Inspection on 16/01/09 for Chilterns Manor

This inspection was carried out on 16th January 2009.

CSCI 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chilterns Manor 17/01/08

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Chilterns Manor Northern Heights Bourne End Buckinghamshire SL8 5LE     The quality rating for this care home is:   one star adequate 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: Jane Handscombe     Date: 1 6 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 03000 616161 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Chilterns Manor Northern Heights Bourne End Buckinghamshire SL8 5LE 01628528676 01628527735 chilternsmanor@centurioncare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Centurion Health Care Ltd care home 22 Number of places (if applicable): Under 65 Over 65 0 22 dementia old age, not falling within any other category Additional conditions: 22 0 The maximum number of service users to be accommodated is 22. 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: Dementia (DE) maximum number of places 2. Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Chiltern Manor provides residential care and accommodation for 22 older people. The registered provider is Centurion Health Care Ltd. The home is traditionally furnished and decorated to a high specification set in its own landscaped grounds, and has car parking facilities for approximately twelve to fifteen vehicles. There are 18 single bedrooms, and 2 double rooms over three floors, that can be accessed by stair lifts, most rooms have en-suite facilities, and those that don?t have a wash hand basin; double rooms are single or kin share only. The home is situated at the end of a private road, adjacent to open farmland. Care Homes for Older People Page 4 of 30 Brief description of the care home Chiltern Manor has a Statement of Purpose and Service Users Guide available on application to the home. Information CSCI received 18/01/08/ confirms that weekly fees start from 375 pounds to 850 pounds. Care Homes for Older People Page 5 of 30 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 of the service was an unannounced Key Inspection. A key inspection is one in which the key National Minimum Standards (NMS) - those standards that the Commission considers to be the most important to service users well-being, are assessed. The inspection took place on Friday 16th January 2009 and lasted 10 hours. It was a thorough look at how well the service is doing. We took into account information that we have received about the service in the form of the homes Annual Quality Assurance Assessment (AQAA) and any other information that we have received about the service since the last inspection. The AQAA is a self-assessment of how well the home feels they are meeting the standards of care for people living at the home. All registered Care Homes for Older People Page 6 of 30 homes and agencies must send us their AQAA each year. We asked the views of the people who use the service and other people seen during the inspection or who completed one of the questionnaires that the Commission had sent out. A tour of the home was undertaken and we joined residents for lunch. A sample of peoples care plans and records, medication records and staff recruitment files were looked at. This report summarises how well the home is meeting the NMS, through using the Key Lines of Regulatory Assessment (KLORA). The KLORA sets out the sorts of evidence that best describes the standard - excellent, good, adequate or poor - of the care and facilities provided for people living at Chilterns Manor. A judgement statement summarises each section (outcome group) in the report. The overall quality (star) rating is arrived at through a rules based approach, with the emphasis on three sections of the report that look at the safety and management of the home: Health and Personal Care, Complaints and Protection, and Management and Administration. We would like to thank all those who gave their time and help during the inspection process. What the care home does well: What has improved since the last inspection? Since the last inspection an activities co-ordinator has been recruited and the service now provides a choice of daily activities in which the service users can partake. The activities offered are based upon the likes and dislikes of the service users and are offere on both a one to one basis and in a group setting to meet the needs and preferences of those using the service. Guidance has been sought around the subject of restraint and deprivation of liberty and all staff have been made aware of the homes policy and procedures. All staff are provided with regular supervision and are able to discuss how they are working and discuss their personal development and any training needs. The service have worked upon the care plans, introduced a more person centred care planning process and introduced a keyworker system, to ensure that peoples care and support is more individualised. The key worker system allows for the designated carers to be more involved in the care planning and review process. The service has developed a quality assurance questionnaire to allow residents/ relatives to voice their opinions on the service and provision of care, which will be used to gain feedback on where improvements could be made and thereby enable them to have a say in the running of the home. Care Homes for Older People Page 8 of 30 All the homes policies and procedures have been reviewed and updated where necessary, What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –03000 616161. Care Homes for Older People Page 9 of 30 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 30 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. The