Inspection on 28/08/08 for Bay House

This inspection was carried out on 28th August 2008.

CSCI 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.

Other inspections for this house

Bay House 14/09/07

Bay House 03/10/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Bay House 2-3 Middlesex Road Bexhill-on-Sea East Sussex TN40 1LP     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: Melanie Freeman     Date: 2 8 0 8 2 0 0 8 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. the things that people have said are important to them: They reflect 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 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Bay House 2-3 Middlesex Road Bexhill-on-Sea East Sussex TN40 1LP 01424210202 01424210202 enquiries@bayhousecare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Claire Avery Type of registration: Number of places registered: Mr N Manji care home 36 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 36. The registered person may provide the following category/ies of service only: Care home only Nursing - (N) to service users of the following gender: Either Whose primary care needs on damission to the hoem are within the following categories: Old age, not falling within any other category - (OP) Date of last inspection Brief description of the care home Bay House is a converted Victorian property that was formerly a Guest House. It is situated in a quiet residential area of Bexhill close to the seafront, town centre and mainline railway station. Bay House Nursing Home is registered to provide general nursing care to older people. Bay House has recently been purchased as an on-going concern by Mr N Manji and was registered, by the CSCI, in his name on 7th August 2006. Care Homes for Older People Page 4 of 30 Over 65 36 0 Brief description of the care home The home is registered to accommodate thirty-six residents. The home at present is undergoing a major refurbishment that will affect the amount of double and single bedrooms. Some bedrooms have en suite facilities, with additional toilet and bathroom facilities throughout the premises. There is a small lift shaft servicing all floors. The home has specialist equipment including specialist beds, bath and lifting hoists and walking aids. There is a well maintained garden to the rear of the property that is accessible to service users. Unrestricted parking is available on the road on which the home is situated. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. 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: The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term service user to describe those living in care home settings. For the purpose of this report those living at Bay House Nursing Home will be referred to as residents. This was a key inspection that included an unannounced visit to the home on the 28 August 2008 and follow up contact with visiting health and social care professional. The allocated inspector spent approximately six hours in the home and was able to discuss matters with the registered manager and the registered provider. A tour of the premises was undertaken and a range of documentation was reviewed Care Homes for Older People Page 6 of 30 including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files and quality assurance systems. The homes health and safety procedures and checks were also discussed with the registered provider. The care documentation pertaining to three residents were reviewed in depth and the inspector ate a midday meal with the residents in the dining room. Comments shared by residents and their representatives during the inspection process included Personal observation indicates a high level of care and commitment On my mothers behalf I would like to congratulate the Nursing Home on its overall approachable manner. The staff are extremely courteous both to visitors and their clients. The required Annual Quality Assurance Assessment (AQAA) was completed by the registered manager when requested. It was well completed and its contents were used to plan the inspection and to inform the report. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from four staff members and five residents some of which had been supported in completing these by a family member. The range of fees charged at the time of this inspection report range from 382 to 575 pounds per week, with additional charges made for hairdressing, newspapers/magazines, transport and chiropody. What the care home does well: What has improved since the last inspection? What they could do better: The management of the home needs to improve the admission procedure. To ensure that all prospective residents or their representative are advised in writing, following their needs assessment whether the home is suitable to meet their assessed needs. This ensures that decisions around admission to the home are informed and evidenced. Although the care documentation has been improved it still needs to take into account residents and or their representatives views. In addition should always be fully Care Homes for Older People Page 8 of 30 completed to reflect all the care needs, residents choices and preferences, and how these are responded to. The way that complaints are handled needs to be further improved to ensure robust procedures are followed, and that clear records are retained in the home. All such records must be suitably stored to safeguard any confidential information. The recruitment procedures must be improved to ensure all the required checks are completed and relevant documentation is held on file. This will ensure safe recruitment practice is followed at all times and in turn safeguard residents living in the home. Staff training needs to be clearly recorded to evidence that staff are appropriately trained and to plan a suitable rolling programme of training for all staff. