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Inspection on 20/05/10 for Rivelin Residential Care Home

Also see our care home review for Rivelin Residential Care Home for more information

This is the latest available inspection report for this service, carried out on 20th May 2010.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prior to admission each person wanting to come and live in the home has an holistic assessment to see whether the home can meet their needs. This is used as a basis to develop a fuller care plan to reflect their current needs. Any significant events CQC are informed about so we can make a judgment as to whether the home has taken sufficient action to prevent this person from being harmed. A varied prgramme of activities ensures peoples social, religious and cultural needs are being met. People know the process of how to make concerns known to the management team and feel confident they will be investigated thoroughly. There are sufficient staff on duty at all times to ensure the needs of each individual can be met. Prior to the commencement of employment adequate checks are made to ensure they are safe to work with people in the home. They are then trained and supervised to do their jobs. The management team ensures that all equipment being used in the home is safe to use and it is a safe and comfortable place in which to live. A series of audits takes place through out the year so the owners can ensure the home is being run for the benefit of people living there and the service can meet their needs and expectations and it is a safe place to live and work.

What has improved since the last inspection?

There were no outstanding requirements to be met from the last inspection, but the Company decided to embrace the recommendations made.

What the care home could do better:

No requirements have been set at this inspection.

Key inspection report Care homes for older people Name: Address: Rivelin Residential Care Home 17/21 Albert Road Cleethorpes North East Lincs DN35 8LX     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: Theresa Bryson     Date: 2 0 0 5 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 24 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 24 Information about the care home Name of care home: Address: Rivelin Residential Care Home 17/21 Albert Road Cleethorpes North East Lincs DN35 8LX 01472692132 01472692132 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): J and LD Hayes Limited Name of registered manager (if applicable) Manager Post Vacant Type of registration: Number of places registered: care home 42 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The home can accept specified service user CH under the age of 65 years and this will apply until they reach the age of 65 years or they terminate the contract with the home if prior to that date. Date of last inspection Brief description of the care home Rivelin Residential Care Home is situated in the centre of the attractive seaside town of Cleethorpes, close to all local amenities. These include a library, post office, local shops and the seafront promenade. Local buses provide frequent services to all areas of the town and also to Grimsby town. The accommodation consists of four adjoining houses covering three floors. There are communal bathrooms, shower rooms and separate WC facilities situated on each of the three floors. The service users have the use of several lounges one of which is a smoking room and a large dining room, all of which are Care Homes for Older People Page 4 of 24 Over 65 6 42 0 0 Brief description of the care home located on the ground floor. There is a small courtyard to the rear of the building and three small car parks. Parking is also available on the road. Fees are renewed annually. Additional charges are made for the following toiletries, newspapersmagazines, hairdressing and chiropody. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available on request. Care Homes for Older People Page 5 of 24 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 key inspection took place one day in May 2010. Prior to the site visit a number of surveys were sent to people living in the home, relatives, health and social care professionals and staff. A small number were returned. We also spoke to some health and social care professionals by telephone prior to our visit. We looked at all the information the home had sent us since the last inspection. During the site visit we looked at a number of records and documents and spoke to some people living in the home, visitors and staff. We toured the home and grounds. On this inspection the lead inspector was accompanied by a colleague form CQC. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. in future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 6 of 24 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 24 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 24 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are holistically assessed to ensure they home can meet their needs. Evidence: Prior to admission each person is given an holistic assessment looking at every aspect of their care needs and expectations. This enables the management team to ensure they can meet this persons needs when resident in the home and for the person to see if they would like to stay at Rivelin. On the care plan which we tracked of the latest admission this had been correctly completed. People told us that they were comforted by the amount staff knew about them when they first entered the home. The pre-admission assessment is then used to build a more comprehensive plan of care, to ensure the persons current needs are identified and recorded. The home does not provide intermediate care and therefore Standard 6 is not applicable. Care Homes for Older People Page 9 of 24 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 care plans kept on each individual reflected their current needs and were evaluated on a regular basis. Evidence: At the time of the site visit The Company were revising the format for their care plans. This will also include details of the team leader, key worker and night key worker for each person. This will help individuals to