home provides good clear information, which is used by prospective residents to help them choose a home that is right for them.All residents have their care needs assessed before moving into the home.The home does not provide for intermediate care Evidence: The home provides good clear information, which is used by prospective residents to help them choose a home that is right for them. All seven users of the service who completed questionnaires felt that they had received enough information about the home before they moved in. Whilst viewing the service users guide and statement of purpose, it was noted that they required some updating to ensure that they provide people with up to date information and they meet with Schedule 1 of the Care Homes Regulations 2001. Care Homes for Older People Page 11 of 30 Evidence: All prospective users of the service have their health, social and personal care needs assessed prior to being offered a place at the home to ensure that both parties are confident that the home is able to meet their assessed needs. The assessment is undertaken in collaboration with the individual and/or their representative. A sample of care plans was examined and very thorough assessments had been made of each of the service users care needs. Wherever possible, prospective residents, family and friends are given the opportunity to visit the home and join fellow residents, in order to gain a feel of the home and meet staff before making a decision as to whether the home is suitable. Care Homes for Older People Page 12 of 30 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. The home has a clear and consistent care planning system in place that involves service users and their representatives and ensures staff have the information they need to satisfactorily meet the individuals needs. Poor practices around the recording and administration of medication were taking place suggesting that people were not being administered their medication as prescribed by their GP, which could compromise the health, safety and well being of those using the service. Evidence: Information provided to the Commission, prior to the inspection, informed us that each user of the service has an individualised plan of care detailing their health, personal and social care needs and how these needs are to be met. They contain relevant moving and handling assessments as well as risk assessments identifying any risks that could impact upon their health and the provision of care, and how these identified risks are to be minimised. A sample of care plans were examined and this was followed Care Homes for Older People Page 13 of 30 Evidence: up by meeting with individual residents to confirm that their care needs were being met. On each occasion the care plans gave a good reflection of the person, their care needs and how these would be met. The plans were reviewed on a regular basis, and the daily records reflected the care given as set out in the individual care plans. Generally the records viewed evidenced that the service user and/or their representative are involved in the care planning and reviewing process. Risk assessments were found to be contained within those files viewed which included assessments in relation to moving and handling, pressure area care, falls, nutrition, continence and self medication. Where a risk was identified support plans were in place detailing the actions to be taken to minimise such risks. Care plans were seen to be regularly reviewed and updated where any changes in the individuals needs were apparant. Of the three files viewed one failed to contain an up to date photograph of the individual, which the proprietor assured us would be attended to. The home has good working relationships with the local GPs and community health services and accesses them when appropriate. Evidence of any healthcare treatment, which service users receive, is detailed within their care plans. As part of the inspection process we looked at the medication systems. People are enabled to maintain responsibility for their medication within a risk management process and are provided with secure facilities in which to store them. We discussed the systems in place for checking in medication received into the home from the pharmacist and the systems in place for returning medication. It was noted that one person admitted to the home had brought medication into the home with them whilst awaiting their medication to be supplied by the pharmacist; although the named medication was documented within their file, the actual number of tablets was not documented. Whilst examining their medication administration records (MAR) it was noted that staff had signed to evidence that the medications had been administered although the blister packs which contained the medication did not tally with that upon the MAR sheet. One weeks medication remained in the blister packs which we were informed were due to the fact that the medication brought into the home when admitted were administered and when the blister pack arrived from the pharmacist it was decided to start this particular service users medication on the week 2 column of the blister pack since all the other users of the service were on week 2 of their medication and would allow for ease of auditing. However the number in the blister pack compared to that on the MAR sheet did not tally. Likewise whilst viewing another service users MAR sheet the number remaining in the blister pack did not correlate with the number that had been signed as administered on the MAR sheet, suggesting that the said service users were not being administered their medication as prescribed by their GP. It was further noted that whilst the MAR sheets have a section to Care Homes