Inspection on 28/01/09 for Ashcott Lawns

This inspection was carried out on 28th January 2009.

CSCI found this care home to be providing an Poor 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.

Other inspections for this house

Ashcott Lawns 01/05/09

Ashcott Lawns 29/04/09

Ashcott Lawns 25/01/08

Ashcott Lawns 12/09/07

Ashcott Lawns 14/11/06

Ashcott Lawns 11/10/05

Ashcott Lawns 17/05/05

Ashcott Lawns 19/10/04

Ashcott Lawns 21/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ashcott Lawns Chapel Hill Ashcott Bridgwater Somerset TA7 9PJ     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Shelagh Laver     Date: 0 9 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Ashcott Lawns Chapel Hill Ashcott Bridgwater Somerset TA7 9PJ 01458210149 01458210932 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Monica Diana Corbett care home 17 Number of places (if applicable): Under 65 Over 65 17 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 Ashcott Lawns is registered with the Commission for Social Care Inspection to provide personal care only for up to 17 people over the age of 65 years. The home is not registered to provide nursing care. The registered provider/manager is Mrs M. Corbett. Mrs Corbett lives on the premises. The home has been converted from a Grade II house to provide a homely environment for service users. It has been adapted as far as possible to meet the needs of older people however, service users need to be ambulant as there are further steps to most first floor bedrooms and assisted bathing facilities are limited at this time. This period house is full of character and furnishings and fittings are in keeping with this. The home is located in the village of Ashcott where there are some amenities and village activities. Attractive gardens surround the home and there is ample parking. The current fee range is #430 to #530 per week. Additional charges include; hairdressing, chiropody, personal items and some staff escorts to appointments. Care Homes for Older People Page 4 of 32 Care Homes for Older People Page 5 of 32 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: zero star poor 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 over two days. The first visit took place on 28/01/08 and was unannounced. We (CSCI) met people who live in the home and staff. The building was reviewed and some documents were inspected. The second visit was announced and took place on 09/02/09. It provided the opportunity for further review of documentation and discussion with staff and people who live in the home. The home owner and manager Mrs Corbett was available on both occasions. An Annual Quality Assurance Assessment was requested prior to the inspection. An extension to the submission date was requested and granted but at the time of writing the report it has has still not been received. (The AQAA provides factual information about the home and gives an indication of Care Homes for Older People Page 6 of 32 plans for the coming year.) Comment cards were sent to the home to be completed by people who live there but none have been received. What the care home does well: What has improved since the last inspection? What they could do better: At previous inspections Mrs Corbett has stated that she is aware that the home can only provide accommodation to people who are mobile and is aware that she is registered to provide personal care . It was therefore a concern that at this inspection that someone had been admitted with assessed nursing needs and requiring nursing care. There is currently no recorded system of assessing peoples needs before they come to the home. There must be a robust system in place that ensures the service has the staff skills and equipment to meet peoples needs when they come into the home. The care plans available at the last inspection were not readily available on this occasion. Staff provide care on the basis of knowing the people who live in the home. There is a very brief summary on a post card in the front of the daily records for each person that does not provide sufficient information. Mrs Corbett informed the inspector that a comprehensive care planning system will be purchased and used. The home has been registered with CSCI since 09/04/90 and there have been repeated request to implement and maintain appropriate care planning. The records of two recently recruited care staff were seen. There were no comprehensive organised files. It was not possible to tell when exactly staff started work and therefore whether pre-employment checks had been completed in a timely manner. One reference clearly did not support information given on the application Care Homes for Older People Page 8 of 32 form. The reference had not been discussed or verified with the member of staff. The registered person works many hours in the home and lives on the premises and yet the key management functions and tasks had not been addressed in order to ensure that the home is operating according to the Regulations and National Minimum Standards (Care Standards Act 2000.) The home has continued to run during Mrs Corbetts recent ill health however there is no formal structure of accountability. Senior staff should have training and support so they are able to take responsibility in the home and work to National Minimum Standards in the event of planned or emergency absence of the manager. There are plans to employ additional administration assistance in the near future and steps should be taken to ensure that this person has the required training and skills. There were requirements in previous