Inspection on 06/10/09 for Claydon Lodge

This inspection was carried out on 6th October 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Claydon Lodge 05/11/07

Claydon Lodge 15/05/07

Claydon Lodge 12/12/06

Claydon Lodge 16/01/06

Claydon Lodge 06/09/05

Claydon Lodge 18/11/04

Claydon Lodge 19/07/04

Claydon Lodge 27/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Claydon Lodge Crich Place North Wingfield Chesterfield Derbyshire S42 5LY     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Bridgette Hill     Date: 0 6 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Claydon Lodge Crich Place North Wingfield Chesterfield Derbyshire S42 5LY (01246)852435 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): stephen@claydonlodge.co.uk Mr Diwan Chand,Dr. Anjuman Diwan Chand Name of registered manager (if applicable) Type of registration: Number of places registered: care home 45 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 45. The registered provider may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Date of last inspection Brief description of the care home Claydon Lodge Care Home is located in the village of North Wingfield, which is to the south east of Chesterfield. The home is purpose built and it is registered to provide personal care for up to 45 service users with older persons needs or dementia. The Care Homes for Older People Page 4 of 32 Over 65 0 45 45 0 Brief description of the care home home is arranged over two floors with lounge and dining areas available on each floor. A passenger lift enables those with mobility problems to access all areas of thehome. The range of fees charged at the home are £345.52 - £364.31 per week with extra charges made for Chiropody, toiletries and newspapers. Some top up fees were also aplicable depending ont he type of room to be occupied. The Acting Manager at the inspection gave this information. The most recent key inspection report was available in the entrance hall. The Statement of purpose and Service User GUide were not available for ourselves or residents to view at the visit as they could not be located. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections, undertaken by the Care Quality Commission (CQC), is upon outcomes for people and their views of the service provided. This process considers the Homes capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that needs further development. This inspection visit was unannounced undertaken by Bridgette Hill and an Expert by Experience Jan Colombo. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. In order to prepare for this visit we looked at all of the information that we have received, or asked for, since the last key inspection of the Agency, which took place on Care Homes for Older People Page 6 of 32 6th November 2008. This included: The Annual Quality Assurance Assessment (AQAA). This is a document completed by the Registered Providers of the Agency that focuses on how well outcomes are being met for people using the service. The previous Key Inspection Report, and the results of any Other Visits that we have made to the service in the last 12 months. Relevant information from Other Organisations, and what Other People have told us about the service. Surveys returned to us by people using the service, and from the staff working in the service. What the service has told us about things that have happened in the service, these are called Notifications and are a legal requirement. For this inspection of the service the questionnaires (a survey mentioned above) was sent to 15 people using the service, 8 surveys were sent to staff and 2 healthcare professional surveys returned the surveys to us however we have been told that these only were given out to people past the stated return date. During this visit to the service case tracking was used as a system to look at the quality of the care provided. This involved the sampling of three peoples records, two of these were looked at in detail. The Expert by Experience spoke to 9 residents in them about what it was like to live there. The services care plans and care records were also examined. Discussions were also held with any relatives that were present during the visit to peoples homes. In addition, discussions were held with the Manager of the service about its general operation. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: 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 Care Homes for Older People Page 8 of 32 order line 0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Suitable arrangements for assessing residents are in place however residents do not have access to information about the home. Evidence: The most recent inspection report was on display in the reception hallway for residents or visitors to access. Currently no new residents were placed at the home by Social Services due to concerns over the lack of stable management. We discussed however with the Acting Manager if admission procedures were in place for should new residents be admitted in the future. We were shown a brief policy on admissions and the Acting Manager said they would always go out and assess each prospective resident prior to admission, this is also described to us on the The Annual Quality Assurance Assessment (AQAA) . Care Homes for Older People Page 11 of 32 Evidence: The AQAA told us that the home would invite all potential service users to visit the home before admission along with their relatives or friends. We asked to see a copy of the Service User Guide and Statement of Purpose but this could not be located so was also not accessible to us or to residents in the home. The care files of current residents we looked at contained details of the Social Services assessments and care plans where residents were receiving funding from local authorities. The