit one person was observed enjoying a freshly made sandwich in their room. The Acting manager said the home has a new Activities coordinator who with the aid of people and their relatives is in the process of creating Past Lives documents. The acting Manager said these will help to help in developing a programme of activities for people living in the home. One returned survey from a Pet Therapist shows they visit the home regularly and people enjoy pat a dog sessions. Eight returned staff surveys show they feel the changes in the home are very good as the work they do is more person centered and responsive to the needs of people living in the home. People were observed throughout the visit being treated with dignity and having their wishes respected. The daily records , however, do not contain many descriptive words to reflect and show peoples choices or preferences plus any decisions they make about how they live their daily lives. Care Homes for Older People Page 17 of 29 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 know what they say will be taken seriously and acted upon and they are protected from any kind of abuse. Evidence: To make sure any complaints about the service are dealt with properly there is a Complaints Policy and Procedure for staff to follow. To make sure people and their relatives know how to make a complaint the Complaints Procedure is included in the Service User Guide given to everyone when coming to live in the home. The Complaints Policy is also displayed in the reception area and can be seen by visitors to the home. To protect people from any kind of abuse there is a Safeguarding Policy and Procedure telling staff how to respond to and report any allegations of abuse. It was noted that the homes Safeguarding Policy and Procedure does not include the Local Authority Protocols. To further protect people living in the home staff training records show they have some abuse training as part of their induction. However, discussion with the Acting Manager and the training records show some staff have yet to have Safeguarding training and update training. The Acting Manger said that this training is planned for the coming months. The training records confirmed this. The returned CQC surveys show staff knowhow to report complaints.The returned relatives surveys show they also know how to make a complaint but had never had to do this. The returned visiting Professional surveys show they also know how to make a complaint. One visiting relative said they are very happy with the services provided and never had to complain they said they know how to make a complaint but usually any
Care Homes for Older People Page 18 of 29 Evidence: issues regarding the care of his relative are dealt with immediately. On the day of the visit people were observed being treated with dignity and having their wishes respected. The minutes of the residents and relatives meetings show people and their relatives have the opportunity to comment on the care and services provided. Care Homes for Older People Page 19 of 29 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 live in a well decorated, well maintained home that is comfortable, homely,clean and safe. Evidence: People were observed relaxing in clean and pleasant surroundings. A tour of the home found it to be clean, well decorated and well maintained. Peoples health and safety and well-being is promoted and protected as the maintenance records show the Fire Alarms, Emergency Lighting and Hot water outlet temperatures are checked regularly. Discussion with the new handyman confirmed this.The Acting Manager said the home has employed new domestic staff which has improved standards of cleanliness throughout the home. Discussion with the new Domestic found they have the support and equipment they need and require to carry out their duties effectively. The Acting Manager said there have been many improvements to the environment to make things better for people living in the home. Ten bedrooms have been redecorated and some refurbished. The upper floor and ground floor corridors have been redecorated and new carpets provided. New brighter lighting has been provided throughout the home. To make life easier for people living in the home and those caring for them there are now three new wet rooms. For the comfort and benefit of people living in the home the main lounge has been redecorated and new curtains and furniture provided. The dining room has also been redecorated and new dining room furniture provided. One major improvement noted is that the home now has two new hot water boilers. These
Care Homes for Older People Page 20 of 29 Evidence: improvements to the environment for people using the service are to be commended. The records show To make sure people remain safe the passenger lift and hoists are serviced regularly. To further protect people staff records show they all now have had Fire Prevention Awareness training. Discussion with one visiting relative found they are very happy with the environment as it is always clean. One returned survey from a visiting Therapist says the home is always clean. Returned surveys from peoples relatives and visiting health care professionals show they feel the environment has improved greatly for people living in the home. People living in the home say they have everything they need and are happy with their bedrooms and lounges that are much better. Care Homes for Older People Page 21 of 29 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. Peoples personal and health care needs are met by the numbers and skill mix of staff that are trained and qualified. People are protected by the way staff are selected and recruited. Evidence: Records show peoples care and support needs are met by trained and qualified staff. The Acting Manager says there are enough staff planned to be on duty to meet peoples care needs. The duty rota confirmed this and on the day of the visit enough staff were available and observed to be meeting peoples needs in a relaxed and unhurried manner. Staff said they enjoy working in the home and feel supported in their work. Eight staff surveys returned to the Commission show they are happy with the improvements to the way the home runs. One staff writes The ethos of the home is person centered. It evokes the social model as well as the medical model of health care provision. The staff are supportive of me as a new member of the staff team which allows me to provide high quality care, individually tailored to each residents needs. Another staff writes The home has changed beyond recognition in the past twelve months. The staff and management are friendly and do what they can to help you, it has a lovely atmosphere. Another writes Residents needs and happiness come first. Another staff member writes I believe we have a good team now at the Pines and we are all working very hard to ensure the residents are well cared for and happy. One returned General Practitioner survey says I believe this is a good