reports to improve risk assessments and guidance to staff regarding peoples weights and pressure damage. These requirements have not been addressed and at this inspection some peoples weights were low and there was no plan of action recorded to address this. People living in the home should be able to know in advance what is on the daily menu and to express a choice within the operational limits of a small service. The staff know peoples food preferences but this is no substitute for being told what the main lunch option is and being offered alternatives if it is not wanted that day. Past inspections have suggested that serving dishes could be used as an alternative to ready plated meals for some people but this recommendation has not been adopted. A recent survey completed in the home indicated that people did not want activities. However there should be an effort on the part of the home to provide appropriate entertainment and social interaction in a form that is acceptable to some people. At this inspection Mrs Corbett said that she was employing one or two people to come into the home and provide entertainment. The medication in the home must be reviewed using the appropriate professional guidance. The home has to work with more than one surgery and pharmacy. It is recommended that external guidance is read and discussed and a formal review of the system undertaken. There should be photographs of people in the MAR charts. The number of tablets received into the home should be recorded. The system of giving out medication should be reviewed by all staff involved to ensure they are following good practise. At this inspection the full range of health and safety checks were not examined. The registered person should ensure that she is aware of the checks that should be undertaken and that records are available in an organised manner and available for inspection by the appropriate authorities. The registered person must ensure that staffing is adequate in numbers and skills at all times. The provision of day care will have an impact on the sufficiency of staff for people who live in the home. The home does not employ additional catering or cleaning staff. A review of night staffing should be undertaken. If Mrs Corbett is the second Care Homes for Older People Page 9 of 32 sleeping member of staff she must be sure that she can undertake the full range of care tasks including all manual handling safely. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are admitted to the home without a comprehensive assessment this means that there is no certainty that the home can meet the persons needs. The manager has taken people outside her registration category. This means that the home has breached a registration regulation. Evidence: Some people have been in the home for many years but at this inspection the number had increased from five to nine. There are also people attending for day care and some people have been for respite care. People often come to the home because relatives live close by or the home has been recommended by someone locally. Care Homes for Older People Page 12 of 32 Evidence: We looked at the records of two people admitted since the last inspection. There did not appear to be any formal assessment documents at this inspection. One person who had been reassessed as needing nursing care had been taken back to the home. Another person who had been admitted with short term memory loss. Mrs Corbett was uncertain whether she had been diagnosed with dementia or not. The home is not registered to provide care either for people with nursing needs or with dementia. At previous inspections Mrs Corbett has been clear that she is providing care primarily for people who are mobile and independent and staffing levels, equipment and training are based on this premise. Care Homes for Older People Page 13 of 32 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 spoken to in the home said that care was good and there was support from health professionals. Care is not planned and recorded professionally in the home. Peoples needs may not be fully addressed because of the lack of efficient monitoring and review of care. Medication administration must be reviewed in line with current guiidance and best practice. Evidence: People in the home spoke very positively about the care received. The involvement of people in their care was not seen in care documents although people said that they could make choices about their care. One person for example has a daily shower. This is good practice. Relatives visiting the home confirmed that they were pleased with the care in the home. Since the last key inspection the care plans have been reduced to a post card size Care Homes for Older People Page 14 of 32 Evidence: summary in the front of the daily records. There is no way of tracking aspects of care other than by reading through all the daily records. Care is delivered because the care staff know what they are doing. One member of staff gave a full and competent description of the care given to one person with complex needs. The manager informed the inspector that she was in the process of writing care plans and also had ordered at great expense a completely new system for use in the home. In the owners office there were other files containing information about people but these are not accessible to the care staff. This means that staff have no access to guidance on moving and handling or catheter care required by people. There are no risk assessments for people relating to pressure damage and action to be taken. The monitoring of peoples