Inspection on 07/05/09 for Aspen Lodge Care Home

This inspection was carried out on 7th May 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aspen Lodge Care Home 26/11/08

Aspen Lodge Care Home 13/09/07

Aspen Lodge Care Home 21/02/07

Aspen Lodge Care Home 11/10/06

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Aspen Lodge Care Home 222 Weston Lane Weston Southampton Hampshire SO19 9HL     The quality rating for this care home is:   one star adequate 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: Mick Gough     Date: 0 7 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 28 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 28 Information about the care home Name of care home: Address: Aspen Lodge Care Home 222 Weston Lane Weston Southampton Hampshire SO19 9HL 02380421154 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Aspen Care Ltd care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 20. The registered person may provide the following category/ies of service only: Care home only - (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 (OP) Dementia (DE) Mental disorder, excluding learning disability or dementia (MD). Date of last inspection 2 6 1 1 2 0 0 8 20 20 0 Over 65 0 0 20 Care Homes for Older People Page 4 of 28 Brief description of the care home Aspen Lodge is a registered home providing care and accommodation for up to twenty older people. The home is situated in Weston, close to a park and local shops. Public transport bus stops are located nearby. The property is an extended older detached house with car parking to the front and a patio and lawned garden area to the rear and side of the premises. Although not registered for people with a physical disability the home does have level or ramped access to the front or rear of the property. The home provides private accommodation in twenty single bedrooms and a number have en-suite facilities, some bedrooms are on the ground floor and others on the first floor accessible via a shaft lift. Communal bathrooms and WCs are located around the home. The home was purchased in March 2006 by Aspen Care Ltd, responsible individual being Mr C S Meepegama. Fees at the home are dependant on assessed needs. Members of the public may wish to obtain up-to-date information regarding fees from the care home. 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: This report details the evaluation of the quality of the service provided at Aspen Lodge Care Home and takes into account the accumulated evidence of the activity at the home since the last inspection key inspection, which was carried out in November 2008. The inspection took into account comment cards received from 4 users of the service and 3 members of staff. Included in the inspection was an unannounced site visit to the home, which took place on the 7 May 2009. Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and users of the service. It was also possible to speak with 1 visitor to the home, 3 people who use the service and 2 members of staff and also the registered provider who assisted us throughout the Care Homes for Older People Page 6 of 28 inspection. The home is registered to provide support for 20 residents and at the time of the inspection there were 6 people living at the home. What the care home does well: What has improved since the last inspection? What they could do better: There was 3 requirements made as a result of this visit and other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report, general observations were: The care planning procedures had been improved, however more information needs to be added to individual plans to ensure that there is clear information for staff on what exact support each service user needs and should also provide information on how support should be given. Although care plans are reviewed monthly, when no changes are required or needed, the review notes should provide an evaluation on how the care plan has been working and they should provide information on progress of lack of it as the case may be. Care Homes for Older People Page 8 of 28 Medication procedures at the home were generally sound, however we looked at the homes medication policy and this was found to be out of date and did not provide information to staff on what action they should take when administering any when required medication. We have acknowledge that the home has made progress and moved forward since the last visit but it should be noted that the improvements have been made while there are only a relatively small number of residents and the home must ensure that this improvement is sustained when the number of service users increase. 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 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. Although the homes new admissions process has not been fully tested, no resident would move into the home without having their needs assessed. The home does not provide intermediate care. Evidence: There have been no new admissions since the last inspection of the service. The provider told us that the assessment forms have been modified and we were informed that the home would carry out an individual needs assessment prior to a service user moving into the home. We looked at the homes needs assessment forms, which were on file and we were told that residents would be visited before they moved into the home. Care management assessments would also be obtained if appropriate. The Assessment forms, which will be used included information on; Diagnosis, personal history, risks, relationships, spiritual needs, heath and physical abilities, washing, dressing, bath and showering, medication, behaviour, day routine, night routine, likes Care Homes for Older People Page 11 of 28 Evidence: and dislikes, diet, sight, hearing and continence. The provider told us that it had not been possible to test out the assessment forms as no new service users had been admitted, however he was confident that the homes assessment procedures would ensure that only people whos needs could be met by the home would be admitted.. Intermediate care is not provided at the home. 