Expert by Experience spoke with residents about their admissions. From information we were told it was largely families that had chosen the home for their relatives to stay in. Some residents told us they had visited the home before moving in and others had not. The home does not offer intermediate care as defined by national Minimum Standard 6. Care Homes for Older People Page 12 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The assessment of risk and planning of care was not being sufficiently managed to ensure that residents were not being placed at risk. Evidence: We examined three care plans of residents some in part to examine how care needs were being recorded. Whilst a care plan was in place for each resident it was some months since any of the 3 care plans had been reviewed. The Acting Manager said that so far 2 of the plans of residents in the home had been reviewed since they commenced in post but that they were aware that the others also required doing. Accident records and discussions with the Acting Manager had identified that an increased number of falls had occurred over the past few months so we examined the records of a resident who was experiencing an increase in falls. The resident also had a risk assessment for wandering on file. The care plan did not reflect the resident was at risk of falls or wandering despite a series of recent falls and the risk assessment for wandering stating checks by staff needed to be done. The last documented review of the care plan was in January 2009. Care Homes for Older People Page 13 of 32 Evidence: Some residents in the home had dementia however there was no plan of care in place to detail how this affected the resident and the care delivery needs associated with this. For one resident GP records indicated an episode of mental ill health that required prescribed medication, a plan of care was not in place to record this or detail how the resident would be supported and cared for. None of the care plans we viewed considered the mental capacity of the residents or their abilities to make decisions. Some risk assessment formats were seen in residents files however these had not been reviewed for some months. The AQAA informed us that in the past 12 months 1 resident had developed a pressure area and the resident was still in the home. A complaint we are aware of indicates that 1 other resident has also had a pressure area in the home in the past 12 months. The Acting Manager has been in post for only the past 4 weeks and says they completed the AQAA on the basis of information that was available to them. We examined the file where a resident was reported to have a pressure area. Poor recording of the residents care was found with the care plan and risk assessment not indicating that a reddened area was ever present or that a District Nurse had visited to dress the area which is verbally what staff told us had happened. A care plan for pressure areas was in place and the equipment described in this was being used by the resident. The home had a chiropodist and optician who visited the home regularly which residents were charged for on top of the fees. The AQAA acknowledged the home could improve residents access to dental care. Residents weights were usually monitored monthly to assess for any significant changes and the ones we looked at indicated that residents weights were quite stable. Some record keeping by staff was found to be poor with a lack of dates of signatures to inform the reader how relevant and recent information was. Staff kept notes each day to describe how the resident had been. There were some records in care files to record GP and other health professionals visits and appointments to outpatients. We were told there was good support from GPs to the residents in the home. Whilst there were some records of a variety appointments and tests there was a lack of information regarding the results of appointments or what follow up was required. One record indicated a GP was unable to visit at that time but no subsequent visit was documented so this was not being Care Homes for Older People Page 14 of 32 Evidence: followed through. We looked at how medications were stored and handled at this visit. The room where medications were stored was found to be dirty in a number of areas. The drugs fridge had been defrosted and when switched on was found to be reading at a very high temperature so may be broken. The home uses a monitored dosage system. The medication administration records indicated that there some were some gaps where prescribed medications should have been given. Some medication records had dosages prescribed which could vary and the actual dosage administered to the resident was not being recorded by all staff. Records of medications received and returns were documented. We looked at the controlled drugs book which indicated that there should be medicines in the home which werent and for others more medicines than the balance recorded was found in the cupboard as staff were not recording these robustly. One resident when asked what it was like to live in the home told us It is fine. They do their best. They cannot do more than that. I have nothing to grumble about. Another resident told us I am treated well. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recent improvements have been made but are yet to be fully established which will improve the range of activities, leisure and social opportunities offered to residents Evidence: The Expert by Experience spent time with residents to find out about their daily life and routines. A recent addition to the home is the employment of an activities coordinator who works for 15 hours per week to provide activities to residents. This was welcomed by the residents we spoke with. A board with the month, year and weather on was in the reception area but was not fully up to date. Some activities have begun to take place, one resident told us I enjoy the activities. Everybody joins in with them, I enjoyed an outing to Chatsworth. One resident told us their relatives are allowed to visit at any time. One resident told the Expert by Experience that a relative brought in their dog as well. A hairdressing room was available and a hairdresser visited regularly one resident told Care Homes for Older People Page 16 of 32 Evidence: us they had had their hair done recently One resident told us It is very nice here. I can watch TV, Staff do whatever we ask. The meals are very nice. There is a choice sometimes Staff all seem nice and helpful. There are enough around. One resident told us I decide when I get up and go to bed. The Expert by Experience ate a meal with relatives and considered the food to be tasty and a choice of meal was available including meat free options. Residents told us the food is not bad, if you ask for a drink, they see that you get one another resident told us they breakfast in bed each morning by choice. We observed some staff assisting some residents to eat this was considered to be done in a sensitive manner. One relative on a survey told us that the home could improve by providing regular drinks, quality tea and nice mugs. One resident told us they felt not enough money is allocated for providing the meals. Care Homes for Older People Page 17 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a lack of robust systems in place for complaints and safeguarding adults which may result in residents concerns not being appropriately handled. Evidence: The complaints procedure was situated at each entrance area to the home and in other areas around the home such as the lift. The procedure did not reflect the changes in the CQC (Care Quality Commission) address. The AQAA told us that the home had received 6 complaints over the past twelve months and we examined the records at our visit. The records available told us that only one complaint was on file. The Acting Manager told us that safeguarding adult referrals had also been included in the number of complaints recorded however this still left 2 of the 6 complaints unaccounted for. Since the last inspection the Care Quality Commission has received 2 concerns, 1 of these is currently being investigated by other appropriate agencies. The other concern was taken up directly with the home by the person who contacted us and was reported to be resolved by the complainant, this was however not documented as part of the complaints records we viewed. The Expert by Experience asked residents if they know how to complain. Some residents said they had complained about things such as the laundry service in the Care Homes for Older People Page 18 of 32 Evidence: past and this was much better now. Some residents told us they would speak to their families or staff if they had any complaints. One relative told us they had raised things with the new acting manager and they had been put right. One relative told us I hope it will be better with the new Manager. I have told her about certain things and she has put them right. The training records for staff indicated that all staff apart from 2 had completed safeguarding adult training, 1 member of staff had only commenced in post recently. A suitable safeguarding adult procedure was in place, this gave consideration to any emergency intervention and clearly refers to local safeguarding adult procedures. The AQAA told us that there has been 2 safeguarding adult investigations and since completion a further referral has been made. Whilst conclusions have not yet been reached a theme of the blurring of professional boundaries has been identified. As a result of this the Acting Manager has booked a training session for staff to address this. Care Homes for Older People Page 19 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and provides a comfortable place for residents to live in. The delayed action to address the fire officers report may place residents at risk. Evidence: Since our last inspection visit the home has increased the registered numbers and the ground floor has undergone significant refurbishment to provide en suite accommodation in single rooms to residents. The home is arranged over two floors and a lift is used to help those with impaired mobility to get to their bedrooms. The Expert by Experience observed some quieter areas where chairs had been placed in alcoves or the reception area where residents could rest if they had mobility problems or just sit quietly. One resident told us they liked to sit in the entrance area. At present the majority of residents are accommodated on the ground floor. Some pictures and photograph signage was in place to aid residents to orientate around the home. The decor included some old advertisement pictures which the Expert by Experience considered would aid reminiscence. We found the home to be largely in good order and was clean without any odours, the only exception to this being the treatment room. Residents told they liked their Care Homes for Older People Page 20 of 32 Evidence: bedrooms and they were always cleaned. We viewed a sample of rooms which were personalised with residents own possessions. One resident told us my room is beautiful. I have my own things in it Some residents protected their privacy by having the key to their room and we observed staff asking permission to enter to fix something, the resident agreed and handed over the key. We examined through a range of records how fire safety was being managed. There were regular in house checks of the alarm system and lighting system. The Fire Officer last visited the home in August 2009 where it was identified that the fire risk assessment required updating and some works