weights is unsatisfactory. People are weighed following their bath and the weights are recorded on loose sheets of paper in the bathroom. When people have a low weight there is no care plan to ensure that they are maintaining weight. One person had been steadily losing weight without anyone taking action because she had always been lightand eats well. Another person had lost weight but was gaining it again. This could only be determined by looking back through the sheets of records. There was no understanding of the care needed to maintain peoples weights for example the use of the MUST system. A system for monitoring and responding promptly to peoples weight loss must be implemented. Requirements have been made about care planning in the home since 2006 and a pattern has emerged. Care planning improves for a time and then unfortunately is not maintained. People confirmed that doctors and district nurses attend the home to provide health care. Daily records showed that doctors and community nurses visited people in the home. In the case of one person assessed as needing nursing care the district nurse attends every two days and responds to emergency calls. A community nurse came during the inspection to dress one persons legs and a GP attended promptly in response to a request for treatment. Staff were able to give a good account of the care needed by people in the home and understood the daily needs of people. There is a system of medication administration in place supported by policies and procedures.The records of medication do not contain any photographs or records of the number of medications in the home. Mrs Corbett felt staff were well trained but all were unaware of any CSCI or Royal Pharmaceutical Society medication guidance documents. The home should access guidance documents and conduct an audit of mediction administration procedures undertaken in the home. Care Homes for Older People Page 15 of 32 Care Homes for Older People Page 16 of 32 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 are offered a wholesome diet but do not know what is on the menu. People are able to choose how they spend their days. Visitors are welcome in the home. There is currently no planned activities programme. People should be offered opportunities for entertainment and social activities. Evidence: People spoken to during the inspection were satisfied with the food provided in the home. People said that there was enough to eat. The home does not have a designated cook but one senior member of staff leads the team in food production. This member of staff prepares the menus and knows what people like to eat. Staff said that people could chose to have yoghurts or cheese instead of the main pudding. Two lunches were seen and each looked well cooked and contained fresh vegetables. The National Minimum Standards state that there should be a menu in the home offering a choice of meals in written or other formats which is given read or explained Care Homes for Older People Page 17 of 32 Evidence: to people. Within the restrictions of a small service people should know what they are going to have for lunch and should be able tomake choices about what they want to eat on that day. At previous inspections it was suggested that some people might like serving dishes to help themselves to vegetables. People continue to receive meals ready plated. The provision of meals to older people does require some specialist knowledge and key people in the home should be offered training opportunities in order to understand all the ways in which food can be used to promote health and well-being in the home. People are able to chose how they spend their day. One person was getting up quite late in the morning as she was a night birdand liked to stay up late. People seen throughout the inspection were spending time in their rooms or in the communal lounge. Family are welcomed into the home and were seen visiting people and taking them out. There is no advertised programme of activities and Mrs Corbett said that people who completed a recent questionnaire were happy just sitting in the lounge. One person talked about a trip to the music hall at Christmas. People should be offered opportunities for stimulation and entertainment. Mrs Corbett told us that she was just about to employ an activities co-ordinator and had another person coming to do crafts. Care Homes for Older People Page 18 of 32 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. There is a complaints procedure in place. The lack of opportunity for assessment and review of peoples needs places them at risk that their needs might not be met or that risks to their health and well being might not be recognised. Staff should receive rigourous safeguarding training up-dates and must be clear of the action to be taken. Evidence: There is a complaints procedure in place and people in the home said they would be able to speak to any of the staff about any concerns that they might have. There had been no complaints since the last inspection. Safeguarding training was confirmed in a previous key inspection but at this inspection it was not possible to confirm that any up-dates had taken place. The registered person should ensure that all key staff are competent to implement appropriate action if they are in charge of the home. Care Homes for Older People Page 19 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall the environment in the home is comfortable and homely. Bathing facilities need to be improved to reflect the standards expected in a registered care home. Evidence: Overall the home is comfortable