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Inspection on 10/06/09 for Bassingham Care Centre

Also see our care home review for Bassingham Care Centre for more information

This inspection was carried out on 10th June 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 7 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

This home provides a pleasant, clean and very well decorated environment for residents. Those residents spoken to expressed their satisfaction about all aspects of the care provided. Comments received were, the food is always very good, the staff are always very kind and helpful, I have been here a long time and I am very happy, Staff are very good, they will do anything for you. The staff are very friendly and cheerful . The carers were observed throughout this visit as being competent, kind and polite when speaking to people.

What has improved since the last inspection?

The deputy manager confirmed that they are implementing new care plans for all residents so that information is available to all staff. She stated that ongoing training has been arranged, which includes a greater understanding of what is in the residents best interests and other aspects relating to their general welfare in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards.

What the care home could do better:

Admission forms must address fully any significant or specialist areas of care, which is required. This would ensure that peoples needs are met upon admission to the home. Care plans must document clearly all those care needs relating to people who have dementia including anxieties or orientation issues, which may effect their general welfare. Medication sheets should reflect an accurate record of medication given to residents and at what time it was given.This would ensure that all people are given medication at the prescribed time. Care plans must address the issues of individual residents privacy and dignity and how this is to be delivered. This would ensure that individual residents have their say as to how their privacy and dignity is to be maintained given the daily routines that communal living imposes on them. Care plans seen of two residents did not reflect person centered care planning. This must be introduced so as to ensure that residents are actively involved in their care plans, which would reflect the care that they request. The acting manager was advised about the Mental Capacity Act 2005 and how this addresses the rights of residents. Care plans now need to record any requests made by people affecting their care and general welfare. The provider must keep the commission informed of changes in the management structure of the home. This information would assist in assessments of the home and any risks to residents that these changes may create. Information in the form of documentation relating to the running of the home must be made available to all staff. This will ensure that those staff who need this information has access to it and will help to keep people safe.

