Inspection on 29/09/09 for Belper Views

This inspection was carried out on 29th September 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belper Views 22/04/09

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 25/11/2009.

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 is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Helen Macukiewicz     Date: 2 9 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 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: Mr Alan Kilkenny care home 25 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 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 ups. Day care is charged at 28.00 GBP per day. Hairdressing is Care Homes for Older People Page 4 of 32 Over 65 25 0 2 2 0 4 2 0 0 9 Brief description of the care home charged at 1.00 GBP. The last Inspection report was kept in the office. further copies of this report on www.cqc.org. You can obtain Care Homes for Older People Page 5 of 32 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 at 9.00 am. We undertook a second visit on 7 October 2009 at 12.40 pm to follow up immediate requirements left at the time of the first Inspection date. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people using 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 judgements such as notifications from the provider, complaints or concerns. We also use information from an Annual Quality Assurance Assessment (AQAA), which the Care Homes for Older People Page 6 of 32 provider is required to complete prior to a visit to the service. This provides evidence for us to make informed judgements when assessing the National Minimum Standards (NMS). The primary method of inspection used during the visit to this service was case tracking. This involved selecting three people and tracking the care they receive through review of their records, discussion with them where possible, the care staff and observation of care practices. Time was spent in discussion with the Manager and staff. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. All of the key standards were inspected on this occasion. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: There still needs to be more information provided about the home, a Statement of Purpose needs to be developed for this purpose. Staff need further training to ensure they give people the medications they need. The manager needs to put into place a recorded system to identify when people have not had the medication they need. People need more to do in the daytime, they need more organised activities both inside and outside the home and need to be able to access their immediate community more. Staff need further training in all mandatory subjects, there needs to be an organised system to identify training needs of staff and to source relevant training at appropriate intervals. This would help to ensure staff had the right skills to provide safe care to people. Staff need to be supervised at regular intervals and this needs to be recorded. This is to ensure staff providing care to people are adequately supervised. Systems for monitoring the quality of the service, both at manager and provider level need to be recorded. Copies of the providers monitoring reports need to be sent to us, Care Homes for Older People Page 8 of 32 as evidence. There were several legal requirements of our last Inspection that have not been met within the required timescales. We are considering legal action in these areas and will be monitoring compliance. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 32 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 32 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 are properly admitted to the home, although better information about the home would ensure people had all the information they need to make informed choices about their care. Evidence: We looked at the information the home provided to people about the services they offer. Since we last visited a Service Users Guide had been written. This gave people a summary of what they could expect from the home, including fees payable. There were copies in peoples bedrooms. One visitor we spoke to said they had been given enough information about the home before their relative was admitted. Although there was a new Service Users Guide, there had not been a more comprehensive document, known as the Statement of Purpose devised. This would provide potential purchasers information about what they could expect from the service, in more detail. We had asked for this at the time of our last Inspection. This is a legal requirement that has not been met. Care Homes for Older People Page 11 of 32 Evidence: One person had been admitted to the home since we last visited. There was new documentation in place to support they had been properly assessed prior to their admission. Staff had worked hard to ensure that new documentation was in place in all files. This supported that people also had a proper assessment of their needs following their admission. This included risk assessments. People told us they were happy with their choice of home. In their completed preinspection survey one relative wrote the service (x) receives from Belper Views is excellent, I and my family have total peace of mind that (x) is being looked after; on any visit we are made welcome. One person living in the home wrote Im pleased with everything and another wrote Im very happy indeed. Care Homes for Older People Page 12 of 32 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. People receive the care they require in a private and dignified way. Not all people receive the medications they need. Evidence: Staff had ensured that peoples care files were updated and that the required improvements to care plans were made. When we checked through a sample of care plans, all were in place and had been regularly reviewed. Care plans gave staff clear directions about what the persons care needs were, and how they could meet those needs. Care plans had been updated as peoples needs changed. Personal details about the person were completed except for the marital status, which was known by staff, but not always recorded. Files supported that people were receiving regular visits from their G.P, District Nurses, and also attending outpatients appointments as needed. They also supported that people were being involved in the planning of their care. One visitor on the day told us they thought their relative was being well looked after Care Homes for Older People Page 13 of 32 Evidence: and one person told us that staff upheld their privacy. Staff were observed