Inspection on 16/03/10 for Eliot House Nursing Home

This inspection was carried out on 16th March 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eliot House Nursing Home 12/02/08

Eliot House Nursing Home 10/04/07

Eliot House Nursing Home 19/04/06

Eliot House Nursing Home 16/01/06

Eliot House Nursing Home 09/06/05

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 16/05/2010.

Key inspection report Care homes for older people Name: Address: Eliot House Nursing Home Crooked Billet Street Morton Gainsborough Lincs DN21 3AH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Dawn Podmore     Date: 1 6 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Eliot House Nursing Home Crooked Billet Street Morton Gainsborough Lincs DN21 3AH 01427617545 01427611718 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): MPS Care Homes Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The home is registered to provide personal and nursing care for service users of both sexes whose primary needs fall within the following categories: Dementia Mental Disorder, excluding learning disability or dementia Old age, not falling within any other category The maximum number of service users to be accommodated is 29. Date of last inspection Brief description of the care home Eliott House is a care home providing personal and nursing care for up to 29 older people all within the category of dementia or mental disorder. The home is located in Care Homes for Older People Page 4 of 32 Over 65 0 0 29 29 29 0 Brief description of the care home the village of Morton, which is on the outskirts of Gainsborough. It is a listed building with a new extension to the rear of the property. A staircase can access the first floor or a lift is available. The home has 21 single and 4 double bedrooms. Thirteen of the rooms have toilet facilities. Parking is provided at the front of the home and additional on street parking is available. It is also close to the local bus route. There are local shops and public houses within walking distance of the care home. The home is surrounded by its own gardens, which are totally enclosed, this provides security for residents staying at the home. There are also a number of patio areas where people can sit in warm weather. The current scale of charges at the home ranges from £355 to £752 depending on peoples assessed needs. Additional costs are made for services such as, hairdressing, chiropody, newspapers and escorting residents to hospital etc. These are all private arrangements and the individual residents meet these costs. Information about these costs, as well as the day-to-day operation of the home, including a copy of the last inspection report, is available in the reception area or from the managers office. 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: 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 key inspection was unannounced and took any previous information held by C.Q.C about the home into account. Throughout this report the terms we and us refers to the care Quality Commission (CQC). Before the the visit the provider had returned an Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans for improvement over the next twelve months. We also sent out surveys to residents and staff, 8 of which were returned in time to be included in this report. Since the last key inspection on 12/2/08 an annual service review was undertaken on 16/3/09 to assess how the home was operating, no issues of concern were identified as part of that review. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they received through the checking of Care Homes for Older People Page 6 of 32 records, discussions with them and the staff who care for them, and observation of care practices. A partial tour of the home was also conducted, which included looking at some bedrooms, communal areas and bathing and toilet facilities. Documentation was sampled and the care records of the three people being tracked were examined. We spoke with 7 residents and 4 members of staff, including the acting manager. They shared their views about how the home operated on a day to day basis and the care and facilities provided. Because residents could not always express their feelings and experiences clearly we observed the support they were receiving and consulted with relatives. On the day of the visit 21 people were living at the home. 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: Care records need to identify all the persons needs in detail and provide better guidance for staff to make sure they are fully aware of their role in supporting them. They should also be more person centred so that they tell staff about peoples preferences and their involvement in decision making. The home should be able to demonstrate that people have been involved in planning and evaluating their care, if this is not possible the reason should be recorded. Risk assessments must be completed more robustly so that any potential risks are identified and management strategies documented. This will then provide staff with better information about what minimising actions they need to take. People need to be consulted about their preferred social and leisure interests and the outcome recorded so that a programme of activities can be devised to meet their needs. This information should then be used to formulate individual care plans that tell staff about what people want to do, and their role in supporting them to achieve their goals. There are areas of the homes environment that need attention, this includes some residents rooms, upstairs corridors and the reception carpet. The recruitment process needs to be consistently applied so that people can be assured that staff working at the home are appropriate to do so. This includes obtaining two written references before they start to work at the home. All new staff need to receive an induction relevant to their role at the home. This should be recorded so that the home can demonstrate that they have given them all the information and support they need to carry out their job. All staff must receive training to meet the needs of their job description and the needs Care Homes for Older People Page 8 of 32 of the individual people currently living at the home. This includes specialist training such as dementia awareness and conditions affecting older people. They must also receive regular supervision sessions and an annual appraisal as this will help to ensure they are provided with adequate support and guidance. The company must make sure that water is delivered to the taps accessible to the people who live at the home at an acceptable temperature. This will ensure that people are not at risk of burning themselves. The providers reports following their monthly visit to the home need to be consistently completed and record peoples opinions as well as the overall findings in better detail. They will then reflect what people say about the home, areas that need addressing and what they plan to do about any shortfalls. Other areas highlighted