Inspection on 13/02/09 for Beenstock House

This inspection was carried out on 13th February 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beenstock House 16/01/07

Beenstock House 05/02/06

Beenstock House 10/11/05

Beenstock House 15/11/04

Beenstock House 17/08/04

Beenstock House 17/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Beenstock House 19-21 Northumberland Street Salford Gtr Manchester M7 4RP     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: Wendy Smith     Date: 1 6 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Beenstock House 19-21 Northumberland Street Salford Gtr Manchester M7 4RP 01617921515 01617921616 postmaster@beenstock.plus.com 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) : Agudas Israel Housing Association care home 16 Number of places (if applicable): Under 65 Over 65 15 0 old age, not falling within any other category physical disability Additional conditions: 0 1 A maximum of 15 older people (OP) requiring personal care only may be accommodated. One service user who is under the age of 65 requiring care by reason of physical disability (PD) may be accommodated. Should this service user no longer require the services offered by the home or reach the age of 65 then the place will revert to that of old age (OP). Date of last inspection Brief description of the care home Beenstock House is a care home registered to provide personal care for up to sixteen people. The home offers both long-term care and short-term respite care. The home was first registered on the 18th August 1999 and is owned by the Agudas Israel Housing Association and managed locally by Beenstock Home Management Company Ltd. The home is is set in its own grounds in a residential area of Salford and is located next to a synagogue. The home offers a culturally specific service for Orthodox Jewish people. Care Homes for Older People Page 4 of 29 Brief description of the care home The residential home is integrated into a sheltered housing complex that comprises three floors, with sheltered flats on the ground and second floors, and the residential unit on the first floor. All bedrooms are single occupancy with en-suite facilities. Residents of the home and tenants from the flats share ground floor dining facilities. Ample car parking facilities are available and there are small well-maintained gardens and patio areas around the home. Care Homes for Older People Page 5 of 29 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 quality rating for this service is 1 star. This means that the people who use the service experience adequate quality outcomes. We visited Beenstock House unannounced on 13th February 2009, with a return visit on 16th February to complete the inspection. At the time of our visit there were 13 older people living at the home. During the visit we spoke with residents, staff and visitors. We walked round the building to see all the communal areas and were able to visit some of the bedrooms. We checked some of the records kept at the home and spent time talking with the acting manager. We also looked at any information that we had received about Beenstock House since Care Homes for Older People Page 6 of 29 our last inspection there. Before the inspection the manager was asked to complete a questionnaire to give us information about the service. What the care home does well: What has improved since the last inspection? What they could do better: There is room for improvement in the care plans so that they clearly show a holistic assessment of each persons needs and details of how the care should be given for each person. The care plans should be kept under continuing review and should be written in plain English. The homes pre-admission assessment should be more detailed so that staff have all the information they need to provide care for a new resident. When bedrails are used, a risk assessment should be recorded to show why this is the best way of keeping the person safe. The rails must be fitted safely (this should be checked daily) and fully covered with protective covers to ensure that no part of a persons body can be trapped by the rails. The home should have a complaints book or folder, and a record kept of any complaints or concerns that are received. This will show that peoples complaints or concerns are taken seriously and addressed. All of the people who work at the home, including ancillary staff and volunteers, should receive training about protecting vulnerable people from abuse, so that they would know how to recognise abuse and what action they should take if they suspect abuse. Care Homes for Older People Page 8 of 29 The management should consider replacing the nurses station with an office. This would allow for private conversations to be held and reduce the disturbance caused by telephones and other electronic equipment. The management should consider whether there might be a better way of storing medicines, and siting staff lockers, so that they do not detract from a homely environment. The use of CCTV should be restricted to entrance areas for security purposes only and should not intrude on the daily life within the home. The management should consider installing a sluicing disinfector so that commode pots can be thoroughly cleaned and disinfected and reduce the risk of cross-infection. All staff must complete mandatory training that protects the health, safety and wellbeing of residents and staff. New staff must not start working at the home until their POVAfirst check has been received, so that residents are protected from people unsuitable to work in a care home. Although this is a small home, there is still a need for auditing processes to ensure that care plans, medicines, accident and incident forms, complaints are reviewed on a regular basis and that a good standard of service is being maintained. There should also be established ways of making sure that residents and their families, staff, and other stakeholders are given opportunities to express their views of the service provided. The overall standard of record keeping needs to be improved so that important information is readily available and other documents that do not need to be kept are destroyed. There must be a fire risk assessment for the building that is agreed with the fire service. Staff and volunteers should attend regular fire training and fire drills to ensure that they know how they should respond in the case of a fire. Hot water temperatures should be checked regularly to ensure that residents are not at risk of scalding. