Inspection on 22/04/09 for Belper Views

This inspection was carried out on 22nd April 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belper Views 29/09/09

Belper Views 19/11/08

Belper Views 30/04/08

Belper Views 02/05/07

Belper Views 12/05/06

Belper Views 10/03/06

Belper Views 23/11/05

Belper Views 19/07/05

Belper Views 02/02/05

Belper Views 10/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Belper Views 50/52 Holbrook Road Belper Derbyshire DE56 1PB     The quality rating for this care home is:   zero star poor 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: Helen Macukiewicz     Date: 2 2 0 4 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 37 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 37 Information about the care home Name of care home: Address: Belper Views 50/52 Holbrook Road Belper Derbyshire DE56 1PB (01773)829733 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) : Mr Alan Kilkenny care home 25 Number of places (if applicable): Under 65 Over 65 25 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is: 25 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home The home is a large detached brick building with its own large garden and patio area, set on a hill on the outskirts of Belper. The area offers access to a good range of community and leisure facilities, although there are limited shopping facilities in the immediate area. The home offers accommodation for 25 older people in single rooms, some with en-suite facilities available, and has a good range of communal areas, offering a variety of spaces for people and their visitors to use. People at the home are registered with one of the two local Doctors practices and there is a small community hospital in the town. The current range of fees for the home is 353.92 to 373.17 GBP per week with no top Care Homes for Older People Page 4 of 37 1 9 1 1 2 0 0 8 Brief description of the care home ups. Hairdressing is charged at 1.00 GBP. The last Inspection report was kept in the foyer. You can obtain further copies of this report on www.cqc.org. Care Homes for Older People Page 5 of 37 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: zero star poor 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 inspection was unannounced and involved a visit to the site on 22 April and 28 April 2008. The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people who use the service and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgments. This may include notifications from the provider, complaints or concerns Care Homes for Older People Page 6 of 37 and the pre-inspection questionnaire, which the provider is required to complete prior to a visit to the service. The primary method of inspection used during the visit to this service was case tracking. This involved selecting three people who use the service and tracking the care they receive through review of their records, discussion with them where possible, the care staff and observation of care practices. All of the key standards were inspected on this occasion. We made a second visit on 28 April 2009. This formed part of this Inspection and was used to complete our processes and to monitor whether there had been compliance with the immediate requirements set on the first day of the visit on 22 April 2009. An interim unannounced Inspection took place on 19 November 2008. The purpose of this visit was to follow up on the requirements made at the previous full inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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 8 of 37 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 37 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. Lack of written information reduces peoples ability to make an informed decision about moving in and could lead to people being admitted inappropriately. Evidence: We saw information about the home and the services it offers written in a Service Users Guide. Although this was mainly accurate, we found that some information such as contact points for complaints was out of date. The home should also provide more detailed information in what is known as a Statement of Purpose. This document was not available for people to read at the time of this visit as the manager told us it was being updated. Therefore people wishing to find out about the home did not have full and accurate information on which the base their decision to move in. People we spoke to confirmed they had not been given any information in writing about the home but were told verbally. Care Homes for Older People Page 10 of 37 Evidence: We saw the care records for the latest people to be admitted to the home. The manager had obtained a Social Services and/or Health assessment prior to their admission for all but one person. This supported that she had knowledge about peoples needs so she could ensure they were admitted appropriately. However, this standard needed to be applied for all people, particularly those admitted privately. Care Homes for Older People Page 11 of 37 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. Gaps in paperwork and lack of monitoring systems means there is potential for care needs to be overlooked and medication errors. Not all people have their privacy and dignity upheld. Evidence: Since our last Inspection the manager and deputy had transferred much of the information about peoples care needs on to new paperwork. This paperwork made the assessment and recording of care needs more compliant with standards for record keeping in care homes. However, we found that the old system of day to day recording and care planning was also being used, alongside the new paperwork. This increased the potential for care needs to be overlooked. The manager told us that all staff would be trained to use the new paperwork at a planned staff meeting, and that old paperwork would then be discontinued. We saw that there