for Older People Page 14 of 30 Evidence: document the number of tablets carried forward, this was not being used. An immediate requirement was made to ensure that arrangements are made for the safe handling, safekeeping, safe administration and disposal of medicines received into the care home and to undertake an investigation of the poor medication practices found and to inform the Commission for Social Care Inspection of the outcome and actions taken. We received confirmation that an investigation had been undertaken and appropriate actions taken and measures put into place to ensure that people are administered their medication in accordance with that prescribed by their GP and to ensure that robust procedures are followed to ensure peoples health safety and welfare is protected. In situations in which individuals are prescribed controlled drugs, it was found that they were stored in a designated controlled drugs cabinet securely fixed into the medication trolley. However, in 2007 the law changed; all care homes, whether providing nursing or personal care, must now keep controlled drugs (CD) in a controlled drugs cupboard fixed to a solid wall or a wall that has a steel plate mounted behind it and it is to be fitted with either Rawl or Rag bolts for which a requirement has been made within this report A controlled drugs register was in place containing the required records of receipt, administration and disposal of controlled drugs. We chose to undertake an audit of the controlled drugs prescribed to users of the service and found the number held within the cabinet tallied with those documented within the controlled drugs register. Throughout the inspection it was evident that staff understood issues about privacy and dignity; the residents were seen to be assisted in a kindly and respectful manner, and staff were observed to knock on doors prior to entering a persons private room, the bathrooms and toilets Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are able to take part in meaningful activities suited to their needs and abilities and maintain contact with families, friends and the wider community.The food provided in the home is of good quality, freshly prepared and cooked on the premises, offers choice and meets the dietary needs of those using the service. Evidence: Discussions with service users was positive acknowledging that the lifestyle experienced at Chilterns Manor matches their expectations and enables them to exercise choice and control over their lives. There is a varied programme of activities provided for those who wish to partake, based upon the likes, dislikes and abilities of those using the service, which include general knowledge quizzes, music and movement sessions, bingo and reminiscence. Activities are provided both on a one to one basis and in group setting to meet peoples individual needs. There is a visiting hairdresser who visits the home once a week for those who require. A librarian also visits the home on a regular basis offering a selection of books and magazines for service users to choose from if required, and a Care Homes for Older People Page 16 of 30 Evidence: chiropodist visits the home on a 6-8 week basis. The home will make arrangements to enable residents to visit their own church or for someone from their church to visit and we are informed that a monthly communion service is held for those who wish to partake. People who use the service are provided with good quality food, which is freshly cooked on the premises and are offered a choice. Special diets are available to meet residents health and cultural needs. The chef always endeavours to take individual tastes into account and discusses their preferences with them periodically. Breakfast can be taken either in the dining room or service users own rooms; many of the residents choose to take their breakfasts in their rooms and are offered a tray service. Lunch is the main meal of the day and is usually taken in the dining room although those who wish can take their meal in their rooms. The inspector took lunch with those using the service, which consisted of haddock in breadcrumbs, peas or baked beans and chips followed by the choice of hot toffee sponge and custard, profiteroles or ice cream. It was noted that the menu was slightly different to that served and the service was reminded that any changes to the menu should be documented to allow for an audit trial if the need arose. The dining environment was found to be relaxed and comfortable and residents were able to enjoy their lunch at their own pace. Discussions around the meals provided were all very complimentary and comments included food is always beautifully cooked, its a very varied menu we have here and the meals are lovely. The home welcomes visitors at any time. Care Homes for Older People Page 17 of 30 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 good 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 complaints procedure in place, which is accessible to service users, family members and visitors to the home. Policies and procedures are in place to safeguard service users from harm Evidence: There are policies and procedures in place to guide staff on how to respond to any suspicion of abuse. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff members responsibility to whistle blow on any poor practice or concerns that come to their attention. During the last 12 months, there has been one safeguarding incident which the service dealt with appropriately and for which a safeguarding investigation was undertaken with involvement of all relevant parties under the local authorities interagency policy and procedure, to ensure the health, safety and well being of those using the service. Those who completed questionnaires were confident about how to make a complaint and that any concerns are taken seriously and acted upon. The homes complaints procedure is clearly set out in the Statement of Purpose and Service Users Guide. The service have received one complaint during the last 12 months, which was dealt with under their complaints procedure and which the Commission were notified about. Care Homes for Older People Page 18 of 30 Evidence: Where people require the services of an independent advocate, the service will enable service users to access such a service. An independent advocate regularly visits one user of the service. Care Homes for Older People Page 19 of 30 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 who use the service are provided with a comfortable, safe, homely and clean environment in which to live. Evidence: The proprietor informed the inspector that the home always encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, which was confirmed by those spoken to during our visit and evident on touring the home. Residents spoken to on the day informed us that they were happy with their bedrooms and their surroundings, that the home is kept to a high standard of cleanliness at all times. The laundry is fully adapted to meet the laundering needs of the residents with infection control policies and procedures in place and evidently followed. Colour coded laundry bags were observed as was protective clothing and hand washing facilities. Staff have received infection control training. People using the service are enabled to access their communal and private space, through the provision of a number of aids and adaptations. The home provides grab rails in corridors, bathrooms and toilets and hoists and assisted toilets and baths are Care Homes for Older People Page 20 of 30 Evidence: available to meet the service users needs. The home has sufficient toilet, washing and bathing facilities, all of which were accessible and clearly marked. Accommodation for each resident is furnished and equipped to ensure them the right to comfort and privacy in a homely atmosphere. Care Homes for Older People Page 21 of 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good recruitment procedure in place to ensure that only suitable staff are employed to work with the users of the service, although verification of references which do not contain a company stamp needs attention. The staff team are provided with a good range of training and ongoing support and supervision to ensure they have the relevant skills and knowledge to enable them to deliver the care safely and competently. Evidence: The staffing levels on the day of inspection were sufficient to meet the needs of the residents. Three staff files were sampled which showed evidence of a systematic and thorough recruitment process, with references and required checks having been taken up before employing the member of staff. However, it was noted that whilst references are sought those without a company stamp are not always followed up, for which a recommendation has been made within this report. The proprietor informed us that the letter sent out requesting references has been changed requesting that the response be accompanied with a company stamp or provided upon letterheaded paper. We are informed that all newly appointed members of staff undergo induction training upon appointment to their posts, and are provided with mandatory training, offered ongoing training and encouraged to undertake the National Vocational Qualification Care Homes for Older People Page 22 of 30 Evidence: (NVQ) in Care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. The staff records viewed contained evidence of induction training and supervision. The home has a good programme of training in place for staff, including mandatory training in Health & Safety, Fire Safety and Manual Handling. We are informed that staff have been made aware of the Mental Capacity Act and an awareness into the deprivation of liberty and restraint since the last inspection. The proportion of care staff who have attained National Vocational Qualification (NVQ) in Care at Level 2 or above is above the 50 recommended by the Commission; of the twelve permanent care workers, nine have achieved the qualification with a further three staff undertaking the NVQ at level three and one staff member at level 2, which is commendable. Feedback from seven people using the service who completed questionnaires tells us that the staff are always available when they need them and that the staff always listen and act on what they say. Comments during the visit included; Im looked after very well, absolutely excellent, couldnt wish for better staff. Feedback from staff was also very positive, of the six surveys completed and returned all tell us that their induction covered everything they needed to know to undertake the job when they started, all tell us that they are provided with training which is relevant to their role and tell us that they are regularly or often provided with support and discuss how they are working. Feedback from health professionals was also positive, and all tell us that the care staff either always or usually have the right skills and experience to support individuals social and health care needs. There is a good feeling of teamwork amongst all the staff and those spoken to are very happy to be working at the home. Care Homes for Older People Page 23 of 30 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 approach of the home creates an open, positive, transparent and inclusive atmosphere. The rights and best interests of service users are not being safeguarded appropriately; poor recording procedures in relation to administration of medication could compromise the