below would benefit from some attention. Assessments completed before people move into the home should be completed in more detail. This will help to show that the home has considered their needs and assessed that they can meet individual needs and preferences. Care records need to demonstrate that the home has considered recent legislation about protecting people rights and choices especially regarding their capacity to make decisions about their daily lives and have planned their care accordingly. They should make sure that staff understand their role in this process by providing appropriate training in this subject. Monthly care plan reviews should be more detailed and provide a meaningful evaluation of whether the planned care is still appropriate. Care plans should be audited and old information archived so that staff have easy access to up to date information about the people they are supporting. The quality assurance system should be consistently maintained and the outcomes made available to people who use the service and their representatives. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A satisfactory admissions procedure helps to make sure that the home can meet the needs of the people who come to live there. Evidence: Te home does not admit people without an assessment of their needs being completed. The file of a recently admitted person contained information about their assessed needs, but this had not been recorded comprehensively on the preadmission assessment form. However further information was recorded on the referral form. People confirmed that an assessment of their needs had taken place and that they had received sufficient information about the home to help them decide if it could meet their needs. The manager said that although people sometimes come to the home for short stay Care Homes for Older People Page 11 of 32 Evidence: placements it does not provide intermediate care. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although people are receiving a good level of care, which is delivered to suit their preferences, there are shortfalls in the care planning and risk assessment documentation that could lead to peoples care needs not being fully met. Evidence: The care records we looked at contained information about some of the care and support people needed, but not others. For example although staff were aware that the resident suffered from a medical condition and appropriate care was being provided there was no care plan highlighting this subject, or guidance for staff as to how they needed to support the person. The plans we saw were written as nursing instructions that made no reference to peoples individual preferences and abilities. In a file for someone who had been recently admitted the care plans completed by the homes staff did not identify all the persons assessed need. Therefore staff had to rely on the assessment information collated prior to admission and the hospital assessment, which contained good information. Care Homes for Older People Page 13 of 32 Evidence: One file did not contain care plans about meeting the persons hygiene or nutritional needs. Daily notes indicated that supplements had been provided and personal care needs had been met, but staff had no comprehensive guidance to help them provide individualised care. However people told us that staff always met their needs and provided care and support how they wanted it delivering. None of the plans we saw outline the arrangement for meeting peoples social needs, but one did contain good information about their past history, both social and medical. Assessments for potential risk areas, such as manual handling and falls had been carried out, but the information had not always been incorporated into the care planning process in sufficient detail. In two of the files the risk assessments were not dated and there was no indication of a review date, Another file contained a risk assessment for using a belt in the wheelchair to keep the person safe, but there was no documentation regarding the decision making process behind its use, such as holding a best interest meeting. A relative had however signed to say that they agreed with the use. A record of what care had been provided was being completed daily and entries clearly outlined how people had spent their day and any events that day. Care plans had been evaluated monthly, but these contained no meaningful evaluation of the effectiveness of the planned care. Most entries said no change with a date and signature. Not everyone had signed their care plans to acknowledge that they agreed with the planned care. However the people we consulted confirmed that they had been asked about their care requirements and that staff delivered care and support to suit their needs. The acting manager said that a new care planning formate was being introduced and showed us two samples of what it contained. She said that once fully implemented it would address the shortfalls we had identified. This also included considering peoples capacity to make decisions and thereby protect their rights and choices. Staff training sessions about this subject were planned for the near future. Records and peoples comments indicated that residents had access to outside health professionals such as doctors and district nurses. Peoples health was being monitored on a regular basis. We saw staff speaking to people with respect and in discussion with them. They had a Care Homes for Older People Page 14 of 32 Evidence: good understanding of the people they were supporting and how to maintain their privacy and dignity. People said that they were happy with the level of care and support provided. One relative told us, they care for the residents very well. Another commented X (a resident at the home) has improved greatly since she first entered Eliot House. Records and discussions with staff demonstrated that the home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. Audits of the homes systems had been undertaken by the pharmacist to make sure that the home was following a robust process. The nurse on duty had a good understanding of the medication procedures and confirmed that refresher training was to be provided shortly. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to social stimulation which they enjoy, but lack of documented consultation and planning could lead to their individual needs not being fully met. People receive a nutritious and varied diet that is based on individual preferences and health requirements. Evidence: The home does not currently employ an activities coordinator, but the manager said that one was to be recruited as soon as possible. Stimulation is therefore facilitated by the care staff. Forthcoming activities were displayed on the notice board and people told us that these met their needs. Various activities take place on a regular basis these included, a weekly baking session and monthly visits from Rural Services who bring in pets, such as rabbits and hamsters, for people to hold and interact with. Other activities that had been provided included, a pantomime company visiting the home, a boat trip, an excursion to the coast, a rock and roll evening, visits to local garden centres and a Pink Day to support a breast cancer charity. Although people said that they enjoyed the activities provided records failed to Care Homes for Older People Page 16 of 32 Evidence: demonstrate that they had been consulted about their hobbies and interests and plans had not been formulated to meet individual needs. These would help staff to be aware of their role in supporting people to maintain their social interests. People told us that they were happy with the activities that took place and said that they could choose not to join in if they preferred not to. They said that relatives could visit at anytime and that they were always made welcome by the staff. People ate lunch either in their rooms or in the airy dining room, where the menu was displayed on the wall. Staff assisted them in a calm and relaxed manner. People told us that the food was good and met their needs. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are protected by clear policies and procedures for handling complaints and allegations of abuse. Evidence: The home has a complaints procedure, this is displayed in the home and included in the Service User Guide, this is given to people when they come to live at the home. No areas of concern had been raised over the last year, but a system was in place should any complaints be made. People said that they knew how to make a complaint and would be comfortable highlighting any issues. Residents and relatives told us that they had no complaints. The home has procedures concerning the protection of vulnerable adults. Staff demonstrated a satisfactory knowledge of what to do if they suspected abuse could be occurring and confirmed that they had received training in this subject. Care Homes for Older People Page 18 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. People live in a comfortable environment, but some areas are not adequately maintained and decorated. Evidence: We took a partial tour of the home looking at the bedrooms of the people being case tracked, communal areas and some bathing facilities. The general atmosphere of the home was welcoming. Bedrooms had been personalised by the resident or their relatives with photographs, mementos and small items of furniture. One room we saw had been recently redecorated and a new carpet fitted. One of the lounges was in the final stages of being redecorated and the shower room had been decorated and a new floor fitted. However other areas of the home looked in need of attention. The carpet in the main reception area was stained and the upstairs corridors looked shabby, with marked woodwork. The companys monthly reports talk about the redecoration programme being ongoing, but the manager could not show us a copy of this. Although there was clear pictorial signage directing people to the toilet and bathroom facilities bedrooms only had numbers, which could make is difficult for people with dementia to locate their room in a corridor full of identical doors. Care Homes for Older People Page 19 of 32 Evidence: Separate housekeeping staff are employed to maintain the cleanliness of the home. On the day we visited it was clean and tidy throughout with no unpleasant odours. Everyone we consulted told us that the home was always fresh and clean. Although people raised no concerns about the environment in general one person felt that the home needed updating in some areas. Care Homes for Older People Page 20 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. Systems are in place to recruit staff, however some areas are not robust enough to ensure peoples safety. People receive care from staff who are knowledgeable about the people they support, but shortfalls in staff training could lead to peoples needs not being fully met. Evidence: Records and observations on the day showed that there was sufficient staff on duty to meet peoples needs. People were complimentary about staff and the way care is delivered. Two people said that staffing levels were always satisfactory and another said that they usually were. One person said. they do a fantastic job. Staff also said that they felt that the current staffing levels were satisfactory. However one person said that more staff would be beneficial. We saw staff supporting people in a calm and relaxed manner offering them choice and consideration. We looked at the files of 2 staff who had been recently employed to see if their recruitment had been carried out correctly. One file contained all the essential checks needed, such as two written references and a C.R.B. (Criminal Records Bureau) check. However the other one had only one written reference, the acting manager arranged for this to be re-applied for immediately and has since confirmed that a satisfactory reference has been received. Care Homes for Older People Page 21 of 32 Evidence: Although most staff told us that they had received a satisfactory induction to the home records failed to demonstrate this, and one person said that their induction had been minimal. The manager showed us a new induction booklet that she intends to introduce to make sure that new staff receive all the information they need. Staff have received training in subjects such as, manual handling, protection of vulnerable adults from abuse, fire safety, first aid and infection control. Although some staff had also received specialist training to meet peoples individual needs, such as dementia awareness and conditions affecting older people, others had not. The manager said that more training was planned for the future. The manager said that she wanted to encourage staff to complete an N.V.Q (National Vocational Qualification) in care. Information provided showed that out of the 14 care staff employed 7 had attained an N.V.Q. award. Residents and relatives told us that they were very happy with the way staff supported people. One person said, they are always kind and considerate. Staff said that they felt well trained and supported and they demonstrated a very good knowledge of the people they were caring for. Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Supportive leadership and guidance is provided to staff to ensure that care is delivered in a consistent manner. There are systems in place to ensure that the health and welfare of residents and staff are protected, but some systems are inadequate. Evidence: Since the last key inspection the Registered Manager has left and an acting manager, Pam Timmins, was appointed in December. Ms Timmins is a qualified nurse with management experience and has been working in the care industry for over 22 years. People praised the support provided and said that the manager and staff were approachable and kind. When asked what the home did well one person told us, care very well for the residents. Another said, Pam and her staff do a fantastic job, I am really glad that my father is part of the Eliot community. The staff said that the new manager was supportive and approachable. Their comments included, there have been big changes since the new manager started, her Care Homes for Older People Page 23 of 32 Evidence: welfare is always the welfare of the residents and what is best for them, since the new manager started the home is on the up and we still have a long way to go but Pam has made a big difference. Things that they felt could be improved included updating the kitchen and its equipment, a better induction package for all grades of staff and better benefits for staff in general. Although staff said that they felt supported in their work, records and staff comments failed to demonstrate that they were receiving regular supervision sessions and an annual appraisal. The manager said that she had, had to prioritise other things but would be starting sessions as soon as possible. The home has a quality assurance system so that they can gain the views of the people who use the service. The AQAA said that this included surveys, but these had not been consistently used and analysed. Since the new manager has started she has sent surveys to people and the ones we sampled contained positive responses. Meetings have not been held regularly in the past, but the manager said that she was addressing this as well. The provider, or their representative, should visit the home at least once a month to make sure that it is operating satisfactorily and procedures are being followed, They must then complete a report of their findings, including what they have looked at, who they spoke to and what they told them. They should also outline what they are doing about any shortfalls they find. On reviewing these reports we found that they had not been consistently completed and the content did not provide sufficient detail. The home holds a small amount of money for people in safe keeping in case they need to purchase anything. We found that the records and amounts sampled were correct with receipts and signatures being maintained. There are health and safety polices and procedures to guide and instruct staff. There is also a programme in place to service and maintain equipment in the home on a regular basis and thereby keep people safe. Information provided demonstrated that regular checks on equipment, such as fire equipment and hoists, had taken place as scheduled. Information provided showed that the temperature of the hot water being delivered from taps used by the residents was too high, which could result in people having access to water that was too hot. The manager had asked the handyman to monitor Care Homes for Older People Page 24 of 32 Evidence: these and she had submitted a quote to the proprietors for regulating valves to be fitted. This had issue had not been addressed at the time this report was completed. Care Homes for Older People Page 25 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R 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 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 15 Care plans must be in sufficient detail to enable care staff to provide comprehensive care. This will help to make sure that staff have access to clear information about the people they support and can therefore meet their individual needs. 07/06/2010 2 7 13 Risk assessments must be up to date and completed more robustly so that any potential risks are identified and management strategies documented. This will then provide staff with better information about what minimising actions they need to take. 31/05/2010 3 12 15 Information collated about people social interests and needs must be used to formulate care plans to address this subject. 28/06/2010 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 This will help to make sure that people receive the level of stimulation they prefer. 4 19 23 All areas of the home must be decorated and maintained to a satisfactory standard. This will enable people to live in a suitable environment which is decorated and furnished to suit their needs. 5 29 19 The process for recruiting staff must be robust and include undertaking all essential checks, such as obtaining two written references. This will help to protect people living at the home from unsuitable people being employed. 6 30 18 The training programme must include specialist subjects to meet the needs of peoples living at the home, such as dementia awareness and conditions affecting older people. This will help to make sure that staff have the knowledge and skills to meet 06/09/2010 26/04/2010 04/10/2010 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 the needs of the people living at the home 7 30 18 Records must demonstrate 26/04/2010 that all staff have received a satisfactory induction to the home. This will ensure that they are aware of how the home operates and their role within the home 8 36 18 There must be a system in place for staff to receive regular supervision and appraisal. This will help to ensure that staff are adequately supported in carrying out their job. 9 37 26 Monthly visits to the home must be made by the proprietor, or their representative, and a report completed detailing their findings, and any actions to be taken to address any issues found. These reports must be forwarded to CQC until further notice. This will provide an ongoing evaluation of how the home is operating and any areas that need addressing Arrangements must be made to ensure that people 26/04/2010 31/05/2010 10 38 23 10/05/2010 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 are not at risk of injury. This includes ensuring that hot water is delivered at an appropriate temperature. This will help to ensure that people are not at risk of injury. 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 3 Initial assessments undertaken before people move into the home should be completed in more detail. This will help to show that the home has considered all the persons needs and assessed that they can meet these individual needs. 2 7 It is strongly recommended that the decision making regarding the use of any restraints, such as lap belts, are appropriately recorded and include the outcome of best interest meetings. This will help to demonstrate that peoples rights and choices are being respected. 3 7 Care planning and the assessment process should include reference to the Mental Capacity Act, 2007 and the effects it has on peoples lives. This will help to make sure that peoples rights and choices are protected. 4 33 The quality assurance system should be constantly used to ensure that peoples opinions about the running of the home are taken into account and that staff are following the homes policies and procedures. This will help to demonstrate that the home has a Care Homes for Older People Page 30 of 32 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 structured process for seeking peoples views and making sure that systems are robust. 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. 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