was still some information missing from both new and old style paperwork. Peoples photographs were not always present, although verbal Care Homes for Older People Page 12 of 37 Evidence: communication and stability of staffing in the home ensured that people in the building were always known to staff. Peoples marital status and preferred names were not always stated. This would help staff to provide more individualised care. We found that one person did not have an assessment of their needs by care staff, or a plan of care in place. This persons daily notes recorded some of the care that staff had given them. However, lack of detailed information about them meant that care needs could be overlooked and could not support a planned approach to meeting actual or potential needs. We saw space on the new care planning documentation for both staff and the person whose plan it was, to sign to confirm their agreement to its contents. However, we found that none of the people living in the home, or their relatives had signed them. People confirmed that they had not seen their paperwork. This meant that staff were not fully involving people in the planning and reviews of their care. Despite gaps in recording, people and their relatives told us that they were getting the care they need. People told us they saw their G.P when needed, chiropodist and optician. One person told us they were able to access G.P. facilities within the community, but that the G.P. also came to see them at the home. There was evidence in the paperwork that people received visits from specialist nurses and district nurses in the Community and that people attended out patients appointments when needed. One relative said on the whole (x) is very happy here. A social care professional who completed a pre-inspection survey for us wrote provides appropriate level of care....they are often able to cope with residents who have behavioural problems, or perhaps bring about a more appropriate behaviour regime. Although staff told us they had received medication training, we saw that the management of medication within the home was not being monitored effectively. We saw that the dose of one persons medications had been incorrectly recorded, although when we checked we found they had been receiving the right dose. We found that the same persons medication chart had omitted two medicines they had been on when discharged from hospital. This person had been without their correct medication for 12 days. The staff took immediate action on the day of our visit, to contact the persons G.P. to ensure they got their medication. We also saw that not all of the medicines being brought in to the home were being recorded, this meant that there was potential for unaccounted medicines within the building. We also found that one medication was not being stored in the correct medication cupboard. By the time of our second visit, we were assured that the staff had taken action to address issues. However, we were concerned that the systems in place within the home, to monitor medicines, had failed to identify these errors. Care Homes for Older People Page 13 of 37 Evidence: On the second visit we also found that each persons medication was being started on a different day. Although this did not present staff with any problems, it would reduce the potential for errors if everyones medication charts started on the same day. This would also make it easier for staff to audit charts. We found that people were not always receiving their medication at the times stated on medication charts, and that coding systems were not clearly explained on the paperwork. We saw some evidence that staff upheld peoples need for privacy. People living in the home told us that they saw visitors in private and that staff knocked on their bedroom door to request permission before entering. Visitors told us that their relatives were treated with dignity and respect, and had their need for privacy upheld. However, we observed that staff were not always upholding the privacy and dignity of people who were unable to express an opinion. Staff were using one persons bedroom for purposes other than their care. This person lacked capacity to consent to such use. We had not received any concerns about peoples care since we last inspected and people we spoke to were happy with their arrangements. However, we found this was mostly as a result of the good relationships and communication between staff themselves and between staff and people living in, and using the service. Supported by a low staff turnover and stable management. This good practice was not mirrored in record keeping standards and management audits. This is where the service falls short of regulatory requirements and where staff will need to focus their attention. Care Homes for Older People Page 14 of 37 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 are able to lead an active lifestyle but records do not support that people are able to choose what they do. Evidence: In her completed pre-inspection self-assessment the manager told us that they could do more activities and outings with residents. Some people we spoke to said that there was not much to do during the day. One said it could be a bit boring. People were watching television, or doing jigsaws. Most people told us they were unwilling or unable to go out into the community. However, those who were able to, or who chose to were supported to go out. One person had been supported to book a two week holiday by the sea. Staff also supported people to meet their spiritual needs. The manager recognised that a flurry of recent admissions had meant that there were some more people who would be able to go out and that she would need to organise some trips out to meet their needs. People told us that staff had booked entertainers to come in to the home and that they enjoyed these. Talking books/newspapers were available