Inspection on 22/03/10 for Comberton Nursing Home

This inspection was carried out on 22nd March 2010.

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

Other inspections for this house

Comberton Nursing Home 03/11/09

Comberton Nursing Home 11/09/08

Comberton Nursing Home 15/05/06

Comberton Nursing Home 06/02/06

Comberton Nursing Home 09/08/05

Comberton Nursing Home 24/01/05

Comberton Nursing Home 06/09/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Random inspection report Care homes for older people Name: Address: Comberton Nursing Home King William Street Amblecote Stourbridge West Midlands DY8 4EP zero star poor service The quality rating for this care home is: The rating was made on: 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 review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Monica Heaselgrave Date: 2 2 0 3 2 0 1 0 Information about the care home Name of care home: Address: Comberton Nursing Home King William Street Amblecote Stourbridge West Midlands DY8 4EP 01384262027 0138476943 comberton@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Mandy Coyne Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Jayantilal James Bhikhabhai Patel care home 36 Number of places (if applicable): Under 65 Over 65 36 0 old age, not falling within any other category physical disability Conditions of registration: 0 36 The maximum number of service users who can be accommodated is: 36 The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability (PD) 36 Old age, not falling within any other category (OP) 36 Date of last inspection Care Homes for Older People Page 2 of 17 Brief description of the care home Comberton Nursing Home is located near to Stourbridge town centre. The home is sited in an attractive residential area. The home itself is a large detached property that has been converted and extended to its present form a 36 bedded nursing home. The home comprises of three storeys. Bedrooms are located on both floors. The main living areas, kitchen, offices, laundry and a shower room are on the ground floor, further bedrooms, the bathroom, toilets and the treatment room on the first floor. The lower ground floor accommodates the office and staff room. The home has well maintained gardens to the front and rear and a good sized car park at the front. Comberton is registered to provide care to a maximum of 36 residents who have nursing needs. Please contact the home direct ly to enquire about current fees. Care Homes for Older People Page 3 of 17 What we found: We, the Care Quality Commission (CQC) undertook this random inspection visit on 22nd March 2010 to to check the homes compliance with the twenty five requirements issued at the key unannounced inspection on 3rd November 2009. These related to the admission process, reviewing risk assessments, risk assessments for the use of bedrails, care planning, management of pressure relief, ensuring people receive an adequate diet and fluid intake and nutritional supplements, management of incidents of bruising and appropriate follow up to ensure the protection of people, and the arrangements for the safe administration of medication. Requirements were also made for improvements to the environment, the review of the staffing numbers and dependency level of the people being cared for, ensuring appropriate recruitment checks, updated staff training in respect of fire prevention, and that the proprietor ensure a manager is registered with the Commission. This random inspection was unannounced which meant the home was not given notice of our visit. One inspector and a pharmacist inspector spent a day at the home from 09.55 to 17.45. We looked at the admission and assessment procedures, medication systems, care records, the records relating to the management of risks, and the systems for dealing with safeguarding people, including staff recruitment. We also looked at monitoring records for people needing pressure relief, and those needing support to maintain fluid and food intake. We looked at some bedrooms, and particularly those with bedrails. We talked with people living at the home, staff and the acting manager and proprietor. The home has had a recent history of instability. The key inspection of 11th September 2008 shows they were given a two star rating. A further key inspection of 3rd November 2009 found a number of areas that required attention. As a result of those findings we gave them a zero rating. Dudley MBC imposed a temporary suspension of purchasing approval on all Poor zero rated services. The acting care manager told us that the home was complying with this suspension and is currently running at eleven beds less. The registered manager left the home in 2009. An acting manager took day to day responsibility for the home for a short while. Following the key inspection in November 2009 the provider told us in their improvement plan that a more experienced manager had been recruited. The current acting manager commenced employment on 11th January 2010. The acting manager is not registered with the Commission. The acting manager and proprietor were present at the home. We advised the acting manager and proprietor that we had a Code B notice which enables us to collect any evidence if we consider a breach of regulations or lack of compliance to the action required. This evidence may then lead to a Statutory Requirement Notice being served. We did not need to serve a Statutory Requirement Notice. Management and staff assisted us to complete our inspection and we were made to feel welcome. This random inspection was undertaken to check compliance with the requirements we made at the key inspection on 3rd November 2009. Choice of Home. The home is registered to care for people for reason of old age and physical disability. At the previous key inspection in November 2009 someone had been admitted who suffered with a mental health problem. Although the persons nursing needs Care Homes for Older People Page 4 of 17 outweighed the mental diagnosis and that was the primary reason for their admission the home is not registered