Inspecting for better lives Key inspection report
Care homes for older people
Name: Address: Ashlea Lodge Residential Home Hylton Road Millfield Sunderland SR4 7AB 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: Sam Doku
Date: 1 3 0 5 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 27 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home
Name of care home: Address: Ashlea Lodge Residential Home Hylton Road Millfield Sunderland SR4 7AB 01915109405 01915109406 ashlea.lodge@btconnect.com(Notavailable130208) Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Winnie Care Limited care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 40 The registered person may provide the following category of service only: Care Home only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 40 Dementia Code DE, maximum number of places 15 Date of last inspection Brief description of the care home Ashlea Lodge is a two-storey building, which has been specifically designed to provide personal care for older people who may have a variety of needs, including people who have dementia. The layout of the building allows for the home to be divided into two Care Homes for Older People
Page 4 of 27 Over 65 0 40 15 0 Brief description of the care home separate units and each contains a lounge, dining room, kitchen, bathroom, toilets and en suite bedrooms. A garden, which is accessible to people who use a wheelchair is at the rear of the building and there is a car park at the front. The home is located close to St Marks Church and a GPs surgery, both of which are easily accessed. The Metro line has a station within walking distance from the home. In addition, there is a regular bus service, which stops opposite the home. Ashlea Lodge is situated relatively close to a shopping area, which has a post office, grocers and public houses. The home is registered to admit 40 people who may have physical disabilities or who may have dementia type illness. The home is owned by Winnie Care Limited. The scale of charges for the home is 407 to 422 pounds per week. 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: 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: The quality rating of this service is 0 Star. This means the people who use the service experience poor quality outcomes. The inspection was unannounced and commenced on 11 May 2009 and completed on 12 May 2009. Before the visit the inspector looked at: Information we have received since the key last inspection visit on 15 May 2007. How the home dealt with any complaints and concerns since the last inspection. Any changes to how the home is run. The providers view of how well they care for people, as highlighted in the details provided in the Annual Quality Assurance Assessment (AQAA). The views of the people who use the service. The comments made by the
Care Homes for Older People Page 6 of 27 residents in the three residents surveys that we received. The comments made by the staff in the three staff surveys that we received. During the visit the inspector did the following. Talked to the people who use the service, the manager and the care staff. Looked at information about the people who use the service and how well their needs are met. Looked at other records which must be kept. Checked that staff have the knowledge, skills and training to meet the needs of the people they care for. Looked around the home to make sure it is safe and secure. Checked what improvements have been made since the last inspection. The inspector told the manager what he found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use the services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: The quality of staff induction into the workplace is poor. This poor standard was commented on in the last key inspection report May 2007. The information provided by the manager in the AQAA states that staff induction is carried out over six weeks. However, the records show that staff induction is carried out in a one day. There is no further evidence to support the six week induction period that was stated by the manager. The records show that none of the staff, apart from the recently appointed senior principal, have up to date training in first aid, moving and handling, food hygiene, fire safety, safeguarding adults (POVA) and health and safety. Staff who were spoken with confirmed that they have not received their refresher training for the past three years or so. To address this, an Immediate Requirement Notice was served on the provider, and as a result the Commission has received written confirmation that the training will be provided to all staff by end of July 2009. The staff who work on the dementia care unit were interviewed and none had received recent training in dementia awareness. The environment in the dementia care unit should be one that allows the residents of orientated easily. For example, different door colours and signs on doors may help residents with orientation. There were poor practices observed regarding the serving of mid-morning drinks for the residents. The staff member did not offer residents choice of coffee, tea or juice. Everyone was given tea. The task was carried out without any conversation between the person serving the tea and the residents. Biscuits were dished out to the residents without being ask if they wanted one or what type of biscuit they would like. Care Homes for Older People