for those with visual impairment. Care Homes for Older People Page 15 of 37 Evidence: Some paperwork had been filled in to show what activities people had taken part in, although records were not complete. Not all people had their social and spiritual needs assessed in care documentation, so it was unclear as to whether entertainment programmes were meeting individual needs. Lifestyle choices and preferences were assessed for those people who had a plan of care, these showed peoples preferred routines. People told us that the daily routine was flexible and that they could come and go as they pleased. One said staff are very good, you can do what you want in the day. One relative told us we make sure (x) has enough to do during the day, (x) did tend to isolate themselves in their room but staff encouraged (x) to come out. People told us that the food was good and that they are offered plenty of food. The cook knew about peoples individual dietary needs, she had menus and described how she offered people choice, but was not routinely keeping a record of the choices she offered to support this. Fresh fruit was available along with ample food stocks in the kitchen area. Care Homes for Older People Page 16 of 37 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 kept safe and have their right to complain upheld. Evidence: In her completed pre-inspection self-assessment the manager wrote that they had not received any complaints since we last Inspected. This was consistent with what people told us on the day. People felt confident they could raise concerns with the manager or senior staff, and that she would sort things out. People told us they had never had any cause to complain. People were less confident about who they would contact outside the home. The written information about the home, both in the Service Users Guide and displayed complaints procedure both had the incorrect contact details for us. One relative told us they taken minor issues to the manager in the past, but had all issues resolved to their satisfaction. There were no recorded minor concerns in the complaints log. In the absence of recording all issues raised, the manager would have to rely solely on verbal feedback from staff to audit trends within the home and identify any recurring issues. There had been one safeguarding issue in the past 12 months, this had been resolved. The manager had worked co-operatively with social services throughout. Some staff had training certificates in their files to show that they had attended a safeguarding adults course in 2008. However, there were at least two staff members who had never Care Homes for Older People Page 17 of 37 Evidence: attended this in respect of their employment in the care home. When asked, staff were unclear about the exact procedure should a safeguarding concern arise, but would ultimately keep people safe, through their response. There was heavy reliance in the managers presence to deal with any issue, and no clear and available guidelines should the manager be unavailable. Contact numbers for key organisations were not clearly displayed and staff could not locate the safeguarding policy. There was information about the Mental Capacity Act on display in the foyer although the manager and deputy told us that they had not undertaken any training on this, or the Deprivation of Liberty guidance. Therefore they had limited understanding of their legal obligations and peoples rights in relation to this important legislation. Care Homes for Older People Page 18 of 37 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. The environment is suited to the needs of people living there, although outstanding maintenance potentially compromises some peoples privacy. Evidence: In her completed pre-inspection self-assessment the manager told us all fire doors have been upgraded, new carpets planned. We saw that a programme for refurbishing the home was underway. Where complete this had made a significant improvement to peoples environment. Some of the work had not been completed which meant that some people did not have a lockable bedroom door and one toilet door had no lock on. Both these areas impact on peoples privacy and dignity. Some bedroom doors were not closing fully onto the rebates which compromises fire safety within the building. However, the manager told us that the owner was currently working on the doors to ensure they met standards. People told us they were happy with their environment, one relative said the home always smells clean. People told us that they were given a choice of bedroom when they first moved in. People were happy with the laundry service and told us that clothes were quickly returned. There was equipment available for the maintenance of infection control and Care Homes for Older People Page 19 of 37 Evidence: dealing with soiled laundry. Care Homes for Older People Page 20 of 37 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Gaps in recruitment practices and training means that people are not fully safeguarded by the home. Evidence: Staffing rotas showed that there was a stable staff team with low staff turnover, thus ensuring people had continuity of care. Staff told us they worked well with each other and we observed that communication was positive between them. There was management support four days/week on the rotas we saw. For two days/week the manager and deputy worked together. There were three staff provided throughout the day plus cleaning staff and a cook. Two care staff worked each night. People told us that staff were quick to respond when they asked for help. One relative told us there are always staff around We noticed that three shifts on a staffing rota had been covered by a member of staff who was not a regular employee. We found that there were no recruitment records for them, which meant that people could be put at risk through unsuitable workers. We