Inspection on 13/03/09 for Evergreen

This inspection was carried out on 13th March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Evergreen 17/04/08

Evergreen 16/05/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Evergreen 15 Collier Road Hastings East Sussex TN34 3JR     The quality rating for this care home is:   two star good 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: Deborah Calveley     Date: 1 3 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Evergreen 15 Collier Road Hastings East Sussex TN34 3JR 01424427404 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Greenheart Enterprises Ltd care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 16 The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission ot the home are within the following category : Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Evergreen is a registered independent care home providing nursing and personal care up to a total of 16 people over the age of 65 years. The home is situated approximately within I mile or walking distance of the seaside town centre and mainline rail station. The building has been upgraded to meet the National Minimum Standards and was registered at the end of 2006. It provides 16 single rooms with en suite toilets. Communal space is found on the ground floor and includes a lounge, Care Homes for Older People Page 4 of 27 Over 65 16 0 Brief description of the care home dining room and a large conservatory. The home provides nursing care and support to residents who are both privately funded and those who are funded by Social Services. The homes literature states that the homes mission is to maintain, restore and promote to exceptional standards the health, safety and welfare of each individual in our care. Care Homes for Older People Page 5 of 27 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: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term service user to describe those living in care home settings. For the purpose of this report those living at Evergreen will be referred to as residents. This was a key inspection that included an unannounced visit to the home and follow up contact with residents representatives and visiting health and social care professionals. This unannounced inspection was carried out over 5 hours on the 13 March 2009. There were 13 residents living in the home on the day of which four were case tracked and spoken with. During the tour of the premises four other residents both male and female were also spoken with. Care Homes for Older People Page 6 of 27 The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Two members of care staff were spoken with in addition to discussion with the appointed manager and registered person. Telephone contact was made with visiting professionals following the visit and their views and comments are incorporated into the report along with the information received verbally during the site visit. An Annual Quality Assurance Assessment was received from the Manager completed in full prior to this key inspection. There were surveys returned prior to this inspection informed the inspection process and any comments received are reflected in the body of the report. Fees currently range from 575 pounds to 750 pounds per week Additional charges are made for individual newspapers chiropody hairdressing and physiotherapy. What the care home does well: What has improved since the last inspection? The management team have worked hard over the past year and have introduced clear, up to date procedures reflecting best practice in regard to the handling of medicines. The home have ensured that all the homes policies and procedures are up to date and provide clear procedures to promote and protect the health and welfare of residents. The recruitment practice has been improved to ensure all the necessary checks are completed by the home before staff are deployed to work in the home. Systems for quality auditing have been developed with the questionnaires received being reported on and responded to and they are available to any intrested parties. Robust Health and Safety systems have been developed in respect of the homes environment and garden and include regular risk assessments. Care Homes for Older People Page 8 of 27 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 27 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 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission. Evidence: There is a Statement of Purpose and Service Users Guide in place which contains a good level of information about the home and the services it provides along with some information regarding the qualifications of staff. In order to reassure prospective residents that the staff have the knowledge and competency to meet their needs more information regarding the training and updates they receive would be beneficial. These documents are written in a formal style and it was discussed that it could be made more user friendly, e.g in a larger print accompanied by photographs. It was confirmed that all residents are provided with a copy of their own on moving in to the home and a copy is kept in their individual care plan. Care Homes for Older People Page 11 of 27 Evidence: It was confirmed whilst talking to residents that the contract arrangements were clear and understood. There is a copy of the terms and conditions of residency included in the homes information documents. A review of the care documentation confirmed that pre admission assessments are completed by the manager. The last three admissions to the home were identified and the records relating to the admission procedures followed were reviewed. This confirmed that pre admission assessments are completed and in the main provide a clear assessment of prospective residents care needs. Prospective residents are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. This approach could be more clearly recorded on the assessment documentation to demonstrate the procedure followed. It was confirmed that the home confirms in writing that having regard to the assessment that the home can meet the assessed needs of the prospective resident. Intermediate care is not provided at Evergreen Nursing Home. Care Homes for Older People Page 12 of 27 