Key inspection report Care homes for older people Name: Address: Bassingham Care Centre The Old Rectory 2 Lincoln Road Bassingham Lincs LN5 9HE     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: Douglas Tunmore     Date: 1 0 0 6 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 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 30 Information about the care home Name of care home: Address: Bassingham Care Centre The Old Rectory 2 Lincoln Road Bassingham Lincs LN5 9HE 01522788215 01522788509 bassingham_sherry@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Cornward Limited care home 61 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 61 The registered person may provide the following categories of service only: Care Home with Nursing - Code N 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 Dementia - Code DE Date of last inspection Brief description of the care home Bassingham Care Centre is situated in its own grounds in a village location, which has a church, shops and public house. Parking is available at the front and side of the building. The home is registered to provide care and accommodation for people over 65 years, offering nursing and personal care for up to 61 people. Accommodation is provided in two areas. The main house was a former rectory and has been adapted and extended to provide accommodation for residents on two floors. Care Homes for Older People Page 4 of 30 61 0 Over 65 0 61 Brief description of the care home The first floor is accessed by a shaft lift. Rooms are shared or single and some have en-suite facilities. The second area consists of bungalow style units, which are currently unoccupied; the manager stated that it is the providers intention to sell these. There is a large garden, which has a lawn with flowerbeds and seating for people to use in fine weather. Care Homes for Older People Page 5 of 30 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 an unannounced visit undertaken by two inspectors and it formed part of a key inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. From 1 April 2009 the duties of The Commission for Social Care Inspection (CSCI) has now been taken over by the Care Quality Commission (CQC), the new independent regulator of all health and social care in England. Throughout this report the terms we and us refer to the Care Quality Commission (CQC). The provider had returned the Annual Quality Assurance Assessment (AQAA) before the date in which it was requested to be returned in order to accommodate the possibility of an inspection visit. This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. The main method used to carry out the inspection is called case tracking, this includes following the care of a sample of people through their records and assessing Care Homes for Older People Page 6 of 30 their care. We spoke with seven people who use the service and saw rooms of people who gave us their permission. We spoke with four care staff members,the cook and the cleaner. We spoke with one visitor as part of the information gathering process. During this visit the deputy manager was kept informed of the general outcomes of this visit as was the quality development manager by telephone. We were told that the current fees for a weeks stay at the service range from three hundred and ninety eight pounds to six hundred and fifty five pounds. This does not take into account any monies paid in relation to nursing care determination assessments, which would be deducted from the total costs. Additional charges made for the service user includes chiropody, hairdressing toiletries, hairdressing and newspapers. The providers Service Users guide and the last inspection report is available from the deputy manager. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Admission forms must address fully any significant or specialist areas of care, which is required. This would ensure that peoples needs are met upon admission to the home. Care plans must document clearly all those care needs relating to people who have dementia including anxieties or orientation issues, which may effect their general welfare. Medication sheets should reflect an accurate record of medication given to residents and at what time it was given.This would ensure that all people are given medication at the prescribed time. Care plans must address the issues of individual residents privacy and dignity and how this is to be delivered. This would ensure that individual residents have their say as to how their privacy and dignity is to be maintained given the daily routines that communal living imposes on them. Care plans seen of two residents did not reflect person centered care planning. This must be introduced so as to ensure that residents are actively involved in their care plans, which would reflect the care that they request. The acting manager was advised about the Mental Capacity Act 2005 and how this addresses the rights of residents. Care plans now need to record any requests made by people affecting their care and general welfare. The provider must keep the commission informed of changes in the management structure of the home. This information would assist in assessments of the home and any risks to residents that these changes may create. Information in the form of documentation relating to the running of the home must be made available to all staff. This will ensure that those staff who need this information Care Homes for Older People Page 8 of 30 has access to it and will help to keep people safe. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure that their needs are met, although not in a consistant way due to shortfalls in recording. Evidence: We were told that, a pre-admission assessment is carried out by the acting manager (RGN) and the form completed for all prospective residents, then this information is used in conjunction with the information from inquiry form and information from funding bodies as appropriate to ensure that the home can meet the needs of the resident. We looked at an admission form, which was not fully completed. The entries were brief and did not refer to specific and significant or specialist areas of care, which were needed. The deputy manager agreed that this was poor recording. Copies of assessments from Social Service departments or hospitals are obtained and Care Homes for Older People Page 11 of 30 Evidence: kept on residents files. People who live at the home told us that they had a chance to look around the home before they moved in, and they were given a booklet with lots of information about the home. Staff told us that when a new person comes to live at the home they are given lots of information about how to care for them, and they are able to see their assessments and care plans. This home does not provide not intermediate care service. Care Homes for Older People Page 12 of 30 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. Care planning, recording and medication systems put residents at risk of not having their needs met. Evidence: We are told that, our care plans identify specific needs of the residents and provide nursing and care staff with full information of how a particular need should be cared for. However, the care plans for two residents didnt include specific information of how to meet their needs relating to dementia. We looked at those files of two people who were being case tracked and found that care plans evidenced that accidents are recorded and files also contained body maps for the mapping of any cuts or abrasions to residents. The deputy manager evidenced in the homes diary that training is to be undertaken by all staff on the 15 th June 2009 relating to the Mental Capacity Act. Care plans looked at did not make mention of new laws about decision making, which might effect peoples lifestyles. Care Homes for Older People Page 13 of 30 Evidence: Those care plans of two residents being case tracked had not recorded how their individual dignity and privacy must be maintained at all times. The manager stated that she would address this issue and get staff to discuss with people