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Inspection on 15/08/09 for Aylesham Court Nursing & Residential Home

Also see our care home review for Aylesham Court Nursing & Residential Home for more information

This inspection was carried out on 15th August 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a clean and pleasant environment for the residents to live in with bedrooms that they can personalise as they wish to. The residents have a staff who are well trained and recruited to give them safe care. They have enough activities during the week for them to enjoy. The home provides a varied and nutritious diet with a range of choices for the residents to enjoy.

What has improved since the last inspection?

The staff make sure that they sign for all the medicines that they have given to the residents and no longer use printed labels on the medicine sheets. That where hand written entries are made onto the medicine sheets they are checked and signed by two people.

What the care home could do better:

There should be enough staff and equipment in place to reduce the number of pressure sores in the home. People living in the home should have their needs met at the proper time. That an improved method of administering medicines is put in place to make it safer, easier and quicker to give the medicines. When a resident is got up late, alternative arrangements for them to have their breakfast should be made to make sure that they don`t have long gaps between meals. The complaints policy should be updated and produced in a large print to make sure that all the residents can read it. Consideration could be given to upgrading the call bell system to record the time it takes to answer a bell and to make sure that all the calls are registered on the sysytem. The hazard of storing hoists in a bathroom could be reduced if alternative storage is found. The staffing level must be reviewed to make sure that the residents needs can be met in a timely manner and that the quality of the care is reviewed and improved. The application form could have more space on it to make sure that a full employment history is obtained. Arrangements should be made for the staff to be given the opportunity to have formal supervision with their line manager at the required intervals to have the opportunity of discussing work and training issues. Consideration could be made to let the care manager to have access to the office when she is in charge of the home.