to care for people with mental health problems and staff had not received training. We were concerned that admission to the home may be agreed without any reference to a needs assessment. People may be admitted outside the registered category and the home would not be able to meet their needs. One requirement was made in this outcome area for the home not to admit anyone outside the primary needs of old age and nursing care. We were told by the acting manager that no new admissions had been made since November 2009. We were told by the acting manager that Dudley MBC had imposed a temporary suspension of purchasing approval on all Poor zero rated services. The acting care manager told us that the home was complying with this suspension. The proprietor was present and enquired whether this random visit would change the homes overall rating as the home was currently operating at eleven bed vacancies. We explained that a random inspection cannot change the outcome rating. We explained to the acting manager and proprietor that evidence of continued compliance was needed to increase the current rating of the home. The acting manager told us that pre admission documents had been improved so that all future admissions to the home would be within the registration category to ensure the needs of people can be met. We saw the pre assessment document. This was seen to be comprehensive covering all aspects of need and included information relating to other professionals that may be involved or needed such as the district nurse or occupational health. The acting manager told us that all pre admission assessments will be carried out by her or the RGN staff to ensure they are thorough and that she can confirm the potential new residents need is within the registered category for the home. We were told that the pre assessment can take place either in the persons own home or via them visiting Comberton Nursing Home. We saw that people are advised of this process in the pre admission policy which is given to enquirers. Following the pre admission assessment a placement will be offered only if the needs assessment indicates that the home can meet those assessed needs. We saw that there is a letter to send to people following their assessment confirming the home can meet their needs and confirming their agreed placement. We were told that there have been several enquiries for placement to the home and that they have now drafted a bed enquiry form designed to capture initial referral information and dependency levels. This also indicates whether the enquirers dependency needs are high, medium or low and whether or not they are suited to the category for the home. We found that improvements had been made in relation to needs assessment with additional improvements seen to be in place for the admission of new people. This process is now more robust and provides a clear framework for the assessment of needs thus ensuring places will be offered to people only where the home is able to meet these needs. As there has been no admissions to the home these procedures have not yet been fully tested. We shall be continuing to monitor the admission process to ensure it is robust and consistent but we consider that the requirement made under Regulation 12(1) has been met. Health and Personal Care At the key inspection we issued six requirements relating to care planning and health care. Care plans must include all areas of need and outline in detail the action required by staff to meet peoples needs effectively. Care Homes for Older People Page 5 of 17 Care Plans We looked at the care files for four people who live at the home and it was positive to see that improvements had been made in relation to care plans. The care plans that we saw provided staff with detailed information about how they should assist people to meet their individual needs. Care plans were seen to be personal to the individual including a personal history and identifying choices and desires. For instance one stated the person enjoys time in her own room. Due to hearing difficulties she has been provided with ear phones so can listen to the TV and the home contacted Birmingham Institute for The deaf to provide CDs so she can follow news reports. She also has a newspaper from BID. It is positive to see that the home has tried to provide individuals with the aids to follow their personal interests. The care plan also reflects a personal care routine and how the individual is supported with this. The choices made in the care plan were evident through the items observed in the bedroom. We saw care plans included evidence of appropriate strategies to reduce risks. For example one care plan seen showed a strategy for managing behaviour that can challenge. There was evidence of assessment by the behaviour team. The triggers were known and reflected in the care plan. These included back ground noise which results in the person shouting which in turn agitates others. The peak times for such behaviour to occur were recorded and actions evident to support the person to have a quiet time away during peak times. The care plan also highlighted the medications in use. These were noted to be well documented with clear reasons for the use of PRN or as required medication in place. We spoke to staff who showed a good understanding of how to meet this persons needs. We observed staff interacting positively and following the guidance we saw in the care plan for this person. We saw examples of good outcomes for people who have diabetes. The care plan was up to date and stated the condition clearly. The plan was comprehensive and gave guidance to staff on the optimal blood glucose range. It provided guidance to staff if the blood sugar was low, for example to give a milky drink. It says how often to monitor blood sugar such as once weekly. It also states if unwell would be increased due to altered blood sugars. A second care plan for diabetes showed the persons diabetes is insulin controlled managed via a glucose pen. This is reflected in the care plan. We checked the drugs cabinet