to be routinely knocking on doors, to request permission before entering. Several people told us that staff maintained their dignity and treated them with respect. In their preinspection surveys people living in the home told us they got the care and support they need. They wrote the following comments: looking after us very well, good care, care for individuals and attend to individual needs and that the home take care of us. One relative wrote (staff) do not think twice in calling the Doctor and went on to say that the staff give (x) their dignity. There had been improvements to the management of medicines since we last visited, which meant that medicines were being given out and recorded in a safer way. Better storage facilities for drugs had also been provided. Some staff had received medication training. However, we found that one person had not received all the medicines they required, but had them signed off as being given on the medication record. The manager said she regularly checked medicines to ensure discrepancies did not occur. However, she did not record this. We found no other discrepancies with peoples medications. Care Homes for Older People Page 14 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples lifestyle choices are limited at the home and they do not have enough opportunity to access their local community. The meals provided meet peoples expectations. Evidence: The home provided people with some regular activities. People received regular visits from a singing group. One person regularly went out into the local town using a local bus service. Staff had accompanied people to Chiropody appointments at the local Hospital. The manager showed us some Birthday cards that people had made, and we saw people knitting and listening to music during the day. Two people had access to a regular supply of talking books. Peoples care files showed that staff had asked them to supply a life history so they could get to know them better. Staff had written an individual social care plan, although they did not include anything about how they could assist people to access their local community or individualise daily routines. Staff were also recording what activity people had taken part in, including Bingo and nail care. Again, these records were limited and did not provide a full picture of the activity they undertook. Care Homes for Older People Page 15 of 32 Evidence: People told us that they would like to see more activities taking place both inside and outside the home, although they acknowledged the staff had made improvements in this area. On the day, peoples comments included not much to do at all, I dont do anything, Im alright now they have put the music on, they have the tele on but most of us cant see it and activities are getting better, there is more to do but it is still not enough. In their pre-inspection surveys some people living in the home also wrote there were never any activities they could take part in. Other surveys from relatives, staff and people in the home contained the following comments in the section about what the home could do better: outings; when I visit there is little sign of any organised activities, join in making things and maybe encourage service users to participate in more recreational activities both inside and outside the home. In particular, people said they would like more outings. People told us their daily routine was flexible, they could get up and go to bed when they wanted and spend time in their bedrooms. They could watch Television in their rooms anytime. One person said they dont routinely have the option of breakfast in bed but added I expect you could if you asked. Visitors were allowed anytime. People described the food as very nice, food is good, you can have what you want and we have crisps at night. Im quite happy with what we have. People could eat their lunch and tea in their bedroom if they wanted. The menus we saw showed that people were offered a varied diet. Care Homes for Older People Page 16 of 32 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 may not have the all information they require in order to raise concerns. Gaps in staff training means that all safeguards are not in place. Evidence: Not everyone who filled out a pre-inspection survey for us knew how to make a complaint, but said they had not got any concerns. One person wrote no complaints, very well taken care of. On the day of this visit, people said they would see the manager or proprietor with concerns. We found that the contact points for complaints had not been updated at the time of our first Inspection visit. We had asked for this to be done at our last Inspection. However, by the time of our second visit people had the right information available to them. The manager told us she had not received any concerns about the home since we last visited, but had new recording forms should she receive one. These gave clearer guidance for staff on the procedures to follow should concerns be raised. The manager said that no-one was subject to any form of agreed restraint, such as bed rails. There had been no safeguarding issues since we last visited. One member of staff said they had attended recent training on safeguarding adults, but staff training records showed that not all staff had received this mandatory training. Safeguarding Care Homes for Older People Page 17 of 32 Evidence: procedures were seen in a staff policy file. One member of staff said they hadnt seen these but was able to provide a safe response when questioned. The need to ensure that all staff had the required training and knew where to find safeguarding procedures was a legal requirement of the last Inspection that has not been fully met. Management had undertaken training in the Mental Capacity Act and deprivation of liberty. New documentation was in place within care files to enable staff to write a brief summary of any factors that may impact on peoples liberty, and to record if they needed an assessment of capacity or support to make decisions, with key contact points. Care Homes for Older People Page 18 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment of the home meets with peoples expectations. Evidence: The proprietor had undertaken an audit of all areas of the home on the day we visited, with a view to making improvements where needed. He showed us a list of the jobs he had identified, and had set aside a team of maintenance staff to undertake repairs within the next two weeks. We saw evidence of an ongoing programme to upgrade bedroom facilities, including the provision of more privacy