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 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 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 good information to prospective residents on the services and the costs involved. The admission procedure ensures that prospective residents are fully assessed by a competent person ensuring their needs can be met by the home following admission. Evidence: The home has a suitable combined statement of purpose and service users guide. This document is displayed along with the last inspection report in one of the entrance areas. A review of this document indicated that it needed to be updated slightly to fully reflect all the required information that it needs to contain. For example it should contain a copy of the terms and conditions of residency and the fire precautions in place. The registered manager confirmed that she would review and update this document as necessary. Care Homes for Older People Page 11 of 30 Evidence: An assessment of the admission process followed included a review of the documentation relating to the last two admissions to the home.These confirmed that everyone is assessed by the registered manager before a placement in the home is offered. These assessment cover all care needs including the individual nursing needs. These documents could be improved further with a clear record of where the assessment was completed and the input from other people involved in the care. Although it was confirmed that prospective residents and their representatives are advised verbally that the home is suitable to meet their assessed needs, this must be confirmed in writing. Contact with a visiting social care professional confirmed a high satisfaction with the admission process all staff are very helpful and work well with us and the residents family. Although intermediate care is not provided at Bay House respite care is offered and the staff work with residents to ensure their stay is a good experience, with their independence promoted. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual plans of care are devised and reviewed regularly and record the support provided by the community health care professionals. The homes practice ensure resident’s medicines are administered safely. Care is delivered in such a way that promotes and protects the residents’ privacy, dignity and individuality. Evidence: The care documentation pertaining to three residents were reviewed in depth as part of the inspection process and each of these residents were spoken to during the inspection visit. Each resident had a plan of care based on an assessment process that includes relevant risk assessments. Although the plans of care recorded the health care needs of residents they did not record residents choices, preferences or skills in maintaining Care Homes for Older People Page 13 of 30 Evidence: their independence. Some of the documentation was not fully completed, for example, the social plan of care, an individual risk assessment for medicine self-administration and the daily personal care sheets. The registered manager was aware that there are still some areas for improvement with regard to the care documentation and is to complete some further auditing. On the whole the care plans provide guidelines for staff to follow in order to meet the health care needs of residents. There was evidence that the care is reviewed and evaluated regularly. Records indicated that the home works closely and in consultation with a variety of specialist health care professionals, and contact with some of these confirmed that this was a productive relationship that benefited the residents. All feedback received about the care provided at Bay House was positive with one resident saying she was very happy in this home. Observation during the visit to the home confirmed that good practice was being followed in respect of medicine administration with medicines being administered directly from a drugs trolley. All medicines are administered by a registered nurse and the medicine administration charts were found to be accurate and complete. The medicine storage room is also the managers office, which leads to a cramped facility and may compromise the security of medicines. The registered manager advised that this is a temporary arrangement and a new office is to be provided shortly. The storage and administration records in respect of the controlled drugs were found to be suitable. As a matter of good practice it was recommended that any medicine prescribed on an as required basis is done so in accordance with individual guidelines. Direct observation confirmed that staff have a good rapport with residents and treat them with a good level of dignity and respect. Residents rooms are seen as their own personalised space with residents having their own possessions around them. Care Homes for Older People Page 14 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. People in the home enjoy the activities and contact with staff and the activities coordinator. People are supported to maintain links with their family and friends and with the local community. Residents benefit from a varied diet that suits their needs and preferences. Evidence: During the visit to the home the residents were seen to enjoying contact with staff, visitors and with the activities co-ordinator, who works in the home two afternoons a week. She was seen to interact with a large number of residents who all knew her and responded positively to her company. She spent time looking at photographs with residents and discussing them in a small group, and catching up individually with other residents. Her rapport with residents was seen to be positive and productive. The manager and home owner recognise the importance of activities and entertainment in the home, and are working to increase the hours for the activities co-ordinator. Visiting is also an important part of the home and is very much encouraged. Visitors spoken to said that they felt able to visit at any time and are always warmly received. One visitor and relative spoke very positively of the activities and entertainment Care Homes for Older People Page 15 of 30 Evidence: provided commenting on the trip to a rabbit sanctuary and the Christmas party. They also said there was an opportunity for residents to be taken out by staff. It was also noted that during the inspection visit one resident was taken out by a staff member to the local shops. A meal was eaten with residents in the dining room. This included a soup starter and a choice of main meal and a choice of dessert. The meal was well presented and served directly from a food trolley by the chef, and was responsive to individual choice on the day. Soft diets were well presented and pureed food was served separately so that residents could mix the tastes as they wished. The food eaten during the inspection visit was very good with an emphasis on home cooking, the meat was lean and easy to cut and chew. The tables were well set up with condiments and linen table clothes and the dining experience for residents was a good social event. It was however noted that all residents eating at the tables were wearing bibs and this gives an institutional feel to the home and care. Although it is recognised that these are appropriate and needed in a number of cases alternatives must be available and choices