Inspection on 10/06/09 for Acorn Hill Nursing Home

This inspection was carried out on 10th June 2009.

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

Acorn Hill Nursing Home 10/07/08

Acorn Hill Nursing Home 21/09/07

Acorn Hill Nursing Home 12/04/07

Acorn Hill Nursing Home 12/04/06

Acorn Hill Nursing Home 02/09/05

Acorn Hill Nursing Home 15/04/05

Acorn Hill Nursing Home 02/09/04

Acorn Hill Nursing Home 28/01/04

Similar services:

Trevayler Residential Care Home

St Marys Nursing Home

Thornham Grove

Cheaney Court Care Home

Thistle Hill Hall

Chater Lodge

Conifer Lodge

Tixover Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for older people Name: Address: Acorn Hill Nursing Home Radstone Walk Rowlatts Hill Leicester LE5 4UH     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: Keith Charlton     Date: 1 2 0 6 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Acorn Hill Nursing Home Radstone Walk Rowlatts Hill Leicester LE5 4UH 01162760600 01162761428 saidz@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: GB Care Ltd care home 49 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia physical disability Additional conditions: The maximum number of service users who can be accommodated is 49 The registered person may provide the following categories 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: Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD Physical Disability - Code PD Date of last inspection Brief description of the care home The last inspection of this service was on the 10th July 2008. Acorn Hill Nursing and Residential Home is a care home offering accommodation for up to forty-nine older people. The home is registered to admit older people with dementia and/or mental disorders and physically disabilities. The home is located in a residential area to the east of Leicester. It is easily accessed by road using the outer ring road. The centre of Care Homes for Older People Page 4 of 28 Over 65 0 0 0 49 49 49 Brief description of the care home Leicester is approximately fifteen minutes away by car and there are adequate car parking spaces. A bus service is available from outside the home with more frequent bus services available near to the home. Fees are from £308 to £1750 per week. This information was provided the day of the inspection by the Manager. There are charges for additional services such as hairdressing. The building itself is a purpose built property offering accommodation on three levels. The home is equipped with a slow moving lift. There is a large garden to the rear of the property with a lawned area, established plants and trees and a patio/sensory garden area with seating. All areas of the home and outside areas are accessible for people with mobility difficulties. Care Homes for Older People Page 5 of 28 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: The quality rating for this service is One Star. This means the people who use this service experience adequate quality outcomes. We as it appears throughout the Inspection Report refers to The Care Quality Commission. The inspection process consisted of pre-planning the inspection which included reviewing the Annual Quality Assurance Assessment AQAA which is self-assessment tool completed by a representative of the service. We have sent surveys to people who use the service along with staff. When we receive these surveys back we will include the results of them if received before the final Report is published. The unannounced site visit commenced on the 10th June 2009 and was carried out by Keith Charlton. Care Homes for Older People Page 6 of 28 The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was case tracking. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Acorn Hill. Four residents were selected and discussions were held with four residents though this was limited as all residents except one had difficulties with communication due to their dementia, six visitors - five of which were relatives, the Manager, a representative of the Company and three members of staff. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by ensuring that: Assessments are detailed and contain all aspects of individual needs to make sure staff can meet those needs from day one of a persons admission. All aspects of care e.g. proper toileting programmes, improving nutrition if this is identified as a problem, stated dates of health checks, a full record of daily living wishes etc are detailed in Care Plans to assist staff to meet all residents needs and that there is always swift access to medical services at all times as needed following falls, medication recording is always done after issuing it to residents and that relevant medications are kept at the correct temperature etc. Staff need to respect residents at all times and respond to their needs as per the action stated in the care plan. The food supply needs evidence that all residents cultural needs are met, that food is not served cold and that it is appropriate to peoples needs. All residents hobbies and interests need to be recorded and action is taken to meet these needs by way of more outings and more varied activities. The Complaints Procedure needs to be clearer for residents and their representatives so that complainants can go to the Lead Agency to reach a proper resolution. Staff need to know the full abuse procedure to protect residents effectively. Care Homes for Older People Page 8 of 28 An environmental audit is recommended to make facilities better signed for residents with dementia etc. Maintenance issues need to be attended to quickly to provide an attractive, odour free and safe home for residents by way of protecting them from tripping hazards in storage areas etc . There were some comments regarding how busy staff were and that they could become fatigued so long staff shifts are not recommended. It is recommended that the Manager has administration support to free her from these tasks so the quality of the service to residents can be effectively promoted. The staff training programme needs to become more comprehensive through ensuring all staff receive thorough training to increase their skills in delivering good quality care for residents. Management need to take action if issues are identified, e.g. through staff appraisals. Residents must have a safe environment through management effectively ensuring that all staff who work at the home have full references in place before they commence employment, that effective fire safety is observed, that there are Risk Assessments for all safe working practices in place to eliminate risks for residents and that regular staff supervision is in place to support staff to give more effective care to residents. 