Key inspection report Care homes for older people Name: Address: Aylesham Court Nursing & Residential Home 195 Hinckley Road Leicester Forest East LE3 3PH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Anthea Richards     Date: 1 5 0 8 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Aylesham Court Nursing & Residential Home 195 Hinckley Road Leicester Forest East LE3 3PH 01162395599 01162395982 dudda@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd care home 60 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) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: No person under 55 years falling within category PD may be admitted to the home. No person who falls within category PD may be admitted to the home when 14 persons of category PD are already accommodated within the home. To be able to continue to accommodate the named person in category PD who is under 55 years of age, subject of variation application V10139, who is currently residing in the home as agreed with the previous registration authority. Date of last inspection Brief description of the care home Aylesham Court is a 60-bedded a purpose built care home providing personal and nursing care for older persons. It is located on a main road on the outskirts of Enderby and Kirby Muxloe in Leicestershire and is easily accessed by public transport from the City of Leicester and the County. The home provides residential and nursing care for sixty service users whose care needs fall within the categories of Older Persons and or Physical Disability over 65 Care Homes for Older People Page 4 of 28 Over 65 60 60 0 14 Brief description of the care home years of age or Terminally Ill. The home is arranged over two floors with good access for residents with a physical disability. The first floor is accessed by, either the stairs or a passenger lift. There are bedrooms, lounges and a dining room on both floors. The two spacious lounge areas on the ground floor have an outlook onto the well-landscaped gardens, which are mainly laid to lawn with surrounding shrubbery and have a patio area where the residents can walk and sit. The home has two large dining rooms, which are well decorated, and have a private area where the residents can have a meal with relatives or friends if they wish. The home has fifty-four single bedrooms and two double bedrooms; all have en-suite facilities of a W.C. and wash-hand basin. Many of the ground floor bedrooms overlook the patio area. The latest copy of the Inspection report from the Commission for Social Care Inspection is available at the reception desk. The current fee level ranges are agreed dependent on the residents needs. There are additional costs for individual expenses such as personal toiletries, optician, hairdressing and some recreational activities. 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 was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we [throughout the report the use of we indicates the Care Quality Commission], spent six hours reviewing information received by the Care Quality Commission [CQC] since the last Annual Service Review (ASR)on the 11th February 2009. Following the results of the ASR we decided to bring forward the date of the next key inspection. The visit took place on the 15th August 2009 and lasted eight hours. During the visit we checked all the key standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means that we looked at the care provided to four of the residents. Care Homes for Older People Page 6 of 28 To achieve this we spoke with the staff supporting their care and looked at the records relating to their health and welfare. We spoke with the residents and visiting families. With their permission the residents bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them was seen. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit we spoke with the clinical team leader, the residents, the staff and families visiting the home. We checked the Annual Quality Assurance Assessment (AQAA) that the home had sent to us when we asked for it. We looked at the surveys that we had sent out and had returned to us by the staff, the residents and relatives of the residents. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 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 9 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents needs are always assessed before moving into the home and they have good information to help them make the right choice about the home. Evidence: The residents and the families spoken with, told us that they had received a Statement of purpose and a service user guide. The residents spoken with confirmed that they had had a visit from someone from the home and had the information that they needed to make a decision. The Statement of Purpose and Service Users Guide gives people the information that they need to know about to help them make a decision about the home. All of the residents case tracked had thorough, completed pre admission assessments in their care plans. These had been completed by the manager or a senior member of staff. Care Homes for Older People Page 10 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. The residents receive good care from a staff who where they can, mostly meet all the individual care needs, with privacy, dignity and respect. Evidence: The case tracked records were found to contain good individual evidence of the care being given to the residents and reflected the care that they needed. There was evidence that the residents and/or their relatives had been involved in planning the care, although they had not all signed the care plans. We spoke with many residents and families who all told us that they usually received the care that they needed but that the staff sometimes struggled to give it at the time that they needed it. The care staff were seen to be treating the residents with dignity, respect and consideration when talking to them and giving them care. They were seen to be knocking on the residents bedroom doors before they went into them. There were concerns raised on the visit and in the surveys received that the home was short of staff. On the day of the visit the numbers of staff on duty was good for the Care Homes for Older People Page 11 of 28 Evidence: number of residents, however the numbers did not appear to be adequate for the needs of the residents. We saw people not being got up until 11:00 and call bells sometimes not being answered for 30 mins. The home has a high number of people with pressure sores, which could show that adequate attention is not being given. Comments received included: Not up to the expectations that I had of a BUPA home Staff are excellent but unable to cope with the high needs of the residents and the call bells are not always answered promptly I come every day to make sure that she gets the care Care has gone down, staff are excellent but insufficient. There are records of the involvement of G.P.s, chiropodist, optician, where needed in the care plans, showing that thorough health care is being provided for the residents. There was evidence that the care plans are regularly reviewed and the residents and the families spoken with confirmed that they had been involved and were aware of the care to be given and that they agreed with it. The daily