their personal care needs and how these should be met. The deputy manager told us that she would ensure that this is included in the new care plan files. Staff told us that they have a key worker system in place, with good access to care plans and general records. People who live at the home told us that staff talk to them about their care, and will do things in they way that they like them to be done. They said that they get all their needs met, and staff know how to look after them very well. People also said that they can see people like their GP or optician whenever they need to, and a relative said that they are satisfied that people get a good standard of care. We saw that there is a relatives guide for dementia awareness available in the main entrance to the home. Files seen also confirmed that health care professionals visit the home when required by the residents. We saw that staff spoke to people in a nice way and they addressed them by the names they prefer. We also saw that staff helped people to maintain their dignity. For example they helped people to adjust their clothing, they spoke to them in private about their needs, and responded to peoples request for help in a timely way. The deputy manager showed the inspectors a sample case file with records of care, which were to be Incorporated into all residents care plans, giving up to date information to carers to enable them to provide comprehensive care. The implementation of the new files is taking place immediately she stated. The medication process showed that there were three discrepancies relating to three different residents. One carer had signed that she had given lunch time medication three hours before it was due. However, the medication had not been given. We watched staff giving people their daily medication, and saw that they did this in a safe way. For example they locked the medicine trolley up whenever they moved away from it. One resident self medicates and her file had a risk assessment to ensure safe practice. The Quality and development manager was contacted who stated that they may Care Homes for Older People Page 14 of 30 Evidence: switch the current medication system for a blister pack system which would help ensure that medication errors do not occur. People were seen to be treated with dignity and respect during this visit. Care Homes for Older People Page 15 of 30 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 enables residents to maintain and develop social interests and relationships of their choice. Residents receive a nutritious, varied diet, which meets their individual preferences and health requirements. Evidence: We were told that, Residents are given the option of how they wish to spend their day. The weekly activities program is displayed on a board for all to see. We have structured menu choice system in place which allows the residents to choose daily their meals for the following day, they also have a choice of where they wish to take their meals. The staff are aware of that. This may change daily. Visitors are able to stay for meals if they wish to do so as this has a positive effect on the residents. We know that the activity co-ordinator has recently left the home, and the manager said that they are advertising for a replacement. During the visit we saw some people playing cards, knitting, and doing art work. People told us that the activity coordinator used to arrange things like bingo, and they liked that. They also told us that staff will sit and talk to them, and they sometimes go out for a walk with them. People said that they would like more staff to be available for trips out. Care Homes for Older People Page 16 of 30 Evidence: One residents file showed that she had in 2008 been interested in gardening and undertaken Christmas shopping, sun bathing in good weather and making peg bags. The deputy manager confirmed that children from the local infants school attend the home to sing as well as brownies. She also stated that religious services are undertaken on a monthly basis within the home by a visiting vicar. We spent time talking to people over lunch. They said that they have lovely food, and theres always a choice. They told us that meat is always tender to eat, and vegetables are nice and soft. The meals looked nicely presented, and people were given the foods that they preferred. For example some people had mash potatoes and some people chose roast potatoes. We saw that people could choose where they ate their meals, and there were enough staff around to help them eat if needed. People were able to eat their meal at their own pace, and the atmosphere in the dinning room was relaxed. People told us that when they receive their mail they are able to deal with it in their own way. Some people told us that they have not received voting information since they have lived at the home, and they would like the opportunity to vote in elections. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by knowledgeable staff and people know how to complain. Lack of access to important procedures puts people at risk. Evidence: We are informed that. the complaints procedure has been developed and is available to the residents both in statement of purpose and service user guide. Policies are available on complaints, protection of vulnerable adult and whistle blowing. Most of the staff have received training on safeguarding vulnerable adults. The provider has worked closely with the local authorities safeguarding vulnerable adults team regarding an allegation of neglect of a resident at the home. No evidence was found of neglect but communication for this organization was highlighted for improvement. However, staff did not have access to procedures relating to the protection of people. The provider had a complaints procedure, which tells residents and relatives how to make a complaint and how it will be handled. A copy is given to all new residents as part of the Service User Guide and displayed in the home. We saw that the complaints policy was displayed in the entrance hall where people could see it, and the people we spoke to said that they knew how to make a complaint. They said that staff listen to them when they have a concern, and try to Care Homes for Older People Page 18 of 30 Evidence: help them. There was no information readily available to people who live at the home or visitor, about how to recognize or report abusive situations. The deputy manager confirmed that all staff had received training in safeguarding vulnerable adults. Staff knew about safeguarding vulnerable adults and knew who to report it to. People said that they felt safe living in the home. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a comfortable, warm and clean environment that meets their individual needs. Evidence: We were told that, Bassingham ensures that the residents using the service live safely and are not at risk in their environment. Size layout and design as well as all adaptations and equipment available are taken into full consideration prior to offering the residents accommodation at BassinghamBassingham. Risk assessment and moving and handling assessment are carried out to ensure promotion of residents health, safety and well-being. We looked around the house when we arrived, and we saw that everywhere was clean and tidy. We saw that people had personalized their rooms and had their own furniture in place wherever they wanted. People told us that they think the lounge areas and dinning rooms are comfortable and there is enough space in them. Staff told us that some of the bedrooms have recently been decorated. There are well kept gardens around the house and people told us that they enjoy sitting out there in good weather. Staff were using aprons and gloves whenever they needed them, and we saw that there were good stocks of both things in the home. Staff showed us that they were Care Homes for Older People Page 20 of 30 Evidence: aware of how to stop infections spreading, for example, with good hand washing techniques. There are three hoists available for staff to help people move about, and records