Inspection on 13/11/08 for Fanshawe

This inspection was carried out on 13th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fanshawe 23/03/07

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: Fanshawe 53 Hooe Road Hooe Plymouth Devon PL9 9QS     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: Kim Fowler     Date: 1 3 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: Fanshawe 53 Hooe Road Hooe Plymouth Devon PL9 9QS 01752481663 01752482775 fanshawe@talktalk.net Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): R.M.J.J. Healthcare Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 23 Number of places (if applicable): Under 65 Over 65 3 23 old age, not falling within any other category physical disability Additional conditions: 0 0 The maximum number of service users who can be accommodated is 23. The registered person may provide the following category of service only: Care home with nursing- Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Physical disability over 65 years of age- Code PD(E) Old age, not falling within any other category- Code OPmaximum 3 places Date of last inspection Brief description of the care home Fanshawe Nursing Home, is owned by Mr Bassett T/A as R.M.J.J Healthcare Ltd. And is situated in Hooe, Nr Plymstock, near to local shops and on a bus route. Originally a Victorian house it has been modernised and extended. The accommodation Care Homes for Older People Page 4 of 29 Brief description of the care home comprises of 11 single bedrooms and 6 double rooms over 2 floors. There is a passenger lift providing access to both floors.The communal areas are on the ground floor and comprise of a homely lounge, a small lounge adjacent to the dining room and a conservatory/sun lounge.There is access to a small patio area with seating provided. The home provides nursing and personal care to a maximum of 23 people, over the age of 65, male and female, with physical disability and /or frailty.The home provides a comfortable friendly atmosphere, people are encouraged to furnish their rooms as they choose, and each room is individual in its character. The fees range from 484 pounds to 605 pounds. These may vary depending on peoples individual needs. 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: The quality rating for this service is 1 star. This means the people who use this service experience adequate outcomes. The unannounced inspection took place over 1 day and started at 9:30am and finished at 4.20pm. The Registered Provider, Mr Sean Bassett, and the new manager were both available throughout the inspection. The inspector made a tour of the building and spoke to most the people living at the home and three visitors visiting at the time of the inspection. Documentation relating to the care planning process and the management of the home were examined. Surveys were sent to people living in the home and three surveys were returned to the Care Homes for Older People Page 6 of 29 Commission as well as one from a visiting Health Care Professional. Any comments are in the relevant section of the report. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Pre-admission assessments are not routinely undertaken and completed, therefore, new admissions cannot be certain that their needs can be fully met at Fanshawes. Evidence: Of the files examined of people living in the home all four showed evidence that not all pre-admission assessment information on individual care needs had been documented in full before their admission to Fanshawes. This included an incomplete Nursing Assessment for one new admission. One person admitted under the RITA (Rapid Intervention Treatment and Assessment) did not have a completed pre-admission assessment completed, neither was it signed or dated. People admitted to the home under the RITA scheme have all the information provided by the RITA team with this admission taking place as an emergency admission. Therefore the home relies on the RITA team to provide full and completed information on all forms. A further examination of this file showed that the format used on this admission was different to Care Homes for Older People Page 11 of 29 Evidence: another admission. It showed some information had not been completed in both section of the admission form used by the placing authority. The home agreed to discuss this with the placing authority to ensure both section of the form are complete. Admission is a particularly difficult time for new admissions. If the assessment has not been carried out before admission, the care staff may not be fully aware of individual needs. This information is vital if the new admission is to feel safe and secure in a new environment. Other people living at the home were spoken with about their admission. One person thought they had received information prior to moving in and another said, My family visited the home. The homes AQAA states, A full pre-admission assessment is carried out by the nurse on duty and goes onto say, The nurse on duty must make sure they gather all information over the phone to determine that the home can meet that persons needs. Fanshawe Nursing Home accepts people under the RITA scheme and holds a number of beds that are contracted to continuing care. These people are usually admitted via the local authority. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff and manager provide good personal support to people who live at the home. Ensuring the promotion of privacy and dignity at all times. The homes poor practices relating to medication administration and incomplete care plans place people living at the home at risk. Evidence: Four files were examined for people currently living in the home and each held a care plan. However all were the same standard documents and none were individualised for each person and were not followed up with individual assessments to provide information for staff on how to met individual needs. This included one persons care plan stating they had a broken skin area on admission and no information for staff on how to manage this area and what current treatment is required and by whom. Other care plans highlighted health care issues included, insulin controlled diabetic and catheter care and neither were followed up to provide Care Homes for Older People Page 13 of 29 Evidence: information for staff