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. Service users health, personal and social care needs are set out in a plan of care, however there is not enough detail in some care plans to provide staff with all the information they require to meet the support needs of service users. Regular reviews are undertaken but review notes do not always provide clear evaluation of how the care plan is working for the service user. Risk assessments are available in care plans and provide clear information for staff on how identified risks can be minimised. Medication procedures are generally sound however the home must produce a clear medication policy and provide information and guideance for staff when administering any when required medication. The health care needs of service users are met and service users at the home are treated with dignity and respect. Evidence: Care plans were seen for 3 residents and all of these plans contained a map of life, which provided a life history of the resident, there was a personal history profile which Care Homes for Older People Page 13 of 28 Evidence: is obtained from the service user or their relatives and this provided information on the person childhood, adolescence, adulthood and retirement. These provided good information about the residents history and staff told us that this was very useful when chatting and supporting residents, especially those who had dementia. Care plans seen contained information on, communication, religious needs, health care needs, falls, daily living, night support, memory, finances, household activities, social activities and eating and drinking. Care plans had been changed since the last visit and the plans gave staff more information on what support the service users needed. The home has employed an outside organisation to help with the care planning at the home and it was clear that improvements had been made. The home used a check list, which when completed created a profile and individual action plan for each resident. Although this was a very useful tool more information needs to be added to individuals plans. One plan under the heading what service user can do, the response was - needs assistance. Where the plan indicated what staff will do, the information was promote independence and assist. This information did not tell staff what support was needed or how support should be given. This was discussed with the provider who understands that care plans need more information for staff to provide them with information on what exact support was required and also provide information on how staff should support the person. In general care plans were simple and easy to follow and we saw that plans are reviewed each month, key workers reviewed the care plan with the service user concerned and then reported to the manager to let him know if any changes were needed to the care plan; if no changes are required the manager signs a review sheet and indicates that there are no changes, but there is no evaluation on how the care plan has been working and they should provide information on progress of lack of it as the case may be. However if changes are required then the care plan is re written and staff are informed of any changes. Daily recording takes place at the end of each shift and the records seen provided good information on how the resident had been throughout the shift and provided information on care delivery. We saw that there were risk information sheets for each resident and these provided information on the level of risk that has been identified. If risks are indentified as being significant then a full risk assessment is carried out and this provided information on the type of risk, present control measures to minimise the risk and also information on any additional control measures that may be required. Care Homes for Older People Page 14 of 28 Evidence: Service users at the home are registered with 2 different GP surgeries and they may keep their own GP if possible. Currently dental services are provided at a local surgery and there is a visiting optician who calls at the home and there is a chiropodist who calls every 4 to 6 weeks. The Community Nurse services are provided by one of the surgeries and other health care professionals are arranged through GP referrals. The home kept records of any health care visits and residents spoken to told us that there health care needs were met and that they could see a doctor whenever they needed to, we were able to speak to one visitor to the home who also told us that thier relatives heath needs were met. Residents and staff who completed questionnaires all stated that they felt that health needs were met by the home. We looked at medication procedure at the home and all staff who are authorised to administer medication receive appropriate training. The home uses a monitored dose system provided by a local pharmacist and there are clear routines in place for the receipt storage and disposal of medication. Medication administration recording was inspected and these were up to date with no gaps. The home currently keeps controlled drugs for one resident and these were stored appropriately and there was a controlled drugs book, which had 2 signatures and provided a clear audit trail. Currently no service users at the home self medicate. We looked at the homes medication policy and this was found to be out of date and did not provide information to staff on what action they should take when administering any when required medication. The provider told us that a new medication policy would be put in place next week and that a procedure would be put in place for the administration of any when required medication. Staff were observed interacting with service users appropriately and they were seen to treat service users with dignity and respect. Staff were heard to use service users preferred form of address when talking to service users and staff were seen to knock on service users doors before entering. All residents we spoke to and all those who completed surveys told us that staff treated them with dignity and respect. Care Homes for Older People Page 15 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 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 range of activities for service users, which meet their expectations and the religious and recreational interests of service users at the home are provided for. Service users are able to maintain contact with family and friends and visitors are welcome at any time. Service users are supported to exercise choice and control over their lives as much as possible and they are provided with a balanced diet in pleasant surroundings at time convenient to them. Evidence: The home does not have a dedicated activities co