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. Care plans provide a good framework for the delivery of care which give clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting residents health and general needs with accessed additional specialist support when needed. Medication practices in the home promote and protect the health needs of residents and on the whole the privacy and dignity of residents are promoted. Evidence: The care documentation pertaining to four residents were reviewed as part of the inspection process. The care plans are in a booklet format and are based on the Roper Logan and Tierney activities of daily living. These were found to include plans of care, nutritional assessments, personal histories and individual risk assessments. On the whole the care documentation demonstrated that the health social and welfare needs were reviewed and evaluated. However some shortfalls were identified and discussed. For example, one resident has a skin problem at present and is receiving input from the general practitioner, this was Care Homes for Older People Page 13 of 27 Evidence: not reflected in the plan of care, with guidance for staff to follow. Residents are all weighed regularly and this is then recorded. From viewing the records some residents have had unstable weights over the past few months, but there was no evidence that these were being followed up to explore the reasons for the varied weights within the documentation. The residents are assessed as to their moving and handling needs and linked to the tissue viability assessment, it would be beneficial to all the care team if the equipment used for each individual is identified clearly also documenting which hoist and sling is used, what setting the air matresses/ cushions are to be set at. these areas were discussed during the site visit and it was confirmed that she would address these, therefore a requirement has not be made at this time but will reviewed in depth at the next key inspection. Relatives and residents spoken with were satisfied with the care provided at the home, one saying The home should be congratulated for its care, my relative receives good nursing care and the care workers are kind, considerate and supportive of her every need Staff are efficient courteous and very kind. Residents spoken to were also satisfied, comments included They look after me very well, I am have my own room and the staff are kind Its my home. Two visiting care professionals contacted as part of the inspection process were also positive about the care provided saying, I have only seen consideration and good care shown to the residents. The clinical room for the home is situated on the ground floor. It is fairly small and has lockable cupboards for its medicines dressings and controlled medications. It also has a clinical fridge and temperatures of the fridge and room are recorded daily. A Monitored Dose System (MDS) is being used in the home and all medications and support is provided by a local pharmacist. All medicines are stored securely within an appropriate storage area. There are policies and procedures in place for staff to refer to regarding the safe administration storage disposal and recording of medication. The systems for recording and checking controlled drugs were found to be thorough. Medication Administration Charts (MAR) were found to be competently completed. It is recommended that unused (obsolete) equipment is removed and oxygen if not in use or ready to be used be returned to a pharmacy. Staff were seen to be respectful and considerate to all residents and visitors, whilst attending to their needs and the interaction between staff and residents was positive, thoughtful and friendly. Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. Care Homes for Older People Page 14 of 27 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. The lifestyle experience by residents meets their expectations choice and preferences at this time. Meals remain good in respect of both quality and variety that meets the majority of residents tastes and choice. Evidence: Care plans evidence some residents past histories and social preferences, but as yet they are not linked constructively to a formal activity programme. Activities should be an important part of life to the residents of Evergreen as there are some independent people living there and therefore it is identified as an area that requires further development to meet all the residents social needs. From direct observation the morning shift did not evidence any organised activities, but a slide show was booked for that afternoon, which all residents appeared to enjoy. The residents enjoy the activities provided and some residents spoke of going out for walks over the West Hill weather permitting. It was confirmed by staff that the residents are encouraged to attend facilities away from the home these include shopping trips, church services and visits to a local public Care Homes for Older People Page 15 of 27 Evidence: house. It was not clear from documentation how often these take place. During the visit it was noted that staff were spending time with residents chatting with them and offering them a beverage. A member of staff escorted one resident to a local shop and this something he enjoys regularly. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. There are communal areas throughout the home that are available to residents and their visitors for private meetings if required. Many of the residents have individualised their bedroom with items from home and residents and relatives spoken with confirmed that they are encouraged to make it homely, one resident though still boxers that needed unpacking. It was observed during the inspection that the routines at the home are flexible residents spoken with confirmed that they were consulted about all aspects of their lives. The home has an advocacy policy in place and the information regarding this is available to all residents. The cook was available to talk with and was able to discuss the menus devised and the dietary needs of the people who live in the home. The kitchen was clean and well organised with storage for dry stores as well as refrigerated stock. An environmental health officer visited in the latter part of 2008 