Inspection on 06/10/08 for Blackwater Mill Residential Home.

This inspection was carried out on 6th October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blackwater Mill Residential Home. 27/01/10

Blackwater Mill Residential Home. 06/03/09

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Blackwater Mill Residential Home Blackwater Mill Country Retirement Home Blackwater Newport Isle Of Wight PO30 3BJ     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: Anita Tengnah     Date: 0 6 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Blackwater Mill Residential Home Blackwater Mill Country Retirement Home Blackwater Newport Isle Of Wight PO30 3BJ 01983520539 01983520539 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Buckland Care Ltd Type of registration: Number of places registered: care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 50. The registered person may provide the following category/ies of service only: Care home only ? (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability (PD) - 4 Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Blackwater Mill Country Retirement Home is a registered care home that provides personal care to 50 service users in the older person category and people with a physical disability. The home has recently changed hands and Buckland Care Ltd owns the service. The registered manager has left since this visit. The home is a substantial detached three-storey property set in extensive landscaped grounds, which includes a Care Homes for Older People Page 4 of 34 Over 65 50 0 0 50 Brief description of the care home lake. It is located in rural Blackwater approximately two miles south of Newport town centre with its shops and amenities. Care Homes for Older People Page 5 of 34 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: An unannounced inspection visit was carried out on 6th October 2008. The visit was carried out over one day and lasted for six and a half hours. As part of our inspection process we sent out the Annual Quality Assurance Assessment (AQAA). This gives us information about the service and was completed and returned to us. During our visit we looked around the building and spoke to the service users and staff. we also looked at care and staff records and observed the staff practices as part of our visit. The current fee charged is 479 to 580 pounds per week. Care Homes for Older People Page 6 of 34 Care Homes for Older People Page 7 of 34 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. Care Homes for Older People Page 8 of 34 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 34 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 34 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an assessment process in place. However this must be further developed to ensure the care needs are assessed prior to providing care and the home can meet these needs. The home does not provide intermediate care Evidence: We looked at the pre admission process that the home has in place. This included a service users guide and and a statement of purpose. The manager reported that this was made available to all prospective service users. We looked at the record of a newly admitted service user and we found that a care management assessment was available. We could not evidence a pre- admission assessment as carried out by the home. An admission record was available but this did Care Homes for Older People Page 11 of 34 Evidence: not indicate when it was completed. Staff reported that this was the only assessment they had. There was no evidence of how the information was received such as people involved in the assessment. According to the care managers assessment it showed that the person had short memory loss and would not be able to participate in the assessment process. We looked for the pre admission assessment for another service user who had been admitted in the last few months and this was not available. Staff reported that this was somewhere but this could not be located. The pre- admission process was inadequate and the records were not available to show how the home would be meeting the service users needs. Staff did not have adequate information required in order to safely formulate the persons care plan. Care Homes for Older People Page 12 of 34 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of care plans and assessments including moving and handling, fall assessments and nutritional assessment does not protect the service users. The access to healthcare was satisfactory. However service users were not always referred when identified as needing reviews. The medication management is inadequate to fully protect the service users. The service users are treated with respect. Evidence: We looked at four care records as part of case tracking to see how the home plans to meet the needs of those service users accommodated. We found that the care plans contained minimal information relating to the care needs and did not reflect what action was needed for staff to meet those needs. Care Homes for Older People Page 13 of 34 Evidence: We found that information was inadequate to ensure that those service users needs were met. One of the service users who had been admitted in June 08 did not have any care plan in place. The manager reported that this had been in place but the care plan was not found. We found that this person had complex needs and required support with all his care, mobility including catheter care. There were no care plans in place to show how these care needs would be met. This posed a high risk to this persons health and safety as there was no moving and handling assessment available in the records that we looked at. Records showed that one person had required three carers to attend to his personal care needs and needed hoisting. There was no care