were needed to protect fire exit routes. The Acting Manager told us the works had not yet been completed. The laundry area was fitted with one washer and one dryer which were fully working, it has been identified that the care staff do the laundry and this can detract from the number of care hours being provided. One resident told us that they had a problem with laundry when they first arrived, but it is all okay now Some staff training on infection control had been completed we saw stocks of gloves, hand gel and wipes and suitable hand washing facilities to limit the risk of infections at the home. Care Homes for Older People Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provision of care staff is affected by them undertaking non care related duties which may adversely affect the care residents receive. Staff are suitably recruited however a lack of robust induction and gaps in training may adversely affect their ability to deliver care. Evidence: The home had 15 residents in at the time of our visit. The staffing rota indicated that Senior Carers were on duty for each shift, these staff had achieved their National Vocational Qualification (NVQ) level 3 in care. The Acting Manager told us that as well as caring the care staff and activities coordinator on duty also did laundry, cleaning and cooking. This was as only 1 cook was employed and no laundry or specific domestic staff were employed. One staff member regularly did some cleaning as well as some caring duties. We found that the home was clean but that care related recording was found to be out of date and not being reviewed as identified in the health and personal care section. We were told that adverts were out to recruit laundry, kitchen and domestic staff and a number of phone calls from people seeking jobs were taken during our visit. The home has 14 staff of whom 11 have achieved their NVQ (National Vocational Care Homes for Older People Page 22 of 32 Evidence: Qualification) level 2. There is a structure of care staff in place with some staff being designated Senior Carers who have completed NVQ level 3 training. We were told there was a plan for some staff to enrol on a Leadership in Care course. Staff were being suitably recruited to work with vulnerable adults and the three staff files we looked at contained all the required references, checks and criminal records bureau checks. The Acting Manager told us a skill based pack had been found in the home but that recently appointed staff had not completed this. The staff files we looked did include a checklist type induction. The AQAA identified to us that staff training was an area that could be improved, this included mandatory training. Since commencing in post the Acting Manager has arranged a number of training sessions, some have been delivered, others are planned in the near future. Whilst there remained some gaps in the training matrix for moving and handling, safeguarding adult and food safety training the majority of staff had completed training. Additional training had also been held for most staff in health and safety, infection control and Coshh (control of substances hazardous to health) One particular deficit identified in the training matrix was that only the Acting Manager had completed first aid training, therefore no designated first aid person was available for staff or residents. The first aid boxes also required restocking to ensure they had required items in them if they needed to be used. Only the Acting Manager had completed recent dementia training, some staff had not received training at all, for others it was not recent.As the home registered to accept residents with dementia staff require training to meet the needs of residents. It is also identified as a deficit at this visit that no care plans we viewed considered how residents with dementia were to be cared for. The Acting Manager had obtained copies of the General Social Care Council Code of Conduct booklet and additional training in Boundaries and professional conduct and challenging behaviour was booked. Care Homes for Older People Page 23 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inconsistent management of the home and a lack of quality assurance processes have resulted in a range of deficits where the home has not been run in residents best interests. Evidence: The AQAA had been completed by the Acting Manager who has been in post since 7th September 2009. It told us that there had been several managers in post this year. The new Acting Manager in post is suitably qualified having achieved their NVQ level 4 in management they also told us they are planning to do a leadership in care course. A deputy Manager has also recently been recruited and has so far worked 1 shift in the home. Residents and relatives told us that the last permanent manager of the home was good but that things had deteriorated since they left. We did receive one comment that the new Acting Manager had made some improvements. One comment was made from a relative that improvements could be made to the home by having a Manager Care Homes for Older People Page 24 of 32 Evidence: with vision and direction. The AQAA was open in telling us that wide range of areas required improvement, this included staff training, care plans and expansion in the range of leisure activities offered. There have not been any in house quality assurance surveys completed, the Acting Manager told us this was being planned. The surveys we supply to the home were given out however one relative commented that these were late being given out as the new Acting Manager had only just found them. We asked to see the Providers monthly quality reports for the home and was told that the last one to be completed was 27.6.09. The reports were completed for the few months prior to this but did not detail any