identify with certain people, if they need to raise concerns. Prior to the site visit we sent out a number of surveys to people who use the service, relatives, staff and health and social care professionals. We had a small number returned. We also were able to speak to some health and social care professionals by telephone and in person prior to our visit. Most people gave positive comments about their experiences of using the service, and they particularly liked, what was termed the homely atmosphere and kindness of staff. Some were concerned that the building work and refurbishment was taking so long to complete, but hoped this would improve their environment. We tracked three care plans in detail and also checked the accident records of two Care Homes for Older People Page 10 of 24 Evidence: other people currently living in the home. There has been an improvement in the way the care plans are now used and staff appeared more confident in what they needed to record for each person and why. Each of the ones we saw had been signed by the person themselves or their advocate to show they had agreed the plan and what it hoped to achieve for each person. There was better recording of events when other health and social care professionals had been asked for advice and each one had been fully evaluated at least monthly, but in some cases where the persons needs had changed. For example, where a person was experiencing difficulties in walking and moving a core care plan identified the initial problems. A further risk assessment had then been carried out on their ability to move, their emotional status and how they were coping with a disability and how staff could assist this person in a practical way. There were also details of permission for this person to have bed-rails fitted and instructions to staff on how to use them. This was also included in the night care plan for this person. In the health professionals section there was written evidence that a physiotherapists advice had been sought regarding exercises for this person. This ensures that all risks have been taken into consideration when moving this person. We observed this person being moved in the home and safe practices were being demonstrated by staff. In another care plan a person was exhibiting disturbed sleep patterns at night, which was affecting their daily living tasks. A night care plan was put into place which described their sleep pattern and gave instructions to staff on what distractions needed to take place to enable them to rest more. This included care of any incontinence problems, safety in darkened rooms, dietary needs and any medication to be given. There was written evidence that staff monthly evaluated this and also made daily entries to show how well the person had slept during each night and if not how this had affected their daily life. There were some inconsistencies in some of the plans. For example in some were records relating to monthly checklists by the key worker and team leader and hygiene records, but not in others. The daily report sheets also need expanding upon. Although the core care plans were more detailed and had been evaluated regularly, the daily report sheets were only briefly completed and did not always give an accurate descriptions of that persons daily life. We also looked at the accident records for two people resident in the home and found there had been accurate recording of events. Each significant event had been detailed on an accident form and in the daily report sheet. This was then checked by a member of the management team on an accident follow up form and weekly report. This ensures the local team were always aware of any concerns and could follow the progress of peoples health and well being. Where necessary they also sent us a Regulation 37 report so we could make a judgment as to whether they had taken sufficient action to protect each individual. Care Homes for Older People Page 11 of 24 Evidence: People we spoke to during our visit told us they had all their needs met and that they could discuss concerns openly and in confidence. Needs were also addressed at night as they told us their night call bells were answered promptly. During the day we observed some care practices and interactions between staff and people living in the home and found them to be appropriate. The atmosphere was a happy one. Staff need to ensure they are preserving the dignity of individuals at all times as we did observe this not being so when some one was being lifted with the aid of a hoist. Visiting health professionals told us that staff have risen to every challenge given to them to help people with their needs. And that they have good relationships with staff who will always telephone or e-mail them for advice. We randomly checked some medication records and found there to be accurate recording on each file. There were also details on the file in the form of a letter showing where staff had asked for a medication review from GPs. This ensures that staff are ensuring people are receiving medication as prescribed. The new drug storage area ensures that items can be securely locked away and accessed on a need to know basis only. Temperatures were being recorded to ensure items were safe to use. Staff should ensure that no details of peoples medication records or other note form information on people living in the home is left unattended for people to read as this could breach their confidentiality and suggestions were made to the management team on how this could be improved. Care Homes for Older People Page 12 of 24 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. A varied programme of activities ensure peoples social, religious and cultural needs are being met. Evidence: In the care plans kept on each person staff make an initial assessment of their social, religious and cultural needs. People are encouraged to also complete a social family history - a This is Your Life section - so staff can have some ideas of how they have lived their lives, which could have contributed to their well being. We saw written evidence and spoke to people living in the home that supported that they regularly attend events such as a local social club, take part