plan, no risk assessment, moving and handling assessment for this person in place at the time of the visit. Another service user had been identified as being at high risk of falls. Care record identified that a fall risk assessment was needed in May 08. However this persons care plan and records seen showed that this had not been completed. We found that three service users were receiving a blood thinning medication that required close monitoring and regular blood tests. There were no care plans in place to inform practice and to ensure that these are monitored as required, the staff said that the district nurses would be responsible for this. Another persons care record showed that they had chronic pain, however no pain care plan was available to show how her pain management was being addressed by the home. The care records for the service users personal care were also minimal and other instances showed there were no care plans and did not take into account the peoples personal wishes and the support that they needed. We found that although staff identified problems that needed to be addressed in their daily records, these were not followed through. This included referral to GP for one of the service users who needed a medication review and falls risk assessments for two of the service users. There were no risk assessments such as moving and handling, falls, dietary needs, skin integrity assessments in place in any of the service users records that we looked at. One of the service users record showed that they had a sore sacrum and scrotum and another had fragile skin. There was no follow up action or care plan in place to show how this would be managed. Care Homes for Older People Page 14 of 34 Evidence: There was no evidence that these care needs had been assessed including their risk factors and no care plans had been developed to show how these needs would be met. Staff reported that all the service users are registered with local GPs and that they have access to external health care as needed. The manager stated that they had good relationships with the district nurses and supported the service users as required. We looked at the management of medication that the home undertook on behalf of the service users as part of this visit. Staff reported and we observed that two carers carried out the medication administration. The home was using the Monitored Dosage System(MDS) that ran over a twenty- eight day cycle. We found that the pharmacist produced a printed Medication Administration Record (MAR) sheet for each of the service users. The staff then transcribed all the medications on to another sheet and used a coding system to record the medication administered. The hand written record was not countersigned by another person and has the potential for error. It was also difficult to track any changes in medication and who had authorised these as there were no records of these being maintained. There was no procedure in place for transcribing prescribed medication, or record of when medication are discontinued or changed by the GP. A record of medication administered was maintained, however these did not include creams and ointments as prescribed. The home had controlled medication and two carers completed the records on administration. There was some record of medication received but these were not available for all the medication received into the care home. We tried to audit some of the medication but we could not complete this, as they were not all recorded when received into the care home. When we looked around the home we found that some service users had creams and ointments in their rooms that had been prescribed for other people. This posed a high infection control risk to the service users. Staff also reported that they were using one bottle of aperients for all the service users that these were prescribed for, as they did not have adequate space on their trolley. This was brought to the attention of the registered person as medicines supplied for the individual service users are the property of the named person and must not be used for other people. The manager reported that the home had purchased an individual locked cabinet for Care Homes for Older People Page 15 of 34 Evidence: the service users medication that would be put in their bedrooms. This would be as part of medication management process, as the manager stated that the home was also planning to use the printed MAR sheets as supplied by the pharmacist. There was no procedure for pain assessment and as required medication at the time of the visit. This poses the risk of people not receiving their appropriate medication as prescribed. We noted that following change in Regulation, the home has not as yet taken any action to replace the controlled drug cupboard to meet with current Regulation. The fridge temperature was not monitored and a procedure was not in place to record the minimum and maximum temperature of the drug fridge to ensure that the medication is stored at the correct temperature. Staff recorded the date of opening of medication to ensure that they were used within the recommended date. The six service users that we spoke to and interaction observed throughout the day showed that people were treated with respect. The comments we received were that the staff were very good. Two of them said that they preferred to stay in their rooms and this was not a problem. Care Homes for Older People Page 16 of 34 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. The social and recreational facilities available to the service users are satisfactory. The service users are supported to maintain links with the community and their family and friends. The meals are varied and looked well balanced. However the lack of nutritional assessment does not protect the service users. Evidence: The