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 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 29 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. People of the Orthodox Jewish faith can be confident that their religious and cultural needs will be met at Beenstock House. Assessments are carried out to make sure that their health and personal care needs can be met at the home. Evidence: Beenstock House is a large modern building situated in an area of Salford that is predominantly populated with people of the Orthodox Jewish faith. There are 16 sheltered housing apartments on the ground floor and the second floor, and the care home is on the first floor. The home has 16 bedrooms that can be used for either long or short stays. When we visited there were 12 people living at the home, two rooms were vacant, one person was having a short stay, and one person who usually lives at the home was in hospital. All of these people are of the Orthodox Jewish faith. A member of staff who Care Homes for Older People Page 11 of 29 Evidence: we spoke with said that the home is very much part of the local community and is next door to a synagogue where about a thousand people visit every day to pray. This means that the people living at the home have many visitors. Referrals for places at the home come from Orthodox Jewish communities in the north of England as there are very few homes that specifically cater for the religious and cultural needs of this group of people. The acting manager was aware that there may be pressure to accommodate people who require nursing care, but said that she would always request a reassessment if she considered that a persons health needs could not be met at Beenstock House. The Manchester Jewish Federation employs social workers who can provide a community care assessment of peoples needs. We saw assessments from social workers for two people who had come to live at the home within the last few months. There were also assessments by health professionals for both of these people. The acting manager told us that both of these people had been visited by senior staff from the home before they came to live there. The homes pre-admission assessment form is not very thorough and we advised the acting manager to look at Standard 3.3 of the National Minimum Standards for Care Homes for Older People for guidance on what should be included in the assessment. This will ensure that the staff know about peoples care needs and whether this is the right home for them. Care Homes for Older People Page 12 of 29 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 health and personal care needs of the people living at the home are met to a good standard, but the recording is not satisfactory, and people may be put at risk if guidance for the safe use of bedrails is not followed. Evidence: There is a care plan for each person. The care plan forms are attached to a large and heavy plastic holder which is difficult for the staff to handle. It also means that the information for each person is not kept separately. This is a traditional hospital type format and the acting manager said that she is planning to introduce a new care planning system that will have an individual folder for each person. The care plans have some good content but are difficult to follow and need a thorough overhaul. In the care plans people are often referred to as the client, rather than using their name and we considered that some of the language used was not appropriate, for example Client will not comply with instructions. May become aggressive. There was unnecessary use of pseudo-medical jargon rather than plain Care Homes for Older People Page 13 of 29 Evidence: English and simple instructions, for example Medication administrator must give the medication in the order instructed by the GP. Some of the care plans did not include an assessment of the persons needs and some had not been kept up to date. Most of the care plans were written about a year before our visit, with infrequent reviews recorded since then. Many of the reviews consisted of no change. Many of the care plans did not have a picture of the person. Our observation was that people are treated very much as individuals with their own individual needs, but the recording did not reflect this. Staff are very respectful to residents and they are always addressed using their title and their surname. At the handover meeting it was clear that the care staff know each person well and are aware of their needs and preferences. There was evidence to show that the health needs of the people living at the home are monitored, for example monthly weights, but these were not recorded in their care plans. We saw a list of hourly checks of residents during the night, however this was not very helpful as it did not contain important information, for example about a person who needs regular repositioning. This was recorded on a turning chart in her bedroom. Two people need to receive nutrition by a feeding tube and this is regularly supervised by district nurses. One person identified as being at risk of falling has a pendant to wear that is linked to the nurse call system, and another person who is very deaf is supported to communicate by writing. The manager told us that none of the residents has a pressure sore and we saw that pressure relieving mattresses were in use for people identified as being at risk. We noticed that two people had bedrails in use and for one person, who was being cared for in bed, the rails were not fitted with protective covers, although covers were available in the home. It is very important that a risk assessment is documented whenever bedrails are used, and all precautions put in place to ensure that there is no risk of entrapment of the persons limbs or neck. We were told that the local Jewish community has its own paramedic service that can respond very quickly to any medical emergencies. It is unfortunate that the home was built without a medicines room. This means that medicines have to be stored in a corridor area. We found that the storage, including controlled drugs, was secure. The medicines trolley is kept secured to the nurses station in the middle of home. None of the people in the residential home look after their own medicines. New Care Homes for Older People Page 14 of 29 Evidence: medicines are checked in and signed for on the medicine administration record sheets. There were some instructions from the dispensing pharmacy that needed to be clarified, for example for one person vitamin B was prescribed with the instruction Take one or two tablets 3 times a day. The homes staff need to know whether the person requires