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 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Acorn Hill do not have their needs assessed in detail before moving into the home. Evidence: Residents were not able to confirm that they had been provided with sufficient written information about the home due to their dementia conditions but relatives spoken with said they had enough information at the time of the admission to make up their minds about the home. We case tracked a person living in the home who had moved into Acorn Hill in the past. We also checked that this person had his needs properly assessed prior to moving in, to ensure that the staff at the home could meet his needs. We found that the assessment system had information regarding residents needs though some sections had not been properly completed - e.g. past health checks had not been included, which is useful to prompt these checks and improve the health and daily Care Homes for Older People Page 11 of 28 Evidence: quality of life for people, there was no information regarding hobbies, and there was contradictory information that stated his mental state was both confused and alert etc. Care Homes for Older People Page 12 of 28 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. People at Acorn Hill receive adequate health and social care practice. Evidence: No relatives spoken with could recall having a care plan though thought staff knew the care needs of their relative. We checked the care plans of four people living at the home who were case tracked. Plans showed detail regarding the support required by staff to ensure the physical health of people living at the home, and there was information to inform staff of the residents personal history though there were gaps in the information of preferred daily living routines of residents, which does not ensure peoples social and emotional well being are fully taken account of by staff. Continence information was recorded though this assessment needed more detail to work out the individual needs of a resident so staff could prompt before they needed to go to the toilet, and therefore make sure that they were comfortable at all times. Staff said they had not read all Care Plans - this is needed so that they can fully understand residents needs. The Manager said this would be followed up. Accident records were checked and although medical services were mostly contacted when a Care Homes for Older People Page 13 of 28 Evidence: resident had a potentially serious injury, this was not always the case. A monthly audit is recommended to be in place to review why accidents happened so that prevention could be put in place, thus protecting residents health. We checked the medication records, and found that there was generally good recording of the administration of the medicines in the home, though there were some gaps that the Manager said she would follow up. Medication had not been recorded for two residents on the morning of the inspection which was then rectified by a Nurse when we checked it had been given to residents. The fridge temperature has been higher than it should be which has a harmful effect on medication that needs to be kept cool. The Manager said that this issue is being followed up at present. Controlled medicines storage was in a secured cabinet. The Manager needs to check that this storage conforms to the latest legal requirements. We spent time watching staff interaction with people living at Acorn Hill. We saw staff being friendly and caring to people throughout the day doing their best to meet the needs of people living at the home and relatives confirmed that staff were friendly to residents though we also saw an instance where a resident appeared to be taken for granted when a staff member was filling in records beside a resident, and also staff not taking action to reassure a resident who continually was shouting out despite the care plan stating that reassurance was needed for this person. Care Homes for Older People Page 14 of 28 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. Resident cannot always have a lifestyle of their choosing. Evidence: Relatives thought that there appeared to be a good amount of current activities now that there is an Activities Organiser. The Manager said that this person works three hours on five days a week and it is planned that she becomes full time in the near future. We saw that there is a current list of activities and evidence of activities displayed on a board near the office. Staff said residents said they had games and quizzes, and there were trips out to the local shops. There is also TV, and we witnessed age appropriate music being played in a lounge and relatives said staff took residents out to the garden in good weather, which we also saw being done. There was no specific activities for dementia residents though the Manager said that history books were in the process of being set up - we looked at one which had impressive detail with photos of the persons life set out. The Manager said memory boxes were also being set up to help residents with reminiscence. The Manager said she was arranging training for the Activities Organiser on providing specialist activities for people with dementia. There were some comments that there needs to be more outings. The Manager said Care Homes for Older People Page 15 of 28 Evidence: that these are to be arranged on a more regular basis. We discussed a number of other activities that could take place - music and movement, knitting, crafts, school children visiting, nostalgia talks etc. The relations between staff and residents were observed to be relaxed. Staff said there were no rules in general though many residents were seen to be asleep at 9.30 in the morning so rising times need to be reviewed, and a staff member said no alcohol was allowed for all residents except one person - the Manager said this was not the case and she would follow