Inspection on 22/06/10 for Primecare Nursing Home

This is the latest available inspection report for this service, carried out on 22nd June 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Primecare Nursing Home 23/01/08

Primecare Nursing Home 15/02/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 03/09/2010.

Key inspection report Care homes for older people Name: Address: Primecare Nursing Home 62 Downs Grove Vange Basildon Essex SS16 4QL     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Diane Roberts     Date: 2 4 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 26 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 26 Information about the care home Name of care home: Address: Primecare Nursing Home 62 Downs Grove Vange Basildon Essex SS16 4QL 0138470275 0138479658 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Choicecare 2000 Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 42 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 42. The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category - Code OP - maximum number of places: 42. Date of last inspection Brief description of the care home Primecare is a purpose built care home and is registered to provide personal and nursing care with accommodation for 42 people over 65 years of age. Accommodation is provided over two floor levels and a shaft lift is available to give access to all areas. The accommodation is comprised of thirty-four single and four shared bedrooms. Ensuite facilities have been provided in eight of the bedrooms. There Care Homes for Older People Page 4 of 26 Over 65 42 0 1 6 0 2 2 0 1 0 Brief description of the care home are two large communal lounge areas, one on each floor and the dining room is situated on the ground floor. People living at the home have access to a patio and garden which is accessible to people who use wheelchairs. The grounds include well maintained gardens and good car parking facilities. The home is within easy reach of Basildon town centre, public transport services and local amenities. The current rate of fees range from £434.60 to £625.00 per week. Additional charges are made for hairdressing, chiropody, toiletries and newspapers. Information about the home is made available to prospective residents in the Statement of Purpose and Service Users Guide. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited the home for most of the day and met with the manager in charge that day and some of the care team. We also met with the operations director. The inspection took place over two separate days. Prior to this inspection we reviewed all the current information that we had on the home and this included action plans submitted to us by the homes management team after the last key inspection. On the day of the inspection we spoke with 3 residents and 3 staff at the home. It was also possible to speak with a relative. Whilst at the home we also reviewed records and undertook a tour of the premises. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. 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 7 of 26 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 8 of 26 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. Prospective residents can be assure that their needs will be assessed prior to admission and that they will have the information that they need about the home. Evidence: The service user guide has been updated since our last visit and this was seen to be clearly available in the reception area and in every residents bedroom, in a special rack, along with the complaints procedure. Access to this information is much improved since our last visit. The guide contained the relevant information but more consideration could be given to improving the format to make it more user friendly for the residents. Consultation with the residents may be of value in considering this. The manager completes all pre-admission assessments. It was possible to see one complete pre-admission assessment and this was detailed, signed and dated. There was some information on social history, abilities, choices, understanding but this is an area that could still be developed further. In addition to the assessment, the manager had referral information available from the referring authority and overall enough Care Homes for Older People Page 9 of 26 Evidence: information on which to base a decision regarding admission. It was not possible to speak to any new residents at this visit about their experiences on admission to the home. Care Homes for Older People Page 10 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can generally expect to have their care needs met but outcomes could still be improved. Evidence: The new manager has been in post a few weeks and during this time he has introduced and rewritten, with input from the clinical lead, nearly all the residents care plans. We looked at three care plans and one further care plan to cross reference. Overall these are much improved and contain more detailed care plans, person centred information, residents preferences and resident and family input. However, there are some areas for work and this system need to be embedded into the nursing and care staffs routine, so they become working documents and staff use them as reference in the day to day planning and delivery of care. This was evidenced by, for example, recent changes to care needs not being updated on the care plan that was in place and from discussion with staff, changes to care management, for example with residents nutrition that were not reflected in the current care plan. The manager said that his priority was to get the basic care plans in place and then for the care staff to work with a named nurse to develop them further. We did note that in some cases, for Care Homes for Older People Page 11 of 26 Evidence: example, elimination, the care plans are the same for each resident and staff need to be aware that the plans must be individual to residents assessed needs. The further development of person centred planning may help this. Care staff spoken to know there is a new system and that the need for recording matters that affect residents now needs to be done, but they are yet to be fully involved in the care planning system. They identify that now they are completing fluid charts more consistently than before and recording what people have eaten. The care plans in place were sufficiently detailed