locks on bedroom doors. One bedroom in particular had a damaged ceiling and we would expect this to be prioritised within the forthcoming repairs. We found that there was only one staff call point in the conservatory. This was not sufficient to ensure that all people sitting there had access to a call bell. The manager was aware of the need to provide an additional point and was looking into this with the provider. People told us that they were very happy with the laundry service. One described it as absolutely marvelous, and another said it was very good. Staff told us that all the laundry equipment was working at the time of our visit. We saw there were arrangements in place to maintain infection control. Staff had Care Homes for Older People Page 19 of 32 Evidence: hand rub available and gloves and aprons for protection. There were public health notices around the home advising people on good practice. Care Homes for Older People Page 20 of 32 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. People are cared for by sufficient numbers of caring staff. However, gaps in training and recruitment means that people could be exposed to potentially unsuitable workers who do not have the right skills and training. Evidence: There was no staffing rota for the week of the inspection at the home. The manager told us that the administrator had taken it to do staff wages, and confirmed that all staff knew what they should be working. Staffing rotas for the previous week showed that there were three care staff on duty during the day and two at night. Additional support was provided by domestics, a cook, an administrator and the proprietor and his wife. People told us they thought there was enough staff. They said that although there had been times when the home was short, two new staff had recently been appointed to address this. In their completed pre-inspection survey one relative wrote they (the staff) create a very happy, caring and professional environment and another told us that staff showed good interpersonal skills, carers show great care and responsiveness to those they look after. They show much patience and retain their sense of humour. People on the day of this visit also spoke highly of staff. Their comments included staff are very nice, the staff are very good and I get on well with all the staff and thats really important. Three people told us that staff were respectful when caring for them. Care Homes for Older People Page 21 of 32 Evidence: One person said weve all got respect, we have respect for one another and we get on well with all of them. Theres plenty of them around, they are very good to us. People confirmed that staff regularly checked on them through the night and attended to their needs. We found that 11 of the 16 care staff had National Vocational Qualifications in care subjects to level 2 and above. There were also certificates in staff files to show they had received some first aid, dignity, fire safety and mental capacity act training recently. The manager had forms to show that she had booked some staff on a nutrition course, dementia care and palliative care courses. However, staff had not received mandatory training in subjects such as basic food hygiene and COSHH. We found that some staff had never had moving and handling training, and others had out of date certificates in their files. We observed staff using wheelchairs without footrests during this Inspection suggesting that practices in the home needed to be improved and that staff training was required. The need to ensure all staff received the required mandatory training was a legal requirement of our last Inspection, this has not been met. Due to the fact that no new staff had actually commenced work at the home, we could not fully assess compliance with recruitment procedures. However, two new staff were in the process of being recruited. There were gaps in the employment history one person had provided and both had not been subject to any health screening. Advice was given to the manager about what checks needed to be made and an extended timescale was given for compliance in this area. One person was covering shifts in the home, this person was known personally to the proprietor and manager. A satisfactory criminal records check was seen for this person, but no recruitment history, or training records were in place. Some paperwork was in place to provide any prospective new staff with an induction, although this needed further development and co-ordinating into a working document. Care Homes for Older People Page 22 of 32 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. Management in the home is not effective in ensuring legal requirements, which may be necessary to safeguard people, are met. Evidence: In their pre inspection survey one person living in the home wrote management and staff are very good to us. The manager of the service had a Registered Managers Award and had updated her knowledge in the past year by attending some, but not all the required mandatory training. The deputy manager, appointed in September 2008, was still in place and also had a Registered Managers Award. We saw from the staffing rotas that both managers were not being provided with the supernumerary time we would expect to ensure standards and legal requirements within the home were met. The projects that the deputy manager had taken on at the time of our last visit had been achieved. She had successfully developed a staff handbook, and conducted a full review of the homes policies. We also found that the manager and the registered person had been successful in improving care planning and medications. However, Care Homes for Older People Page 23 of 32 Evidence: they were still not fully aware of our legislative requirements surrounding the operational running of the home. As a result we had not received a notification legally required from them concerning a serious injury sustained by a person living in the home. This is a legal requirement of our last Inspection, that has not been fully met. We also found that there were several requirements made at the time of our last visit, that had not been complied with. The registered person was not in day to day charge of the home. Although he had appointed a person to undertake monitoring visits on his behalf, only one had taken place and we had not received a copy of this and did not see it at the home. Such visits are required monthly, and a copy of the report was requested at the last Inspection. This is a legal requirement that has not been met. Shortly after our Inspection we were sent a copy of