Inspection on 14/10/08 for Glengariff

This inspection was carried out on 14th October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glengariff 07/11/07

Glengariff 29/01/07

Glengariff 01/02/06

Glengariff 07/10/05

Glengariff 22/03/05

Glengariff 21/08/04

Glengariff 27/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Glengariff 59 Moss Lane Pinner Middlesex HA5 3AZ     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: Ram Sooriah     Date: 1 6 1 0 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 30 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 30 Information about the care home Name of care home: Address: Glengariff 59 Moss Lane Pinner Middlesex HA5 3AZ 02088665804 02084262257 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr &Mrs D.E Spanswick-Smith Name of registered manager (if applicable) Mrs Karen Spanswick Smith Type of registration: Number of places registered: 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 who can be accommodated is: 16 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Glengariff is a registered care home providing personal care for up to 16 older people. Residents at the time of the inspection were mostly female although the home is registered for residents of mixed gender. The home is a family-run business, having been established by the owners in the 1960s. The manager is the daughter of the owners. She has been much involved in the business over a number of years, and became the home?s registered manager in Care Homes for Older People Page 4 of 30 care home 16 Over 65 16 0 Brief description of the care home 1995. The family owns a similar care home, Abbotsford, at 53 Moss Lane. The home is situated in a quiet residential area of Pinner. It is fifteen minutes walk from local shops and public transport links. The forecourt has parking for a maximum of seven cars. The building has a ground and a first floor. Access is by passenger lift or stairs. Accommodation of residents is on both floors in fully furnished bedrooms. The home has two communal bathrooms, both of which have facilities to support residents with getting in and out of the bath. There are four other toilets available. The home has a large lounge that offers three interconnected areas, one of which doubles as the dining area. The home also has a paved garden to the rear. The home charges 566.10 pounds per resident. There were fourteen residents in the home at the time of the inspection. Care Homes for Older People Page 5 of 30 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 last inspection was unannounced and took place on the 7th November 2007. This key inspection was also unannounced and started on the 14th October 2008 at 0950 to 1310 and finished on the 16th October from 1120 to 1255. During the course of the inspection we talked to four residents, five members of staff and observed care practices and interaction of members of staff with residents. We also toured some of the premises and looked at a sample of records that the home keeps. The manager also completed an Annual Quality Assurance Assessment (AQAA) about the service. The content has been used where possible to inform this report. Care Homes for Older People Page 6 of 30 We would like to thank all the residents for their contribution to the inspection and the manager and all her staff for their support and assitance during the inspection. What the care home does well: What has improved since the last inspection? The home has introduced a format to record the assessment of the needs of residents. This provides essential details about the needs of residents and forms the basis of care planning. Residents and their relatives are more involved in the actual care planning process than noted during previous inspections. They signed the care plans to show that they are involved in drawing up and in the review of care plans. The abuse policy of the home has been reviewed to reflect the policy of the local borough and contains details of the local safeguarding adult team. The environment of the home has been further improved in a number of areas including communal areas and bedrooms of residents. The home has a modern lift to transfer residents between the two floors. At the time of the inspection the home had all the necessary certificates in place to demonstrate that equipment is maintained as required to ensure the safety of people who use the premises. Care Homes for Older People Page 8 of 30 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 30 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 30 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. Residents and their relatives receive enough information about the service for them to make an informed decision about using the service that the home provides. Residents needs are assessed appropriately to make sure that their needs will be met if they come to live in the home. Evidence: The service users guide is kept updated and is given to all residents to provide them information about the service. This was confirmed by the manager and two residents who spoke to us. In the past the service users guide has been assessed as comprehensive and informative. As all residents are privately funded they all receive a contract detailing their rights and obligations if they choose to live in the home. Copies are kept in the office. Residents said that their relatives normally deal with this aspect of their care. Care Homes for Older People Page 11 of 30 Evidence: We looked at the care records of three residents. All the residents had a preadmission assessment format in their care records that had been appropriately completed to show that their needs had been appropriately assessed. There were also discharge letters from hospital when residents had been in hospital prior to coming into the home. The residents in the home are privately funded and as a result do not always have needs assessments that had been completed by a local authority. The