to guide staff and person centred information contained in the plans is developing. We noted that some residents had identified care needs, such as wounds, where staff were providing care, but no care plan was in place. Blank wound assessments were seen in the care plan for residents with wounds. We also noted that records need to be signed and dated by the staff completing them as, for example, some assessments had not been signed or dated. Residents generally had the risk assessments in place that they needed and overall these have improved. Residents are now being properly assessed for the risk of pressure sores and in relation to nutrition. The risk assessment for pressure areas gives good direction for staff on the level of risk and the appropriate equipment that may be required. However, from recent notifications, received after the site visit, two residents have developed home acquired pressure sores. Residents are being weighed regularly and there is evidence of input from a dietitian. However, where health care professionals have written regarding their visit, any advice or direction from them should be reflected in the care plan so it is evaluated. Risk assessments in relation to the use of bed rails still requires a review as the team still need to assess whether the use of bed rails is appropriate and safe for the resident. At the current time the risk assessments primarily discuss the safe use of bed rails, which is relevant, once deemed to be safe to use. These assessments should also be signed by the person assessing the use and any risks. One resident was noted not to have a manual handling or falls risk assessment in place. Staff complete daily records in relation to care planning and these primarily stated that personal care had been given and that the resident had taken their medication. They did not reflect the resident or their wellbeing. The nursing and care team have had records training and the manager acknowledges that he needs to implement this and that the daily records need work as they are perfunctory and do not allow for them to be used for an evaluation. Residents we spoke to said the staff know my needs, I see the doctor promptly when I need to and I see the chiropodist. Relatives we spoke to said that they felt the care Care Homes for Older People Page 12 of 26 Evidence: provided to their relatives was fine and the staff were always very helpful. They also confirmed that they had seen and were going to read the recent care plans. On touring the home we noted that residents were often in their rooms alone and in two cases had not been left with a call bell to hand. Staff need to be more aware of this. Residents in surveys said I have never seen my care plan, they get me to hospital on time and I would like more baths than washes, I am happy with my personal care, I would like continuity of carers so I dont have to tell them what to do and personal care has improved quite drastically in some respects, the staff seem to be happier. We reviewed the medication administration systems in the home. Since starting work at the home the manager has changed the medication round so that the nursing staff do the round alone either upstairs or downstairs and give and sign for any medication themselves. The medication administration charts were generally clear but staff do need to ensure that handwritten prescriptions are recorded neatly to reduce the risk of errors. Overall items had been signed for appropriately with only an odd missing signature Medication is checked in to the home and recorded properly. Staff are recording dates of opening on boxes of tablets but not always on liquids, which aids auditing when required. Staff were heard to ask residents whether they required pain relief on medication rounds. Care Homes for Older People Page 13 of 26 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. Residents can expect to have choice in the day to day lives. Evidence: Residents that we spoke to said that they had choice with regard to the daily routine, for example one residents said that if they were not ready to be helped, staff would come back. Staff spoken to discussed and appreciated that resident had choice. Since the last inspection the provision of activities and the hours activities officers work has improved. Oner person now works 9-5 Monday to Friday and another comes in one day a weeks. A programme is in place which the activities officer says is a rough guide as every day residents are consulted on what they would like to do and who is willing to take part. In the recent hot weather she said that residents were reluctant with group social activities so she has been undertaking more one to one work, mainly chatting and hand massages. Some of the one to one time is more person centred and based upon a residents particular preference, such as reading from a specific book. The activity officer, from discussion, knows the residents well. She tries to do exercise with them most days to help their joints and is aware of their limitations and choices. Care Homes for Older People Page 14 of 26 Evidence: The activities officer has also been working with residents and helping them to personalise their rooms, with relatives input as well. Care plans are no in place and generally they are very good, quite detailed with past interests, abilities and what people enjoy doing and what staff should do. They could be developed further with more info, perhaps from the care plans which contain good social histories, on their past hobbies as some plans lacked this and then the activities officer can develop a more meaningful and person centred one to one routine, as due to the dependency of residents, many are unable to join in the group activities. The activities officer keeps good records of the activities undertaken and whether residents have taken part and how they have enjoyed it. Overall the provision of activities and social care has improved in the home. Residents we spoke to said they always bring me my daily paper and the activities officer always comes in and chats with me and we do word searches and she brings me books in to read. Residents in surveys said I would like to go out in the garden more and I feel that there is a lack of information, I enjoy activities especially when we have entertainers in, Activities recently undertaken include - evidence of activities officer spending time with people looking at