the one visit made and saw a copy at the home. However, this had not been effective in identifying outstanding requirements identified through this report. No quality assurance systems were in place at the time of the visit. No questionnaires seeking the views of people who use the service had been issued. Improvements had been made to medication practices and care planing, but no formal monitoring systems were in place to ensure these areas continued to be safely maintained, and we saw that a medication error had occurred. Although we did not fully check recruitment practices, there was evidence to suggest that the management of the home still required more experience and knowledge of the legal requirements surrounding the employment of staff. Staff were still employed to work at the home without sufficient training, induction and recruitment records. This left people exposed to a potentially unsuitable care workers. The need to ensure staff received the right training was a legal requirement that has been unmet from our last Inspection. A check of the systems for handling peoples personal money showed that there were discrepancies between the amount held on behalf of people, and their financial records. An immediate requirement was made at the time for the manager to address this. By the time of our second visit money held corresponded with balance sheets. However, receipts were not available for all transactions. The way the home was managed ensured that staff were regularly supervised by the manager, although there were no formal systems in place to ensure staff received regular formal supervision. This was a legal requirement of the past two inspections, that had not been met. There were records in place to support that equipment used by people in the home, was safely maintained. Care Homes for Older People Page 24 of 32 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 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. An extended timescale to meet this requirement has been given. This must be completed by 30 November 2009. This is to ensure people have an informed choice about whether to move in to the home and to prevent inappropriate admissions. 31/07/2009 2 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. 31/07/2009 3 29 19 and schedule 2) 30/06/2009 Documentation to support the recruitment of staff must be compliant with Regulation Page 25 of 32 Care Homes for Older People 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 19 and Schedule 2. All staff who are employed by the home and who may have unsupervised access to people must be subject to Criminal Records Bureau checks. Compliance with this regulation could not be checked at this Inspection. An extension to meet this requirement is given. This must be complied with by 30 November 2009. This is to ensure people are kept safe at the home. 4 30 18 1)c) All staff must receive basic food hygiene updates. This is to ensure that peoples wellbeing is not adversely affected by gaps in staff knowledge. 5 30 18 1)c)i) There must be arrangements in place for the two staff members identified during the Inspection to attend 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 peole living in the home. 6 32 37 The registered person must 30/06/2009 14/05/2009 31/01/2009 Care Homes for Older People Page 26 of 32 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 notify us without delay of any occurrence listed within this regualtion. To ensure that people are kept safe at the home. 7 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 receive and to keep them safe. 8 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. 9 33 24 You must establish and maintain a system for 31/07/2009 Care Homes for Older People Page 27 of 32 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 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. 10 36 18 2) All staff who work in the 31/07/2009 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. Care Homes for Older People Page 28 of 32 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 35 13 6) All accounts for money held on behalf of people living in the home must be audited. All money belonging to people must be correctly accounted for in the records held at the home. Receipts must be kept for all monetary transactions. Balance sheets must correspond to the amount of money held on behalf of people. This is to keep people protected from financial abuse. 05/10/2009 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 9 13 2) People must receive the medications they are prescribed. Staff must not sign for medications that have not been given. All staff responsible for administering medications 31/10/2009 Care Homes for Older People Page 29 of 32 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 must be provided with further training in handling medicines. This is to ensure people receive the treatment they require and are kept safe. 2 9 13 2) The manager must record 31/10/2009 any audits of medications, as evidence that this area is being monitored effectively. This is to ensure people get the medication they need. 3 27 17 2) and schedule 4. A copy of 31/10/2009 the duty roster of persons working at the care home must be kept in the home at all times. This is to support that staff numbers are sufficient at all times, to meet peoples needs. 4 29 18 A staff file, demonstrating 30/11/2009 the training, recruitment, induction and supervision received must be kept at the home, in respect of the person identified at the Inspection as being known to the manager and provider, who is working shifts. Care Homes for Older People Page 30 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure that people are not exposed to potentially unsuitable workers. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 7 12 13 Peoples marital status should be recorded in their care files, to ensure personalised care. People should be offered more social activity at the home. This is to improve their quality of life. People should be assisted to access their local community more and organised trips out should take place at intervals agreed with people living int he home. This is to ensure people do not become socially isolated. A formal induction and foundation training programme should be established for any new staff employed. The managers at the home should be given supernumerary time to ensure the legal requirements listed in this report can be achieved. This is to ensure safeguards are in place for people. 4 5 30 31 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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