Inspection on 21/04/10 for Burgess Park Nursing Home

This inspection was carried out on 21st April 2010.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burgess Park Nursing Home 08/03/10

Burgess Park Nursing Home 05/01/10

Burgess Park Nursing Home 04/12/08

Burgess Park Nursing Home 07/12/07

Burgess Park Nursing Home 15/05/06

Burgess Park Nursing Home 21/10/05

Burgess Park Nursing Home 14/04/05

Burgess Park Nursing Home 01/12/04

Burgess Park Nursing Home 11/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 17/07/2010.

Key inspection report Care homes for older people Name: Address: Burgess Park Nursing Home Burgess Park Picton Street Camberwell London SE5 7QH     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: Alison Pritchard     Date: 2 7 0 4 2 0 1 0 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 29 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Burgess Park Nursing Home Burgess Park Picton Street Camberwell London SE5 7QH 02077032112 02077014220 burgesspark@schealthcare.co.uk www.schealthcare.co.uk Exceler Healthcare Services Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Grzegorz Zbigniew Bielinski Type of registration: Number of places registered: care home 60 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: 60 The registered person may provide the following category of service only: Care home with nursing (CRH - N) 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 Burgess Park Nursing Home is located in a residential area of Camberwell. The home is registered to provide care for sixty older people who have nursing needs. The facilities in the home are spread over three floors. There are lounges on the Care Homes for Older People Page 4 of 29 Over 65 60 0 0 8 0 3 2 0 1 0 Brief description of the care home ground and first floors of the home and dining facilities are on the ground floor. Bedrooms are located on all three floors of the home. Twenty three of the bedrooms have en-suite facilities. There is a passenger lift allowing all residents to have access to all parts of the home. There is a garden to the front of the home and parking is available on the street and in a small car park to the side of the home. The current manager has been in post since early November 2009. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was unannounced. On the first day two inspectors visited the home. We spent time looking around the building; we spoke to service users and staff; looked at a range of records and spent time observing care practice. A pharmacy inspector visited the home in mid March 2010 to look at the management of medication. The findings from that visit are reported here. We also have access to notifications from the home about events that take place; we have received information from other professionals involved with the service and we have made specific requests for information from the Registered Manager and the Service Manager. Care Homes for Older People Page 6 of 29 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. 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 7 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 8 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments before admission allow the home to be sure that they can meet the potential service users needs. Visits to the home by the potential service user or their representative are encouraged. Evidence: We checked files of newly admitted service users on this visit and at our previous random inspection in March 2010. In each case we found that an assessment of the persons needs had been conducted prior to their admission. We spoke to one of these service users at this visit. She told us that, although she had not visited the home before she moved there a close relative had done so and had the opportunity to assess its suitability. The service does not provide intermediate care so the standard about this kind of service is not applicable. Care Homes for Older People Page 9 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans did not fully describe service users needs. Service users health will be better promoted by improved recording and referrals to health care professional being made more promptly. Arrangements for managing medication must be improved if service users are to be protected. Evidence: All of the five files at which we looked had care plans. We found several areas about which we were concerned. At the random inspection we found that the care plan of a service user had no reference to his sight impairment. On this occasion we found that this had still not been addressed despite this having been raised as a concern in the report. We were glad to see that a care plan had been written to address the service users needs arising from diabetes about which we had also raised concerns. In another file we saw that a nutritional assessment had been conducted in mid February 2010 and the outcome was that dietetic advice should have been sought to ensure the service users health and well being. It was unclear about when the referral had been made. Referrals were made for several service users in early April 2010. We Care Homes for Older People Page 10 of 29 Evidence: spoke to staff about the food preferences of this service user, they were able to describe them well but some of these preferences were not reflected in the care plan. The home has contact with a range of health care professionals, including the GP; the Care Homes Support Team; podiatry and speech and language therapists. We checked to make sure