this up. Visitors are welcomed at Acorn Hill and we were informed by visiting relatives that they could come at any reasonable time and they were always greeted in a friendly way by staff. Relatives largely said that the food appeared good though one relative said his mother was given vegetables she did not like. We spoke to the cook who said he would write down residents preferences so that they got food they liked at all times. A relative also said that as so many residents needed help with eating that food got cold so it was unappetising to residents. The Manager said she would follow this up so that food was of the appropriate temperature. We also found that there was not sufficient detail on the records of people from minority communities so it could not be proved they got the food they wanted though there was one specialist meal provided to one resident once a week. The cook said that he was shortly to train to learn how to cook food from other cultures. Lunch was a choice of two hot dinners and a resident said she was offered an alternative to these choices as well if she wanted. Food was well presented though the chop served was fatty and the Manager agreed it was not an appropriate food for a lot of residents as it was difficult for them to eat. The meal was followed by a dessert. Two fresh vegetables were served - this choice showed a commitment to healthy eating. Food records showed a good variety of food served. Care Homes for Older People Page 16 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are taken seriously though residents are not fully protected from abuse. Evidence: The AQAA stated that staff have been trained in safeguarding residents from abuse. A relative said he had a complaint and would be taking it to the Manager where he thought it would be sorted out. There was one complaint in March this year but no evidence to support the allegation made. We spoke with staff and asked what they would do if it was reported that a member of staff had been seen hitting a resident. They were clear that this was unacceptable and needed to be reported to the Manager. One staff was unsure of how to contact the right outside agencies. The homes Complaint procedure was not in line with the current need to refer complainants to the Lead Agency, the Adult Care Department of the Local Authority. Staff were found to have proper checks in general before they started work with written references in all cases except one where there was only one reference before employment commenced. Care Homes for Older People Page 17 of 28 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 living at Acorn Hill live in a generally homely and well maintained environment but odours need to be eliminated. Evidence: All residents spoken with said they liked their bedrooms: I can have my bedroom the way I like it, one resident said We saw people at Acorn Hill living in a newly refurbished and generally well maintained environment though one bathroom floor had paint marks on it which need to be removed to ensure this space is homely and not looking messy. The furnishings in communal areas are homely, and people can bring their personal possessions into their bedrooms. The service has improved the environment to further help residents with dementia, e.g. photos on residents doors to orientate them to their bedrooms but this needs to be further progressed e.g. colour coding toilet doors, pictures of residents favourite scenes on bedroom doors etc to make facilities clearer and orientate residents to go to their own bedrooms etc. There were some low level odours to some corridors and easy chairs which need to be eliminated. We also saw in the dining room that plastic aprons had been left on dining room tables which did not promote the homeliness of the service.The Manager said these issues would be followed up. Care Homes for Older People Page 18 of 28 Evidence: There was a suggestion on this inspection that the home should have a peninsular bath to further assist people. The Manager agreed this would meet residents needs and said she would raise this with the Providers to have it installed. Care Homes for Older People Page 19 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are met by a trained staff group though issues raised need to be dealt with. Evidence: There were some remarks in information we saw in the homes records, which caused us concern: Short staffed, Not working as a team, No team work, Staff standing around chatting and leaving meals to get cold, Residents not getting enough fluids as beakers coming back unused, Information not properly disseminated to staff. However relatives and staff generally said that there were enough staff to meet residents needs regarding personal care though there were also comments that at mealtimes there were not enough staff to help residents that needed help with feeding. The Manager said she would be following up these concerns. Domestic staff stop work in the middle of the afternoon so care staff then have to do these tasks though the Manager said she had identified this as needing action and said there will be an extension of three hours of domestic cover up until the tea period. A staff member said that although she had only been working at the home for eight months she had been encouraged by management to do the NVQ 2 course and had already completed a number of training courses and a thorough induction. We found Care Homes for Older People Page 20 of 28 Evidence: that staff have been on a number of training events to help update their practice on areas such as Moving and Handling, Fire Safety, Infection Control though not all staff have attended Dementia and Challenging Behavior training and some issues regarding residents health conditions were missing - e.g. Sight and Hearing Impairment, Stroke, Parkinsons Disease, Mental Health conditions, Diabetes etc. The Manager said that these would be added to the training programme. Staff said they had been encouraged to complete the skills training - NVQs - for staff and the Manager confirmed that over fifty per cent of staff had completed this. The Responsible Individual stated that some staff are working towards the higher NVQ level 3 award. Staff records showed that proper checks had been carried out to protect residents from unsuitable staff except one reference was not