health, safety and welfare of those using the service. Evidence: At present the home does not have a registered manager in place, temporary arrangements have been in place since May 2008 in which the proprietor together with a senior member of care staff has been managing the home. We were made aware of the situation and assured these would be short term arrangements and a person would be recruited to manage the home and subsequently register with ourselves. However, to date the registered person has not yet appointed a person to manage the home as is required under the care home regulations 2001. A requirement has been made within this report to ensure the registered person recruits and register an individual to Care Homes for Older People Page 24 of 30 Evidence: manage the care home. The inspector discussed health and safety issues and saw appropriate maintenance records relating to maintaining a safe environment for residents. Regular safety checks are undertaken relating to fire safety and infectious diseases and regular servicing and maintenance of equipment, all of which were seen to be documented appropriately. There were some shortfalls in relation to fire drills; although the service undertake monthly fire drills which are logged accordingly, the logs viewed highlighted the staff members names who had taken part although the documentation was not signed by the said carers to evidence they had partaken. The proprietor assures us that these will be signed in future to evidence they have taken part. The home does not act as agent or manage monies on behalf of residents, however there are systems in place to ensure that residents small amounts of cash are, when required, safely stored, managed and there are receipts and records for all transactions. The home engages regularly with users of the service to gain feedback on the service it provides; this is undertaken on both an informal and formal basis through feedback and annual surveys, noting any comments or concerns when undertaking residents care reviews and in resident meetings. It is recommended that the annual questionnaire allows for family members, GPs, social workers and any other stakeholders involved with the home to take part to allow for a more rounded view of the service. The home deals with a number of diverse care needs and ensures to offer a personalised service to meet the needs of their clients. There is a commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. Care Homes for Older People Page 25 of 30 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 9 13. (2) The registered provider must 17/04/2008 ensure a controlled drugs cupboard, which complies with the misuse of Drugs (safe custody) Regulation 1973 is provided for the secure storage of any Controlled Drugs, which are prescribed for people who use the service. Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 9 13 requiring the registered 19/01/2009 person to ensure that arrangements are made to ensure the safe recording, administration and disposal of medicines received into the care home, to undertake an investigation of the poor medication practices found and to inform the Commission for Social Care Inspection of the outcome and actions taken Regulation 13(2) of the Care Homes Regulations 2001 requires that: The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 Review and ammend the information within the statement of purpose and service users guide to ensure that people are provided with up to date information including that 31/03/2009 Care Homes for Older People Page 27 of 30 listed under schedule 1 of the care homes regulations 2001 Regulation 4(1) of the Care Homes Regulations 2001 requires that: The registered person shall compile in relation to the care home a written statement (in these regulations referred to as the statement of purpose) which shall consist of a) a statement as to the aims and objectives of the care home; b) a statement as to the facilities and services which are to be provided by the registered person for service users and c) a statement as to the matters listed in Schedule 1. 2 9 13 Controlled Drugs, must be 30/03/2009 stored in a Controlled Drugs cupboard fixed to a solid wall or a wall that has a steel plate mounted behind it and it is to be fitted with either Rawl or Rag bolts complying with the Misuse of Drugs (Safe Custody) Regulations 1973. Regulation 13(2) of the Care Homes Regulations 2001 requires that: The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and Care Homes for Older People Page 28 of 30 disposal of medicines received into the care home. 3 31 8 The registered person must 30/04/2009 ensure to recruit and register an individual to manage the care home. Regulation 8 (1)(a)(b) of the Care Homes Regulations 2001 requires that: (1) The registered provider shall appoint an individual to manage the care home where(a) there is no registered manager in respect of the care home; and (b) the registered provider (i) is an organisation or partnership; (ii) is not a fit person to manage a care home; or (iii) is not, or does not intend to be, in full-time day to day charge of the care home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 15 29 33 Any changes to the menu should be documented to allow for an audit trial if the need arose. It is recommended that any references received without a company stamp are followed up to verify their authenticity It is recommended that the annual questionnaire allows for family members, GPs, social workers and any other health professionals involved with the home to take part to allow for a more rounded view of the service. Page 29 of 30 Care Homes for Older People Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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