record of care was up to date making sure that the residents receive the right care and the staff know what has happened to them during the day or night. There are records of the residents nutritional needs and weight, which makes sure that they are eating well and are not losing or gaining large amounts of weight. There were records of the dietician and speech and language therapists being involved when the resident had swallowing difficulties. There were risk assessments in place to cover all the identified risks for the residents and how the staff should manage those risks. This makes sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. Medication records for the case tracked residents were in order. Medicines are given by the trained nurses who receive regular updating and supervised medicine rounds. Care Homes for Older People Page 12 of 28 Evidence: We saw that the medicines were administered individually and the residents were seen to be taking them. Medicines are still supplied in packets and a monitored dosage system could be considered. This is a system where each tablet is in a separate pop out card, which is a safe method of administration, helping to make sure that the resident is always given the right medicines. This could make it quicker for the nurses to complete the medicine round. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. All of the residents have a self medicating drug assessment to identify people who are able to look after their own medicines and those who are not. There is a lockable cupboard in the bedrooms for medicines to be stored. The care manager carries out a regular written audit of the medicines and the medicine sheets to make sure that they are correct. The controlled [dangerous] drugs in the home were checked and found to be correct and the staff were aware of the requirements for the storage and documentation of these drugs. Care Homes for Older People Page 13 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 enough activities for the residents to enjoy and take part in and meets their spiritual and nutritional needs. Evidence: The home employs an activities organiser who, provides activities in the home. She regularly documents the activities that the residents have taken part in into the careplans. The care plans describe the residents past life and their interests so that the home can help them continue those interests if they wish to. Activities include craft work, newspapers, nails, hairdressing, card games, board games, discussions and outside entertainment such as singers. The annual quality assurance assessment tells us that they are encouraging activities at the week-end, but there were none taking place on the Saturday that we visited. Visitors are welcomed into the home at any time and are invited to attend social functions and the regular resident/family meetings. The menus seen gave choices of meals and the cook and the staff had individual contact sheets telling them about the residents needs and likes and dislikes. The cook Care Homes for Older People Page 14 of 28 Evidence: regularly talks with the residents about their choices, which we saw on our visit. We saw the menus put onto the tables with individual ones for those with special diets such as vegan. We spent time with the residents during their lunch, which was well presented and they told us that they were enjoying. The food is good The staff were seen to be sitting with the residents to help them with their meals. It was seen that a resident was not given breakfast until 11:00, lunch was then served at 12:45 only giving a short gap between and a very long gap since tea-time. Religious needs are catered for by the residents having a regular service in the home or by visits from a local minister. The hairdresser visits regularly, which the residents told us that they appreciated. Care Homes for Older People Page 15 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 are good systems in place to support and protect residents and staff are aware of the processes. Evidence: There is a complaints policy in place which gives the details of how to complain and who to complain to in the home if they needed to. One copy had not been updated and was in a small print that was difficult to read. The policy could be made available in a large print and other languages if it was needed, which makes that as many people as possible could read it. The complaints form was clear and easily followed. The home told us that they had received 18 complaints in the past year, 10 of which had been upheld. All had been resolved and satisfied the person who had complained. The Care Quality Commission received one of these complaints that had been resolved. The residents, the families spoken with and the surveys told us that they were aware of how to make a complaint and were happy that it would be dealt with properly. The staff were aware of how to deal with a complaint and were happy that they would be dealt with correctly. Care Homes for Older People Page 16 of 28 Evidence: The staff spoken with were able to describe how they would deal with an allegation of abuse, knew the areas where abuse could happen and could describe the process that they would go through if they suspected any abuse. They confirmed that they had had training in safeguarding adults and whistle blowing and the manager and the records seen supported this. They were confident that the management would handle any issues correctly. We looked at the accident book, which had been completed correctly. The manager completes an audit of all the accidents to try to avoid some of them happening. These practices make sure that the residents are safe from any abuse and that any concerns are handled properly. Care Homes for Older People Page 17 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents and staff are well protected by the policies and procedures in the home that provides a safe and very pleasant environment to live in. Evidence: Aylesham Court is a large, purpose built care home on Hinckley Road in Leicester Forest East. It has two floors, with the first floor able to be reached by the stairs or the passenger lift. The home has a large lounge and dining room on each floor. These were all bright, well decorated and suitably furnished. There are bedrooms on both floors and those of the case tracked residents that were seen, with their permission, were clean, bright, well decorated and were well personalised. The residents spoken with told us that they were pleased with their rooms and that they were kept clean and decorated. All of the bedrooms have ensuite facilities. Some of them look out onto the garden which has a patio area and seating. I like my room. There was evidence of equipment in the home to help the residents, such as Care Homes for Older People Page 18 of 28 Evidence: wheelchairs, special mattresses and hoists. There was a good provision of bathrooms in the home that were mainly found to be clean and free of any items that could cause a hazard for the residents. One of the bathrooms was being used as a store for hoists, which could cause a problem for both residents and staff to reach the bath. We were told in the surveys received and by the residents and the families on the day of the visit that there were long delays in