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Inspection on 02/06/10 for The Kensington Nursing Home

Also see our care home review for The Kensington Nursing Home for more information

This is the latest available inspection report for this service, carried out on 2nd June 2010.

CQC found this care home to be providing an Good 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

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

The care plan and healthcare records looked at were relevant and up to date. All of the medication looked at was stored safely and the medical administration records were fully completed. The group activities are varied and all residents are encouraged to participate. The environment is well decorated, comfortable, clean and suitable for its stated purpose. The training and development of staff is given a high priority. Staff commented on the good standard of training provided and on the support provided by senior staff, including the Registered Manager and the Training officer.

What has improved since the last inspection?

The statement of purpose and service user guide are up to date and have all of the required information in place for prospective residents and the residents living at the home. Staff working at the home are familiar with safeguarding procedure and have all received training to ensure they are knowledgeable about how to report an incident. staff are receiving regular structured supervision meetings.

What the care home could do better:

The organisation to look at the activity plans specifically for residents that have dementia and other cognitive impairments to ensure they are providing person centered activities on a one-one basis. staffing levels at critical times specifically meal times should be looked at to ensure that meal times are an enjoyable experience for residents. The daily records completed by some staff were not legible. The safeguarding records are in place and have full investigation records, the outcome of the investigations are not clear. The safe storage of frozen food should be known by all kitchen staff.