and saw the pen was there. Contacts with the diabetic nurse and or clinic were evident. We consider that the requirement made under Regulation 12 has been met. Pressure Care We saw that care plans identified where people were at risk from developing pressure sores. Risk assessments were seen to be in place and up to date. These identified clearly the risk and the preventative steps to minimize the risk. The equipment necessary to reduce the risk was also evident. For instance the person had been stepped up to a Zurich mattress for improved pressure relief. The care plan provides staff with precise guidance in providing pressure relief to include observing for any redness or discoloration of the skin or infection. This means the persons skin integrity is checked regularly. We looked at the turning charts. These showed regular two hourly pressure relief. These records showed the time staff had turned the person and onto which side. We observed that two hours later the staff returned to the bedroom to complete this task. These records were looked at for a twenty four hour period and we established consistent pressure relief was evident for that person. We visited the bedroom and looked at the Care Homes for Older People Page 6 of 17 bed. We found the Zurich mattress was in place. We were told 6 people have broken areas and use pressure relieving mattresses. A sample of these was included in the people we case tracked and we saw their mattress and pillows in place and turning charts. Pressure relief is known and practiced and evident in their care plans. We found that a robust system is in place to reduce the risk of pressure sores with appropriate equipment and regular pressure relief. We consider that the requirement made under Regulation 12 has been met. Food and Fluid Monitoring We saw guidance for maintaining a nutritious diet. This was supported by a nutritional risk assessment which identified the risk clearly and the nutritional supplement needed. We looked at the medication records and saw the nutritional drink had been prescribed. We cross referenced this with the fluid monitoring charts which showed the vitamin supplement is actually drunk. We spoke to care and nursing staff who were able to identify those people who required support to maintain adequate fluid and food intake. We saw food and fluid monitoring charts were in place for each of these people. The charts showed what had been eaten and drank and the quantity. The entries were consistently made and dated. This means people are not at risk of inadequate nutrition or dehydration which could cause discomfort and infections. We consider that the requirement made under Regulation 12 has been met. Bed Rails We issued a requirement to review risk assessments in respect of bed rails. Where it is deemed that a person is a risk of falling out of bed alternative options should be considered to safeguard them. We viewed three bedrooms belonging to people who require a bedrail. We saw that bedrails were in place as reflected in their care plan. Staff showed us risk assessments for each person using bedrails. These showed the reason why the person required bedrails and why other options are not safe. This ensures that controls have been considered and explored in the best interests of the individual. For example one risk assessment says the individual is unable to maintain her balance and good positioning due to a stroke. This causes her to lean to one side where she is at risk of falling from the bed. The risk assessment is signed by the assessor in this case the acting manager. It is positive to see that the resident and or their family have been consulted on the use of the rails and signed agreement for this. Risk assessments are dated ensuring staff has current guidance. The risk assessments we saw also shows the recommended safe measurements between the rail and mattress so that there is no risk of entrapment. We spoke with the maintenance man who confirmed he and the acting manager do monthly audits on all bedrails to ensure they are in good repair and safe for use. We saw the audit book which showed where adjustments or repairs have been made to rails. The manager told us 21 people currently use bedrails and the same format is in use for all showing the controls in place to manage the risks. We consider that the requirement made under Regulation 13 has been met. Managing accidents and incidents of bruising We issued a requirement that staff must record all incidents of bruising and there must be appropriate follow up with an investigation of the cause and referral under the safeguarding procedures where necessary to ensure peoples well being. We noticed that a lady sitting at the table had visible facial bruising. We spoke to the care staff on duty to explore the cause of this. We were told that the lady needed the toilet in the night but the agency staff on duty did not realize she needed the hoist and she fell on to the cupboard at the side of the bed. We were told she was taken to hospital and kept Care Homes for Older People Page 7 of 17 in for a couple of days. We spoke with the acting care manager to explore what actions had been taken. She showed us the accident report which was dated at the time of the accident. It stated the lady slipped and fell whilst being assisted to the toilet. It was signed by the agency staff on duty at that time. We looked at the daily record sheet for the same period. This showed timed entries reflecting the sequence of events such as reporting the accident to the off site manager and changing symptoms observed following the accident resulting in the lady being taken to hospital. We saw a body map which identified the location of bruising. We saw documentation that the accident had been notified appropriately to the commission via Regulation 37. We noted it had been appropriately referred under the safeguarding procedures. An investigation had taken place to identify the cause and records showed that the home had taken appropriate steps to protect the person from further injury. We also saw that the manual