that instructions given by health care professionals are followed. We found that the records of when dressings on pressure areas were not clear. We saw an example where the instruction was for dressings to be changed three times a week. The records were inconsistent and difficult to monitor whether this advice was observed. Our view was that the care notes in this respect did not aid communication between the nursing staff. At the time that we visited the care plans for the three units were stored on the ground floor. We were concerned that staff did not have easy access to the files for reference or recording, this may have contributed to the inconsistent recording. We also noted some aspects of recording that were unhelpful for example on a moving and handling risk assessment, was the comment has her moods in response to a query about the persons psychological state. This kind of comment is neither useful or respectful and should be addressed. Service users expressed satisfaction with the way that they were cared for. We observed warm and kindly interraction between service users and staff. Visiting professionals are able to see their clients in private in their bedrooms. Most service users were well dressed and groomed. We were concerned to see that one person was wearing a shirt which had initials and room number clearly visible on the inside of the collar. This did not respect the service users dignity. The CQC Pharmacist Inspector visited the service on March 17th 2010 to assess how the service manages medicines. They found a number of issues which could put residents at risk. The service must improve its handling of medicines to protect the health and safety of people living there. A detailed report has been sent to the Manager to help the service to identify and correct the issues found. This is a summary of some of the issues found. Records showed that three prescribed medicines for 1 resident were not available at the home for at least 3 days. This could have had a negative outcome on this persons health. Another resident may have been without prescribed medicines for 8 days as records of medicines given could not be located for an 8 day period in February 2010 and the original prescription from the GP dated 16th February 2010 was still at the home. Care Homes for Older People Page 11 of 29 Evidence: One prescribed medicine to be given twice daily was only being given once a day, so not according to the printed instructions on the medicines chart. A medicine which had been discontinued in January 2010 was still being stored in a medicines cupboard. Out of 15 medicines records sampled, 8 did not contain any information on allergies, placing residents at risk of being prescribed medicines they are allergic to. Doses of some prescribed medicines have been changed from the GPs initial instructions, however it is not clear from the record who has made the changes as staff have not initialled and dated the record, or added any reference to when the change was made. Creams have been prescribed for some residents. In some cases, staff are not signing the medicines record so there is no evidence that these are being used. One resident had missed their night time doses of medicines for 4 out of the 9 days prior to the inspection as they were sleeping. One reason for this is the medicines round is taking place too late on some evenings. There must be sufficient staff on duty to ensure medicines are offered at convenient times. Auditing of medicines held was difficult as staff do not always record the quantities of medicines received, or brought forward from the previous month onto the medicines record. If this is not done, checking to see if medicines have been given will not be possible. Due to the issues found, a requirement has been made on medicines handling. Care Homes for Older People Page 12 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an activity programme which service users said they enjoy. We received mixed opinions about the meals provided in the home. We observed that they are sometimes late being served and staff need further guidance on how to assist service users. Evidence: An activity co-ordinator is employed at the home for 45 hours a week. At our visits as part of this inspection and our visit in March we saw and heard about a range of activities. These included singing with visiting musicians; exercise sessions; bingo; reminiscence; films; church services and art and craft. A choir has been formed and service users are joined by children from a neighbouring school. It is planned that pub sessions will be arranged using a newly refurbished leisure room. There are also plans to introduce birds and fish to one of the communal rooms on the ground floor. A hairdresser visits the home each week. There is an activity room available and it contains a range of leisure equipment. Meetings are held with service users and relatives. Relatives are also able to visit the manager of the home every Friday afternoon when he holds a surgery session. Clothing companies sometimes visit the home so that service users can make Care Homes for Older People Page 13 of 29 Evidence: purchases; the activity co-ordinator has also made arrangements for service users to purchase toiletries of their choice on line. We heard that service users have appreciated this new opportunity. The kitchen has had a variety of staffing problems and some staff have left their posts. On the two days that we visited a chef from another Southern Cross home was covering the catering