answering call bells. We saw this on the day of the visit when a call bell was not answered for half an hour. The call bell system can only register three calls at a time so that there is often a back-log of calls. The kitchen has had a recent Environmental Health Officer inspection and was given a good rating. There are pleasant gardens with patio areas, with tables and chairs, that are accessible for the residents to walk and sit. Fire alarm testing, drills and instruction were found to be up to date, this was confirmed by the records seen, the staff spoken with and the manager. Hot water temperature records were found to be up to date and within recommended levels. The residents and the families spoken with were happy with the cleanliness of the home, and told us that the staff worked hard to keep it clean. There are staff employed to complete the cleaning in the home and they have had training in health and safety. The cleaning products are stored in a locked cupboard, which we saw. This was confirmed by the staff spoken with, the records seen and by the manager. Care Homes for Older People Page 19 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are protected by the recruitment and training practices in the home but care is compromised by the staff numbers or use of the staff. Evidence: We looked at three staff files and they all contained the documentation that is required. These included two written references, a Protection of Vulnerable Adults check and a Criminal Records Bureau check. The application form did not contain space for a full employment history to be written. The staff spoken with confirmed that they had received recent training in moving and handling, challenging behaviour, safeguarding of vulnerable adults and first aid. This was confirmed by the records seen and the manager. The manager holds a training matrix showing when courses would be held and which staff needed to attend. The residents, the families spoken with all felt that the staff were well trained to do their job but that their were not enough staff to look after them. All of the surveys sent back to us told us that there were not enough staff to give the care at the time that it was needed. We were told that when the care was given that it was excellent. The staff are excellent but insufficient Care Homes for Older People Page 20 of 28 Evidence: During the time that this report was being written we received a complaint about the time that care was being given. this is being investigated by the Social Services. The home has achieved over 50 of the staff being awarded a National Vocational Award at level 2 or above. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. Care Homes for Older People Page 21 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents safety is protected by the practices in the home but their views are not always taken into account in a home that is not always run in their best interests. Evidence: The home manager has been in post since April 2009 and was on holiday on the day of the visit. The clinical team leadre was on call and came into the home to accompany us on our visit. She did not have access to the offices in the home and the administrator let her have them. There are regular meetings held for the residents and for their families, to discuss activities and menus in addition as to how the home is meeting their needs. These were confirmed by the residents and their families and by the minutes that we saw. There is an annual quality questionnaire sent to the residents and their families and the questionnaires that we saw on the visit confirmed this. The families and the residents told us that they had completed the questionnaire. Care Homes for Older People Page 22 of 28 Evidence: We received comments from the residents and the families at the visit and from the surveys received by us, amongst which were that the manager did not respond to their concerns that the care was not being given at the right times and that call bells were not being answered very quickly. This was brought to the previous managers attention at the Annual Service Review when she told us that this would be dealt with. The concerns about these issues has been documented earlier in the report. The residents accounts were seen and found to be in order and had two signatures on each entry. This makes sure that the resident and the member of staff handling the money are protected. We saw that receipts were obtained for purchases. There was evidence from the staff spoken with and from the records seen that they were having regular, practical assessments but were not given the opportunity of formal supervision with their line manager. Formal supervision of the staff gives them and their line manager the opportunity to discuss work and training issues and needs. There are regular staff meetings held, confirmed by records held and by the staff spoken with. The manager completes a regular audit of any accidents that have happened in the home to make sure that if at all possible they could be avoided. The areas of health and safety such as hot water temperatures and fire alarm testing were found to be in order. Care Homes for Older People Page 23 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 24 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 12 That the residents needs are met within an appropriate timescale. to make sure that the residents receive their full care needs when it is needed. 30/09/2009 2 8 12 (1)(a)b)That sufficient staff and equipment is available to reduce the incidence of pressure sores. To make sure that the residents skin integrity is maintained. 30/09/2009 3 27 18 (1)(a)That the staffing levels 30/09/2009 are reviewed to make sure that the residents have their care needs met in a timely manner. To make sure that care needs are met to the residents satisfaction. Care Homes for Older People Page 25 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 4 32 24 (1)That the quality of the 30/09/2009 care in the home is regularly reviewed and improved. To make sure that the residents receive care to meet their needs at the time that it is needed. 5 36 18 (2) That all the staff have the opportunity of formal supervision at the required intervals. To have the opportunity of meeting with their line manager to discuss work and training issues. 31/10/2009 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 2 3 4 5 9 15 16 19 19 That consideration is given to putting a safer, easier and quicker method of medicine administration in place. If a resident is being got up late, that an alternative arrangement for breakfast is made. That the complaints policy is updated and produced in a large print. That alternative storage is found for the hoists in the home. That consideration is given to providing a new call bell system to make sure that all the calls are registered and that they are recorded. That the application form has enough space on it to contain a full employment history. That the care manager has access to the office when she is Page 26 of 28 6 7 29 32 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations left in charge of the home. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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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