handling review sheet had been updated and the risk assessment to reflect the poorer mobility and the use of the hoist. We discussed with the acting manager that the information provided by the agency did not have the dates of training or certificates to verify training done by the agency staff. We were told they have requested this from the agency. From the records available it is clear that Comberton have improved their documentation and that there is an awareness to refer incidents under safeguarding. They have a good audit trail of the steps they have taken and these are in line with good practice. We consider that the requirement made under Regulation 12 has been met. Medication The pharmacist inspector visited the home on 22nd March 2010 to undertake a random inspection in order to check the management and control of medicines. We looked at medication storage, some care records and medication administration records. We spoke to one member of staff and the Acting Manager. Medication was stored within locked cupboards in a locked treatment room. There were two locked medicine trolleys kept downstairs to store peoples medicines. The medicine trollies were neat and tidy, which made it easy to locate peoples medicines. This means that there was provision for the safe storage of peoples medication. Medication was available to give to people as prescribed although sometimes we found that there was a lack of stock control. For example, we found that some recently delivered medication was not required due to the large amount already available in the cupboards. We counted 9 boxes of one medicine prescribed for one person stored in a stock cupboard dating back to January 2010. We saw that later dated boxes were at the back of the cupboard and were not brought forward in order to be used first. This means that the stocks of medicine were not always checked or controlled. We looked at the medication administration record (MAR) charts, which were printed by the pharmacy and overall found that they were well documented with a signature for administration or a reason was recorded if medication was not given. We saw that the times of administering medicines were clearly highlighted on the MAR charts and we saw clear directions recorded for the application of any external preparations such as creams or ointments. This ensured that staff knew when to give medicines. New medicines that were added onto the MAR charts by a member of staff were not always checked by two members of staff for accuracy. This meant that it was not always possible to be sure that the new medicine information was correct. Care Homes for Older People Page 8 of 17 The Manager informed us that regular checks were made on the medicine records and we were shown completed audits and checks made on peoples medication to ensure that they are correct and up to date. This means that there are arrangements in place to ensure that medication is administered as directed by the prescriber to the person it was prescribed, labeled and supplied for. We found that other medication records were generally up to date. For example, we saw current records for the receipt and disposal of medication. The date of opening of boxes and bottles of medicines were usually recorded and balances of medication were carried forward from old records to new records. These records helped to ensure there was a clear audit trail of medication. We found that counts and checks made on medication were accurate, which showed that people who live in the service were being given medication as prescribed by a medical practitioner. Information about peoples medicines were generally recorded in their care plans. For example we looked at the care plan for one person who was prescribed a medicine for anxiety and agitation to be given when required. The care plan included information about the persons behaviour and how the medicine was being managed. We saw records that documented when the medicine had been given and the reason why it had been given. This means that staff was making sure the person was only being given this medicine when they needed it in order to help their agitation and anxiety and therefore keep them safe from harm. We saw that medicines were given to people safely. For example, during lunchtime we witnessed a member of staff administering medicines. The member of staff took medicine from the medicine trolley, locked it and then checked the MAR chart again before taking the medicine in a pot to the person. The member of staff signed the MAR chart after the medicine had been taken. This procedure was repeated for each person. This means that medicines were checked and handled safely before being given to the person. We consider that the nine requirements made under Regulation 13 in the previous report have been met. A new requirement under Regulation 13(2) is made as a result of this random inspection. The service should make arrangements to ensure that medication administration records are accurately maintained and checked. This is to ensure that information recorded on the medicine record charts is accurate to ensure the health and welfare of people living in the service. A new requirement is made under Regulation 12(1) as a result of this random inspection. The service should make arrangements to ensure there is an effective system in place to request, obtain and retain adequate supplies of prescribed medicines so that stock levels are kept at a safe level. This is to ensure the amount of medicines stored within the service is a safe level to ensure the health and welfare of people. Complaints and Protection We issued a requirement that effective systems must be implemented to ensure all safeguarding issues are referred to the Local Authority safeguarding unit. This is to ensure people are effectively safeguarded. At the previous key inspection the reason for the use of bedrails was not documented. A record of an incident indicated that one person had bed rails in place and they did not require them which could constitute restraint. We saw at this random inspection