duties along with a kitchen assistant. This is a lower staffing level than the three members of staff who would normally be available and those staff who were working in the kitchen were very busy. The impact of this on service users was for some people to have to wait a long time to be served with a meal. This was particularly the case for service users who chose to eat in their rooms. We observed two lunchtimes. On the first day we observed that a service user left most of her main course but ate all of her dessert independently. After she had finished her dessert member of staff approached her and encouraged her to eat the main meal. Despite the service user indicating that she did not want any more the staff member persisted and began to feed the meal to her with a spoon. We felt this was insensitive and displayed a lack of understanding on the part of the staff member. On the second day that we observed a lunchtime we saw a member of staff being very sensitive and patient with service users despite being the only member of staff available to assist in the dining room (more details about this are in the section on staffing below. A choice of meals is available. We received mixed feedback about the food. Some people said that they enjoyed the meals; another service users said that they did not enjoy the food as it had little taste; a third person said that the food was getting better and was pleased to have been served some Caribbean food at a Sunday lunch time. It is possible that staffing problems have contributed to the variable quality of the food and the catering arrangements such as the timings of meals. The quality of the food should be closely monitored by the home and service users views convassed regularly. Care Homes for Older People Page 14 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have received training in safeguarding issues and service users we talked to said that they could raise issues of concern. Some notifications about allegations of misconduct had not been made promptly as required. Evidence: Service users that we talked to felt able to raise issues of concern either with someone in the home or with a relative. We saw records of complaints made to the home and the action taken in response. Issues raised in complaints had led to management action such as unannounced visits at night time to check that staff were working as required. The majority of staff (93 ) have attended training on safeguarding issues. Issues of concern have been appropriately reported to the local authority. In one instance an allegation of misconduct was reported to CQC later than required by regulation which demands that such notifications are made without delay. Another incident involving medication had not been reported formally to the CQC although other similar instances had been. The safeguarding policy of the managing organisation allows for the suspension of staff members pending investigation. Care Homes for Older People Page 15 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although some redecoration and refurbishment is underway, further work needs to be done to make the environment suitable for the service users. The toilet, bathing and washing facilities particularly need improvement as do the laundry facilities. Evidence: The home is purpose built, bright and with a range of communal rooms on all three floors. The home is set back from the road with a pleasant front garden area. Each resident has their own bedroom with 24 of the bedrooms having en suite facilities. There are a range of communal rooms on the ground floor including lounge areas, space for dining and space for activities as well as a room which has the dual role as a pub / social room and staff training room. However, there is a need for refurbishment to make sure that good quality living accommodation is provided for residents. Some of the communal areas, such as bathrooms and toilets are showing signs of wear. The manager told us that the lounge areas have been redecorated and new furniture obtained. There is a plan to decorate each of the bedrooms at the rate of 2 bedrooms per month. There are also plans to replace existing beds with new profiling beds and we have been given a refurbishment audit which sets out the decorating needs for the bedrooms. We carried out an inspection of the homes physical standards with the manager and a Care Homes for Older People Page 16 of 29 Evidence: visiting manager from another Southern Cross care home. We noted that the homes bathrooms and toilets particularly needed improvements. A number of the bathrooms, for example, were not available for use, and others needed repairs. One bathroom had a broken bath panel and chipped paint work. The bathing facilities are relatively basic in terms of their provision for people with disabilities. Some of the baths do not have any assisted means for residents and in others the facilities are, now rather old fashioned, bath hoists. There are plans to replace many of these bathrooms with level access shower facilities. This will improve the facilities provided for residents. In our inspection we saw that where decoration of rooms had been carried out the standard was good and enhanced facilities were being provided. We also noted that there has clearly been a great deal of activity at the home to improve and regenerate the facilities and the service in general. For example, the renewal of furniture and and clear out of stored items. However, this has lead to the temporary placing of items on the stairs