Inspection on 30/06/09 for Briardene Care Home

This inspection was carried out on 30th June 2009.

CQC found this care home to be providing an Adequate 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Briardene Care Home 03/06/09

Briardene Care Home 01/05/09

Briardene Care Home 16/02/09

Briardene Care Home 16/09/08

Briardene Care Home 11/06/07

Briardene Care Home 08/06/06

Briardene Care Home 06/09/05

Briardene Care Home 14/12/04

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: Briardene Care Home Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA     The quality rating for this care home is:   one star adequate 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: Elaine Charlton     Date: 3 0 0 6 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 34 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 34 Information about the care home Name of care home: Address: Briardene Care Home Newbiggin Lane Westerhope Newcastle upon Tyne NE5 1NA 01912863212 01912866820 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Windmill Hills Ltd care home 59 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Briardene is a care home with nursing providing care for older people with physical and mental health needs. The home is owned and managed by Windmill Hills Limited that is part of a larger group, which provides care services for a variety of client groups. The home is staffed by registered general nurses supported by care staff. The philosophy of care is to support the residents in their activities of daily living and to provide for their physical and mental health needs. The home is situated in Newbiggin Lane in the west of the city of Newcastle upon Tyne fairly close to local shops and public transport links. The building is comprised of three floors, the top floor being staff accommodation. The lower two floors are resident accommodation with 62 single bedrooms all with en-suite facilities. On each of these floors there are a number of bathrooms, toilets, lounge and dining rooms. The home has a visitor coffee room and hairdressing room. There is also a kitchen and laundry Care Homes for Older People Page 4 of 34 Over 65 31 28 0 0 1 6 0 2 2 0 0 9 Brief description of the care home room. To the rear of the home there is a very nice garden and patio area. Fees in the home vary and are available on request from the organisation. 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is one star, this means that the people who use this service experience adequate quality outcomes. An unannounced visit was made on the 30 June 2009. A total of eight and a half hours were spent in the service. The manager was present throughout the inspection. An operations manager also joined us shortly after the start of the inspection. This inspection was carried out following the service of a Code B Notice using our statutory powers in Part II of the Care Standards Act 2000, and paragraph 6.7 of the Police and Criminal Evidence Act 1984 (Code of Practice for the Searching of Premises and the Seizure of Property Found on Persons or Premises). Two random inspections had also been carried out on the 1 May 2009, and 3 June 2009, after concerns had been raised with CQC and the Newcastle safeguarding team. Care Homes for Older People Page 6 of 34 Before the visit we looked at Information we have received since the last key inspection on the 16 February 2009. The Annual Quality Assurance Assessment (AQAA) that gives CQC evidence to support what the service says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are. How the service has dealt with any complaints and concerns since our last visit. The providers view of how well they care for people, and the views of people who use the service, their relatives, staff and other professionals who visit the service. We have also reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. During the visit we Talked with people who use the service, staff and the manager. Looked at information about the people who use the service and how well their needs are met. Other records which must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. We looked around the building/parts of the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since our last visit. We told the manager and operations manager what we found. The day after the inspection the responsible person for the organisation contacted CQC to discuss our findings and to provide us with a draft improvement plan. 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 on page 4. Care Homes for Older People Page 8 of 34 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 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to move into the home have their differing and diverse needs and wishes properly assessed so that everyone is sure they can be met. Evidence: We saw the admission assessment for the resident who had most recently moved into the home. It included enough information for staff to be able to assess whether the persons care and support needs could be met. An assessment from a healthcare professional was also available. The home does not provide intermediate care. Care Homes for Older People Page 11 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal care that is not always well planned but does take account of their diverse needs. Staff do not regularly follow good practice guideline, policies and procedures for the safe handling of medication which could place people at risk. Evidence: We looked at the records for four other people who live in the home including those of two residents who had recently raised concerns about the quality of care they were receiving. Not all documents were signed by a resident or their representative. This included a care plan covering deprivation of liberty issues. Care plans did not always reflect the care a person needed and for one resident who had recently lost weight there was no care plan to cover this and food and fluid intake charts were not in place. We saw risk assessments and risk management plans in place. These included details Care Homes for Older People Page 12 of 34 Evidence: of the type of equipment staff needed to use when assisting a person with their care and support needs. As we walked around the home we saw one gentleman being given choices about whether he wanted to be inside or out, and about what he wanted to drink. This was done in a very senstive way. For the same resident, although they were receiving visits from the Macmillan Nurses, there was no end of life plan in place. Through records, staff records, complaints and safeguarding, issues have been raised about the ability of staff to provide the right care and support, their attitude, inappropriate topics of conversation