Page 8 of 27 The care received by one resident who depended entirely on the staff for all her needs, including dietary needs was very poor. The residents dinner was put on her table and a folk put in her hand without being told what was on her plate. The pork chop that was on her plate had about half an inch of fat round it, and the carer failed to trim this off but instead cut them up with the rest of the lean part of the meat and gave them to the resident to eat. The resident was not offered any assistance with her meals and in the end the inspector had to intervene, otherwise the residents would have gone without eating her meal as she was not able to manage the meal on her own. The monthly review of the care plans was ineffective and did not truly reflect the care that people need. For example, one residents file showed that she had been loosing weight over a twelve month period from 12 stones 12 lbs to 9 stones 9 lbs, but the monthly review of the care plans made no mention of this steady loose of weight, so that an appropriate care plans could be put in place to address the weight loss. Furthermore, a nutritional risk assessment was carried out and the residents was scored as being at risk, yet the care plans did not set out what actions need to be taken to reduce this risk. The monthly evaluation of the care plans did not take into account the risk that had been identified. The home needs to improve on the way complaints are received and recorded. There is no central complaints record and therefore it was difficult to assess the number of complaints that the home had received since the last key inspection. However, a recent written complaint dated 6 May 2009 to the Area Manager and the home manager had elements in the complaint which meant that a safeguarding alert should have been made to the social service department but the manager failed to raise the alert until the Commission became aware of the incident and the Commission raised the alert with Sunderland Council. 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.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 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 10 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. There is good information about the home which allow prospective residents to make informed choices about whether or not to come and live at Ashlea Lodge. Furthermore, detailed pre-admission assessments allows peoples needs to be planned for. Evidence: There is good information available in the home about the home and the company, which owns the home. Information about the home is freely available in the reception area and also on the notice board in the foyer. The manager confirmed that welcome packs are available for all prospective residents. Each pack includes a copy of the service user guide, information about the company and a sample copy of the contract whcih sets out the terms and conditions of residence. However, the information about the contact details of the Commission in the in the service user guide should be amended to reflect the correct details of the
Care Homes for Older People Page 11 of 27 Evidence: local office of the Commission. Four residents assessment files were examined. These contain details of the assessments carried out by the home before admission was arranged. The files also include assessments that have been carried out by the social worker when arrangements were being made to admit the residents to the home. These assessments were very detialed and provided good information that was used to formulate the initail care plans for the residents at the time of their admission to the home. The manager and senior staff confirmed that it is the policy of the home to invite prospective resident to the home before admission is finally arranged. Two relatives and a residents confirmed that they were offered the opportunity to visit the home and to meet with the staff and existing residents before they made the final decision about Ashlea Lodge. Staff also described the admission process for two of the most recently admitted residents and this includes the arrangements for a visit to the home by the residents concerned. Care Homes for Older People Page 12 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are poor personal care practices that seriously compromise the health and dignity of the residents. Evidence: The records show that the residents have access to GP services and other healthcare professionals. The record of professional visits show that residents have attended outpatient appointments, visits to dentist, visits to opticians and treatment from chiropodist. There are regular visits from district nurses to carry out annual health check on the residents. At the time of the inspection visit, one such annual health check was being carried out by the district nurse. The medication administration system was examined and there were no discrepancies noticed. The checks that were carried out were found to be correct. The manager had set out personal care plans for each resident. The files of four people show evidence of the care plans but the monthly review of the care plans are not carried out to reassess the current care needs of the residents. All of the monthly
Care Homes for Older People Page 13 of 27 Evidence: reviews had the same wording to say that there has been no change to the needs of the person concerned. However, a detailed look at one residents care and reviews showed that the staff who undertook the reviews of the care plans did not take into account the changing needs of the resident. Consequently, the residents current care needs are not being met. Another care plan that was reviewed also showed a similar picture. These reviews were ineffective in reflecting on the care that the person is receiving and identifying changes. The care plans should be altered to reflect their current situation. This is not happening in Ashlea Lodge. There were poor practices in the way residents are supervised and assisted with their meal and drinks. In one case a residents who is blind received poor level of attention from the staff during lunch. The resident was not told what was on her plate and the staff member did not trim off the large amount of fat on her meat but instead cut them up with the rest of the food for the resident to eat. There was no attempt to help the resident with her food and in the end she gave up as she could not see the food on her plate