one or two tablets and it is not appropriate for this to be left to their discretion. Administration records are good and indicated that people always receive what has been prescribed by their doctor. In the centre of the home is a large nurses station which contains several telephones, an intercom for the main entrance and an intercom for the apartments. These make a considerable amount of noise with their various ringing tones and detract from a homely atmosphere. This is also the only area where staff can have hand-overs and where relatives and other visitors can be spoken with, which means that there is an issue with privacy and confidentiality that the acting manager was very aware of. The work top of the nurses station is too high for anyone working behind it to see over. There are shelves containing a lot of files that would be better kept in an office. Care Homes for Older People Page 15 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff working in the home, and a group of volunteers, ensure that the people living at Beenstock House are supported to maintain their religious and cultural observances. Evidence: Beenstock House is specifically for older people from the Orthodox Jewish community and aims to ensure that their religious and cultural way of life can be maintained when they are no longer independent. The home has a team of volunteers from the Jewish community who provide social activities for the people living at the home. The acting manager told us that there are more activities than any home I have been in and said that the volunteers work well with the care staff. The volunteers spend time talking with people, do baking, singing, fruit carving. They provide a wide variety of social activities and take people out with a carer. Most tenants of the apartments, and residents of the home, use the large dining room on the ground floor but they can have meals in their room if they prefer. There is always a Jewish cook to provide kosher meals and strict dietary rules are observed. People spoken with were happy with their meals and with flexibility in meal times to allow for prayer. Care Homes for Older People Page 16 of 29 Evidence: There is a religious supervisor who ensures that peoples religious needs are catered for particularly with regard to religious festivals. There is a library in the building and people are assisted to visit the synagogue. Bedrooms have been personalised with peoples own belongings. Care Homes for Older People Page 17 of 29 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. The people who live at the home could be better protected by providing more training for staff about safeguarding and ensuring that details of any complaints are recorded. Evidence: The home has a complaints procedure and this is displayed at the nurses station. The acting manager told us that she had not been able to find any complaints records in the office. The residents we spoke with said that they were very satisfied and never had to make a complaint, however they also said that they would not like to complain but might tell a relative if there was something they were not happy with. The acting manager intends to establish a complaints file and record any formal or informal complaints or suggestions for improvement. The records we saw showed that staff received some training about abuse when they started working at the home, but the acting manager was aware that more thorough and robust training about safeguarding vulnerable people is needed for all staff. Care Homes for Older People Page 18 of 29 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. People have a spacious, clean and comfortable environment to live in, but some improvements are recommended. Evidence: The exterior of the home is in good repair and there are pleasant outdoor areas for people to enjoy. The interior is spacious and well-maintained. Each resident has a large bedroom with en-suite facilities. All of the doors are linked to the fire alarm system so that they can be left open if the person wishes but will close automatically if the fire alarm is activated. There is a pleasant lounge for people to use and a large dining room on the ground floor that is shared with the people who live in the apartments. A large block of staff lockers, and cupboards and a trolley for medicines storage, detract somewhat from a homely appearance, as does the large nurses station in the middle of the residential area. CCTV is used to monitor the exterior of the building and the entrance area, and this is acceptable; however a separate CCTV system shows the communal areas inside the home (though not residents rooms) and this is an invasion of peoples privacy and should be removed. Care Homes for Older People Page 19 of 29 Evidence: The manager has a small office on the second floor of the home. It would be most beneficial if an office could be provided for the manager within the residential unit. All parts of the building were very clean and there were no unpleasant odours. There is a spacious and well-equipped laundry. A relative told us that she considered her mothers commode pot was not always cleaned properly. The home does not have a sluicing machine to disinfect commode pots and the committee should consider providing this equipment. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to meet the needs of the residents, but people may be at risk due to a lack of regular training for staff. Evidence: The acting manager told us that there are some staff vacancies and carers from an agency are used to ensure that there are always enough staff to meet the needs of the residents. The agency sends the same people, who have got to know the residents and how the home works. There are four care staff on duty in a morning, three in an afternoon and two at night. The same staff also provide a domiciliary care service to some of the people who live in the apartments in the same building. There are three senior care staff; one has NVQ level 3, one has NVQ level 2, and the other is an overseas nurse. In addition there is a male carer who works part-time and can assist the male residents with personal care. Two of the female care staff are from the Jewish community. A receptionist is on duty during office hours. There is also an administrator who manages the kitchen and domestic staff and is warden for the apartments. We looked at recruitment records for three care staff who started working at Beenstock House in 2008. They had all completed application forms and two Care Homes for Older People Page 21 of 29 Evidence: satisfactory references had been received for