on how to manage theses issues for individuals. One person living in the home has a allergy recorded onto their care plan however it is not clearly written on what it reads and what reaction the person would have or in the event of an emergency, no advice for staff on how to manage this situation. One person recently re-admitted from hospital did not have their care plan updated to show their change in health care needs. The new manager has plans to review and update all care plans held. One person has recently had an accident were they had become stuck between the bed rail and the mattress on their bed. This showed that the person concerned had severe laceration to one leg. This incident resulted in an investigation by the Health and Safety Executive and an improvement notice being issued. This investigation highlighted several issues including the home needing a more robust assessment for the use of bed rails and a multi disciplinary team agreement on the use of bed rails for individuals. The new manager stated that this improvement is now routinely being carried out. All people living at the home have access to all health care services and information was recorded into each persons file that there was input from other professionals including GPs, chiropodist and consultants based at the local hospital. The home also has a qualified nurse on each shift to assist in meeting peoples health care needs. One person living in the home said, I asked to see the GP and he came today. Completed care plans would give detailed instructions to all staff to ensure intimate personal care and health care needs are being provided in a manner that meets with peoples approval. This is particularly important if the people living at the home have limited communication skills. Only the qualified nurses administer medication and a medication round was observed during the inspection and discussed with the qualified nurse on duty. Information was received by the Commission, from the home, about a recent medication error and this was discussed in full detail with the senior nurse on duty and the Registered Provider. The notification received by the Commission stated that one person living in the home had received the wrong medication for 10 days before this was noticed by the home. Mr. Bassett stated that the home had discussed this with all qualified nurses and all nurses had been required to read the Nursing and Midwifery Guidelines for supplying, storage, administration and disposal of medicines. Care Homes for Older People Page 14 of 29 Evidence: Many of the people living in the home were spoken with during this inspection and those who were able to state that the staff respects their privacy and dignity at all times. Observed during the inspection were staff knocking on peoples doors to promote privacy and shutting the bedroom door when attending to a person personal care needs. One person said, My door is shut when staff help me. The homes AQAA returned states, That each persons care needs are unique and have to be assessed individually and goes onto say, All service users have a comprehensive care plan and extensive assessments to ensure all health needs are met. Care Homes for Older People Page 15 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 at Fanshawe can be confident that the home offers good wholesome meals. The home welcomes and encourages families and friends to visit. Evidence: Observed during the inspection was a Music and Movement session being carried out and many people living in the home involved in this activity. Other activities are arranged in the home by the care staff on duty including bingo. Staff were seen interacting with people and discussing everyday topics and included assisting individuals when needed showing staff were aware of the needs of people living in the home. Due to the high needs of most people living in the home many are unable to go out independently or with assistance, however some family members take people out. All family visits and contact is recorded into individual files and daily records examined Care Homes for Older People Page 16 of 29 Evidence: showed recent family visits for several people living in the home. Three visitors were spoken with during the inspection and one was able to confirm that they were able to visit at any reasonable time. Some people were observed remaining in their individual bedrooms and one person said, I like to stay in my room most days. All bedrooms visited contained personal possessions and items and several people living at the home said that the home encouraged them to bring in items from home. Those people who were able to made positive comments about the food provided. The homes 4 weekly menus was displayed for all to see and showed a varied and nutritional diet. It was evident from the food seen served at lunch time, Beef casserole, mash potatoes and fresh vegetables followed by home made strawberry mouse, that the food was home cooked using fresh products. The meal was well presented and freshly prepared. The tea menu was taken around to people to choose their preferred choice. Observation showed staff assisting people with their meals including providing assistance with cutting and eating. One person had been out when lunch was served and on there return was offered a full lunch with staff assistance. The homes AQAA states, Meal times are unhurried and relaxed. The comments received from people living at the home about the food provided included, Very good. One person said of the lunch observed being served, The food is excellent! Some people spoken with were able to confirm that food was plentiful and very good, and that drinks and snacks were available at all times. Also that alternative to the menu is available upon request and one spoken said, I can have something else if I want. A recent outbreak of Salmonella was traced to the kitchen area and a visit was carried out by the Environment Health and Public Health agencies. A Requirement was issued to have the kitchen Deep Cleansed and this requirement was carried out immediately. This issue is discussed further in the Environment section of this report. Care Homes for Older People Page 17 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. The people who live at Fanshawe and their relatives felt that any issues of concern or complaints