in order to direct her cutlery to it. As a staff member attempted to take her plate of unfinished food away, the inspector had to intervene and ask for the staff member to assist the resident with her food as she has not eaten much. The inspector check the residents care plan and other details such as weight chart. It was evident that in the last twelve months, the resident had lost 1st. 3 lbs. and this gradual loose of weight was never acknowledged in any of the monthly reviews that have been carried out by the senior staff. It was also noticed during lunch that on two occasions, staff were assisting residents with their lunch, were doing so by standing over the residents. One of the staff involved in this practice was a senior care assistant. The service of the mid-morning drinks for the residents was undertaken by a volunteer worker who has been assisting with non-intimate personal care activities. There was no choice of tea, coffee or juice. Only tea was available and the inspector observed that the volunteer did not engage in verbal communication with any of the residents. Teas were handed to residents or placed on the coffee tables besides them without saucers. The volunteer went round with biscuits in his hand and either put them in the residents hands, on the coffee tables or on the arm of the chairs. Each resident was handed two biscuits and there was no opportunity for anyone to say what type of biscuit they wanted, or if they wanted any biscuit at all. Furthermore, the majority of the residents in the lounge were asleep in their chairs at the time, and these residents were not woken up to be asked if they wanted a drink. Those residents went without a mid-morning drink. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are supported to maintain contacts with their relatives thus promoting their sense of belonging. The residents receive nutritious a diet but staff need to be aware of the individual dietary needs in order to fully promote the health and wellbeing of the most dependent residents in the home. Evidence: Two service users stated that they have the opportunity to go out when they want and the staff support them with this. There are regular visitors to the home and at the time of the inspection there were a number of people visiting their relatives. The residents have good contacts with their relatives and this is confirmed in the visitors sign-in book. On the day of the inspection a birthday party was organised for one of the residents. Relatives, families and friends were invited to the party. One relative said that she has observed that the staff always acknowledge residents birthdays with a cakes or something to celebrate their birthday with. Care Homes for Older People Page 15 of 27 Evidence: The home employs an activities coordinator who works five days of the week. She keeps record of all the activities organised, and also records which residents participate in the activities that are organised for them. Some residents stated that they could do with having more trips or drives in the minibus in the summer months. This was also commented on by two staff members who felt that this would be enjoyed by a number of residents. The staff are making arrangements for one resident who likes gardening to continue to enjoy his hobby while at Ashlea Lodge. Staff are in the process of creating a space in the garden for him to start growing his plants. Also plant pots have been acquired to help him with his hobby. The staff confirmed that a few of the residents get visits from their local church vicar. The residents and relatives commented positively of the food provided in the home. Residents said that there is always plenty to eat and that they are offered choice of meals. The past menus show that the residents are provided with nutritious meals. The meals were served in a pleasant settings and the residents were generally given plenty of time to enjoy the meals. However, the practice of standing over residents when assisting them with their meals is a poor one and should cease. Also attention should be given to those residents who require assistance with their meals to make sure that they receive an adequate diet. Furthermore, the care practices observed by the inspector which relates to to the serving of mid-morning drinks as described in outcome area 1 of this report did not offer the residents the opportunity to exercise choice and the practice compromised their dignity. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is lack of training in safeguarding adults among the staff team. Furthermore, there is also a lack of awareness among staff about deprivation of liberty matters. These, potentially compromise the legal rights and welfare of the residents. Evidence: There is a complaints procedure in the home and this is also displayed in the reception area for residents and visitors to see. A summary of the complaints procedure is included in the service user guide. Of the three surveys that were received from the residents, two of them said they would know how to make a formal complaint and the other one did not know how to go about making a formal complaint. There is no complaints book in which to record all complaints that have been received and how they were dealt with. The manager indicated that complaints are recorded on individual files and one such complaint was shown to the inspector. Both the manager and her line manager agreed that there needs to be a better way of recording all complaints that have been received and a record of how the complaint were investigated and the outcome of the investigation. A letter of complaint and concerns, dated 6 May 2009 was received by the manager and the inspector was shown a copy. There were aspects of the concerns which was clearly a safeguarding matter and at the time of the inspection, no action had been taken by the manager to alert the Local authority safeguarding team of the incident.