on this matter recorded. This was discussed with the manager and owner who were receptive to this recommendation. The menus in the home provided choice and a good variety. The chef has regular individual contact with residents that ensures individual needs and preferences are responded to. All feed back about the food reflected a high satisfaction with the provision. One resident was heard to say to a visitor jolly good food here and the visitor said like a hotel. A survey received indicated that residents preferences are responded to they gave him mussels when I said that he liked them. Care Homes for Older People Page 16 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. Whilst people are confident that concerns raised will be responded to effectively procedures followed need to ensure suitable record keeping. The procedures for Safeguarding vulnerable adults and the recruitment practice followed in the home did not ensure residents are safeguarded at all times. Evidence: Although the home has a complaints procedure a review of this confirmed that this needed to be updated to fully reflect the required information and practice in the home. Records held in respect of complaints made confirmed that the home manager is responding to residents views. It was however unclear how any complaint would be recorded in the managers absence and how confidentiality of concerns raised is maintained. One formal complaint has been referred to the home since the last inspection and a full investigation was completed. The investigation and action taken in response to this was not clearly recorded within a complaints record. Residents and visitors confirmed within the surveys and verbally that they would be happy to raise any concern with either the manager or owner of the home who are both found to be very approachable. Care Homes for Older People Page 17 of 30 Evidence: A review of the Safeguarding procedures identified that these need to be updated. The registered manager confirmed that she was in the process of updating a number of procedures in the home. She demonstrated that she had the most recent local policies and procedures on Safeguarding Vulnerable Adults to inform the practice in the home. Staff have received training on Adult Abuse issues and the registered manager has a good understanding of these matters. Contact with a visiting social care professional confirmed that she has worked in conjunction with social services to promote peoples safety. During the visit it was identified that the recruitment practice followed was not always ensuring that staff have Criminal Records Bureau check completed before working in the home unsupervised. Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Bay House provides a clean and comfortable environment that has been improved to provide a premises where the needs of residents can be met. Evidence: Bay House has undergone major refurbishment over the past year that has included an extension to provide more single accommodation and a large communal room. The major portion of the upgrading work has now been completed to a good standard. The registered owner confirmed that the final phase which includes the provision of a new passenger lift and the upgrading of an area that has been left until the new lift provision, the stair wells, reception areas, the laundry and garden, all of which are to be completed by the end of May 2009. The home now provides an attractive environment with most residents enjoying well decorated single rooms that are well adapted to meet the needs of individuals with varying disabilities. There is a large and light communal area that was seen to be well used during the inspection visit. Although there is only one communal room its size and shape allows for different parts of it to be used for a variety of uses. In this way residents benefit from social interaction and can also have private space if wanted. The home was found to be clean and fresh and staff were seen to be following good infection control practice. A relative commented on the homes cleanliness saying I Care Homes for Older People Page 19 of 30 Evidence: have noticed how clean my mums room is which adds to the pleasant atmosphere in her room. The home is being over hauled at the moment but it is being well managed and everything is still kept up to scratch. Bathrooms always clean, bins emptied regularly and carpets vacuumed daily. Residents said that their laundry was dealt with well, and clothing seen during the visit had been appropriately laundered. Care Homes for Older People Page 20 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 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 not fully safeguarded by the homes recruitment practice. The staffing arrangements and skill mix provides a competent and well motivated staff team that on the whole meets the health and social needs of the residents in the home. Evidence: At the time of this inspection visit 24 residents were living in the home and the level of dependency is mixed, with some residents receiving a high level of nursing care. A duty rota is maintained and confirmed that staffing levels are maintained throughout the week, with a registered nurse being on duty 24 hours a day. Although the staffing levels were seen to be appropriate at the time of the inspection visit, some direct feedback from a resident and a visitor indicated that at week ends the call bell is not responded to as quickly as it should be, and as it is during the week days. This feedback was discussed with the manager who agreed to investigate further to ensure suitable levels are maintained at all times, and that the staff working are responsive to residents needs. All feedback about the staff was positive surveys recorded On my mothers behalf I Care Homes for Older People Page 21 of 30 Evidence: would like to congratulate the Nursing Home on its overall approachable manner. The staff are extremely courteous to visitors and clients Personal observation indicates a high level of care and commitment. The staff surveys reflected a high satisfaction with the working arrangements, training and management support. Bay House is very good on providing training courses both in house and outside sources. One staff member reflected a satisfaction with the service she and her colleagues provide in the home by recording I think that this is one of the best places. I would place a member of my family here. Although staff training is well developed in the home the records available during the inspection did not reflect this commitment, and need to be improved. Records held in the home did however record