and homely. People have bedrooms that are personalised. The communal rooms are attractive and well furnished. The lounge is light and bright. Some areas would benefit from tidying and there is some inappropriate storage. At the inspections in 2007 and 2008 issues were raised about the standard of bathing facilities in the home. At the inspection in 2008 en-suites, shower rooms and bathrooms were seen almost completed. It was therefore disappointing to see the bathroom used for storage. People are still bathed in a small downstairs bathroom. At this inspection the side of the bath was coming away. There is an uncovered radiator and the room contained communal toileteries and cleaning materials that were due to be put away. A new bath lift has been purchased but the old bath knight has not been removed necessitating a manoevre to get the new hoist past the old equipment. The new shower room has Care Homes for Older People Page 20 of 32 Evidence: been completed and is enjoyed on a daily basis by one person. Rooms contained hand wash and gloves for staff use. The laundry facilities on the second day of inspection were not satisfactory. There were large puddles of water on the floor and the roof was leaking. In an area containing electrical equipment these arrangements must be improved. Bath water temperatures are recorded prior to bathing. Care Homes for Older People Page 21 of 32 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 poor 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 are generally satisfied with the care they receive however staffing procedures must be improved. Recruitment practices and procedures must be improved and implemented in line with National Minimum Standards and Regulations. There should be a clear training plan and records showing what training has been provided to which staff. Evidence: There is a group of established staff at Ashcott Lawns who are kind and cheerful. They deliver care to people who live in the home and work together to keep the home going in times of absence of the manager. All staff undertake all tasks and there are no separately employed domestic or kitchen staff. At times this can place a strain on the staff resources. Two new members of staff have been recruited. One new member of staff was on duty. She said that she had an induction and had been given lots of support in the home. Recruitment records were not stored in an organised way. It was difficult to piece Care Homes for Older People Page 22 of 32 Evidence: together whether all information was available as Mrs Corbett had to keep going upstairs to locate additional documents. For one person the reference given purporting to be an employment reference was not one. For another member of staff there was no application form and it seemed most unlikely that the CRB had arrived before employment commenced. During the inspection there appeared to be sufficient staff on duty. At night there is one member of staff on duty. If Mrs Corbett is the sleeping member of staff she must ensure that she is able to assist with all turns and manual handling procedures should they be necessary. Mrs Corbett trains staff using DVDs and written policies and procedures that are signed by staff. There is no clear record of when refresher training was due. There should be a clear training plan showing which staff have received which training. At this inspection records of staff appraisals and supervisions were not inspected. Care Homes for Older People Page 23 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management system of the home need to be improved. The manager has many years of experience but now needs to review the systems that need to be in place and ensure that they are maintained. Evidence: Mrs Corbett has owned and managed the home for many years and is committed to the welfare of people in the home. For several years the home has run with a very low occupancy. Past inspections show that she has addressed requirements made to meet regulations but improvements to the systems have not been maintained. Recently ill health has made it difficult to for her to maintain robust systems in the home. Currently there is no deputy manager or management structure within the home Care Homes for Older People Page 24 of 32 Evidence: although clearly some staff are experienced and have run the home during Mrs Corbetts absence. Mrs Corbett asked for assistance from staff during the inspection. One member of staff compliles the menus and orders the medications and gave an account of this. Another member of staff was called to demonstrate how the new bath lift was operated. Senior care assistants run the shifts when Mrs Corbett is not in the home. CSCI was not informed of any absence of Mrs Corbett from the home or the management arrangements that were put in place during her absence. At the time of the inspection she was still not fully recovered. The systems for recording care planning, staff recruitment and training were difficult to assess. There were paper files and information needed for inspection located upstairs in Mrs Corbetts room. Staff would not have access to this information and the inspector was shown pieces of evidence that were not organised or co-ordinated. Mrs Corbett has taken a person into the home who is outside her registration category. Routine maintenance was not fully assessed at this inspection. The fire alarm was last tested on 31/12/09. Mrs Corbett says she tests the alarm roughly weekly. The new hoist was serviced 06/02/09. The hoist is kept in the room of one person. There are infection control implications if it