Care Homes for Older People Page 22 of 29 Evidence: Nursing Home. To make sure people are cared for correctly a sample of staff records show they have induction training. However, the induction training record is not very detailed and does not show exactly what aspects of training are covered and to what depth. The Induction training records do not say if they meet Skills for Care or National Training Organization standards recommended by National Minimum Standards. To make sure peoples needs are fully met the records show some staff have received Mental Health Act and Deprivation of Liberty training. Records also show some staff have received training in caring for those with Dementia. Other training includes Moving and Handling, Food Hygiene, First Aid and Infection Control. People are protected by the way staff are selected and recruited as a sample of staff records show references, Police and POVA (Protection of Vulnerable Adult List) checks are taken up before they are employed. Records also show Nurses Registration details with the Nursing and Midwifery Council are also checked. Records show people living in the home are cared for and supported by qualified staff as nearly all care staff either have or are working to wards National Vocational Qualifications. This practice is to be commended. Care Homes for Older People Page 23 of 29 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 well run , well managed home where they have a say in what happens to them and where their Health Safety and Wellbeing is promoted and protected. Evidence: The home is well run and well managed as records show there have been improvements to the care management systems in the home. These improvements include the assessment and care planning process. The eight returned staff surveys show they feel the care management systems have become more person centered and the needs of people living in the home come first. A returned survey from a Primary Healthcare trust Manager says the care management systems continue to improve. One returned survey from a visiting General Practitioner says they believe this to be a good Nursing Home. However, acting manager manager has not yet made an application to the Care Quality Commission to be registered. People are protected by the staff management systems as there have been improvements to the staff recruitment and selection , staff training, appraisals and supervision. People have a say in the running of the home and the quality of services provided as their views and
Care Homes for Older People Page 24 of 29 Evidence: those of their relatives and visiting healthcare professionals is sought through satisfaction surveys. However , the Acting Manager said the information gathered through quality assurance surveys has yet to be collated and a report provided showing what people said about the home and showing any changes to how the home runs as a result of their comments. The minutes of the residents and relatives meetings show they have the opportunity to comment on the running of the home and the services provided. The minutes of the staff meetings, supervision records and appraisals show they have the opportunity to comment on the running of the home. Peoples health , safety and wellbeing is promoted and protected as the the maintenance and staff training records show Health and Safety checks are carried out regularly and staff have Health and Safety training. One visiting relative said that their relatives needs are fully met and they are happy with the services provided. Care Homes for Older People Page 25 of 29 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 29 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 3 To show people have a say and as a matter of good practice people of their representative should wherever possible sign their pre admission assessments to show and demonstrate their involvement in the assessment process. To show people have a say and are involved in developing their assessments and care plans and as a matter of good practice peoples signatures should be obtained whenever possible to reflect and show their involvement. To To protect people living in the home is acknowledged that the Medication Policy and Procedure has been updated and improved , however, it should also make reference to the Royal Pharmaceutical Guidance on the Administration of Medicines in Social Care Settings. To further protect people and as a matter of good practice the medicine administration systems should be checked by a Pharmacist. As a matter of good practice and to show people have a say and make decisions about what they do and how they live their daily lives descriptive words should be used in the daily records and record of activities to reflect their choices and preferences. 2 7 3 9 4 14 Care Homes for Older People Page 27 of 29 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 5 18 To make sure people living in the home remain protected and safe those staff that require it should have the planned Safeguarding training and update training and the Acting Manager inform the Commission once this has been done. As a matter of good practice and to further protect people living in the home the Safeguarding Policy and Procedure should include the Local Authority Safeguarding Protocols. To make sure people receive the care and support they need and require the records showing induction training for new staff should contain more details showing the material covered. The records should reflect the areas and depth of training suggested by the Skills for Care or National Training Organisation recommended by the National Minimum Standards. To make sure people living in the home receive a consistent and well managed service the Acting Manager should submit an application to be registered by the Care Quality Commission as soon as is practicable. The information gathered through quality assurance satisfaction surveys should be collated and a report provided showing what people said about the home. The report should also show any changes made to the way the home runs as a result of their comments. 6 18 7 30 8 31 9 33 Care Homes for Older People Page 28 of 29 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 29 of 29 - 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!