home has a varied programme of activities that was available to the service users. We spoke to four service users and they were aware of some of the activities provided. There home has a list of forthcoming activities that were planned for October 08 that was displayed in the corridor leading to the dining room. Activities included a Harvest festival , slide show and a weekly shop run by a volunteer. The staff reported that this enabled the service users to purchase small items such as sweets, crisps and biscuits and they enjoyed this service. Care Homes for Older People Page 17 of 34 Evidence: The service users also have Holy Communion that was provided at regular intervals. Two of the service users said that they preferred not to take part in the activities and remained in their rooms. One service user said that they enjoyed the games such as scrabble. The home has a well established library on the first floor. One service user said that they always enjoyed spending quiet time in the library until lunchtime. They reported that their daughter brought in books regularly and there was always something in the library that they had not read. Another service user said that they spent all their time in theirs room and loved the books that theirs relative brought in. Discussed that often they donated the books to the library once they had finished with them. The four service users records that we looked at did not contain any information about the activities attended. A record of peoples interests, hobbies should be recorded as part of their assessments and an action plan put in place to show how these would be met. The home has an open visiting policy and it was evident from the record of visitors, as kept by the home that there was no restriction on visiting. Comments received and three service users confirmed that they have autonomy to receive their visitors in private. Comments were that their family visited at different times and this was never a problem. The lunchtime meal was observed where the majority of the service users attended the dining room for their meals. The manager said that the dining room has been recently extended that would allow for extra space to accommodate the service users. We noted that the meal served in the dining room appeared varied, nicely presented and the service users spoken with said that the meals were good. The daily menu was displayed on a board in the dining room. There was staff available throughout the meal to offer support. The chef served the dessert from a trolley and the service users were offered a choice from the sweet trolley. Staff were seen in two of the service users rooms assisting them with their meals as required, in a sensitive manner and meals did not appear to be rushed. We found that in one of the service users bedroom they had thick and easy that had been prescribed for them, however their care plans did not contain this information in order to inform practice. Care Homes for Older People Page 18 of 34 Evidence: In another service users record we found that staff had recorded that this person must choose from the main menu from now on. Another entry showed they must stick to the menu on the board. Care record also showed that their family were providing them with cereal, green tea and juice. This was discussed with the manager who stated that this had been sorted and the home provides them with all their meals. We noticed that for those people who were eating in their rooms, both meal courses were brought to them at the same time. The service user spoken with said that this was the normal practice as this was a busy time although the hot dessert did often get cold. Care Homes for Older People Page 19 of 34 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of process in place to ensure that records of all complaints are maintained as required. The lack of a robust recruitment procedure puts the service users at risk of harm. Evidence: The home has a complaint procedure and two of the sevice users we spoke to said that they would talk to the staff if they were not happy. Another service user said that they would go to the office. The manager was unable to find the complaint log at the time of the visit. Two records of complaints were found and these had been completed. One of these related to a safeguarding investigation that social services undertook following a report of alleged theft of a service users money and the Police were involved. The manager reported that other complaint was investigated internally and resolved. We had received an anonymous complaint that was referred in July 08 to the safeguarding team. The investigation was completed and minutes of this were sent to us. The complaint was not substantiated. There was no record of this at the service as Care Homes for Older People Page 20 of 34 Evidence: the complaint log could not be found. We found that staff recruitment processes were inadequate to safeguard people using the service. We were unable to find any record of staff training in the prevention of abuse at the time of the visit. We have raised a safeguarding alert following this visit, as we had concerns that the health and welfare of people accommodated at the service was not adequately protected. Care Homes for Older People Page 21 of 34 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 service users are provided with a warm and homely environment that meet their needs. The infection control procedures were satisfactory. Evidence: We walked round the home and looked at the communal areas, bathrooms, laundry and a number of the service users bedrooms as part of this visit. It was evident that the home has an ongoing programme of refurbishment. Recent refurbishment included the dining room that was near completion and waiting for carpets to be fitted. The home was