ordinator and care staff arrange activities for residents who wish to participate. The home has used an outside consultant to assess suitable activities for residents and the home has purchased a number of different items to stimulate residents. Activities include; arts and crafts, extra large playing card, bingo, ten pin bowling set, a knobbly ball which is soft and washable, skittles, memory games and quiz book. Music, videos and hand and nail care including hand massage. Visiting entertainers also come to the home and these include music for health, line dancing, aroma therapy and musical entertainment. The home keeps a record of all activities and records showed that in the month of April 29 different activities took place in the home. On the day of the visit we saw residents taking part in arts and crafts and also staff were seen helping residents to make use of Care Homes for Older People Page 16 of 28 Evidence: the garden. The provider told us that the home tries to arrange trips out in the summer months but to date no trips have been organised or planned. Residents who we spoke with on the day of the visit told us that they were happy with the activities provided. Staff told us that residents mainly go out with family. None of the residents at the home attend any form of day service so are reliant on the home for activities. The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway. We had the opportunity to speak with one relative who was a visitor and they told us they were happy with the home and said that they were always made welcome. Residents were observed to be free to choose where and how they spent their time and there were no restrictions imposed upon them. We observed staff supporting residents and they were able to control their own lives as much as they were able and were given choices regarding the clothes they wear each day, times of rising and going to bed, activities, meals, newspapers etc. A number of residents had bought some of their own possessions into the home and rooms had been personalised. The home operates a 4 week rolling menu that is changed seasonally and it appeared that residents were very happy with the food provided by the home. Those residents spoken to said that the food was plentiful and good. Breakfast is normally cereals and toast although a cooked breakfast can be provided on request. Lunch is the main meal of the day and residents are offered a choice at meal times and we were told that staff go round to residents in the morning and tell them what choices are on for lunch each day, they are then able to make a choice and the cook will provide what they want. Tea is normally a snack type meal or sandwiches. Hot and cold drinks are available throughout the day and night and we were told that the kitchen is open 24 hours a day and staff can make residents drinks or snacks whenever they want. Residents are encouraged to eat their meals in one of the two the dining rooms but may eat elsewhere if they prefer. Care Homes for Older People Page 17 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a simple, clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures protect service users from any form of abuse. Evidence: The home has a clear complaints procedure, which contains all of the required information and is available in the entrance to the home and there is also a post box where complaints could be posted anonymously. The home has a complaints log where any complaints made to the home are recorded, together with the actions taken to investigate and also the homes response. We looked at the homes complaints log and this showed that there had been 2 verbal complaints made to the home since the last visit and these had both been responded to appropriately and resolved to the satisfaction of those concerned. Residents spoken with said they would speak to a member of staff if they had any concerns. A visiting relative told us that they had not had any reason to make a complaint but were confident that any issues would be resolved. Staff members spoken to were aware of the complaints procedure. All staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. The homes provider and also staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. Care Homes for Older People Page 18 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. Residents live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. Residents are provided with the specialist equipment they require and the home was clean, pleasant and hygienic and free from offensive odours. Evidence: The home is laid out over two floors and there are a total of 11 bedrooms on the ground floor 6 of which are a new addition to the home. The new building has a new well equipped bathroom with a specially adapted bath. Upstairs there are 9 existing rooms and 1 new ensuite bedroom. There are two sets of stairs that lead to the upper floor and these both have suitable handrails in place and there is also a small passenger lift. All areas of the home were well lit and had suitable furniture and fittings which were of good quality. There is an enclosed rear garden and also a paved area to the sides of the home. The garden was free from obstructions and was a safe area for residents who have dementia to wander if they wished. There is a laundry which is situated downstairs which has industrial washing machines and tumble drier. Although there were no hand washing facilities in the laundry room, there were suitable signs directing staff to the nearest hand washing facilities and staff were issued with hand washing gel and protective clothing to help prevent the spread of infection Care Homes for Older People Page 19 of 28 Evidence: Care Homes for Older People Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has sufficient staff on duty to ensure service users receive the support they require. Staff were found to be well motivated and competent to do their jobs. The home has a robust recruitment procedure and the home provides training for staff to enable them to carry out their roles effectively Evidence: We looked at staffing levels and this showed that there are a minimum of 2 care staff on duty throughout the day. At night there are 2 staff on duty, one of whom may sleep between 2300 and 0600. There is also the registered provider and a manager who work at the home and who are in addition to the care staff. There is also a cook and a domestic staff member who work at the home. With the