would be taken seriously and dealt with. Robust procedures in place referring safeguarding issues to the appropriate agency would ensure the safety and protection of people using the service. Evidence: The homes complaints procedure was displayed for all to access and the complaints file was available in the main office. This showed some incidences that should have been passed to the local Safeguarding team and not dealt with under the homes complaints procedure. However the owner pointed out that one of these issues were with the previous owner. The other issue was well over a year old it would have no merit now to refer this at this late stage. The information recorded on this issues was unclear and should have been reported to the police to investigate to clarify the facts. A discussion was held with the owners on what to report and to whom. One complaint had been sent to the placing authority and this issues was dealt with in a Random Inspection carried out in July 2008. This inspection showed the complaint had also raised a Safeguarding alert. This alert raised concern about care practices and at the time of the Random Inspection had been resolved with the family concerned. Mr Bassett confirmed that the family had raised no further issues of concern. Care Homes for Older People Page 18 of 29 Evidence: A Health Care professional had also raised concerns about care practice issues and these were also dealt with in the Random Inspection and showed that the home had taken on board the issues raised by this professional and a subsequent phone call from this Health Care professional confirmed that all issues raised were satisfactory dealt with. One recent safeguarding alert was made re the incident of bed rails and the injuries sustained by the person concerned. This involved the Health and Safety Executive and an Improvement Notice being issued. This issues is discussed further under the Management and Administration section of this report. Most of the staff members on duty were interviewed during this inspection. From discussion with these staff members it was confirmed that none had completed the local authorities Adult Protection Safeguarding training. This training would provide staff with the knowledge and understanding on what issues are safeguarding and which to deal with under the homes complaints process. Some people living at the home were spoken with and some were aware of the homes complaints procedure and a few stated that they had never had any need to use it. The one relative spoken with stated that they had, No complaints with the home. Care Homes for Older People Page 19 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. People living at Fanshawe live in a pleasant home that is comfortable and warm and which provides sufficient facilities to meet their needs. Evidence: A full tour of the premises showed that the home is suitable for its stated purpose. The home is well kept and accessible for all the people currently living at the home. The home was found to be clean, tidy and free from offensive odours. Some people were able to confirm that they found the home comfortable, clean and warm. One person spoken to said, Its very nice here. Individual bedrooms showed that peoples rooms contained personal items including furniture, ornaments and pictures that reflect their personality and interests. There are 2 lounges areas one which can be used for visitor or a quite area, a conservatory and a dining room. The laundry is located separately from the home and is sufficient to deal with the amount of washing produced. Appropriate disability equipment is provided in the home, and these include a Care Homes for Older People Page 20 of 29 Evidence: passenger lift, hoists, wheelchairs, and a call bell system. This equipment provides the people living at the home with a building that is appropriately adapted to meet their needs. Some new nursing beds have been purchased since the last inspection. Risk assessments are in place and are reviewed annually or as necessary if anything changes. The process for the removal of clinical waste was discussed and was satisfactory dealt with and one staff member confirmed they had completed infection control training. Other staff confirmed that the home provided disposable aprons and gloves for their protection. And the manager confirmed that some staff had completed infection control training. The homes AQAA states, The home believes that adherence to infection control is paramount importance in ensuring the safety of both service users and staff. As previously mention under Daily Life and Social activities section of this report the home has had a recent outbreak of Salmonella that affected 5 people living in the home and several staff members. This outbreak resulted in visits from the Environmental Health and Public Health Agencies to take swabs to find the source of the outbreak. One source of the infection was found to be in the kitchen area and a Requirement Notice was issued by the agencies involved to have the kitchen Deep Cleansed immediately. Mr. Bassett, the Registered Provider, confirmed this had been carried out and that the homes cleaning system had been changed to include a deep clean of the kitchen area on a regular bases. The kitchen area was inspected and found to be clean, however it was reported to Mr Bassett that the kitchen door was held open with a wedge when it was vacated. Care Homes for Older People Page 21 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. People living at the home are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Evidence: On day one of the inspection there were 20 people living in the home and 4 care staff supported these people with one qualified nurse, the manager, cook, cleaner and laundry staff also on duty. The duty rota was examined and it shows sufficient numbers of staff for the amount of people living in the home and their dependency. Mr Bassett was also available to assist. The staff interviewed felt that the home had sufficient staff on duty and observation of staff throughout the inspection showed them to be relaxed, patient and helpful when assisting the people. One staff interviewed said that when people are on leave or sick it could leave them very busy. Some of the people living at the home were able to state that the care received is very