is to be used by other people and additional slings should be available. Staff confirmed that they have been trained to use the hoist by Mrs Corbett. We would expect the person providing training to staff in a home to have Manual Handling trainer training from a reputable training company. Discussions indicated that Mrs Corbett needs to up-date herself in some areas. For example the risks to people that can be encountered from poorly fitting bedrails. Staff in the home are not aware of the wealth of guidance and information that is available for example on the CSCI web-site. Care Homes for Older People Page 25 of 32 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 7 13(4)(c) The registered person must 15/04/2008 devise appropriate assessments for service users relating to moving & handling, risk of falls and reducing the risk of pressure sores. Previous timescale 26/10/07 not met. Timescale of 15/04/08 not met. 2 33 24 The registered person must establish and maintain an effective quality assurance system which will seek the views of service users, their representatives and any other interested stakeholders. Previous timescale 28/12/07 not met 15/04/2008 3 38 13(4) Staff must receive 15/03/2008 appropriate training in moving and handling with at least annual updates. - All staff involved in the preparation or serving of food must receive appropriate training in food hygiene. - Suitable arrangements must be made for the training of staff in Page 26 of 32 Care Homes for Older People first aid. - All staff must receive regular training in fire safety. Previous timescale of 10/10/07 not met. 4 38 13(4) & 23(4)(a) After consultation with the fire authority, the registered person must devise a satisfactory fire risk assessment which meets with current requirements. Previous timescale 01/10/06 and 22/10/07 not met 15/04/2008 Care Homes for Older People Page 27 of 32 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 3 14 The registered person must ensure that the needs of people are assessed by a suitably qualified or trained person. A comprehensive assessment ensures that the persons needs can be met and that the home has appropriate equipment and can provide staff with appropriate skills. 16/03/2009 2 7 15 Care plans must be reviewed 01/04/2009 and kept up to date by care staff. Peoples needs change and the care must be up-dated if it is to give accurate information to staff. 3 7 15 Comprehensive care plans 01/04/2009 must be in place at all times that set out in detail the action to be taken by staff to ensure all aspects of the health, personal and social Care Homes for Older People Page 28 of 32 care needs of people are met. A care plan form the basis of professional care and gives clear guidance to staff. 4 18 13 The registered person must make arrangements to ensure that staff are up to date with Safeguarding of adults training. Training musty be repeated to ensure all new staff reciev this and that established staff receive up-dates. 5 29 19 The registered person must ensure that a thorough recruitment procedure is operated ensuring the protection of the service user. Recruitment procedures that are not thorough may enable people to work at the home who are not suitable and may place people at risk. 6 31 18 There must be clear lines of 01/04/2009 accountability within the home that enable the home to function during the absence of the manager. All required records must be kept clearly to ensure information is passed on and reviewed. People in the home and staff must feel confident that systems in the home will be 20/03/2009 01/04/2009 Care Homes for Older People Page 29 of 32 maintained in the absence of the manager. 7 31 9 The manager must ensure that she is physically fit enough to manage the care home. The manager must be able to work safely and effectively in the home. When counted as a member of staff she must be able to assist with hoisting and manual handling. 01/03/2009 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 9 The medication administration procedures in the home should be audited and reviewed to ensure best practice. It is recommended that external guidance documents are accessed and used as the basis of staff training. There should be photographs of people in the MAR charts and it should e clear how many tablets are checcked into the home each month so that a clear audit trail can be seen. The menus should be prepared in advance in consultation with people who live in the home and displayed so that people know what they will be having for lunch. Any choices available should be clearly displayed. Staff responsible for preparing meals should be offered opportunities for specialist training. The registered person should continue to try and provide opportunities for entertainment and stimulation within the home. The registered person should ensure that all parts of the home are so far as is reasonably practical free from hazards. This refers specifically to the need to tidy areas of the home and to ensure that appropriate storage is provided. The registered perosn should ensure that assisted bathing facilities are provided to meet the needs of people in the 2 15 3 15 4 19 5 21 Care Homes for Older People Page 30 of 32 home. 6 30 The registered person ensures that there is a training and development programme in place that meets the needs of the home and the staff. There are records that show which training has been ccompleted and when refreshers are due. Care Homes for Older People Page 31 of 32 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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