warm, bright, clean and homely. Furnishing was of very good standard and appropriate to the needs of the service users. The service users are provided with ample communal areas where a variety of activities are undertaken. Most of the bedrooms seen have views of the garden. The service users’ bedrooms were personalized with pictures, televisions, small items of furniture and family photos. It was evident that the service users are encouraged to bring in items of personal belongings on admission. The manager said that the some of the bedrooms had also been refurbished and the Care Homes for Older People Page 22 of 34 Evidence: rest of the dining rooms carpet was planned for renewal in the new year. We spoke to six service users and they all said that the home was always clean and they were satisfied with their rooms. Call bells were available in the bedrooms that we looked at and accessible to three people who we visited in their rooms. There is a laundry in place and all the service users laundry was undertaken internally. The laundry room was in a good state of repair and equipped with adequate facilities and well managed. There was a separate room where the clean laundry was sorted and stored prior to being delivered to the service users. Information about infection control procedures and equipment such as disposable gloves and aprons were available to staff. The home was clean with no adverse odours in any part of the service when we visited. Care Homes for Older People Page 23 of 34 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. The staff recruitment process at the home is inadequate and poor. This puts the service users at risk of harm and poor practice. There is a training programme in place, however training records need to be further developed to evidence training completed to include induction. Evidence: We looked at the duty roster that the home provided to us. This showed that there is an average of six staff during the day and four staff at night. According to the roster the manager provided out of hours cover and also worked at the weekends to supplement the staffing. Staff reported that they are short of staff at the weekends as the overseas students had returned to their home country. We have serious concerns about the staffing levels at the service as the duty roster showed that some staff were working up to forty- eight hours without a break. The roster showed that staff were working all day and all night without any breaks. This practice puts the service users at severe risk of harm, as staff would be tired and unable to provide care safely. We were unable to ascertain in what capacity the staff were working, as the roster had Care Homes for Older People Page 24 of 34 Evidence: staff first names and also we noted that there was a lot of staff movements and changes over a number of weeks. It was difficult to assess whether the staff absence was replaced with agency cover and the staff skills available at the service. The four service users we spoke with as part of the visit were complimentary about the staff. They said that the staff worked very hard and they tried to do their best. Two of them said that they sometimes had to wait for help as the girls are very busy. Another comment was you just have to wait until someone is free. We looked at a sample of five newly recruited staff records as part of case tracking. We found that one staff member had completed an application form, two references and a POVA firs check prior to starting work but no CRB clearance until a month later. There was no evidence of any supervisory practice during that period. Two staff who had started in September 08, one had a POVA first check and both of them did not have any references or CRB clearance. These staff did not have any other records in place as their files could not be located. Another staff member who started work in August 08 did not have any records to show what checks had been completed. We located one induction record for one staff member who also had an NVQ 4 in care. There were no induction records available for all the other staff we case tracked. There is a training programme in place and five carers were attending an infection control course on the afternoon of the visit. The manager reported that five staff had completed training in safeguarding, and five in infection control in September 08. There is a planned training programme until the end of December 08. Care Homes for Older People Page 25 of 34 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. The home has a manager who is highly regarded , but there was a lack of clear lines of accountability for the service. The financial interests of the service users are safeguarded through good accounting. The process of seeking the service users views was incomplete at the time of the visit. There is an inadequate procedure in place to ensure that the health and safety of the service users is promoted. Evidence: The home has a registered manager who has completed the NVQ 4 in care and the registered managers award. The staff and the service users we spoke to were complimentary about the manager and said that she was helpful and they would approach her if needed. Care Homes for Older People Page 26 of 34 Evidence: We found that there were inadequate records and assessments available to inform staff practices and ensuring that people receive an adequate level of care. The care plans lacked details of assessments and action needed in order to ensure that the care needs are met. The health and welfare of people was not protected through adequate recruitment checks. Infection control and procedures for the safe management of peoples medication and creams and ointments put them at risk of harm. The lack of manual handling assessments, risk assessments for falls and nutritional assessments did not