that the home has in place effective risk assessments which clearly show the reason for the use of bedrails. We saw no evidence that these were used as a means of restraint. We consider Care Homes for Older People Page 9 of 17 that the requirement made under Regulation 13 has been met. Environment We issued three requirements relating to maintaining a safe environment and reducing the risk of infection. Safe Storage of cleaning materials We viewed the toilet and bathroom areas of the home and found that these were free of cleaning materials. We asked the acting manager to show us where these were stored. She showed us the secure cupboard where cleaning materials are kept this was locked. We saw that risk assessments had been completed and appropriate action taken to ensure cleaning materials were out of the reach of people to ensure their safety. We consider that the requirement made under regulation 13 is met. Clinical Waste A requirement was made for the clinical waste bin to the rear of the home to be kept locked when not in use to ensure clinical waste is stored safely and reduce the risk of infection. The bins to the rear of the property were viewed by us and the acting manager. The contractor had just been to empty them and the van was visible as we made our way outside. On reaching the bins three were visible. The manager said only the first one was in use. The lock on this was viewed and found to be open. The manger locked it at this point. The second bin was not locked and when we looked inside clinical waste was evident. At this point a staff member came outside and approached the first bin which was now locked. She did not have a key when asked. She moved to the second bin which was open. We asked the acting manager why staff would do this. She said she did not know the other bins were being used and that clearly if the staff did not bring the key with them this other bin was the option. At this point the proprietor joined us. We explained the bins and waste were not secure. He told us that his contract covered all three bins. It was evident that it was the contractor who had left the bins unlocked. The acting manager contacted the contractor whilst we were on site and ordered new bins and re enforced that the contract was for three bins to be emptied. The acting manager drafted a protocol for staff for accessing the key for waste and this was implemented. We cannot be sure that the home did not comply with this requirement as the contractor was the person to leave the bins unlocked. In view of the fact that a protocol has been drawn up the home has been asked to monitor this part of practice. We consider that the requirement made under regulation 13 is met. Infection Control A requirement was made for the disinfector on the first floor to be repaired or replaced in order to reduce the risk of cross infection. This was viewed by us and the proprietor. The disinfector seen was the old non working one. The proprietor told us he had ordered a new disinfector. We asked the proprietor if he could demonstrate compliance in this area. He was able to verify this by producing documentation in the form of an order confirmation dated 15.2.10. We could see from this that the order had been made prior to our visit and that a delivery date was confirmed for the week commencing 5th April 2010. T he management of contaminated pots and commodes was discussed and we found the practice to be in line with current infection control guidance. We saw that infection control procedures were available in the home to guide staff. The risk of infection is currently managed and the purchase of the disinfector will further enhance this. We consider that the proprietor has demonstrated his intention to comply with this requirement but has to wait for the delivery. We consider that the requirement made under regulation 13 is not met. We will assess compliance during our next regulatory Care Homes for Older People Page 10 of 17 activity specifically if the disinfector has been delivered. Staffing We issued three requirements in this outcome area. The requirement made under Regulation 18 and 12 required a review of the number and deployment of staff. That appropriate action is taken to ensure there is sufficient staff on duty at all times to meet the needs of the current number and dependency of people living in the home. There is a temporary suspension of purchasing approval on all Poor or zero rated services. The home is currently operating with 11 bed vacancies. The acting manager said they are currently managing the needs of twenty five people. She told us that 168 nursing hours per week are needed when at full occupancy but with eleven vacancies this is manageable. Review of Dependency Level She showed us a resident dependency levels chart dated 2.3.10. Each resident had been assessed by the home to identify their needs and whether they had a high medium or low dependency level. We also saw an evaluation sheet for mobility. Information from these records shows that ten of the twenty five people require hoisting. Eight of the twenty five people require a wheel chair. Seven of the twenty five people are mobile. Five people are high dependency. Two people require a peg feed. Four people have a catheter and twelve people require help with feeding. The current staff ratio works out as one staff to five people on a shift with an RGN leading the shift. A range of ancillary staff support the care staff. Observations made during the visit showed staff to be responsive to needs. Discussion with individual residents showed that they had no concerns about the time it took for staff to assist them. The care plans show personal needs and routines are known and staff meet these needs currently without difficulty. We consider that the home has met the requirement made under Regulations 18 and 12 to review dependency levels and the staffing compliment and deployment of staff to meet the current number and dependency level of the people being cared for. However the current occupancy numbers are 11 lower than registration so the home has