that induction training is provided to new staff and this was reflected within the staff surveys. The registered manager and the AQAA confirmed that most care staff working in the home have an National Vocational Qualification in care, at level 2 or above, or are studying for one. The recruitment files pertaining to three staff members were reviewed as part of the inspection process. This review identified that one senior staff member was working in charge of the home without a Criminal Records Bureau (CRB) check being received. It is however acknowledged that this was being processed. Once this shortfall was identified to the homes management they responded appropriately, ensuring that the check was sourced before this individual worked in the home again. As a senior member of staff it was not possible for her to be fully supervised with a completed POVA first check. Some staff are recruited through an Agency and the registered manager needs to ensure all the necessary documentation in respect of these individuals is held in the home. This should include clear evidence of an individuals right to work and that all the required checks have been completed in their country of origin. Care Homes for Older People Page 22 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements provide clear leadership and an appropriate management structure. Systems for monitoring the quality of the service takes into account residents views. Residents finances interests are safeguarded. The health, safety and welfare of residents and staff are generally promoted and protected. Evidence: The registered manager is a qualified Registered General Nurse and has been working in the private health sector for many years as a deputy manager and NVQ trainer. She has completed the Registered Managers Award in June 2007. Direct observation in the home confirmed that she works closely with staff on a day to day basis, and has a good rapport with them and the residents. There is a clear management structure in the home with staff having designated responsibilities. Each department has its own manager, and these managers are Care Homes for Older People Page 23 of 30 Evidence: accountable for their own areas of expertise but are led by the registered manager. In addition the recruitment of a deputy manager is being progressed which, will further strengthen the management structure. The registered provider is also available full time in the home until the refurbishment is fully complete. All feedback about the management of the home was very positive with both residents and visitors commenting on how approachable the manager and the owner are, and how they feel the home is run in an open way. One staff recorded They are always updating the training, willing to listen and discuss things, the manager and the owner always have an open door for staff which I find great. Make it a friendly place to work which I think we all do our job that bit better. The AQAA was well completed and was used as an audit tool both the manager and owner found the completion of this document a useful process. Questionnaires are used to review the service in the home and these were last completed in June 2006. These still need to be audited and reported on and this was discussed with the manager and registered provider. They agreed to do this before repeating the questionnaires this year. The management team are all involved in completing full audits of the services and facilities that are used to inform an annual action plan for the home. A review of the homes policies and procedures confirmed that these were supplied by a consultative company. Most of these need to be reviewed and updated to reflect the practice in the home and most current legislation and guidelines. The manager confirmed that she was working on these. The home does not hold any monies on behalf of residents and any extras are paid for by the home by using the petty cash. This would include any shopping trips, and any money spent on behalf of residents are then invoiced on a monthly basis. Staff surveys confirmed that staff meet regularly with the manager and are given the opportunity to raise any issues for discussion. The home has a facilities manager who works with the registered provider to monitor and maintain the safety of the premises. Environmental risk assessments are completed and records confirmed that the hot water supply is checked to ensure water is supplied at a safe temperature. Staff receive training on health and safety and systems are in place to report any health and safety risk identified. The AQAA also confirmed that relevant safety checks have been completed. Care Homes for Older People Page 24 of 30 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 That the registered person 01/10/2008 ensures that the prospective resident is advised in writing that having regard to the needs assessment the home is a suitable placement. This will ensure any prospective resident has all the necessary information to make an informed choice about where they want to live 2 7 15 That residents or their 01/11/2008 representatives are consulted regarding the formation of the plans of care and are involved in the review process. That the care documentation is fully completed to record all care needs, residents choices, preferences and the care provided. This will ensure all care needs and care provided is recorded and residents are Care Homes for Older People Page 27 of 30 aware of the agreed care provision and are in agreement with it. 3 16 22 That the registered provider 01/11/2008 ensures a suitable complaints procedure is established to ensure a suitable record of complaints is maintained. This will ensure a clear procedure for staff and complainants to follow and ensure clear records are held in the home. 4 29 19 That the registered person 01/10/2008 operates a thorough recruitment procedure that ensures the fitness of people working in the home. This should include a CRB check and suitable evidence of an individuals right to work in the home. To ensure all staff are suitable to work in the home and to safeguard residents. 5 30 18 That all staff are trained and 01/11/2008 competent to do their jobs. Records within the home can demonstrate that staff are appropriately trained. To ensure that residents are cared for by staff trained to do so. 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 28 of 30 1 15 That the use bibs is reviewed to ensure they are always used appropriately and that the reasons for their use is recorded. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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