and language. A random check of medication held in the home was carried out during which the following issues were identified: - The temperature in the ground floor treatment room was excessive and was recorded as regularly exceeding 25/26 degrees centigrade. - During the lunchtime administration of medication on the ground floor both the nursing and residential trolleys were left unattended whilst medication was taken into the dining room. - For one person who went out after lunch with family and was given their medication to take whilst they were out, it was recorded in the medication administration record (MAR) as being administered. - Handwritten entries on MAR charts had not been double signed to say that they had been properly transcribed. - We saw gaps in the MAR charts at regular intervals so it was not clear whether residents had had all their prescribed medication. - Records for medication received into the home, dispensed and what remained in stock did not agree. For example, for one resident 25 Simvastatin 10mg tablets had been recorded as received, 15 administered but there were 11 left in stock; for the same person 60 Nicorandil 10mg tablets had been recorded as received and administered but there were still 15 left in stock. Care Homes for Older People Page 13 of 34 Evidence: - Petty cash was seen locked in the controlled drugs cabinet. - In the second treatment room we found large stocks of thickening powders for residents who were no longer in the home. These totalled 77, 225mg containers. There were also two unlabelled boxes of vanilla ensure. - Refrigerated items had not been dated when opened, and one item had no label on it. Controlled drugs are kept securely in a second treatment room on the top floor of the home. These were all checked and stocks were correct. A bound, controlled drugs register is also in place. We were told that a new copy of the British National Formulary (BNF) a medication reference guide had been ordered from the pharmacist as the one in the home had been issued in 2007. Care Homes for Older People Page 14 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. People are not fully supported to lead an interesting, healthy and fulfilling life that takes account of their wishes and diverse abilities. Evidence: We saw one dairy of social events and activities that recorded only visits from family and there were no social activities taking place whilst we were in the home apart from television and music. Several residents were seen enjoying spending time in the garden, there were seats, tables and parasols in place for their comfort. On the first floor, after lunch, carers were seen sitting in a lounge area but they were not engaging with residents who were in the same room. We were told that an entertainer had been in the home in April and May, and that other activities had included reminisence, recall, reading, pampering and arm chair exercises. The activities organiser told us that they were due to have use of a mini-bus for two Care Homes for Older People Page 15 of 34 Evidence: weeks and would be taking people out for trips. One resident went out for the afternoon with her family. Staff told us that she did this regularly and likes to buy herself treats for mealtimes whilst she is out. The same lady told us that she had chosen to have tomato soup, pizza and the pudding of the day for her lunch because I just fancied it. A relative told us that she was happy with the care and support given and said staff were lovely. We observed the lunch time serving practice on the ground floor. Meals were served to residents from a list on the wall, but we did not see anyone being asked which vegetables they wanted. Chef had prepared a vegetarian sausage casserole for one resident and this had been placed in the hot trolley for serving. When it was transferred to the plate the carer poured extra gravy over the meal from the trolley. Chef confirmed that on this particular day the gravy was a vegetarian one for all residents but this is not always the case. The dining room is light and bright, and tables were nicely set but residents were wearing blue, plastic aprons whilst eating their meal. Care Homes for Older People Page 16 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are not always protected from harm when staff do not follow proper policies, procedures and guidance for the acceptance of complaints and concerns. Evidence: The organisation has policies and procedures in place that promote the acceptance, recording, investigation and proper feedback for complaints, concerns and allegations. Several complaints had been received since the last inspection and three incidents have been referred to the adult safeguarding team in Newcastle. Evidence from records, attendance at safeguarding meetings and two recent random inspections is that the manager does not always properly record complaints, concerns and incidents. Information provided to CQC and other professionals is not always correct We saw records of incidents involving staff where they had not provided care and support or acted towards a resident in a way that promoted their privacy and dignity and was not respectful. Protection of vulnerable adults training is not up to date. Care Homes for Older People Page 17 of 34 Evidence: Staff are told about whistle blowing and there is a policy to support this encouraging people to speak out if they witness unacceptable behaviour. Care Homes for Older People Page 18 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. People live in a home that is warm, clean, comfortable and safe and allows them to spend time privately or with others as they choose. Evidence: We looked around the home and saw that it was generally clean, tidy and odour free. Everyone has a private bedroom and is provided with equipment and specialist beds that make their life easier and more comfortable. Issues identified during our tour of the premises were brought to the attention of the manager and included. - An uncovered sugar bowl in a servery area. - Duvet covers not fastened over the quilt and missing pillow cases. - Shower gel, creams and sterident tablets were left out in en-suite rooms that were not locked. - In the hairdressing room shampoo and setting lotion had not been locked away. Care Homes for Older People Page 19 of 34 Evidence: - A residents dentures were seen in a dirty, uncovered dish. In another room a pallette was laid on the sink. - The floor in the cleaning cupboard needed cleaning. - There was a problem with the refrigerator temperature in one of the serverys which did not appear to be cool. A member of staff said this was a new refrigerator. Residents were seen enjoying the private garden leading from the