good.One person living in the home said of the staff, Excellent. Examination of staff files showed that all staff had the required pre-employment checks, including CRB (Criminal Record Bureau Disclosure) in place ensuring as far as Care Homes for Older People Page 22 of 29 Evidence: possible unsuitable staff are not employed. One staff member is currently working under supervision while the completed CRB is returned. The information on the staff files was inconsistent and was not able to confirm the number of staff who holds an NVQ qualification and what other training staff had undertaken. There were no certificates of training held on individual file to confirm any training completed. One file did hold information that one staff had undertaken Health and Safety and First Aid training. The AQAA states that only 2 staff holds an NVQ. This is a nationally recognised care qualification for which staff have had their work performance and knowledge evaluated by an external training organisation. Through this training staff received further training in first aid and health and safety ensuring they have the knowledge to deal with emergencies. One staff member spoken with confirmed that they had completed training in Fire Safety, 1st Aid and Manual Handling. This staff member also confirmed that they hold an NVQ qualification. The new manager plans to review and update all staff files. The new manager has introduced a new Induction training to be undertaken by all staff. This new format showed the Induction training to be comprehensive in detail and the manager stated that it would meet the Skills for Care standards. One survey returned said, Very good staff. Some of the people spoken with during the inspection spoke well of the staff and said they were kind and caring and confirmed they responded promptly to requests for assistance indicating that there are sufficient staff on duty to meet the needs of those currently living in the home. One person in the home said of the staff, Lovely staff. Care Homes for Older People Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The new management arrangements are improving the records held in the home. The owner, manager and their staff team strive to provide a homely and stimulating environment. Evidence: The Registered Provider, Mr Bassett and the new manager are in day-to-day charge of the home. The new manager has started the Registration process with the Commission and hold the Registered Managers Award and has been in post for 6 weeks. The manager is aware of the issues that require updating and has plans to update all records as required. A discussion was held with the manager on quality assurance. The manager confirmed that these had been completed within the last year. The results were discussed at a meeting arranged by the home and invited the people living in the home and their relatives. This was to enable the home to provide feedback to everyone. Care Homes for Older People Page 24 of 29 Evidence: Mr Bassett confirmed that a small amount of personal money is held for each person and no large amounts are held. If the home require or purchase item for people living in the home the Register Provider will bill the appropriate person. The staff spoken with and records examined confirmed that staff have not received regular supervision. However the new manager is aware of this and has plans to rectify this by booking supervision sessions for all staff. Sampling of records indicated equipment is now serviced regularly and maintained in good order. Health and Safety is a priority in the home and records examined showed fire safety training and fire protection is in place and up to date. The accident records were accurate and files examined showed that information is recorded onto accident forms and also written into peoples daily records with appropriate action taken when needed. As previously mention the home had an outbreak of Salmonella and the home received a visit by the Environmental Health and Health Protection agencies. The requirement to close and Deep Cleanse the kitchen has been carried out. The home were issues with an improvement notice by the Health and Safety Executive due to a person living at the home receiving an injury from Bed Rails. The improvement notice included the completion of Risk Assessments for any person using bed rails. The home has also put in place a new procedure for the correct use of these rails. A maintenance programme has been introduced to ensure all bed rails are fitted correctly and no faults are noted before their use. Care Homes for Older People Page 25 of 29 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 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 3 14 New admissions to the home 31/03/2009 would benefit from a completed pre-admission assessment. This would ensure the home is able to meet the needs of new admissions. 2 7 15 Care Pans must be completed with individual needs recorded, including how these needs would be met. This would ensure that each person living in the home would have these needs managed. 31/03/2009 3 9 13 All medication must be recorded and administrated correctly. This would protect people living at the home. 31/03/2009 Recommendations These recommendations are taken from the best practice described in the National Care Homes for Older People Page 27 of 29 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 15 The home should make suitable arrangements for maintaining satisfactory standards of hygiene within the home to prevent infections and the spread of infections. Any issues that affect the well being of people living in the home must be forwarded to the appropriate agency. All staff would benefit from completion of the local authorities Safeguarding training. Detailed staff files including information on what training had been completed would ensure that all staff are appropriately qualified to work at the home. The new manager should complete the Registered Managers process with the Commission. The staff would benefit from regular supervision to ensure that they are supported to carry out their roles. All areas of the home should remain safe for people using the service, particularly bed rails. 2 3 4 16 18 30 5 6 7 31 36 38 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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