pictures, external entertainers, colouring, skittles, church services, one to one chats, hand massages, time in the garden, reminiscing, watching films, exercises, word games and quizzes. The records are limited at the current time as activities have only recently started to be recorded. We did not observe the lunchtime routine at this inspection. Staff were heard to be giving residents choice in relation to their dinner and tea. A hot option is available at tea time along with sandwiches. Drinks of juice available at other times other than tea rounds. In the dining room condiments and items such as gravy boats are now in use, promoting resident choice and independence. The tables are nicely laid and tablecloths are used. Residents we spoke to said I have no complaints about the food and it always hot when its brought to my room and the food is fine, continues to get better and you get plenty of choice. Care Homes for Older People Page 15 of 26 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. Residents can be assured that their concerns would be listened to and acted upon. Evidence: The complaints procedure has been reviewed and updated since our last visit. This is now available in reception and in every residents room. Copies are also available on request at the office. The content of the procedure is now up to date, however it is lengthy and font is small. Consideration should be given to how user friendly it is for residents living in the home. There have been no complaints since new manager started but he is currently finishing the investigations of previous complaints handed over to him. Records show that these are being dealt with correctly. Consideration should be given to developing a more formal way of logging and recording complaints management. Staff files show that staff have been issued with a copy of the complaints procedure and they have signed to say that they have read it. Residents we spoke to said I have no complaints and am quite happy with everything. The manager has the local safeguarding guidance available but this is on a disk and not easily accessible to staff. The guidance should be printed off and made available so staff are aware of local procedures and documentation. Safeguarding referrals that were logged around the time of our last inspection are yet to be concluded and these will be referred to in our next report. Staff training records show that since the last inspection all staff have undertaken training on safeguarding vulnerable adults. Care Homes for Older People Page 16 of 26 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. Residents live in a home that is clean, safe, well maintained and that meets their needs. Evidence: We toured the home with the manager. Overall the home was seen to be very clean and tidy and no odours were noted apart from the ongoing issue with the sluice which is currently being addressed. Since our last inspection key parts of the home have been decorated, such as lounges and bathrooms and efforts have been made to make the home have a more homely appeal. For example, more furniture, other than chairs are in the lounges, tablecloths are used in the dining room, more pictures have been put up around the home, although there still could be more, and pot plants and magazine racks were seen. Thought has been given to residents dining upstairs and a table and chairs has been put in the lounge so some residents can sit at the table to eat and do activities. Access to the garden has also been made easier with less of a step out over onto the raised seating area. Overall the environment has improved. A maintenance man is now working at the home Monday to Friday. A book is available in reception for staff and relatives to record what work needs doing and the maintenance man signs these off when completed. On talking to residents and from observation there is evidence of shelves and pictures being put up promptly and decorating taking place. Care Homes for Older People Page 17 of 26 Evidence: Residents who commented in surveys said I like the new decorating and the new pictures, the upstairs lounge is very homely and cosy and I am happy that it has been noticed that this room is my home. Records in relation to fire safety were seen to be in order but fire drills are not currently being undertaken with care staff and the manager said that he plans to introduce this in the near future. Care Homes for Older People Page 18 of 26 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. Residents can expect to be care for by generally competent staff who continue to develop their knowledge base. Evidence: Since the new manager has been in post, he has reviewed the staffing levels in relation to the dependency of residents, using a dependency tool. Following this the current staffing levels have been increased and are now 7 during the morning, including one nurse plus the manager and in the afternoon the same or 6 and at night 4 plus one, possibly five. This includes the one to one care required by one resident. The levels may change due to dependency needs and occupancy levels. The rota shows that these levels are being maintained, however, short notice staff sickness is an issue and agency staff are occasionally used. We spoke to one agency staff who had not been to the home before and was providing one to one care. She was unsure of the nurse call system and was seen to be sitting with the resident reading a magazine, but had not read or been offered the care plan to read by the nurse in charge. There are no current care staff vacancies at the home as the manager has recruited and is waiting for new staff to start. Residents we spoke to said all the staff are very good and the staff are alright to me. Care Homes for Older People Page 19 of 26 Evidence: From the training records, four out of the twenty eight care staff have NVQ qualifications. Nine care staff are currently undertaking these qualifications. We reviewed the staff files and these have improved since our last visit with the new staff having more robust references in place and all the required documentation and checks in place. The management team have developed a spreadsheet that outlines all the staff who are working in the home on visas and any limitations to their working and when the visas expire. On discussion the manager is up to date with regard to the management of these staff. The pin numbers and registration