ensure that care was provided in a safe manner. We found that substances that are detrimental to the health and welfare of people were not always maintained safely including materials left in peoples bedrooms, cleaning cupboard with hazardous substances left unlocked. Others were also found in the laundry and hairdressing room that were removed at the time of the visit. A sample of the personal allowances as managed by the home was looked at. There was a good system in place and all the service users money were kept separately. Receipts and invoices were maintained of transactions. Random checks of three of the service users personal account were found to be accurate. All transactions undertaken with the service users were recorded accurately. There is a lack of clear procedures in place to record mandatory training to ensure that staff have required training and updates in health and safety to protect the people living at the home. We received a copy of the training matrix at the time of the inspection. This showed the dates in 2007-2008 that updates for staff were due to be completed, however there is no record to show that these had been achieved. The manager reported that the company carries out an annual audit of the service users views in order to assess how the home was meeting its commitment as per the statement of purpose. This has not yet started and the manager was not aware when this was planned for. We found that during the visit staff personal records were not managed securely and on various occasions we were told that the records such as care plans, assessments, complaint log, accident records and rectuitment records could not be found. This put the service users and staff at risk of their records falling in the wrong hands and having confidential information about them being divulged. There is an ongoing programme for the servicing of fire equipment, hoists, Care Homes for Older People Page 27 of 34 Evidence: wheelchairs, lift and emergency lighting. Information we have received showed that these are completed at regular intervals. Care Homes for Older People Page 28 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 29 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The registered peson must 30/11/2008 ensure that a pre-admission assessment is completed for all new service users prior to admission and records are maintained. So that information is availlable to make a judgement regarding their care needs and how you are going to meet those. 2 7 15 The registered person must 30/11/2008 ensure that care plans are developed following a comprehensive assessment and put in place to show how the service users needs in respect to their health and welfare will be met. So that staff have the correct information to meet the assessed needs of the service users 3 7 13 The registered peson must ensure that risk assessments including 30/11/2008 Care Homes for Older People Page 30 of 34 manual handling, fall and tissue viability are in place to protect the people accommodated at the service. Detailed action plan on how these risks are managed must be put in place. So that the people receive appropriate care and are not put at risk of harm. 4 9 13 The registered person must have arrangements in place for the safe handling, recording, safe administration and disposal of medication received into the service So that people receive their medication safely at all times. 5 16 17 The registered person must ensure that a complaint log is maintained to record all complaints made and includes details of investigation and any action taken as required So that people can be confident that they would be listened to and any concerns they raise are dealt with effectively. 6 18 12 The registered person must ensure that the home is conducted in a way that promotes the welfare and well being of people accommodated. 30/11/2008 30/11/2008 30/11/2008 Care Homes for Older People Page 31 of 34 So that they are protected from the risk of harm. 7 28 18 The registered person must ensure that at all times suitably qualified and experienced staff are working at the home and in such numbers that is appropriate for the health and welfare of the service users. So that staff do not work excessive hours and care can be provided safely at all times. 8 29 19 The registered person must 30/11/2008 ensure that there is a robust recruitment procedure and all necessary staff checks are completed prior to employment. So that the service users are safeguarded from the risk of harm and poor practice. 9 30 18 The registered person must ensure that there is an induction programme in place for all new staff so that staff fulfil the aims and objectives of the service So that you can ensure that staff have the support and skills to provide care safely. 10 31 12 The registered person must ensure that at all times there is clear lines of accountability for the service, and to promote and make proper provision for 30/11/2008 30/11/2008 30/11/2008 Care Homes for Older People Page 32 of 34 the health and welfare of the service users. So that the service users are protected through effective management. 11 37 17 The registered person must ensure that all records pertaining to staff and the service users are kept securely at all times To ensure that personal informations about the staff and the service users are kept cofidential. 12 38 13 The registered person must 30/11/2008 ensure that arrangements for the training of staff are in place and records of these are maintained to ensure the health and safety of the service users are promoted and protected at all times. So that staff and the service users are not put at risk of harm. 30/11/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 33 of 34 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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