Key inspection report Care homes for older people Name: Address: The Kensington Nursing Home 40-42 Ladbroke Road London W11 3PH     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: Jackie Derbyshire     Date: 0 2 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 27 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 27 Information about the care home Name of care home: Address: The Kensington Nursing Home 40-42 Ladbroke Road London W11 3PH 02077278033 02077929712 smallc@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Christine Small Type of registration: Number of places registered: care home 53 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia physical disability Additional conditions: The maximum number of service users who can be accommodated is: 53 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: Physical Disability Code PD Dementia Code DE Date of last inspection Brief description of the care home The Kensington Nursing home provides 53 places for people needing residential and nursing care, including 3 places for people needing palliative care. The building comprises of 3 stories, to which there is lift access. All bedrooms are single rooms with en suite facilities. There are various communal rooms, including a pleasant dining room and conservatory on the ground floor, a newly established library and smaller dining and sitting rooms on each floor. The home is decorated with fixtures and fittings of a high standard. The home operates as 3 units, on separate floors, each managed by a Care Homes for Older People Page 4 of 27 Over 65 0 0 53 53 Brief description of the care home senior nurse. The home has attractive, well-maintained gardens to the rear of the building. It is owned and operated by BUPA and located in Notting Hill, close to the tube, shops and services. There are currently forty- seven residents living at The Kensington Nursing home. The weekly fee varies from £1450-£1550 and £250 a night respite care. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means that the people using the service receive a good service. Throughout this report the word we will be used as meaning the Care Quality Commission CQC.This unannounced inspection took place on the 2nd June 2010 when we spent 7.00 hours visiting the home.The Compliance Inspector was accompanied by Sheila Lycholit and Anne Farley Compliance Inspectors. We spent time talking with the registered manager, residents,relatives and visitors, the assistant chef and care and nursing staff. There are currently 47 residents living at the home, 18 commissioned by local authorities and 29 private residents. There are 48 staff currently employed at the home including: nurses,care staff, kitchen staff and maintenance and housekeeping staff. We looked at the care records of 6 residents. We looked at 6 staff files including recruitment, supervision and training records. The CQC received 5 resident and relative Care Homes for Older People Page 6 of 27 surveys and 8 staff surveys, all of the information will be included throughout this report. There were 6 requirements set in 2008 that have mainly been met. We spent time discussing the requirements with the registered manager and looking at relevant records and documentation. There are 4 new requirement and 1 good practice recommendation set from this inspection. Care Homes for Older People Page 7 of 27 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 8 of 27 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 9 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service.The home provides a statement of purpose that is specific to the individual home and the resident group they care for. Evidence: Comments from residents and relatives. Very nice home. The staff look after patients very well. We spent time looking at the homes statement of purpose and service user guide. Both documents were up to date and relevant. There is a lot of information in place showing the homes philosophy of care, services and facilities. The documents can be Care Homes for Older People Page 10 of 27 Evidence: made available in different formats if required. We looked at the records of 6 residents and each contained a contract of terms and conditions for living at The Kensington Nursing Home. We looked at the needs assessments called QUEST Assessments, all of 6 residents assessments were completed prior to moving into the home and then reviewed and up dated as necessary on a monthly basis. All needs assessments were comprehensive showing what care and support each individual required and how the home was going to meet their needs.The home does offer a respite service, we did not look at any respite care records at this site visit. Care Homes for Older People Page 11 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each residents plan; they give a comprehensive overview of their health needs and act as an indicator of change in healthcare requirements. Evidence: Comments from residents and relatives: Kind caring staff. They take good care of me. We spent time looking at the care plans of 6 residents, all 6 care plans worked in conjunction with the QUEST care needs assessments. All of the care plans outlined the specific health and social care requirements of the residents with information showing Care Homes for Older People Page 12 of 27 Evidence: how they were going to meet their needs. care plan records showed that they are reviewed monthly and in some instances sooner when a change occurred in an individuals health or wellbeing. The health care records in all 6 residents files looked at were relevant up to date.The home uses a lot of different monitoring records to monitor the health of the residents including: A Mental Ability Assessment, Malnutrition Universal Screening Tool (MUST) and Waterlow. Records looked at also included monthly weight and observation records, mobilising, medication. All of the residents have access to the GP that visits the home twice a week, however some residents choose to stay with their own GP. All 6 residents files included information on hospital appointments, appointments with health professionals and records of a visiting optician, dentist and chiropodist. None of the residents have any pressure care provided at this present time, there are currently 5 residents that are bed bound and are provided with special mattresses and have a turning chart to ensure pressure areas stay intact. Registered Nurses (RNs) confirmed that they received annually training in the handling of medication. The storage of medication was looked at on 3 units, where all medication was found to be kept in a locked walk-in room, maintained at a cool temperature.There was an issue with a new medication fridge, fortunately no medication was stored in the fridge. The registered manager contacted the CQc to inform that the maintenance officer had checked the fridge and it was now set at the correct reset temperature. The storage of controlled drugs was checked on one unit where all drugs were kept in a locked cabinet. The controlled drugs record book was fully completed. Medication administration records seen were up to date. Staff confirmed that the administration of medication is audited monthly by the registered manager. The GP practice that visits the home twice a week regularly reviews