manager stated in the AQAA that she always visit prospective residents to explain about the dependency level of the home and its ethos. She also said that she encourages people to look at other homes, to consult their GP and give them contact details of organisations that might provide advice for more information about moving into a care home. Two residents said that their relatives visited the home to see if the home was suitable for them prior to them coming in the home. They also confirmed that the manager visited them to talk to them about the home and to find out about their needs. Care Homes for Older People Page 12 of 30 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. The needs of residents are on the whole appropriately addressed in care plans that are drawn mostly with the involvement of residents or of their relatives. Residents are appropriately supported to make sure that their healthcare needs are met. Medicines management is of a good standard to ensure the safety of residents. End of life care is not always addressed comprehensively in care records to provide a guarantee that the needs will be met when the time comes. Evidence: Each resident had care records that consisted of a file with the assessment of needs, care plans and old progress notes. Current progress notes are kept in another file, from which these are transferred to the main file at regular interval of time. The home now has a format for the assessment of the needs of residents. These were on the main appropriately completed and addressed not only the physical needs of residents, but the mental health needs as well as the cultural and religious needs of Care Homes for Older People Page 13 of 30 Evidence: residents. Care plans were formulated as required and were on the whole comprehensive. These were reviewed on the whole monthly or when there were changes in the condition of residents. We noted that there were risk assessments in place to address the health and safety of residents. These included manual handling risk assessments, pressure sore risk assessment, nutritional risk assessment and falls risk assessment. There were other risk assessments to address the individual needs of residents.We noted that the risk assessments were not always reviewed monthly and we suggested that the manager clearly identifies a date for the review of risk assessments to make sure that these are kept up to date according to the individual needs of the residents. For example one resident had a manual handling risk assessment that was dated March 2006. Care plans contained records of the input of healthcare professionals such as the GP and the district nurses in the care of the residents. We noted that the records showed that residents were seen by the dentist, optician and chiropodist. We also noted that a resident was referred to the occupational therapist when the latter needed a specialist type of footware. The home uses a pressure sore risk assessment to identify residents who are at risk of developping pressure ulcers and referrals are made to the district nurses as required for the provision of equipment. None of the residents had any pressure ulcers in the home but there were a few residents with wounds such as leg ulcers. They were being seen by the district nurses. We found that two residents were particularly at risk of falls and have sustained a number of falls. Their falls risk assessment were also scoring as high risk. We however did not find any plans of care to manage the care of the residents to prevent falls. The manager said that she would ensure that these be put in place and that residents be referred to the falls specialist for advice. We checked the management of medicines in the home. We found that medicines were stored safely and that all appropriate records were kept as required to demonstrate the safe management of medicines. Medicines were signed when administered and codes were used when these were not administered. In cases of variable doses of medicines the amounts of medicines that were administered were recorded. We were informed that only members of staff who have had training in medication were allowed to administer medicines. We found very limited information about the end of life care of residents in the care plans. The manager stated in the AQAA that Residents and families are invited to be involved in the care planning process, however Fears for the Future and particularly Care Homes for Older People Page 14 of 30 Evidence: Death and Dying continue to be an area that some people do not want to openly discuss. We believe that this is an area that requires staff to have specific skills to address and it is recommended that training be provided in this area for staff to be more confident in addressing.The government has launched its initiative in improving the end of life care of people (http:/www.endoflifecareforadults.nhs.uk/eolc/) taking into consideration peoples preferences, choices and wishes. Knowing these will help plan for the care that the residents require when the time comes. The manager is clear that all residents will be cared for in the home with the help of community healthcare professionals when they come to the end of their lives. Care Homes for Older People Page 15 of 30 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 home is much more proactive than previouly with regards to the provision of activities for residents, to make sure that they lead fullfilling lifestyles according to their choices and wishes. The home provides meals that are sufficiently varied, tasty and nutritious to meet the individual needs of residents. Evidence: The care records contain an assessment of the social and recreational needs of residents. The manager stated in the AQAA that as part of the pre admission process I endeavour to give as clear a picture as possible of life at Glengariff, I try to find out what people think living in a residential environment is about and what