and the manager confirmed that the recommendations had been actioned, or were due to be actioned soon in the respect of the fly curtains. The safer cooking better business book is completed on a daily basis and is completed as required. The menus are rotated 4 weekly and are devised with residents residents preferences taken in to account, the menus demonstrate a well balanced and varied diet. The dining room is fairly small with one large table. It has natural light and is pleasantly decorated. The majority of residents eat together with other residents either choosing to eat in their bedroom or the lounge. If families wish to stay for a meal they can for a small charge. The meals provided looked appetising and were served in a manner that ensured it looked attractive. Fresh fruit is provided and it would be beneficial if it were more assessable to the residents. The feedback concerning the meals and the choice of food was positive and included the comments: A nice variety of food, I am a diabetic and they manage to make sure I am having the right food, always tasty. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a formal complaints system with evidence that residents feel that their views are listened to and acted upon. Staff receive training to protect residents from abuse. Evidence: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and in the Service Users Guide. A system of recording complaints was demonstrated to the inspector during her visit to the home. The home has not received any formal complaints since the last inspection. Residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to. The home has relevant guidelines on the protection of vulnerable adults and staff have all received appropriate training. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. Care Homes for Older People Page 17 of 27 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. The home provides a comfortable clean and safe environment for those living in the home and visiting Residents are enabled and encouraged to personalise their room and rooms are homely and reflect the residents personalities and interests Evidence: Evergreen is a large converted premise that has retained a homely environment and upgraded in 2006 to meet the National Minimum Standards. Resident accommodation is provided on three floors with disabled access to the first floor via a passenger shaft lift. All bedrooms are for single occupancy and have an ensuite facility. There are lovely views of the West Hill from the consevatory and bedrooms. A tour of the home was undertaken as part of the inspection process and confirmed that the home is well maintained and decorated and furnished to a good standard. The home have a choice of three communal areas which are attractive and allow for different uses ensuring residents have choice of how they spend their time, the dining room, conservatory and lounge. A tour of the home confirmed that the home is well maintained and bedrooms are attractive with some being very personalised and all bedrooms have an ensuite facility. Residents spoken to said that they liked their rooms one saying that the home Care Homes for Older People Page 18 of 27 Evidence: its very comfortable. There are adequate communal bathrooms and shower rooms in the home with specialist equipment to ensure all residents can have a bath or shower. The home has specialised equipment available throughout the home to promote independence. Call bells are provided in all areas and staff were seen to be attentive and ensured residents had access to these. The home has a range of special mattresses and seat cushions which are used on an assessed needs basis to prevent tissue damage. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Water temperatures are controlled and monitored on a regular basis and a record kept. Random temperatures were taken and were of the recommended level. There are systems in place for monitoring safety issues such as fire checks, fire drills, PAT testing, electrical tests and gas and boiler checks and all the rooms are routinely checked for safety and maintenance issues. The records in the home confirmed they were up to date. The tour of the home confirmed that staff are aware of the fire safety policies, no doors were found inappropriately wedged open. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. The home produced a legionella pilicy and procedure. Sluice facilities were clean and hygienic, laundry areas were found to be clean and safe. In the main good practice in respect of infection control by staff was observed during the inspection visit soiled linen was appropriately put in red bags and all areas of the home were clean. The care staff also do the domestic duties and there is a need that staff either wear a protective overall or change their uniform before recommencing their care duties. Residents were complimentary about the laundry service indicating clothes are generally returned the same day. Care Homes for Older People Page 19 of 27 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. Robust recruitment procedures are in place to protect residents and staff training ensures they are aware of their roles and are able to provide the support and care the residents need. Evidence: There were thirteen residents living in the home on the day of the inspection visit. The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Care staff spoken with said that the levels of staff on duty were sufficient to give the care required and the staff had no negative comments. A roster is held giving names and designations of staff on duty and the registered managers hours are more settled now. The staffing rota evidenced that there are three care staff on duty in the morning and two in the afternoon and they work along side either the manager or a registered nurse. The night shift is covered by two waking care staff and a trained nurse. The care staff also undertake the domestic cleaning and some catering duties in the home this needs to be kept under review to ensure suitable and appropriate staffing at all times and are adjusted when the dependency and number of residents in the home change. Care Homes for Older People Page 20 of 27 Evidence: A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been