in a scheme for cinema visits and use the mini-bus for events further afield. Some people told us that they enjoy visiting friends locally and going shopping, which one person was doing on the day of our site visit. An animal assisted therapy session had been enjoyed by people in April, as well as the monthly church service. Two people are quite independent and go out as much as they like, they told us. Hobbies, such as knitting are included on care plans and then action reported upon when they have completed a task and their level of participation, for example if they enjoyed it, recorded. People told us they are not keen to attend meetings so most events are detailed in a newsletter and the Company is now on Care Homes for Older People Page 13 of 24 Evidence: Facebook so interested parties can contribute. During our site visit people were observed taking part in daily tasks such as helping to fold towels and dusting as well as enjoying some gardening, where a group were sitting in the sunshine and potting bedding plants. We made a tour of the kitchen. The last Environmental Health Officers report had awarded the home a 3-star rating for standards of hygiene, which they hope to improve upon next time. During our visit food was being prepared in a safe and clean environment. All equipment was in working order and the record keeping has now been revised and this appears to be completed regularly to ensure hygiene checks are made. Care staff inform the kitchen of peoples likes and dislikes and we saw the information sheets kept on each person, which staff told us they adhere to. There is a four week menu and the choices available were displayed. People told us hot and cold drinks are always available and one resident told us their choice of a cooked breakfast which they like and that if they wanted to buy for example a piece of steak, the chef will cook this to their taste. After tea is served at 4pm a bed time snack such as a sandwich is offered about 7pm. We observed staff assisting people during a lunch time meal which they did in a dignity manner, with encouragement to that person. A relative told us they are happy to help with their loved ones meal, if they should visit at a meal time, as we feel we are contributing. Care Homes for Older People Page 14 of 24 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 can raise concerns knowing the will be investigated fully. Evidence: Since our last inspection there had been a safe guarding investigation in progress with in the home, but the local team with in North East Lincolnshire safe guarding board had not fed back to either CQC or the home management team. This was being chased up. No other concerns had been raised directly to CQC. We saw the complaints log which showed details of how the home team had dealt with any concerns raised. The details were fully recorded about the concern, the investigation process and outcomes recorded plus action taken by staff. This ensures people can raise concerns knowing they will be investigated fully. People told us that they would be more than happy to raise issues, should the need arise. And described the staff as approachable and open to suggestions. The policy manual was up to date for the policies of complaints, safe guarding adults and whistle blowing for staff which we checked. The complaints process was on display in the main reception area and had the correct contact details for such as the ombudsman and CQC. When we tracked the staff files these showed that some staff have recently received up date training in how to safe guard vulnerable people and others were booked on May sessions. When speaking to staff they could explain clearly the process they should follow if they recognized people may be being put at risk of harm. Care Homes for Older People Page 15 of 24 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 should be able to live in a comfortable and safe environment. Evidence: In the last year this home has had a large amount of building and refurbishment work in progress. The bulk of which has now been completed. This has involved large parts of the home internally and externally being out of action for varying periods of time. To help combat any distress to people living in the home the home had developed a work planner, which is still in operation. We saw this file and it showed written evidence of the weekly contact meetings with the builders and how this information was cascaded to staff, people living in the home and visitors. It also told us which pieces of work had been completed and areas which staff and people living there could use safely. Where necessary the management team showed written evidence of when daily checks were needed, for example when water supplies and fire regulations were compromised for short periods of time. We also saw letters which had been sent to people living in the home, their relatives and other stake holders informing them of the progress. This has ensures that people were not being put at risk at any time and the staff made the environment as safe and comfortable as they could. Whilst touring the home there were some pieces of work which had not been finished. This included ensuring that all fire doors were not wedged open, looking into the padlock system on an outer gate and looking into storage for the lifting hoists. We were assured by the management team that this was still on the planner. Care Homes for Older People Page 16 of 24 Evidence: Some people told us in their surveys and when we spoke to them that they were pleased with the way the home was looking but some expressed that they would be pleased when the noise had stopped and still do not like people wandering around. We observed during the site visit that any people involved in the building work were being escorted by staff to the relevant part of the home they were working in, so were not being allowed to wander at will. When we looked in a selection of bedrooms, some of the linen was in a poor state of repair and there was no evidence that an audit had been completed. This should take place to ensure people are comfortable and there is enough linen for frequent bed changes if required. Each of the rooms had been adapted to