show that they have recently been serviced. Staff told us that the handyman checks the fire alarm call points every week to make sure they are working properly. One bathroom had lots of toiletries around that could cause harm to people if they, for example, were swallowed. The deputy manager told us that there were no risk assessments in place about this. The manager also told us that a risk assessment was not in place for the use of stair gate on a steep staircase. We did see a risk assessment for one person who smokes in their own room. The deputy manager confirmed that these risk assessments would be put in place immediately. Care Homes for Older People Page 21 of 30 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 is adequately staffed with employees who were experienced, competent and trained to care for older people. People are protected by the homes robust employment procedures. Evidence: We were told that, a robust recruitment system is in place to ensure all checks are completed prior to employment. Files are kept for each individual member of staff and include a pre-employment checklist. Staffing levels have increased due to increase in residents occupancy. Duty rotas identify staffing levels and there is a mix of skills to include qualified and unqualified staff in all areas. Additional to nursing and care staff the home employs domestic, catering, maintenance and administrative staff. We looked at three carers personnel files and found that checks had been undertaken. The deputy manager stated that those staff who had Protection of Vulnerable Adults checks and Criminal Record Bureau checks were supervised whilst their these were received. We looked at staff Personnel files and found that all staff either have a national vocational qualification NVQ (national vocational qualification) level 2 or 3 in caring for elderly people and some are working to-wards NVQ 3 certificate. There were certificates relating to training undertaken by staff. Training included manual handling, Care Homes for Older People Page 22 of 30 Evidence: fire safety, health and safety, infection control, dementia and medication long distance learning. We looked at the staff rota, which confirmed that appropriate staffing levels are being maintained and ensures a mix of skills are available to meet the needs of residents. All staff spoken to confirmed that there was enough staff most of the time and that moral was good among the staff. The rota also showed that there are three to four staff on duty in the morning and afternoon and that at night there is one trained nurse and a carer on duty. There is a trained nurse on duty at all times. People told us that staff are around when they need help, and they get their needs met quite quickly. Some people said that there could be more staff to help them have trips out. We saw that staff responded quickly to call bells and, there were enough staff to help people take as much time as they needed with meals. Staff told us that they have lots of training to help them do their job well, and they described a fire safety awareness course, and a recently improved training course about moving and handling people. Newer staff told us that they were given lots of information and training when they started work, and they spent time working with more experienced staff until they gained confidence. Care Homes for Older People Page 23 of 30 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 management and quality assurance systems are not robust to ensure the smooth running of the home. Evidence: We are informed by the provider that, we have appointed the acting manager (RGN) who has worked in the home for a long period of time and who is competent to ensure that residents have continuity of care and that members of staff receive all necessary management support. The acting manager has also been a clinical lead for the home. The acting manager who refers to herself as the deputy manager is a qualified and experienced nurse and has undertaken this post since January 2009. She confirmed that she would not be applying for the managers post and the provider is taking steps to appoint a registered manager. People who live at the home, and staff members, told us that the deputy manager is very supportive to-wards them, and they are able to talk to her if they have a Care Homes for Older People Page 24 of 30 Evidence: problem. They said that she and the staff keep them informed of what is happening in the home, for example they had full details about the electricity cut that was in place during the visit, and all of the arrangements that had been made to overcome some of the problems it would cause. The deputy manager confirmed that surveys have not been sent out to residents, relatives or visiting health professional for a long time. However, she said that residents were receiving monies when required, which was paid through the providers petty cash. The provider told us, that their plan for the next twelve months is, to employ a competent manager who will undergo the registration process and will take on an overall responsibility for the residents and staff in the home. To introduce a robust Quality Assurance System. Quality and Development Manager to introduce various auditing systems that ensure residents live in a safe environment and that any requirements from various inspection reports are completed within the timescales given. The providers AQAA identified that there are a range of policies and procedures available in the home relating to the health and safety of residents. This document also showed dates when equipment was serviced and fire alarm checked to ensure the safety of residents and staff. A number of policies and procedures are to be updated by the provider and this work is ongoing. People were able to tell us what they would do if there was a fire in the home, and staff described the evacuation procedures in detail. When the administrator is not working some systems such as personal finances and access to policies and procedures are not effective, see standards 1 to 6. Care Homes for Older People Page 25 of 30 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 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Each person must have an assessment that reflects their needs. This will ensure that the service users needs will be met. 23/07/2009 2 7 15 Service users plan of care must reflect their needs and include all their needs. This will ensure that the service users care plan is up to date and includes all their care needs, which need to be met . 23/07/2009 3 9 13 A system must be established to ensure that medication is given to people on time and that a record is made confirming this. This will ensure that medication is given at the correct time as prescribed by the general practitioner. 23/07/2009 Care Homes for Older People Page 27 of 30 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 10 12 Service users individual care 23/07/2009 plans must reflect their wishes regarding their dignity and privacy. This will ensure that all residents will be assured that they will be treated with dignity. 5 31 8 The registerd provider must appoint an individual to manage the care home and the manager must register with the commission. This will ensure continuity of management and the smooth running of this home. 28/08/2009 6 33 24 A review of the quality of care must be undertaken and residents, relatives and visiting health care worker are consulted. This will ensure that all those people involved in this home are asked about their opinions, which are recorded and acted upon. 23/08/2009 7 37 17 Records must be made available to ensure the smooth and safe running of the home. 28/08/2009 Care Homes for Older People Page 28 of 30 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 This will ensure that information is readily available to those staff who need it. 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 29 of 30 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 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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