introduced to protect residents and contained all the relevant information required. There was evidence of health questionnaires Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. Discussion took place regarding ensuring that the references are appropriate and from their latest employers. There is an induction programme in place and has been introduced for all staff. However the induction files seen were not completed, and staff need to complete their documentation for them to be signed off as competent to work under supervised. All new staff are required to complete an initial induction programme and undertake mandatory training including fire and health and safety. This leads into foundation training, in preparation of National Vocational Qualification(NVQ) training. At present over 50 per cent of staff have an NVQ qualification with further staff enrolled on a course. The induction and foundation training is in line with the Skills for Care guidance. The manager has employed a training provider to provide the training in the home and to facilitate other training sessions. This person is also working alongside the manager in updating policies and procedures and risk assessments in the home. The staff confirmed that they receive mandatory training and in house training that enables them to perform their role in the home safely and competently. Following discussion with the manager it was found that not all staff that prepare and handle food have received food hygiene training and this needs to be addressed. Care Homes for Older People Page 21 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The overall management of this home is good with effective systems in place to protect residents Evidence: The registered manager of Evergreen is also the company director of the company: she is a registered general nurse (RGN) with experience of working with older people with nursing care needs. She has successfully completed the Registered Manager Award (RMA) and confirmed that she continues with her own learning portfolio and updating her knowledge. The registered manager has worked hard to meet the requirements of the last key inspection and remains committed to providing a good standard of care within a relaxed homely environment. During the inspection visit there was no doubt that the manager had a good working relationship with everyone in the home and everyone spoken to said that she was approachable fair and responded to issues raised quickly. Care Homes for Older People Page 22 of 27 Evidence: Feedback from visitors and health professionals was complimentary regarding the management style of the home. There are systems in place to monitor the quality in the home and include the use of questionnaires. It was confirmed that these are now audited, reported on and responded to. There are resident relative and staff meetings, which are all minuted and areas for improvement and development discussed. The registered manager confirmed that she does not have any involvement with residents monies and all residents have an identified person who deals with their finances with any extras being invoiced on a monthly basis. By direct observation during the site visit the moving of residents in wheelchairs was appropriate and safe, however the staff need to be reminded of the safe techniques when assisting residents to stand and transfer from chair to chair. The environmental risk assessments have been developed and include photographs of the identified risk followed by the action taken, there is a need to develop the risk assessments to incoporate everyday risks within the normal environment, and not just maintenance errors. The AQAA confirmed that relevant safety checks have been completed in the home and records viewed confirmed this. All staff have received core training on health and safety. The accident book was viewed and was found competently completed, however it would benefit the residents health and safety if accidents are cross referenced within their individual care file to prevent a reoccurrence. As found previously the homes policies and procedures are supplied by a training company and evidenced regular review and reflect the practice used in the home and most current legislation and guidelines. To ensure the safety and well being of the residents all staff that handle and prepare food need to undertake the basic food hygiene course. Care Homes for Older People Page 23 of 27 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 24 of 27 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 12 16 That the registered person 26/05/2009 ensures that there is an activity programme in place to meet all the service users social needs and meets their expectations and preferences. That the service users social needs are met. 2 26 13 That the registered person ensures that appropriate steps are taken to ensure that infection control measures are in place to prevent cross infection. This pertains to the care staff attending to domestic chores whilst also providing personal care. To promote the and the residents safety and well being. 25/05/2009 3 38 13 That the registered person ensures that all parts of the home are so far as 25/05/2009 Care Homes for Older People Page 25 of 27 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 reasonably practicable free from hazards to their safety. this includes the development of environmental risk assessments. That all accidents and falls are cross referenced with the individual care plan to prevent a reoccurance. To ensure the health, safety and welfare of service users and staff. 4 38 16 That the registered person ensures that all staff that prepare and handle food recieve the appropriate food hygiene couse To ensure the safety and well being of the service users. 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 26/05/2009 1 1 That the training undertaken by staff is documented in the service users guide and statement of purpose so as to reasssure prospective service users and their families that the staff have the knowledge and training to meet their needs. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. Care Homes for Older People Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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