to continue to demonstrate it has sufficient staffing to meet full occupancy levels. We will continue to monitor this area during our next regulatory activity. Recruitment We issued a requirement under Regulation 19 that the manager must ensure all checks are completed for newly employed staff before they commence working in the home to ensure people are safeguarded. The acting manager stated one staff has been recruited since our last visit in November 2009. Inspection of this staff file showed that appropriate checks had been made to ensure the person was suitable to work with vulnerable people. The POVA Protection of Vulnerable Adults and CRB certificates were seen to verify this. Two references had been obtained from previous employers indicating the suitability of the employee. Interview notes were evident demonstrating that the home had sought to explore the applicants character and responses to the care task to assist them in making a judgment regarding suitability. We talked to the acting manager who demonstrated a good knowledge of her responsibility to ensure a robust recruitment procedure. The system in place ensures an audit trail of documents sent for and returned. The management has reviewed the recruitment procedure and taken action to ensure a more robust procedure which ensures people are protected. We consider that the requirement made under regulation 19 is met. Care Homes for Older People Page 11 of 17 Fire Training We issued a requirement under Regulation 23 that all staff should receive updated training in respect of fire prevention to ensure staff skills remain up to date, they have knowledge of current good practice and people are safeguarded in the event of a fire. This requirement was not assessed on this occasion. We will monitor compliance during our next regulatory activity. Management and administration We issued a requirement under Regulation 8. The proprietor must ensure a manager is registered with the Commission to ensure effective leadership and management systems are implemented in the home to safeguard people. Care Manager Registration The home sent us their improvement plan outlining what actions they would take with timescales to meet the requirements we made at the last key inspection of 3rd November 2009. In this the proprietor proposed he would seek to find a new and more experienced care manger to manage the concerns we expressed about the home. A new acting manager has commenced working in the home since 11th January 2010. She has addressed the majority of the requirements made and has put in place systems for the continued auditing and monitoring of all aspects of the care practice. She demonstrates a sound knowledge of and ability to manage the home. She has worked to the homes improvement plan and demonstrated the improvements made to meet the requirements. We were able to verify where changes had been made to meet these requirements. We found that the care planning and management of risk has been completely updated. Records are clear organized and up to date and support the practices seen. The progress that has been made is visible with improved outcomes for the people who live there. The home is running smoothly with a clear structure and delegation of tasks to ensure the well being of the people living there. The acting manager told us she has discussed her manager application with the proprietor. She is currently working her probationary period. She informed us that there are some areas of the management role she wishes to clarify with the proprietor such as staffing resources and budgets so that she has a clear view of what resources are available to her in order to increase care standards. The manager is not registered with the Commission. We consider that the requirement made under Regulation 8 has not been met. We will continue to monitor progress in this area during the next regulatory activity. What the care home does well: The home had a friendly atmosphere and people were encouraged to personalise their rooms to reflect preferences and tastes. Accommodation was spacious and comfortable providing people with the aids and equipment they needed. The personal appearance of people indicated that they are supported well with their needs. The staff team were responsive to people and interacted well. People told us that staff is friendly and that they enjoy the food. Care Homes for Older People Page 12 of 17 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 2. Care Homes for Older People Page 13 of 17 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 31 8 The proprietor must ensure a 28/02/2010 manager is registered with the Commission to ensure effective leadership and management systems are implemented in the home to safeguard people. Care Homes for Older People Page 14 of 17 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, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The service should make 07/05/2010 arrangements to ensure that medication administration records are accurately maintained and checked. This is to ensure that information recorded on the medicine record charts is accurate to ensure the health and welfare of people living in the service. 2 9 12 The service should make 07/05/2010 arrangements to ensure there is an effective system in place to request, obtain and retain adequate supplies of prescribed medicines so that stock levels are kept at a safe level. This is to ensure the amount of medicines stored within the service is a safe level to ensure the health and welfare of people. Care Homes for Older People Page 15 of 17 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 4 A planned structure for the admission of people should now be considered. This will enable the service to demonstrate that they are able to sustain improved practice and ensure they are able to meet the needs of a greater number of people without compromising existing people living in the home. Care Homes for Older People Page 16 of 17 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. 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