peoples tastes and needs and people told us that they had welcomed being able to bring in personal items from home. Care Homes for Older People Page 17 of 24 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. A robust recruitment process ensures adequate checks are made prior to their commencement of employment and they are then trained to do their jobs. Evidence: We looked at the dependency levels matrix the management team keep to help them determine how many staff should be on duty at an one time. This is calculated monthly and the last one we saw had been completed on 4th May 2010. The dependency levels included a personal emergency evacuation plan (PEEP) for each person. We saw the detailed plans for four people, who lived in the upper parts of the home to ensure staff would be aware of how to move them in the event of an emergency. This plan is kept separately from the main care plans, but it was explained that in the event of a fire staff would go to the fire records, not a care plan. As the (PEEP) also contained other information such as details of their condition, next of kin and special needs. It was not clear how and when this was evaluated, but staff, when questioned were aware of the need to use them in an emergency. We spoke to some staff whilst on the site visit and we also saw in the surveys they had returned that they were happy with the current lines of management and felt the management team were approachable. We looked at five staff personal files and found sufficient evidence to support adequate safety checks had been made prior to their commencement of employment. We also could see on one persons file where disciplinary action had taken place and Care Homes for Older People Page 18 of 24 Evidence: what action had been taken to support that person and ensure they were safely looking after people in the home. Staff told us how pleased they were with the amount of training which was offered to them. We could see on the training matrix and on checking staff folders and the certificates in place that all mandatory training had been given. They had also fitted in topics such as dementia care, dignity in care, record keeping and infection control. We also saw written evidence to support other topics such as health and safety had been planned for May and June 2010. The training sessions appeared to be a combination of day courses, in house training and distance learning. Apart from mandatory training, topics are chosen to cover the needs of people living in the home so staff have the skills to deal with them and also topics identified for individual staff through supervision. This ensures they can look after people safely with a knowledge base which is recent. Care Homes for Older People Page 19 of 24 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. Safety checks are made to ensure the building is a safe place in which to live and work and staff are able to do their jobs. Evidence: We looked at a number of auditing tools during our site visit to ensure the management team were aware of how people were being looked after and if the needs and expectations of these people were being met. This included such audits as monthly pressure sore audits to determine whether people were being put at risk and if treatment was working. A bed-rail audit with a risk assessment for each person. We also saw evidence of how the quality assurance planner worked. For example in January it stated develop training plan and May is covering staff surveys. We looked at the comments from some of the surveys given to relatives and people living in the home. There was no evidence to support on how findings were being used and this should be documented to ensure the views of people are taken into consideration either when planning their care or to develop the service. We looked at the records which are being kept on peoples personal allowance money Care Homes for Older People Page 20 of 24 Evidence: and there appeared to be accurate recording and the money being used for their personal use. A monthly check takes place by an independent Company representative to ensure records are accurate. At the time of the site visit the manager was looking into applying to CQC for the Registered Managers post. People we spoke to appeared to understand the current lines of management and felt the team were open and transparent. To support staff there is now a supervision plan in place and we could see when checking some individual staff members records that these corresponded to sessions which had occurred. There was a balance between discussion sessions and observational supervision which ensures the supervisors can see whether staff are doing their jobs safely. There was good follow through from one session to another, particularly where action needed to be taken, for example when staff had been asked to read a policy or attend a training session. We looked at the safety certificates which ensures that all equipment is safe to use and regular checks are made on the general maintenance of the home for it to be a safe place in which to live and work. Care Homes for Older People Page 21 of 24 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 22 of 24 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 7 7 The daily report sheet kept on people living in the home should accurately reflect peoples daily lives. Staff should follow the Company policy manual and ensure that each care plan file is consistently used and all documentation included, to enable accurate reporting to take place. The Responsible Individual should take necessary action to ensure fire systems are not compromised by the wedging of doors. There should be adequate linen supplies in place to ensure there is linen of a good standard being used at all times for peoples comfort. Any gathering of views by staff from people using the service, visitors and other stake holders should be taken into consideration when planning their care or developing the business. Any action should be documented. 3 19 4 26 5 33 Care Homes for Older People Page 23 of 24 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. Care Homes for Older People Page 24 of 24 - 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!