in place before a staff member commenced employment. Care Homes for Older People Page 21 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complete management systems in place to protect the health and safety of residents are not in place. Evidence: Ann Hagan is the Manager of the home and confirmed she will be applying for registration. Ann is a Registered Nurse and has completed the RMA Award in management skills. She has been updating the staff with training, and this was confirmed by the staff spoken with. For such a large home it would be expected that the Manager has administrative support so that there is adequate time to be able to spend being on the floor spending time with residents and staff ensuring that quality care is in place to meet residents needs, ensuring regular supervision of staff to check that essential skills are in place etc. Satisfaction questionnaires were sent around the home last year, and the results were seen to be generally very positive though they did not contain an analysis of the results to see if improvements in the service were needed or an action plan to Care Homes for Older People Page 22 of 28 Evidence: implement needed changes. There were some aspects in the survey that were seen as issues - there were remarks that relatives were not involved in care planning, of not being aware of the complaints procedure, no religious activities in place etc. Written records regarding finances for residents are properly in place, and monies were checked for two residents and totals were found to be correct in bank books. There was no evidence of residents/relatives meetings discussing relevant issues activities, food etc, which would show involvement in the running of the home. The Manager said these were to begin in the near future. Safe working practice risk assessments were in place though do not cover all risks in the home so these need to be expanded, e.g. the Manager was asked to review the Risk Assessment on window restrictors to ensure intruders cannot enter the building. The service was served a legal notice in 2008 regarding testing for legionella but we saw this has now been followed up to keep residents and staff safe. Staff informed us that they were able to tell management of the problems they were facing and there were regular meetings and appraisals to support them, and we saw records of this though there were no regular supervision records for staff, which would allow performance to be regularly monitored, support given, training needs identified etc. Fire records were in place with regular fire drills though weekly fire bell testing needs to be more frequently done. Staff were asked about the fire drill procedure though they were not aware of the full procedure. The Manager said she would ensure that staff were aware of the complete procedure so as to protect residents from fire. We saw that hot water is regularly tested to meet the National Standard so that residents are not scalded. Care Homes for Older People Page 23 of 28 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 38 13 The health and safety 10/08/2008 systems including fire safety systems in the home and Risk Assessments for safe working practices must be in place to protect residents from harm. Care Homes for Older People Page 24 of 28 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 Care Plans need to contain 12/08/2009 full detail of residents needs. So that staff are able to meet all needs 2 38 13 Proper health and safety 12/07/2009 systems need to be in place in respect of staff being fully aware of the fire procedure, there is regular testing of fire bells, unlocked storage rooms not being a tripping hazard to residents and complete risk assessments for safe working practices being fully in place etc. To protect the health and safety of residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 A detailed assessment is needed to ensure that all Page 25 of 28 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 residents needs are met by the home. 2 3 4 7 8 9 Staff need to read all Care plans to be aware of and act upon all residents needs. Medical services must be contacted if a resident has a potentially serious injury to always protect residents health. Medication neds to be signed after issuing it to residents and medications that need to be kept cool need to kept at the required temperature. Staff must be aware of treating residents with respect at all times. Medical services must be contacted if a resident has a potentially serious injury. That the Activities Organiser attends specialist training on providing activities for people with dementia. Management need to ensure that residents have choices in their lifestyles. Food served needs to be reviewed to ensure it is always relevant and appropriate and covers the needs of people from minority communities. The complaints procedure needs to be changed so that complainants have the details of the Lead Agency. All staff must know all Agencies to contact if abuse of residents is suspected. An environmental audit of the premises is needed to provide better facilities to residents with dementia. All odours need to be eliminated and working practices in line with ensuring that facilities are attractive and homely. Staffing levels need to be reviewed to ensure that they are adequate to meet residents needs. Two references must be received before staff commence employment to ensure that residents are protected from unsuitable staff. The Training Programme needs to be extended to include residents conditions and how to deal with challenging behavior. The Manager needs to act on issues raised by way of staff 5 10 6 7 8 12 14 15 9 10 11 12 13 14 16 18 19 26 27 29 15 30 16 31 Care Homes for Older People Page 26 of 28 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 appraisals, quality assurance questionnaires etc and it is recommended that that administrative support is employed to free up time so that there is time to spend on the floor ensuring residents have a quality service. 17 18 33 36 Quality Assurance systems need an analysis and action plan to improve the service. Regular supervision needs to be supplied to staff to ensure they have the support to provide a quality service. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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