Bistro on the ground floor. Tables, chairs and parasols had been provided for their comfort, the fountain was running and the area was nicely planted. Care Homes for Older People Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment and selection procedures are not always properly followed and training is not up to date which could put people at risk. Evidence: The organisation has recruitment and selection procedures in place but these have not always been properly followed. A decision has been made that staff will now not be allowed to start work in the home until they have a full Criminal Records Bureau (CRB) check carried out at an enhanced level. On an application for someone recently interviewed to work in the home they had declared a caution received some years ago. The manager recorded on the application form that she had discussed this and it would not affect her decision. There was no signed statement from the applicant about the incident and no other information was available detailing what actually occurred. All the staff files have been audited by the operations manager and documents that are not in place have been requested from staff, for example evidence of qualifications. Care Homes for Older People Page 21 of 34 Evidence: Consistent use is not made of the new starters check list so that it is easy to see at what stage a persons application is at. Staff complete a Common Induction Book when they start work in the home. This is not always dated or signed by the line manage or mentor. We were given copies of the training matrix for staff working on both floors in the home. Some staff still need training in moving and handling, first aid, fire safety, health and safety and infection control. Only five staff have received training in tissue viability and this does not appear to have been repeated since June 2007. Fifteen out of 33 care workers have obtained a National Vocational Qualification (NVQ) at a minimum of level 2. This does not quite meet the minimum of 50 required by the National Training Organisation. Nine staff are recorded as being registered to complete an NVQ at level 2 or 3. Kitchen staff have also achieved an NVQ at a minimum of level 2. We were told that when in-house training is provided staff are taken off the floor to complete this leaving a minimum of people to provide the support that residents need. This is not good practice. Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is not consistent and staff do not receive clear guidance and leadership to promote the protection and well being of people who live in the home. Evidence: The registered manager is experienced and has been assessed as having the competencies and skills to run the home. Recently it has been apparent that the manager has not been notifiying the proper authorities when events and incidents have occurred in the home, and has given misleading information to professionals at both CQC and the local authority safeguarding unit. Regulation 37 notifications are not routinely sent to CQC to tell us about events and incidents in the home that may affect the health and well being of residents. On two occasions recently this has not occurred until after a safeguarding strategy meeting has been held. Care Homes for Older People Page 23 of 34 Evidence: From records seen it is clear that complaints are not always properly recorded or investigated. Appraisal and supervision records seen identified a large number of incidents and events where staff had been reprimanded about there behaviour in the home. The records were not always consistent about events. At a recent strategy meeting when the events of incidents affecting two separate residents were reviewed we were told that both incidents had been properly investigated and there were no outstanding issues. During the inspection we looked at records for the above incidents and it appeared that one had not been investigated at all. There were no records in place to confirm an investigation and there were no statements from staff who had been identified in the complaint. We looked at the servicing and maintenance records for the home. These were all up to date with the exception of the portable applicance testing (PAT) certificate that was not dated and the water chlorination test was out of date. Arrangements were made for the water tests to be carried out before the 10 July 2009. We were told that fire checks are regularly carried out but these are not always clearly recorded in the fire log at the required intervals. There was no easy and clear record in place to indicate when staff needed to attend refresher training or take part in a fire drill. Procedures are in place for the safe hadnling of money belonging to people who live in the home. But we were told that unless a person asks for money for the weekend it is not possible to access residents money on a Saturday and Sunday as this is locked away and staff on duty to not have access. We were told that Regulation 26 visits are regularly carried out by the provider but we were unable to find a record for June 2009. Staff meeting minutes were seen but there had not been a meeting since Febraury 2009. One of the issues discussed at those meetings was staff attitudes. Staff do not appear to be signing to say that they have read and agreed the minutes of their meetings. We looked at the staff signing in register for the home. We saw that some staff are Care Homes for Older People Page 24 of 34 Evidence: signing in other members of the team, and others are not signing in at all. Mandatory training in health and safety and moving and transferring is not up to date placing people in the home at risk. Care Homes for Older People Page 25 of 34 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 Ensure that care plans give 01/04/2009 consistent information. Ensure all plans reflect the actual needs of residents and are person centered. Ensure food, fluid and weight records are properly completed. This will ensure that all residents care needs are properly identified. 2 16 22 Ensure that all complaints 01/04/2009 are taken seriously and acted upon over a period of time. This ensures that all improvements made are sustained. 3 18 13 Ensure all staff receive regular training in adult protection. This helps to safeguard residents from abuse. 