found no induction programme for the staff member. By our second visit the manager had asked this person to make a formal application to work at the home. However, the recruitment form used did not comply with legislative requirements for safe recruitment practice. Care Homes for Older People Page 21 of 37 Evidence: We also found that there was no evidence of criminal records checks for some people who were contracted to undertake regular non-care duties at the home. We spoke to staff who told us they had received most of their mandatory training and we saw certificates in staff files that supported this. Staff were planned to attend basic food hygiene and first aid training and we saw confirmation that this training had been booked. We saw that two members of staff had not attended any training organised by the home. This means that people may be put at risk through lack of staff knowledge on basic safety procedures, including fire and first aid. Of the 15 staff in total employed at the home, 11 have National Vocational Qualifications to level 2 or above. We found that there was emphasis on getting staff through this, and mandatory training. However, staff were not provided with many opportunities to attend additional training in areas such as equality and diversity, dignity, choice and rights and complaints management. Furthering staff knowledge in such areas may assist management to address some of the dignity issues raised throughout his report. Care Homes for Older People Page 22 of 37 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Gaps in legislative knowledge and quality assurance systems means that people are being exposed to preventable risks. Evidence: The manager of the service has a Registered Managers Award and has updated her knowledge in the past year by attending mandatory training. A deputy manager had been appointed in September 2008 to assist in the development of care planing and organisational policies. She had also obtained a Registered Managers Award. Both managers told us they had not attended any training yet in 2009 but that some mandatory updates were planned. We saw from the staffing rotas that both managers had about one supernumerary day/week to focus on the paperwork, but both stated they were often called away to cover staffing shortfalls or to answer telephone queries. One of the projects that the deputy manager had taken on was the development of a staff handbook, and full review of the homes policies. Although at the time of this visit, both were at the early stages of development. Care Homes for Older People Page 23 of 37 Evidence: We found that both the manager, and the registered person were not fully aware of our legislative requirements surrounding the operational running of the home. As a result we had only received one notification legally required from them. Also, the registered person had not been in day to day charge of the home and had not been conducting monthly monitoring reviews and reports on the running of the home as legally required. In her completed pre-inspection self-assessment the manager told us we ensure that once a year we send out questionnaires. However, none had been sent out so far this year and there were no other quality control systems in place. The Annual Quality Assurance Assessment (AQAA), referred to as the pre-inspection self-assessment throughout this report was poorly completed. This is an opportunity for providers to tell us about the state of the service, any areas for improvement that have occurred and any actions they intend to take to develop the service. This is a legal requirement. We found that the AQAA was not fully completed. The questions relating to equality and diversity were particularly poorly completed with sections left blank. It did not give us a reliable picture of the service. Good communication internally between staff had ensured that no adverse effects had occurred as a result of poor record keeping in terms of care records. The home had also ensured through diligent practices that medications had been safely administered despite errors in recording dosage and administering at different times than those prescribed. Action had also been taken swiftly in terms of the immediate requirements made at the time of the first visit. However lack of adequate quality assurance systems led to gaps in care planning and medication requirements being missed and ultimately left unattended. The lack of understanding about legal requirements in recruitment left people exposed to a potentially unsuitable care worker and peripatetic workers on the part of both the registered person and registered manager. The manager told us that they were operating the same system for handling money as last year, and no concerns were raised about this by people who used the service. Staff told us they felt supported but had not received any formal supervisions. We saw no record of regular staff supervision or any evidence of a programme in place to address this. Staff policies were being updated by the deputy manager who aimed to put the key policies into the staff handbook. This will be a positive development for the home. However, at the time of this visit staff did not have access to a clear set of accurate policies covering all aspects of the running of the home. We saw that some staff Care Homes for Older People Page 24 of 37 Evidence: members brought their dogs into the home. Whilst people using the service were clearly benefiting from having this arrangement, there was no clear policy in place governing how this should be managed, and which took into account any trip hazards they might present. The manager had taken action to address this by the time of our second visit. A general risk assessment of the environment was seen and service records were all up to date by the time of our second visit, with the exception of the portable appliance testing, which was due, supporting that people were largely kept safe from faulty equipment. Care Homes for Older People Page 25 of 37 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 7 15 1)2) The new care 31/01/2009 documentation acquired by the manager must be completed in full for all people so that their care needs and any risks to them are identified with instructions for staff on how to manage these. Care plans must be updated as care needs change. This documentation must also be commenced immediately for any new admissions to the home. This is to ensure that people have their needs identified and that this is recorded in a logical way. To provide clear instructions for staff so that care needs are not overlooked. 