Care Homes for Older People Page 17 of 27 Evidence: POVA or safeguarding vulnerable adults training was lacking among the staff team. The training records show that none of the staff have received up to date refresher training in safeguarding vulnerable adult (POVA). The training in POVA is one of the training needs that the area manager had consistently identified as needing to be provided. Her reports, dating back to January 2008 makes mention of the need for this training to be provided to the staff. In discussions with staff it was evident that none of them had heard of the deprivation of liberty and the impact of this new legislation on the residents on the dementia unit. There is good supply of Department of Health information leaflets on the Deprivation of Liberty Safeguards in the home. These are freely available in the reception area to the visitors and and staff but staff were not aware of this. 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. The home provides a good standard of accommodation. Furthermore, the home is clean, safe and comfortable, and promotes the safety, independence and self-esteem of residents. Evidence: The home was clean and maintained to a good standard. The corridors are wide and have grab rails to enable residents to move about freely. The wide corridors allow free flow of traffic without restricting movement. The bedrooms that were examined were clean and maintained to a good standard. The residents have been encouraged to furnish their rooms with personal items, making it familiar and homely. All bedrooms have en-suite toilet facility. There are a number of lounges throughout the home for residents to choose from, including a smoking lounge. These are appropriately furnished and maintained to a good standard. The kitchen was clean and well ordered. All cooking appliances and utensils were clean and in good order. There is a cleaning rota in the kitchen to make sure that all areas of the kitchen are given thorough cleaning on a rotational basis. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient staff on duty to meet the needs of the residents. However, the lack of up to date training for the staff seriously compromises the health and welfare of the residents. Evidence: Examination of past rotas and a statement in the AQAA by the manager regarding staffing levels show that the home provides adequate staffing, consisting of three care staff on the dementia unit and two care staff on the ground floor residential unit. The manager is extra to the care team. There is also sufficient numbers of ancillary staff to carry out catering and domestic duties. The manager confirmed that all staff, except two, have acquired NVQ Level II or above. The remaining two staff are currently undertaking the training. However, there is a lack of refresher training in fire safety, POVA, moving and handling, food hygiene, health and safety and first aid. These are serious failings by the manager and the provider and as a result an Immediate Requirement Notice was served on the provider to take immediate action to address these matters. Examination of staff records show that the quality of the induction program for new staff is poor. The records show that the entire induction programmer was carried out in a few hours in one day. This is contrary to the managers statement in the AQAA
Care Homes for Older People Page 20 of 27 Evidence: that induction for staff is carried out over six weeks in line with the Skills for Care Induction standard. The files of the most recently appointed staff were examine and these provide evidence of the manager following proper recruitment procedures. All staff have had enhanced CRBs done and files that were examined showed that applications forms have been completed, and appropriate references have been obtained. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in a way that does not fully meet the needs of the rsidents. This compromises their health and welfare. Evidence: The manager has been managing the home for nearly two years (August 2007) and she is in the process of applying to the Commission to be registered. The manager has a long experience of managing a residential care home. The manager has had suitable training, including the registered managers award, NVQ Level 3 in care and she is currently undertaking NVQ Level 4 in care. Staff and relatives commented that the manager is always available to talk to when they want. Both staff and relatives feel that the manager is approachable and supportive of them. Although the manager has a recent program of staff supervision, records show that there is a lack of consistent supervision for staff. Two staff confirmed that in the past two years they have only had two supervision sessions. The staff records that were examined also showed that staff supervision is not happening regularly. In two of the
Care Homes for Older People Page 22 of 27 Evidence: files that were examined there was only one supervision note for each of the staff members. The line manager for the home carries out regular visits to the home and the reports were examined. The inspector examine the reports dating back to January 2008 and he found that each time the line managers report states that all mandatory training required. Copies of these reports are made available to the manager and the provider but no action has been taken by the manager or the provider to address the training needs of the staff. Examination of the personal allowance records and receipts of transaction show that there is a good system in place and that the residents monies are safe and properly accounted for. Receipts are available for all transactions that have been made on behalf of residents. The company Health and Safety policies remain in place. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH), protection of vulnerable adults, infection control, dealing with violence, disposal of clinical waste and record keeping. Servicing records confirm that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. Regular servicing of fire equipment, passenger lift, bath lifts and hoists, gas and electrical appliances have been carried out by the contracted companies. All the servicing records that were examined were up to date. These included servicing of passenger lift, hoists, water treatment, electrical installation and gas servicing. Records examined indicate that fire precautions relating to weekly fire alarm testing and record of inspection takes place. However, there is no record of staff receiving fire instructions. The manager stated that this is something that she is working on to make sure that each staff on day duty receive at least two fire instructions per year and the four for the night staff. 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 30 18(c)(i) Staff induction programme must be fully implemented and all new staff should receive induction training. This must be documented and retained on the individuals file. 30/06/2007 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 7 14 The provider must ensure 14/07/2009 that the care plans reflect the health and personal care need of the residents. The current care plans do not reflect the current care needs of the residents. 2 8 14 The dietary needs of the residents must fully assessed and care plans relating to these must be followed by all staff. The staff have failed to follow the care plans relating to the assessed dietary needs of a resident. 15/06/2009 3 10 12 The residents must be treated in way gives due regards to their dignity and choice. The practice relating to how drinks were served to residents was poor and gave 15/06/2009 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 no regards to the residents right to dignity and choice. 4 17 13 All staff must receive 30/06/2009 training to prevent residents being placed at risk of harm or abuse. Staff have not received up to date training in POVA and deprivation of Liberty. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 2 1 13 The service user guide should be amended to reflect the current contact details of the Commissions local office. In serving food and drinks to residents the staff should ensure that the residents are offered choice tea, coffee or juice. Furthermore, residents should be asked what kind of biscuits they prefer and not to be denied the opportunity to choose for themselves. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or 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) 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 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