of a fire exit which presents potential hazards to users of the fire escape as well as a possible breach of confidentiality as there are paper records in boxes stored underneath a staircase. These items had been moved by the second day of inspection and the confidential items had been stored properly. The laundry is located on the ground floor of the home. The laundry was visited and the domestic worker in charge was spoken with. We were told that a new laundry storage room is being prepared which will provide additional laundry storage space. This should improve matters as the current laundry room, when we saw it on the day of the inspection, was very cluttered. They were piles of clothes waiting to be washed as well as clean clothes and other items, such as curtains, waiting to be washed. the laundry room itself is not large and the domestic worker was spending time in the hallway working. There are currently no baskets for residents laundry as is often the case in other care homes. None of the residents we spoke to said that they had their clothes mixed up but one person said that it took a long time to get clothes back from the laundry. The laundry arrangements need to be reviewed by the manager to make sure that it is operating efficiently. The refurbishment plans for the home need to be clearer. Although there is a plan and clearly work is ongoing some of the funding for the plans seem to be drawn from the overall home budget rather than a dedicated improvement budget. For example, the manager said that the decoration of the bedrooms is to be funded from the homes overall budget and the work is to be carried out by the homes maintenance worker. This is at a rate of two bedrooms per month over a 16 month period. We have made a requirement for a detailed and timetabled plan for the redecoration and refurbishment of the home to be provided. Care Homes for Older People Page 17 of 29 Evidence: Care Homes for Older People Page 18 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels and shift planning systems must be improved to meet service users needs at all times. Staff must receive an appropriate induction to their role. The majority of care staff have received NVQ training. Staff recruitment records must be include all matters considered. Evidence: When we visited the home to carry out a random inspection in March 2010 we had information from a range of sources that there had been staff shortages on occasions at both night and day shifts. We found then that staffing had been reduced to falling service user numbers. We received assurances shortly after the inspection that increased staffing levels had been agreed so that three nurses were on duty between 8am and 8pm. We made a requirement that staffing levels are maintained and kept under review. Nevertheless, on the first day of our visits to the home we found that, as a result of sickness, only two nurses were on duty in the home. One of the nurses had worked at the home for less than a week and the other had worked there for almost six months. The newest nurse had not received a suitable induction to her role as she had not had the opportunity to read the files of the service users for whom she was providing care. We are aware that the Manager of the home has been addressing a range of staffing Care Homes for Older People Page 19 of 29 Evidence: problems. This has led to some staff shortages, for example, staff have been unavailable for work while issues are investigated. In one case a member of staff has been brought to the home from another Southern Cross service to cover the long term absence of a member of the nursing team. We made a requirement at the random inspection that adequate staffing levels are maintained and kept under review. Our findings on this inspection have led us to judge that the requirement is not met and it remains in place. Our observations of a lunchtime on the second day of the inspection showed us that the systems for shift planning need to be improved. We saw that one member of staff was the only person in the dining room where there were fifteen service users. They needed various degrees of assistance and we observed that the lack of staff caused difficulties for them An example was a service user who had to wait an unreasonably long time to be assisted to go to the WC; another service user fell asleep while waiting to be assisted to eat her meal. Of the 27 care staff 20 are trained to NVQ level 2 or 3, and a further 1 is registered to begin NVQ training. This represents 78 of the care staff team. We checked a selection of recruitment records and found a number of issues of concern. We made enquiries of the Manager and the Service Manager about some employment issues. We were informed about the process that was undertaken to assess the suitability of potential staff members. These included discussions with the potential employee, with previous employers and risk assessments. None of these documents were on the recruitment files. We have made a requirement about this. Care Homes for Older People Page 20 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements have improved since a temporary Deputy Manager has joined the management team. Quality assurance arrangements have changed and should contribute to improving the service. . Evidence: The Manager of the home is appropriately qualified and experienced and has recently been registered under the Care Standards Act. Shortly after the inspection a temporary Deputy Manager joined the management team in the home. This