residents medication. We were told that some of the residents self medicate and this is recorded in the care plan, the medication is kept in a lockable draw in their room. The registered manager informed us that the pharmacy is changing from the 9th June 2010 and all staff have received training from the new pharmacy. The staff induction training records show that all staff are trained in how to treat residents with respect and dignity at all times. On the day of this site visit all staff was seen to work with residents and not telling them what to do. The residents files looked at all had information in place regarding what support was requested for them in the planning for dealing with increasing infirmity, terminal illness and death. The home is providing palliative care. Included in the service users guide is information for residents, relatives and other services showing what support Care Homes for Older People Page 13 of 27 Evidence: the home can provide in the circumstances of a residents death, including their request for their wishes and beliefs being adhered to by the staff. Care Homes for Older People Page 14 of 27 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Group activities are provided both within the home and in the community.The food in the home is of a satisfactory quality and meets the dietary needs of the people using the service. Evidence: Routines, as far as possible, are centred on the needs and choices of residents. Residents get up when they wish and a number were observed in the morning sitting having a cup of tea in their dressing gowns, after having a bath or shower. There is an Activities Coordinator who arranges a weekly programme of activities, which is displayed throughout the building. On the afternoon of the inspection visit, an ice cream tasting session, which was well attended, was held outside in the garden. In discussion a visitor who is regularly at the home commented that while she was generally happy with the care provided, she felt that more stimulation could be given. The residents map of life gave information about her previous career and interests but this had not been developed into an individual programme. For example there was no music in her room, although this had been a particular interest of hers, nor were Care Homes for Older People Page 15 of 27 Evidence: there any books. Her notes did not indicate that she had been given large print books to try or audio books. While it is recognised that progress has been made in developing group activities, it is recommended that the Activities Coordinator and key workers develop individual programmes to support residents existing interests. Residents records show that the home has been successful in maintaining and increasing the weight of residents where low weight was of concern. Residents individual likes and dislikes and whether they need support with eating and drinking is displayed in the pantry in each unit. Residents have a choice of dish at each meal and a Nite- bite menu has recently been introduced to ensure that residents have a choice of snacks when the main kitchen is closed. The increased dependency of residents has led to the main restaurant being used by only a small number of people, with the majority eating in their rooms or in the dining areas on the units.Five residents were in the conservatory/dinning room, there was one care assistant serving the meals that were already plated up and covered.There was an issue with all 5 residents being served at different times. No water or other soft drinks was provided only wine was served on request from residents only this was served to the residents with cling film covering the glasses. On the dementia care unit on the 2nd floor the majority of residents had lunch in their rooms. Seven people needed support with eating, while most of the other residents needed some supervision. This meant that staff were very busy serving meals and supporting residents. A number of residents had pureed food, which was well presented. The dining table was not set for lunch and three residents sat eating, one with some difficulty, off small low tables. Staff stated that none of the residents could be persuaded to eat at the table, though if it had been set for a meal it would have provided encouragement to residents to use it. The TV with 24 hour news was on, while background music might have provided a calmer and more relaxing atmosphere. It is recommended that main mealtimes are reviewed in the light of the changing use of the main restaurant to ensure that mealtimes are pleasant and congenial occasions. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service.The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of formats including other languages. Evidence: We spent time looking at the homes complaint policy and procedure. The complaint procedure is in all of the residents rooms. There is a suggestion box in the reception area with forms for residents, relatives and any other visitors in the home to complete. In discussion with the registered manager we were told that the suggestions raised are taken seriously and would be dealt with appropriately There have been 4 complaints raised at the home in the last 12 months, we spent time looking at the complaints and looked at all of the investigating records. The complaints looked at were dealt with in the relevant timescale and showed the outcome of each complaint. We spent time with a resident who had booked for a weeks respite stay. There were issues that the individual had found unsatisfactory and had liaised with staff. We discussed the issues with the individual and the registered manager, the outcome was the individual had moved into the home on a Bank Holiday Sunday and the manager was not on duty until the Tuesday. The individual told us that as soon as she spoke to the registered manager all of their concerns had been dealt with straight away. The Care Homes for Older People Page 17 of 27 Evidence: registered manager told us that she would recored the issues and what had been done to deal with them. We spent time discussing the safeguarding procedure with the registered manager and looking at the safeguarding records. The home has had 5 safeguarding incidents reported in the last 12 months. The home is reporting all incidents to the CQC and the relevant commissioning local authorities. We discussed the outcomes of the safeguarding incidents with the registered manager as it was difficult to ascertain if the investigation was completed and what the outcome was. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provider and manager have ensured that the physical environment of the home provides for the individual requirements of the people who live there. Evidence: The Kensington Nursing Home is located close to public transport, with Notting Hill tube station and bus routes nearby. Shops, restaurants and other services are nearby. The home is arranged in three units, over three floors and is fully accessible, with a large lift serving each floor. Each unit has a number of communal areas for the use of residents and their relatives. All bedrooms have an en suite washbasin and WC and the majority have a shower. In addition each floor has assisted bath and shower rooms. There is a library for the use of residents on the ground floor, with books, DVDs and a large screen TV. The library has internet connection and PCs for the use of residents and their families. Staff stated that a number of families use the IT equipment to show residents family photos. The Activities Coordinator uses the library for film shows for residents. There is an attractive garden, with seating and raised beds for residents to use. The building is in a good state of repair and decoration and attractively furnished. A team of cleaning staff keep the building clean and odour free. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service.The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service.The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people using the service. Evidence: Six staff files were looked at. All were well ordered and showed that a sound recruitment and appointment procedure had been followed. Criminal record (Independent Safeguarding Authority) checks were on each file and copies of documents confirmed that the originals had been seen. Rotas provide 1 Registered Nurse (RN) on duty at all times, with 4 Care Assistants in the morning and 3 in the afternoon on each unit. Night staffing consists of 1 RN and 1 Care Assistant on each unit.The Team Leader for the dementia care unit was on maternity leave. Her hours were being covered by other RNs working overtime. All staff undertake a structured induction using a handbook, which is signed off by the line manager. Care staff are provided with the Skills for Care workbook. There is a high commitment to training, with 25 out of 28 care staff achieving NVQ level 2 or 3. The home has an in-house training officer who works 4 days a week, providing Care Homes for Older People Page 20 of 27 Evidence: training for staff and arranging training externally. The home is taking part in a number of local training initiatives, including the local PCT/University of Stirling training in dementia care and has enrolled for the Gold Standard Award in end of life care. Core training is monitored by the training officer, who runs regular updates. Care Homes for Older People Page 21 of 27 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 using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service.The manager has the required qualifications and experience and is competent to run the home.The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. Evidence: The registered manager has worked in health and social care for many years, she is a qualified RGN and and has experience of managing care homes.The registered manager has the level 4 NVQ. The registered manager told us that she attends regular training to ensure she is up to date with all policies and procedures for care homes that provide nursing care. We spent time looking at the quality assurance procedure in the home. There are regular self audits taking place including medication, nutrition, and care documents. There was a questionnaire given to all residents in 2009, the outcome was that 63 Care Homes for Older People Page 22 of 27 Evidence: of residents questionnaires were returned. We looked at the outcome of the survey and there were action plans put in place for any issues found. We looked at the monthly management audit records that includes looking at random residents files and ensuring that staff are completing records appropriately. The home has Regulation 26 visits completed on a monthly basis, the records looked at show that these visits by the provider look at all areas of the care, support, health and environment records at the home. The finances of residents are kept by the financial administrator at the home. We spent time looking at the financial transaction records of 6 residents and the balance of their finances. All records looked at were in date and the correct balance was seen on each residents record. Not all residents have their finances kept by the home as there are lockable cabinets in all rooms for residents to keep their belongings. The home liaises closely with relatives, advocates and social workers for residents that are unable to make decisions about their finances. Staff are supported by regular supervision, staff meetings and annual appraisal. The care plan records are kept with the individual, all other records are kept secure in the managers office or the homes computer system that requires a password for access. Records looked at were up to date and relevant. Care staff and nursing staff do need to ensure that the daily records are legible and work in conjunction with the care plan. We spent time looking at the health and safety checks completed on a daily, weekly and monthly basis. All health and safety records show that the home does ensure that all areas of the home are safe for the people living there, the staff and other visitors. There is an issue regarding frozen food storage, on the day of this inspection we looked in the freezers and a box of frozen sausages were opened and also packaging for vegetables. We discussed this with the registered manager who told us the last Food Safety Agency visit in May 2010 had found the same issues. The registered manager was not able to find the record of this visit and we were unable to see the recommendations set by the Food Safety Agency. The registered manager contacted CQC to state that the assistant chef had been in charge of the kitchen on the day of the site visit and had been required to look at the safe storage procedure in the home. Care Homes for Older People Page 23 of 27 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 18 13 The registered manager to 04/10/2008 make sure that all senior staff that are left in charge of the home are up to date with the procedure to follow if a safeguarding incident occurs to make sure all relevant professionals are contacted. Care Homes for Older People Page 24 of 27 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 12 13 The registered manager to 07/09/2010 look at the activity plans for individuals specifically those with dementia or a cognitive impairment. To ensure that activities provided are person centred and have a positive outcome for the individuals that are linked to their interests. 2 15 16 The registered manager to look at the staffing levels at meal times to ensure all residents have their needs catered to. Residents in the home have increased dependency and the manager should ensure each resident is having the support required at the critical meal time. 07/08/2010 3 37 17 The registered manager to make sure that all staff are completing daily records that are legible. 07/09/2010 Care Homes for Older People Page 25 of 27 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 To show what care and support has been provided to residents linked into the care plan. 4 38 13 The registered manager to make sure that all kitchen staff follow the correct safe storage procedures To ensure residents are protected. 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 11/06/2010 1 18 The registered manager to implement a procedure showing the outcome of safeguarding incidents. Care Homes for Older People Page 26 of 27 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 27 of 27 - 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. 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