01/05/2009 4 29 19 Provide evidence that staff 01/04/2009 have been thoroughly screened prior to employment. Where staff are employed there must be evidence as to how that decision has been reached. This help to protect residents from abuse. Care Homes for Older People Page 26 of 34 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 5 29 19 The organisations 30/05/2009 recruitment and selection procedures must be properly followed. This will make sure that people who work in the home are properly screened, are not prevented from working with vulnerable people, helping to keep residents safe and well. 6 31 13 Provide an action plan 01/04/2009 indicating the measures put in place to improve the management of the home. Provide confirmation of the supervisory arrangements in place for the manager, include targets of performance to be reached. Better management of the home will improve standards of care and living for all residents. 7 31 9 The performance and training needs of the manager must be reviewed. This will mean that the organisation is sure procedures are properly followed and people living in the home are kept safe and well. 30/05/2009 8 36 18 The frequency of staff 30/12/2009 supervision must be increased to meet the organisations target and National Minimum Standards. Care Homes for Older People Page 27 of 34 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 This will mean that people who work in the home get the support they need to do their job. 9 38 37 Accidents, illnesses and 30/05/2009 incidents must be properly reported to the Commission. This will make sure that proper procedures are followed and appropriate people are kept informed regarding the health and well being of residents. Care Homes for Older People Page 28 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 9 13 Staff must follow good practice guide lines, policies and procedures for the safe handling of medication at all times. This will help to make sure that residents receive their prescribed medication at the right time, helping to keep them safe and well. 30/08/2009 2 14 12 Staff must receive training that helps them to understand different dietary needs. This will help to make sure that the choices and beliefs of residents are not compromised. 30/09/2009 3 16 12 Complaints and concerns must be properly accepted, recorded and investigated. 30/07/2009 Care Homes for Older People Page 29 of 34 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 will mean that people who live in the home know they are listened to and taken seriously. 4 18 13 Incidents and allegations must be properly recorded and reported to the appropriate professionals. This will help to keep people who live in the home safe and well. 5 27 12 Staff rostered on duty must not be included in training events in the home where this is detrimental to residents and reduces the availability of care and support. This will help to keep people who live in the home safe and well. 6 30 12 Mandatory training in areas of health and safety, fire safety, moving and handling must be updated. This will help to keep people who live in the home safe and well. 7 31 12 The home must be run in a consistent way that promotes the interests and well being of residents. 30/07/2009 30/08/2009 30/07/2009 30/07/2009 Care Homes for Older People Page 30 of 34 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 will help to keep people who live in the home safe and well. 8 31 8 The manager must communicate and cooperate with CQC and other professionals in a clear and accurate way. This will build confidence with professionals that the home is being run in the best interests of the people who live there. 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 30/07/2009 1 7 Care plans should be dated and signed by the resident or their representative or should indicate a reason why they are not signed. This will indicate that the resident has been consulted about how they want their care and support to be provided. Petty cash or other items should not be kept in the controlled drugs cabinet. Handwritten entries on MAR charts should be double signed to show that the dispensing instructions have been properly transcribed. This will help to keep people who live in the home safe and well. Limited life medications should be dated when opened so that it is clear to staff when they should be disposed of. This will help to keep residents safe and well. During the lunchtime administration of medication on the ground floor both the nursing and residential trolleys were 2 3 9 9 4 9 5 9 Care Homes for Older People Page 31 of 34 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 left unattended whilst medication was taken into the dining room. 6 9 Care should be taken to make sure that records for medication received into the home, dispensed and what remains in stock agree. This will show that residents are getting their medication as prescribed, helping to keep them safe and well. Temperature control measures in the treatment rooms should be reviewed to make sure they are not exceeding the recommended level to protect the integrity of medications stored. Activities, social opportunities and community contact should be expanded so that residents lead an interesting and stimulating life. Staff should behave in a way that includes residents, and promotes stiumulating opportunities and activites they can take part in. The use of blue plastic aprons at meal times should be reviewed. This will promote the dignity of people living in the home. Consideration should be given to providing additional training for the manager in the acceptance and investigation of complaints and concerns. This will help people who live in the home to know that issues will be taken seriously and properly recorded and investigated. Repairs, replacements and general housekeeping issues identified in the report should receive attention for the comfort and safety of people living in the home. NVQ training should continue so that the number of staff with a qualification at a minimum of level 2 meets the requirements of the National Training Organisation. This will help people who work in the home to do their job. Considertation should be given to how people living in the home can have access to their money at the weekend if there is a need for them to do so. Records in the home should be kept in a clear, accurate and up to date way. This will mean that everyone has Page 32 of 34 7 9 8 12 9 14 10 15 11 16 12 19 13 28 14 35 15 37 Care Homes for Older People 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 access to the most recent information. 16 38 CQC should be provided with a copy of a dated PAT test and chlorination certificate to evidence that these issues have been dealt with for the safety of people living in the home. Staff should individually sign in and out of the building when they come on and go off duty. This will mean that in the event of an emergency it is easy to check who was in the building. 17 38 Care Homes for Older People Page 33 of 34 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. 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