discussions with staff or residents about the service. We are aware that some incidents which are reportable to the CQC have not always been sent however since the Acting Manager has been in post these are being received regularly to inform us about significant events in the home. Some monies were kept safely on resident behalf for them to access hairdressing and chiropody. Suitable storage and record keeping was in place for this. An office for care staff was available where residents notes were kept, these were observed to be in an open trolley and the door to the office was not lockable. We looked at accident records in the home which were being audited. The Acting |Manager told us that it had been identified that the number of falls had increased in the past few months. Whilst the actions taken to address the situation at the time of the falls seemed appropriate care plans for managing falls were not in place so longer term prevention and risk management strategies were not being considered. We examined a range of service checks for the building and found them to be in date. A handyman was employed who monitored water temperatures in the home which were suitably regulated. Care Homes for Older People Page 25 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 2 4&5 The Statement of purpose 30/11/2009 and Service User Guide must be up to date and made available to service users to ensure they have sufficient information regarding the home Changes have occurred to the management of the home and the timescale has been extended to allow for this. If the extended timescale to meet this requirement is not met, enforcement action will considered. Care Homes for Older People Page 26 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 7 14 Care plans must be kept under review and up to date to ensure they fully document all the residents needs This is to ensure the residents needs will be met 30/11/2009 2 8 14 There must be ongoing review of risks to residents and where risks are identified these are to be supported by aplan of care to demonstrtae how these are to be managed This is to ensure residents are protected as far as possible from identifiable risks 30/11/2009 3 9 13 There must be robust 30/11/2009 recording of controlled drugs to allow a complete audit to be possible This is to ensure there is full accountability for all Care Homes for Older People Page 27 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action controlled drugs in the home and residents medication is securely managed 4 9 13 Where a variable dosage of a medication is prescribed the actual dosage administered must be recorded This is to ensure a complete record of the residents treatment is kept 5 9 13 All entries on the medication 30/11/2009 record must be completed to indicate whether or not the medicines have been administered, if not a code to explain why must be recorded This is to ensure a complete record of the administration of treatments are kept 6 16 22 Records of complaints and how these are handled must be robustly kept This will ensure that residents concerns are listened to, actioned and monitored to enhance the quality of the service 7 18 13 Staff must have access to a whistle blowing policy This will ensure staff have 30/11/2009 30/11/2009 30/11/2009 Care Homes for Older People Page 28 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action information on how to report any concerns they have about the home in an appropriate manner 8 19 23 The requirements described in the Fire Officers report must be actioned This is to ensure the home is safe for residents to live in and all fire regulations are met 9 29 18 A skill based induction pack 30/11/2009 must be used for staff who are new to the home who do not hold any formal qualifications in care This will ensure staff have suitable skills and knowledge to meet residents needs 10 30 18 Staff at the home must be trained in dementia care This will ensure they are able to meet the needs of residents with dementia 11 30 18 There must be a suitable provision of staff in the home who are trained in first aid, this should include work based first aid 31/12/2009 31/12/2009 31/12/2009 Care Homes for Older People Page 29 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure there are competent staff to deal with any emergencies that arise in the home 12 31 8 The provider must ensure 30/11/2009 that a manager is appointed who is suitably qualified and an application made to register the manager with the Care Quality Commission This is to ensure the home is managed in the best interests of residents 13 33 24 There must be robust quality 29/01/2010 assurance systems in place to monitor the quality of the service residents receive This is to ensure residents views are listened to and that the service is able to ensure the service given is a good quality one 14 33 26 The provider must assess the quality of the service on a monthly basis, document the findings and take appropriate actions to the findings This ensures the provider is monitoring quality and ensuring the home is run in residents best interests 31/12/2009 Care Homes for Older People Page 30 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 15 37 17 Records and confidential information must be held securely as per Data Protection Guidance This is to ensure the residents privacy and confidentiality is protected 30/10/2009 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 9 16 Suitable storage of medicines requiring refrigeration should be available The address of the Care Quality Commission must be updated on the complaints procedure to ensure residents have up to date information The first aid boxes should be restocked with all recommended items 3 30 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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