2 30 18 1)c) All staff must receive basic food hygiene and first aid training updates. This is to ensure that peoples wellbeing is not adversely affected by gaps in staff knowledge. 31/01/2009 Care Homes for Older People Page 26 of 37 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 1 7 15 1) A care plan and risk assessments must be in place for the person identified to staff during the first Inspection day. This must be done by 27 April 2009. This is to ensure the persons care needs are met. 14/05/2009 2 9 13 2) Staff must ensure the 13/05/2009 person identified during the Inspection has their doses of medicine correctly recorded on their medication administration chart. This is to ensure the persons welfare is fully protected. 3 9 13 2) Staff must contact the 13/05/2009 G.P. for the person identified during the Inspection by 22 April 2009 to ensure they receive their prescribed medication. This is to enusre the persons welfare is fully protected. 4 9 13 2) Staff must ensure the 14/05/2009 exact amount of medication being brought into the home is stated on the medication chart. This is to ensure that all medications are fully accounted for. 5 10 12 4)a) Staff must only use 04/05/2009 toilet facilities designated for Page 27 of 37 Care Homes for Older People them. This is to ensure peoples right to privacy and dignity are upheld. 6 10 12 4)a) Staff must discontinue 04/05/2009 using the bedroom identified during the Inspection for purposes other than those directly relating to the occupants care. This is to enusre peoples right to privacy and dignity are upheld. 7 29 19 and schedule 2) No staff to be employed without required pre-employment checks. This is to ensure that people are safeguarded at the home. 8 29 19 and schedule 2) Recruitment 14/05/2009 records, evidence of preemployment checks and induction training must be obtained for the staff member who worked 3 shifts, identified during the Inspection. If preemployment checks have not been carried out, the person must not be allowed to work at the home until such checks have been returned. CRB and POVA 1st checks must be sent off by 23 April 2009. This is to ensure that people are safeguarded at the home. 9 30 18 1)c)i) There must be arrangements in place for the two staff members identified during the Inspection to attend 14/05/2009 04/05/2009 Care Homes for Older People Page 28 of 37 mandatory training in all required areas. There must be documented evidence of this by 27 April 2009. This is to ensure that staff are adequately trained to ensure the health, safety and welfare of pole living in the home. 10 36 12 4)a) There must be a policy 14/05/2009 in place for pets brought into the home by staff. This must include risk assessment of animals against issues such as trip hazards they may cause to service users and in case of any allergies service users may have. The policy must include designated areas within the home where staff may allow their pets to wander. To ensure peoples rights to privacy and dignity in their own accommodation is upheld and to keep them safe from preventable hazards. 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 1 5 The Service Users Guide must be updated so that it provides people with accurate information about the service. 31/07/2009 Care Homes for Older People Page 29 of 37 This is to ensure people have a summary of the services provided at the home and their rights. 2 1 4 And Schedule 1) A Statement of Purpose must be written, which contains the information listed in Schedule 1. This must be made available to people who use the service. This is to ensure people have an informed choice about whether to move in to the home and to prevent inappropriate admissions. 3 3 14 No person must be admitted 31/05/2009 to the home without having been assessed as to their needs, and a copy of this assessment must be obtained before they are admitted. This is to ensure that people are not admitted inappropriately and that the home can meet their needs. 4 7 15 2)a) Staff must ensure they make the service users plan available to them, and fully consult with them about its contents. This is to ensure that people give their full consent to any care they receive and that their rights to choose what care they receive are upheld. 30/06/2009 31/07/2009 Care Homes for Older People Page 30 of 37 5 9 13 2) All medication charts must include correct coding systems that are well explained. Medication charts must support that people are getting their medication at the right time. Controlled drugs must be stored in a cupboard that complies with the Misuse of Drugs (Safe Custody) regulations for safety reasons and to meet legal requirements. This is to ensure that people are kept safe through good medication management systems. 31/07/2009 6 12 16 2)m)n) Individual social care 31/07/2009 plans must be completed and social activity must be provided for all. Activities people take part in must be recorded on the social activity plan bit of the new documentation as evidence. This is to ensure social activity meets individual needs. 