of qualified nurses working in the home are also recorded and were seen to be in date. Since we last inspected the home a significant amount of staff training has taken place in order to bring staff up to date. Staff spoken to confirmed that they had attended a lot of training and spoke positively about this, seeing it as an improvement in the home. Records showed that staff have completed a lot of training in the last few months ensuring that they are generally up to date. There are some gaps in relation to fire safety training and from the evidence gather, more staff should attend training in care planning or person centred planning. Once the staff training programme is back on line consideration should be given to ensure staff are up to date with current thinking on, for example, conditions associated with old age. New staff are now being inducted to the home and completing the common induction standards and have identified mentors in place within the home. Care Homes for Older People Page 20 of 26 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. Residents live in a well run home where the management have their best interests in mind. Evidence: The new manager has been in post a few weeks and this is his first post as a manager of a nursing home. The manager is a registered nurse and is currently undertaking the NVQ level four in management. He has particular experience in orthopedic nursing and pain management, which is an asset to Primecare. He also has a teaching and assessing qualification in relation to clinical nursing practice. Staff spoken to speak positively about the changes in the management of the home and how the home is working on a day to day basis. The manager has met with the staff team and the minutes show that he is discussing practice and quality issues as well as the day to day management of the home. He has planned a meeting with relatives in the near future and is developing a residents forum with himself and the deputy on the last Wednesday of every month. Care Homes for Older People Page 21 of 26 Evidence: Residents we spoke to said the new manager is very good, he listens to you and he has a laugh and a joke and steady improvements are being made in the home, but they are still working on it at the moment. Relatives we spoke to said we have noticed the improvements in the environment. Residents who commented on surveys said the new management has given the impression that they are on the ball and are trying to make Primecare a haven we can all be proud of. The management team have recently undertaken a quality feedback survey from relatives and community matrons etc. and the new manager has analysed the results and developed an action plan. Comments included the staff have been working hard recently to improve the quality and individuality of the care plans, the home has improved in the last two months, the directors, when made aware of problems in the home have acted quickly and appropriately to improve matters, clean tidy and welcoming atmosphere, friendly staff, refurbishment has refreshed the building, a welcome pack for new people would be an improvement and redecoration and layout changes in the lounge give a more homely feel. Residents have also been surveyed recently and the manager is in the process of analysing the results and developing the action place. Consideration should be given to the format and the questions on the surveys to ensure that they are user friendly, especially for residents. The manager continues to send back statistics to the provider on the incidence of pressure sores and residents weights etc. Premises audits completed and wheelchair checks are now carried out. The manager is considering what other audits may be needed in the future for example with medication and care planning/management. As the manager has only been in post a few weeks, he has yet to organise and put in place the staff supervision system, but on discussion, he is aware that this needs to be addressed. Accident records were reviewed and these are completed fully by staff and there were no areas of concern. The manager plans to link in with the local falls prevention team for advice and information. Notifications to us, under Regulation 37, are now being sent to the correct address and are being completed as required, for anything that affects the health, safety and welfare of residents. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 8 14 Risks to residents must be fully assessed and the management of the risk recorded and kept under review. So that any risks to residents are managed proactively. 30/04/2010 Care Homes for Older People Page 23 of 26 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 7 15 Residents must have care plans in place for all their assessed needs and these plans must be kept up to date. So that residents care needs are met and in a way that they would wish. 14/09/2010 2 27 18 Staff in charge of the home 31/08/2010 must ensure that agency staff know the systems in the home and the needs of the residents they are caring for. So that residents are safe and that their needs will be met. 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 1 Consideration should be given to making the format of the Page 24 of 26 Care Homes for Older People 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 service users guide more user friendly. 2 3 7 9 Continue to develop the care planning system in relation to person centred planning. Through the use of a medication audit, standards of medication management should be monitored and any shortfalls addressed. Continue to develop a person centred approach to the provision of activities and social care. Ensure the format of the complaints procedure is user friendly and give consideration to introducing a more formal complaints logging/management system. Ensure staff have easy access to local guidance on adult safeguarding procedures. The manager must undertake regular fire drills with staff. Continue to encourage care staff to undertake NVQ qualifications. Consideration should be given to introducing medication and care planning/management audits. The manager needs to implement a staff supervision programme 4 5 12 16 6 7 8 9 10 18 19 28 33 36 Care Homes for Older People Page 25 of 26 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. © 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. 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