current number of residents staffing levels were sufficient, however the provider must keep staffing levels under review as and when resident numbers increase. The home employs a total of 12 care staff and has 11 members of staff who have at least NVQ2, with 3 members of staff currently undertaking NVQ level 3 and one staff member doing NVQ level4. The provider told us that the home would support staff to obtain National Vocational Qualifications. Recruitment records were seen for two members of staff and both files seen contained all of the required information including application form, 2 x references, photo, Care Homes for Older People Page 21 of 28 Evidence: passport, birth certificate, health declaration, Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and contract of employment. Staff training records were looked at and the provider showed us a training matrix, which showed what training is provided and when any refresher training is required. The provider informed us that training is provided by an outside training organisation. Currently staff training is provided in; first aid, food hygiene, moving and handling, fire, infection control, adult protection, medication, H & S, dementia care, report writing and fire. A suitable induction programme is in place based on Skills for Care and staff are expected to complete induction within the first 6 weeks of employment. The records of the most recent employee showed that the induction had been completed and each section had been signed of by the provider. Staff spoken to confirmed that they received a thorough induction and that they are provided with appropriate training in order to carry out their care tasks. Care Homes for Older People Page 22 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. The home does not currently have a registered manager and it is essential for the efficient running of the home that a manager with the necessary skills and experience is employed to ensure that the home is appropriately managed and run in the best interests of the people who live there. Peoples financial interests are safeguarded and the health, safety and welfare of service users and staff are promoted and protected. Evidence: At present the home does not have a registered manager, however the registered provider is currently providing day to day management of the home and his application to be registered with the Care Quality Commission is being processed. We were informed that a suitable manager has been identified and is due to commence work shortly and in due course she will also apply to be the registered manager. In the past the lack of a suitable manager has presented problems for the home and the provider has spent some considerable time in bringing in systems to move the home Care Homes for Older People Page 23 of 28 Evidence: forward, however this progress has been made while there are only a relatively small number of residents and the home must ensure that this progress is sustained when the number of service users increase and ensure that best practice is fully imbedded. The home has an effective quality assurance system in place and questionnaires are sent out to residents, relatives, staff, heath care professionals and other interested parties. We were able to see the responses to these surveys and they were all positive. The provider told us that there are regular service user and staff meetings and minutes of these meeting are kept. Staff receive regular supervision and the provider who is currently at the home on a daily basis carries out his responsibilities as laid down in regulation 26 of the care home regulations. The home does not manage any residents money and they currently do not keep any money for residents. In the past residents were billed at set amount each month for toiletries that were purchased on their behalf by the home and as a result of the previous inspection this practice has now ceased. We were told that if any resident needed anything the home would purchase it for them and then invoice relatives as required and would provided clear receipts. The home does not currently hold any personal spending money on behalf of residents, however we were informed if any service user wanted to have any personal spending money, the home would be more than happy to provide a secure storage for this money and it would be kept separately and receipts would be kept to provide a clear audit trail. There is an in date fire risk assessment for the building and regular health and safety monitoring takes place. The fire logbook was inspected and all appropriate testing and checks have been recorded. Appropriate certificates were in date for gas, fire alarms systems and equipment, fixed electrical wiring, private electrical equipment, stair lift and hoists. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 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 The registered person must 30/06/2009 ensure that when care plans are reviewed and there are changes are required or needed, the review notes should provide an evaluation on how the care plan has been working and they should provide information on progress of lack of it as the case may be. This will ensure that the home can identify and provide evidence that service users care needs are reviewed and continued to be met 2 7 15 The registered person must 30/06/2009 ensure that more information is added to individual plans to ensure that there is clear information for staff on what exact support each service user needs and should also Care Homes for Older People Page 26 of 28 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 provide information on how support should be given. This will ensure that service user get the support they need and in the way they prefer. 3 9 13 The registered person must 01/06/2009 ensure that the home has an up to date medication policy and this shouldprovide staff with clear information on what action they should take when administering medication, including any when required medication this will ensure that staff have clear guideance and also all the information they need to administer medication safely and in line with the homes policy and procedure 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 Care Homes for Older People Page 27 of 28 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 28 of 28 - 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. 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