is a positive development as the management team has been incomplete for some months. Visits required by Regulation have now been allocated to a member of the Southern Cross quality assurance team. She has undertaken an audit of the service provided by the home. An action plan has been put in place to address the issues raised by the audit. Care Homes for Older People Page 21 of 29 Evidence: We checked financial systems. We learned that only very few valuable items are kept for service users, and access to cash and items of value is restricted. Unannounced audits are carried out by representatives of the managing organisation. As we went around the building we found two bottles of Hibiscrub hand cleanser in places which were accessible to service users to whom it could have presented risks. The bottles were removed to safe places on request. We checked health and safety records and found that appropriate checks had been carried out of the fire safety systems and a fire risk assessment was done in October 2010. We also saw a record which detailed monthly checks of health and safety matters in bedrooms. we found that the record was incomplete and somne checks had not been done beyond February 2010 and some rooms had not had any checks carried out. Water temperature checks are carried out and recorded. they showed that the water is at safe temperature for service users. We noted that a test of the lift had made a recommendation for a safety barrier to be provided. The recommendation was made on two consecutive checks, we have made a recommendation about this. Care Homes for Older People Page 22 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 Each service user must have 19/04/2010 a care plan which details how their needs in respect of health and welfare are to be met. To ensure clarity about service users needs and how they will be met. 2 7 12 Record keeping must be improved with relevant supporting documentation and assessment tools used consistently. This will assist in the promotion of the health and welfare of residents. 19/04/2010 3 19 23 The refurbishment and 26/05/2010 redecoration programme must include the kitchenettes as they were noted to be in a poor state of repair. This will ensure that facilities are in good repair, clean and reasonably decorated. 4 27 18 There must be, at all times, 01/04/2010 suitably qualified and experienced staff in sufficient numbers to meet the needs of the residents. To ensure that service users health and welfare needs are Care Homes for Older People Page 23 of 29 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 met. Care Homes for Older People Page 24 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 8 13 The Registered Provider must make sure that referrals to health care professionals are made promptly. This will protect the health and welfare of service users. 15/06/2010 2 9 13 The Registered Provider 14/05/2010 must ensure that there are effective arrangements in place for the ordering, recording, administration and disposal of medicines, in particular ensuring that Medicines are ordered on time so that residents do not miss doses of prescribed medicines Medicines records accurately reflect when medicines have been given and why they have been omitted or changed Care Homes for Older People Page 25 of 29 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 Medicines records indicate the quantity of medicines in stock so that audits can be carried out to ensure medicines are being used as prescribed. Discontinued medicines are returned promptly to avoid being used in error. Allergy information is recorded for all residents This will protect the health and safety of service users. 3 18 37 The Registered Provider 02/06/2010 must ensure that allegations of misconduct are notified to the CQC without delay. So that we can ensure that the correct action is taken in response. 4 19 23 The Registered Provider 21/06/2010 must provide us with a detailed and timetabled plan for the redecoration and refurbishment of the home. So that service users live in a well maintained and decorated environment which meets their needs. Care Homes for Older People Page 26 of 29 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 5 27 12 The Registered Provider must ensure that staff are available at times that service users need assistance. To ensure that service users receive the assistance they require. 25/06/2010 6 29 19 The Registered Provider must ensure that staff recruitment records are complete and include all of the matters taken into account in the assessment of their fitness to work at the home. Thorough and safe recruitment processes contribute to the safety of service users. 25/06/2010 7 30 12 The Registered Provider must ensure that staff receive an induction. To ensure they have enough information to provide appropriate care for service users. 25/06/2010 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 7 Staff should receive guidance about recording to ensure Page 27 of 29 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 that language used is respectful and contributes to the provision of person centred care. 2 15 Meal time arrangements should be improved by staff being guided on how to provide sensitive assistance to service users and by meals being served promptly. The Registered Provider should supply a safety barrier as recommended by lift engineers. 3 38 Care Homes for Older People Page 28 of 29 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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