Inspection on 20/11/08 for Elmcroft Care Home Ltd

This inspection was carried out on 20th November 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmcroft Care Home Ltd 27/05/08

Elmcroft Care Home Ltd 20/06/07

Elmcroft Care Home Ltd 04/07/06

Elmcroft Care Home Ltd 07/02/06

Elmcroft Care Home Ltd 17/08/05

Elmcroft Care Home Ltd 22/03/05

Elmcroft Care Home Ltd 04/02/05

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Elmcroft Care Home Ltd Brickhouse Road Tolleshunt Major Maldon Essex CM9 8JX     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Alan Thompson     Date: 2 5 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Elmcroft Care Home Ltd Brickhouse Road Tolleshunt Major Maldon Essex CM9 8JX 01621893098 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): jan@festivalcare.com Elmcroft Care Home Limited Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 54 Number of places (if applicable): Under 65 Over 65 0 1 0 dementia learning disability physical disability Additional conditions: 26 1 28 One named person, aged 40 years and over, with a learning disability, who requires nursing care by reason of a physical disability. One named person, over the age of 65 years, with a learning disability, who requires nursing care by reasons of a physical disability. Persons of either sex, aged 18 years and over, who require nursing care by reason of a physical disability (not to exceed 28 persons) Persons of either sex, aged 50 years and over, with a terminal illness (not to exceed 6 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 54 persons) The total number of service users accommodated in the home must not exceed 54 persons. Care Homes for Older People Page 4 of 29 Date of last inspection Brief description of the care home Elmcroft Care Home provides nursing and personal care with accommodation for up to 54 older people and younger adults. The home also provides rehabilitation. The home comprises of a purpose built building which was opened in 1989, and additional accommodation and facilities in a new wing which opened in 2007. There are twenty eight bedrooms of which three are double rooms in the original building, and twenty six single bedrooms in the new accommodation. All rooms have ensuite facilities. Many areas of the home have views across open countryside and the surrounding gardens are attractive and accessible to service users. Elmcroft is located in a rural location near to the village of Tolleshunt Major, which is several miles from Maldon. There are no public transport links within easy walking distance. Vehicle parking for visitors is available in the large car park of the home. The weekly fees range from £575 depending on facilities and levels of support required. Additional costs apply for physiotherapy, chiropody, toiletries, hairdressing and newspapers. CSCI inspection reports are available from the manager or are accessible on the CSCI internet website at: www.csci.org.uk Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection commenced on Thursday 20th November 2008, with a further announced visit on Tuesday 25th November 2008 to complete the process. (Our most recent inspection prior to this was on 27th May 2008). The content of this report reflects the inspectors findings on the day/s of the inspection along with information provided by the service and feedback by service users, staff and other parties. The manager was at the home on both days and dealt with the inspection process, with input also from the deputy manager. Discussions were entered into with the manager, deputy manager, service users, visitors and staff on duty. CSCI survey questionnaires were also provided to service users, staff and stakeholders. Feedback received has been included within this report. Care Homes for Older People Page 6 of 29 Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All matters relating to the outcome of the inspection were discussed with the manager of the home, with full opportunity for discussion given and/or clarification where necessary What the care home does well: What has improved since the last inspection? The care planning and provision of care at the home had improved to ensure that staff were now able to meet the personal and healthcare needs of service users. This had been achieved by improvements to care plans and to better consistency of regular permanent staff working with service users. Written medication procedures have been updated to provide clearer guidance to staff on the practices they must follow regarding the ordering, administration and storage of medication. The home had a new activities coordinator who had introduced more regular and a wider range of interests for service users. A deputy manager had been appointed who had worked with the manager towards improving the standard of service given to service users, and better support to staff. All incidents that could be considered a safeguarding adults issue had been properly reported to the Commission and to other appropriate bodies. All staff recruitment records that were seen now had at least two written references. Initial induction training for new staff now followed the best practice guidance for the service. Records were now kept of fire drills and of safety checks/servicing of the homes fire systems, fire equipment and the electrical installation supply. The statement of purpose and service users guide had been reviewed and updated and all service users had been provided a signed copy of their contract. A heated food trolley was now being used to get food from the main kitchen to the dementia wing kitchen without it going cold. The homes staff whistleblowing procedure had been updated to show accurate contact information. Care Homes for Older People Page 8 of 29 Repainting had taken place to walls and doorways in the main building that were marked and scratched. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that information provided by the home enables them to make an informed choice, and that full assessments would ensure that needs could be met. Evidence: The homes Statement of Purpose and Service Users Guide had been updated since the last inspection. These included the information needed to help people make an informed choice when considering moving into Elmcroft. The manager said that a new brochure had also been compiled since the last inspection. This includes a copy of the Service Users Guide and is sent to prospective new service users. Pre-admission assessments are usually only carried out by the manager, although the deputy manager may do this if the manager is unavailable. The format used was new since the last inspection. The manager had devised this and had ensured that nursing and care needs were considered but had also included a section on social history to Care Homes for Older People Page 11 of 29 Evidence: provide additional information for staff. Completed pre-admission assessments were seen in files for people admitted since the last inspection. Areas covered also included medication, nutrition, pressure care, wound care, mobility, safety, sensory and dementia needs. The manager confirmed that trial visits are available for prospective new service users and discussions with relatives and service users confirmed this. One said we could look at the home before deciding if it was what we wanted. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care in a way that respects their privacy and dignity, based on agreed identified needs. Evidence: A new care planning format had been introduced since the last inspection and the manager said that all care plans had been re-written using this system. Care plans inspected were in the new format and had a service users profile, background information, personal details, and next of kin contacts. Files had a care plan index, which itemised numbered areas of identified need. Assessments of identified needs were recorded with the aim of care recorded and instructions for staff on the care required to meet these needs. Areas of assessment were detailed and gave staff the information they needed to ensure service users needs could be met. Care Homes for Older People Page 13 of 29 Evidence: Care plans seen also had risk assessments on pressure care, continence, manual handling, dependency, general identified risks, falls, nutrition and the use of bed guards. Risk assessments showed hazards, control measures, level of risk and the perceived potential for harm. There were records of reviews and of daily staff observations, weight had been recorded and records had been kept of GPs visits and treatment, and on any other medical consultations. Care plans are reviewed regularly by the named nurse who ensures that daily notes record any changing needs. Discussions with individual service users and comments made in surveys returned confirmed that they thought they were treated with respect by staff, and staff on duty were seen to be patient and helpful in their dealings with service users. Comments made included the staff here are very good, the staff are helpful, Im happy here. There were however two comments that some staff do not respond quickly enough when service users needed them. Dentists, a GP, chiropodist and an optician all visit the home to provide for the healthcare needs of service users. Other healthcare services are accessed in the community. Records of visits and consultations with written outcome notes were seen. The medication system was inspected and the staff use a blister pack and bottle to mouth system. Medication policies and procedures were easily available for staff reference and an up to date list of signatures was maintained. Since the last inspection the deputy manager had reviewed medication practice in the home and had introduced a competency assessment for nurses who administer medication to ensure that best practice was adhered too. Medication administration records were looked at, no errors were noted. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in Elmcroft can expect to have a lifestyle that matches their expectations through opportunities for activity, and enjoyable food. Evidence: Regular service users meetings had taken place to ensure that people who live in the home can make their views known and are kept informed about future plans. Minutes of issues discussed included re-decoration, activities and staffing. The manager said that meetings are usually held every month with relatives also invited. Since the last inspection changes had been made to the provision of activities in the home. A new activities coordinator had been appointed who worked full time along with two part time activities staff. The activities coordinator was spoken with and talked enthusiastically about the role and future plans for expanding the range of interests offered. Current activities and interests available included hand and foot massage, nail care, reading, help with letter writing, games, group activities such as cake icing, stencilling and calendar making, quizzes, bingo, sing-a-longs, movement in chairs and 1 to 1 Care Homes for Older People Page 15 of 29 Evidence: discussions. Some service users are also taken out to the shops, bowling and cinema. There are regular visiting entertainers and outings to places of interest in the community, mini bus transport is hired for this. A newsletter was seen displayed in the home which had information for service users and relatives on activities and events that were planned for the future. The activities coordinator had not had any formal training relating to the role and specific to the wide range of needs of service users living in Elmcroft. We were advised by the manager that this was in hand with training planned for the near future. A hairdresser visits weekly to provide hairdressing to service users, and some service users receive visits from local clergy. Six service users spoken with said they took part in activities and that they were usually enjoyable, although some spoken with were not interested in taking part at all. When asked, service users told us that their family and friends could visit at anytime and that staff always made them welcome. Relatives spoken with confirmed that they visit regularly and at any time. Inspection of private rooms evidenced that service users had been permitted to bring their own personal items with them on admission. There was also confirmation of this direct from service users, who, when asked, told the inspector of the furniture and personal items they had brought in with them. A new head cook had been appointed since the last inspection and menus had been revised. The head cook said that service users views and needs are taken account of when planning menus. As a result menus now included soft food options to ensure that those who have difficulty chewing are able to eat the meal as cooked and therefore do not always have to have their meals liquidised. Nutrition records evidenced choice and variety. Portion sizes eaten had been recorded so that staff can see quickly if a service user looses their appetite. The head cook confirmed that the main daily meal is lunch with at least two choices and that there is also a choice at tea. Cooked breakfasts are on the menu every day and are taken by some service users. Suppers are available to those who feel hungry at night. Food stocks were good and service users spoken with were generally satisfied with the food and confirmed that there was always a choice. Comments from service users about the food included: the food is good and the portions are good, the food is good, the food is quite good and the portions are more than enough. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are cared for in an environment where they appeared comfortable to raise concerns, however there was insufficient evidence to show that complaints are dealt with appropriately, nor that staff training ensured service users were protected. Evidence: The complaints procedure was seen and contained guidance on how to make a complaint and who to complain to. Also included were timescales for responses from staff. There was a standard template for staff to record any concerns with four complaints recorded as received since the last inspection. Some evidence was seen relating to these however this did not confirm the investigation outcomes, nor give details of what actions had been taken as a result of the findings. The manager was aware of this shortfall and advised that a complaints log had been devised which would include an investigation progress record along with full details of each complaint and of the outcomes. Service users spoken with said they knew who to speak to if they had any concerns, and they seemed confident that any concerns would be investigated properly. The homes policies on adult protection included booklets from adult protection agencies which had written guidance for staff on recognising and reporting abuse and action to be taken by staff if abuse is suspected. Unfortunately this guidance was not kept in an easily accessible format nor was it all in one place in the home. The Care Homes for Older People Page 17 of 29 Evidence: manager was fully aware of the local adult protection and reporting procedures and staff spoken with also displayed awareness of this subject and procedure. Some had received formal training on this subject and the manager said that additional training had taken place in August 2008 but training records did not record that all staff had received this training. Therefore we have required this takes place. There was a written whistleblowing policy which had been updated since the last inspection. This provided guidance to staff on their responsibilities to report any concerns to the manager. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users live in a safe, mostly well maintained environment. Evidence: Elmcroft Care Home provided a comfortable and bright environment for people to live in. The site visit included a tour of the premises when it was noted that the home was clean and tidy, and generally well decorated and maintained throughout, with no evidence of any unpleasant odours. Since the last inspection redecoration had taken place in some of the corridors in the main building, however further attention should take place to marked/stained carpets and to doors and frames had chipped/damaged paintwork. The manager said that a contractor had already been booked to carry out this work. Furnishings seen throughout the home looked good quality. The bathrooms were in good order and included aids and adaptations to meet the needs of the people using the service. There were sufficient toilets to enable immediate access, and all private bedrooms had ensuite wc. Communal lounges and dining rooms were provided in both buildings and were generally bright and spacious. It was noted that the dining room in the original building was also the main staff access route to and from the kitchen, this resulted in a Care Homes for Older People Page 19 of 29 Evidence: fairly continuous movement of staff through this room at mealtimes. People living at the home were happy with the way their home is kept clean, their comments included the home is always clean and tidy, and in general the home is clean and there are no unpleasant odours. When asked in surveys if the home was fresh and clean other service users replied usually or always. Comments from relatives about the environment and services have included the home is generally clean and reasonably well cared for. The laundry service is of a high quality and the residents personal clothing is well cared for. The laundry was sited in the original building with close access to the new building. Equipment and space provided was regarded as fully suitable for the numbers of people accommodated in Elmcroft. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are cared for by properly recruited and trained staff. Evidence: The homes staffing rota was inspected and showed daytime staffing levels in the main original building as one nurse and seven carers in the mornings, with one nurse and six carers afternoons. Night staffing was one nurse and two carers. Staffing in the new building was one nurse and six carers in the mornings, one nurse and five carers on afternoons and one nurse and two carers at night. These numbers show an increase in care staff numbers since the last inspection. In addition to the nursing and care staff there is a head cook and two assistant cooks, a kitchen assistant, one full time and two part activities staff, a housekeeper, domestic staff and laundry staff, two administrative staff and two maintenance staff. The manager reported that a number of staff vacancies had been filled since the last inspection which had resulted in a big reduction in the numbers of agency staff employed. This had benefited the service users in the consistency of care delivered. Comments received from service users and relatives about staff attitudes included the staff are lovely, they are really good people, I could not fault them, the service users are always clean and well fed, all the staff do everything they can to carry out the wishes of us and to give the best care they can. There were however two comments Care Homes for Older People Page 21 of 29 Evidence: that staff did not respond quickly enough when called and that agency staff did not have good awareness of different service users needs. Three staff recruitment files were inspected for staff employed since the last inspection. Evidence was seen to confirm staff had been properly recruited with application forms completed, interviews held, written references obtained, nurse PIN number confirmed, written terms & conditions issued, and criminal records checks undertaken. Copies of proof of ID, photographs and job descriptions were also on files. Files for staff employed since the last inspection showed that all new staff now undergo initial induction training. After this staff who have not worked in care before move on to the Common Induction Standards for social care workers. Experienced staff have to complete the homes own induction package which has been devised by the manager. Evidence of this being completed was seen. Staff spoken with confirmed they received induction training, they also confirmed that the manager is supportive and will respond to any queries or concerns they may have regarding service users well being. All staff have an individual training record and there is a training matrix that shows training undertaken for the whole team, as well as when updates are due. Training records seen and discussion with staff confirmed that staff had been provided training on induction, first aid, fire awareness, manual handling, food hygiene, The manager advised that training on dementia was planned and that training on adult protection and abuse awareness had taken place in August 2008 with a further session booked. Unfortunately the training record did not confirm that all staff had attended and so we have required that this training is provided. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience 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 home that was now well run and managed, although there was insufficient evidence to confirm that peoples opinions are listened too and acted upon, nor that the manager is supported in making improvements to the service provision. Evidence: The manager had been in post since May 2008 and was committed to improving the service at Elmcroft to the benefit of service users and staff. Significant progress had been made on meeting the shortfalls identified in our last report mainly due to the efforts of the manager and deputy manager (also in post since May 2008). The manager is a qualified nurse and also has a management qualification and has management experience in residential settings since 2003. The service has a quality monitoring process which involves sending surveys to service users and relatives to ask their views on the care, facilities, catering, activities and support provided. The manager said that this had not yet been put into use as she felt Care Homes for Older People Page 23 of 29 Evidence: that the format in place when she commenced working at Elmcroft in May needed updating. We acknowledge the efforts by the manager to improve the quality of service however we need to see evidence that service users views are asked for, with records of the responses and of any resulting actions. The administrator confirmed that the home still holds some personal allowance monies for safe keeping for the majority of service users. Records had been kept of the balances held and of receipts for expenditure. A random sample were checked and found to be in good order. There was a staff supervision process and format in place, and recorded supervision meetings had commenced. However insufficient time had elapsed since our last inspection in May to evidence that all staff will receive regular supervision over an extended time span. We need to see this evidence before we are able to judge that this shortfall is fully met. It should be noted that staff spoken with did confirm that they had received supervision and support from the management team since the last inspection, and that they felt much better supported now than before the current manager was in post. Records of regulation 26 reports (monthly reports required to be carried out by the registered provider) were looked at. The frequency of these had improved since the last inspection with regular reports in place from May to September. However there were no reports available since September 2008, which appeared to coincide with a change of responsible individual named by the registered provider. Because of this we have made a requirement that monthly reports are in place to show that the manager continues to be supported by the provider. Discussions with staff, management and inspection of records confirmed that training is provided to staff in moving and handling, fire safety, first aid and basic training in infection control. Certificates and service records were seen to confirm that the homes hoists, fire equipment & alarms, gas piping, portable electrical appliances and electrical installation supply had all been tested/serviced. Hot water temperature is regulated and manual checks had been carried out in November 2008 and will continue on a monthly timescale. Fire drills had been held and a fire risk assessment was in place. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 37 26 Regulation 26 visits (registered provider visits) must take place on a monthly basis with reports available for inspection. To evidence the appropriate support from the providers and ensure improvement in the home. 31/08/2008 Care Homes for Older People Page 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 22 Evidence must be available confirming that complaints are investigated and that records are kept of the investigation findings and outcomes relating to each complaint received. This is to show that management respond to and deal with complaints appropriately. 31/03/2009 2 19 23 Stained and/or marked carpets in the main building must be cleaned or replaced. This is to ensure that service users live in a well maintained environment. 30/04/2009 3 30 13 All staff need to be trained on abuse awareness. To ensure that they are trained for their roles and service users are protected. 31/03/2009 4 33 24 A system must be in place and implemented for 31/05/2009 Care Homes for Older People Page 26 of 29 reviewing and improving the level of services provided by the home, taking into account the views of service users, their relatives and other stakeholders such as health & social care professionals. This is to show that service users views and opinions are listened to and acted upon. 5 36 18 Evidence must be available to confirm that all staff are provided regular recorded 1 to 1 supervision. To show that they are supported in their roles. 6 37 26 Regulation 26 visits (registered provider) visits must take place on a monthly basis with reports available for inspection. This is a repeat requirement from 27/05/2008. To evidence the appropriate support from the providers and ensure improvement in the home. 28/02/2009 30/06/2009 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 12 18 Staff who are responsible for providing activities to service users should receive training for this role. Information on the adult protection process and reporting procedures should be kept in one place with easy access for all staff to refer too. Page 27 of 29 Care Homes for Older People 3 19 Redecoration should take place to doors in the main building that are marked and scratched to provide service users with a homely environment. Training in working with people who have dementia should be provided to all staff to ensure they are trained for their roles. 4 30 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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) Commission for Social Care Inspection (CSCI). 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