each. For two people, the records suggested that they started working at the home a few days before their POVAfirst check had been received. (This is the initial check to ensure that the person is not on the list of people unsuitable to work as carers.) They had all received some induction training, but we could not be sure that this training meet the Skills for Care induction standard. Other than induction training, there was little evidence of any staff training taking place and the acting manager expressed her concern about this. She had already arranged for staff to have training about safe moving and handling, which was booked for the week after our visit, and she was meeting with the management committee to discuss other training needs. Care Homes for Older People Page 22 of 29 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. There are no management systems in place to ensure that the home is being run in the best interests of the people who live there and that they are kept safe. Evidence: Beenstock House is owned by the charity Agudas Israel Housing Association. It is managed by three trustees and a management committee. The registered manager left the home two weeks before our visit. The deputy manager has agreed to cover on a temporary basis, which may later be made permanent. She is a registered nurse with considerable experience and has a management qualification. She has also worked as an NVQ assessor. She has identified a number of improvements that are needed, including care plans and training, and is having regular meetings with the committee to discuss how the home can move forward. The members of staff we spoke with expressed their confidence in the acting manager, as did the chairman of the committee. Care Homes for Older People Page 23 of 29 Evidence: The manager also has responsibility for the domiciliary care agency that has been registered to provide a care service for people who live in the apartments situated in the same building. There is a administrator based in the building and he is also warden for the apartments. The acting manager told us that she receives good support from the administrator. We did not see evidence of any quality monitoring systems being used in the home. There are monthly staff meetings and the acting manager was planning to start relatives meetings. A volunteers meeting had been arranged for 24th February. The committee meets regularly to discuss the running of the home. There were some records of staff supervision and appraisal but these were not done on a regular basis. The general standard of record keeping was poor. Accidents and incidents had not been recorded in full. We spoke with the administrator and he told us that no personal spending money is kept at the home on behalf of residents. All of the people living at the home have either a family member or an advocate to help them with finances and items such as hairdressing or chiropody can be billed to the relative or advocate. We spoke with the homes maintenance person. He does weekly fire alarm checks and emergency lighting checks. He is aware of the fire procedures for the building and considered that these were adequate, but there were no records of any fire drills. Staff had received some fire training but we did not see evidence of regular updates of this training. The fire detection system had been serviced in November 2008. A requirement about completing a fire risk assessment was made at our last inspection and it was not clear whether this has been addressed. We were told that there are thermostatic controls on all hot water outlets, except for the hand basin in the bathroom, but there were no records of them being checked to ensure that the water in peoples rooms and in the bath is not too hot. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 38 23 The home must obtain advice 05/03/2007 from the fire service on the completion of the fire risk assessment. Care Homes for Older People Page 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Each person must have a 29/05/2009 care plan that is based on an assessment of their needs and is kept under regular review. So that the staff have detailed and up to date information about how they should provide care for each person. 2 8 13 Whenever bedrails are used 11/03/2009 there should be a full risk assessment to show why the rails are being used. The rails must be fitted safely so that there are no gaps where a part of the persons body could become trapped. To ensure that bedrails are only used when it can be shown that they are necessary to keep someone safe. So that when rails are used they are used as safely as possible. Care Homes for Older People Page 26 of 29 3 16 17 Ensure that there is a record 11/03/2009 of any complaints received by the home. To show that peoples concerns are taken seriously and investigated. 4 18 13 Ensure that all of the people working in the home, including staff and volunteers, attend training about safeguarding vulnerable people from abuse. So that they are aware of how to respond to any incident that might occur. 29/05/2009 5 33 24 Establish a system of 29/06/2009 monitoring the care provided that includes residents and their relatives. To identify any improvements that are needed. 6 38 23 Ensure that staff attend regular fire drills and updates of fire safety training. So that they would know what action to take if a fire should occur. 29/05/2009 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 3 Revise the homes pre-admission assessment form to make sure that the staff providing care for a new resident have Page 27 of 29 Care Homes for Older People good information about their individual needs and preferences. 2 19 Consider replacing the nurses station with an office so that there is somewhere for private conversations to take place and so that the people who live at the home are not disturbed by noisy equipment. Remove the CCTV system that shows the interior of the home so that peoples privacy is respected. Provide a sluicing disinfector so that commode pots can be thoroughly cleaned and disinfected. Care staff should receive formal supervision with their manager six times a year. The general standard of record keeping needs to be improved so that important documents that relate to the health, safety and well-being of residents are fully completed and available to look at. Keep a regular check of hot water outlet temperatures to ensure that residents are protected from the risk of scalding. 3 4 5 6 19 26 36 37 7 38 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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