7 16 22 7) The correct details for contacting the Care Quality Commission must be stated on all complaints procedures. This is to ensure people are kept safe through knowledge about their access to an 31/07/2009 Care Homes for Older People Page 31 of 37 external body for complaints. 8 18 13 6) All staff must receive safeguarding training and have access to local procedures, including telephone contact numbers for passing on safeguarding concerns in the absence of the manager. This information must be kept in a place known to all staff. This is to ensure people are kept safe. 9 19 23 4)a) Bedroom doors must be 31/07/2009 maintained so they close fully. This is to ensure fire safety throughout the building. 10 19 12 4)a) Bedroom doors must be 31/08/2009 fitted with a door lock function so that those people who are assessed as safe to do so, may opt to clock their bedroom door themselves. This is to ensure people have their right to privacy upheld and so they can maintain their Independence. 11 29 19 and schedule 2) 30/06/2009 Documentation to support the recruitment of staff must be compliant with Regulation 19 and Schedule 2. All staff who are employed by the home and who may have unsupervised access to 31/07/2009 Care Homes for Older People Page 32 of 37 people must be subject to Criminal Records Bureau checks. This is to ensure people are kept safe at the home. 12 32 37 The registered person must notify us without delay of any occurrence listed within this regualtion. To ensure that people are kept safe at the home. 13 33 24 You must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided by the home. This is to ensure that you are fully aware of what improvements you need to make to improve the quality of service that people receive. 14 33 24 1) There must be systems 31/07/2009 put in place to review and improve the quality of care provided at the home, including the development of systems to monitor medications, care plans and recruitment. This system must allow for consultation with service users and their representatives. This is to ensure that internal quality control identifies and rectifies any shortfalls in care that people 31/07/2009 30/06/2009 Care Homes for Older People Page 33 of 37 receive and to keep them safe. 15 33 26 Where the registered 31/07/2009 provider is not in day to day charge of the home, he shall visit the home in accordance with this regualtion and prepare a report on the conduct of the home. This must be sent to the Care Quality Commission each month. This is to ensure that any shortfalls in practice are identified in a timely way to reduce the impact on people using the service. 16 36 18 2) All staff who work in the care home, including the manager must be supervised and these sessions must be recorded as evidence. To ensure people are cared for by adequately supervised staff. 31/07/2009 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 1 The Statement of Purpose and Service Users Guide should be made available in other formats such as large print or audio version, to ensure that people with sensory loss have equality of opportunity to find out information about the service. The use of a second set of care planning documentation should be discontinued and all care records transferred on to the new paperwork, including daily care notes recorded by care staff. This is to ensure no care needs are Page 34 of 37 2 7 Care Homes for Older People overlooked. 3 4 7 7 People should sign to confirm their agreement to their plan of care. The marital status and photographs should be included in care planning documentation, so documentation supports individualised care. All medication charts should commence on the same day to reduce the potential for medication errors. Staff should record peoples preferred names in their care documentation, to ensure that they are addressed in the correct way and uphold their dignity. All informal concerns should be recorded and a system established for monitoring and audit of such records. This is to ensure the service is run in peoples best interests. Staff should attend training on the Mental Capacity Act and Deprivation of Liberty to ensure they understand peoples rights in relation to this. All bathrooms and toilets should be provided with a privacy lock to ensure peoples need for privacy can be met. All new starters should be placed on a TOPSS certified induction and foundation training course. This is to ensure people are cared for by experienced and competent new staff. Staff should be offered additional training in areas of equality and diversity, dignity, choice and rights and complaints management to further improve the quality of service provided to people. The registered person and registered manager should be fully conversant with the legislative requirements governing the operaton of the care home as stated in the Care Homes Regulations 2001. This is to ensure people benefit from a home that is well managed and which keeps them safe from preventable risks. The manager and deputy should have some additional management training particularly in the areas of personnel management practices and equality and diveristy. The Annual Quality Assurance Assessment should provide us with the details of how you will comply with Regulation 24. This is to ensure people receive the best quality service. The system for supervising staff should include all elements listed in standard 36. Staff should have access to a clear set of accurate policies Page 35 of 37 5 6 9 10 7 16 8 18 9 10 21 28 11 30 12 31 13 32 14 33 15 16 36 37 Care Homes for Older People covering all aspects of the running of the home. This is to ensure staff have the right guidelines and knowledge to keep people safe. 17 38 The testing of portable appliances should occur at regular intervals to ensure people are not exposed to preventable risks. Care Homes for Older People Page 36 of 37 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 37 of 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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