are the main areas of interest to them and what are their expectations. We were also informed that the manager had appointed an activities coordinator but that person had recently left. She stated that she has advertised the job once more. She said in the AQAA that activities is an area where there has not been as much improvement as she would have liked. Care Homes for Older People Page 16 of 30 Evidence: There was evidence of entertainers visiting the home to perform for residents. The manager stated that she has arranged for a christmas card sale and for a clothes sale for residents to choose and purchase what they want to wear. The residents that we spoke to, said that there are things in the home for them to do and that they can decide how they spend their day and can choose what they want to do for the day. The manager told us that in summer, residents are encouraged to use the gardens and to sit outside when the weather is nice. One resident confirmed that she enjoys sitting at the bottom of the garden. From talking to people and to staff we found that the home provides limited outing facilities, relying on mostly the relatives and friends of residents to take the residents out. One resident said that she regularly goes to her relatives for lunch, and another said that her relatives sometimes take her out The home has an open visiting policy. Residents confirmed that their relatives including their grandchildrens are able to visit them in the home. The manager confirmed in the AQAA of the importance of maintaining good relations with the relatives of residents and to keep them appraised of the condition of the residents and to consult them where necessary. We observed lunch on the first day of the insection. Lunch consisted of roast beef,green beans, mixed vegetables and apple crumble and custard. We were informed that staff are aware of the choices of residents and would offer a different meal to a resident who does not eat the main meal. All residents said that the meals are very good and that they are satisfied with the way that the meals are prepared. Most residents had their meals in the dining areas, that were prepared in a congenial manner. Those who wanted to stay on their own for meal times have their choices respected. We noted that residents who needed support with their meals were assited in a discreet manner. Care Homes for Older People Page 17 of 30 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. Complaints and allegations and suspicions of abuse are taken seriously by the service and are dealt with appropriately to ensure that the rights and safety of residents are safeguarded. Evidence: The homes complaints procedure was available in the reception area and in the service users guide, for residents and their relatives to refer to as required. The complaints register showed that there have not been any complaints made to the home. The commission has however received anonymous calls about staffing levels at night and residents sustaining bruises. We discussed these concerns with the manager and she said that no one has had discussions with her about these issues and that she would have taken the issues seriously and looked into these if these were mentioned to her. We looked at staffing levels during the inspection and noted that staffing has remained the same as previously and has not changed. At night there were one waking member of staff and another sleeping member of staff who was on call. One resident had bruises during the inspection and it was noted that the resident had a medical condition that made them prone to bruising. This was addressed in their care plan. There were two residents who have had a number of falls, but they did not only fall at Care Homes for Older People Page 18 of 30 Evidence: night. The also fell in the early part of the evening when there were more staff in the home. The manager clarified that increasing staffing levels at night might not necessarily reduce the falls unless one to one care was provided and that she would increase staffing levels if there was a need for it. She said that she had had discussion with the relatives of the residents who were prone to falling, about the needs of the residents. She agreed to refer the residents to the Falls Specialist Nurse and to have specific care plans in place to manage the risks that residents face with regards to falling (see section under Health and personal Care). We therefore did not find any breeches of regulations in regards to the concerns that were raised. The manager stated that she has reviewed the safeguarding adult procedure of the home for it to reflect the safeguarding adult procedure of the host local authority (Harrow). She said that staff receive awareness training on safeguarding adults during induction and then have more in depth training in this subject. She was able to describe the action that she would take if there were allegations and suspicions of abuse in the home. Staff that we spoke to were aware of the whistleblowing policy of the home. Care Homes for Older People Page 19 of 30 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 maintained, clean and warm environment for residents to enjoy. Evidence: The grounds in front of the home were maintained to a good standard. The grounds at the back of the home looked well kept and inviting with lawn areas, shrubs and flowers. There were areas for residents to sit and enjoy when the weather is nice. We noted that the exterior of the building was in good condition. There were no odours in the home and it apeared clean and maintained. The home has two members of staff who are responsible for cleaning the home on a daily basis. There was evidence of ongoing maintenance in the home. The fire detection system had been overhauled and the electrical system has also been revamped. A new modern lift has been installed to link the ground and the first floors. The communal areas were appropriately furnished and on the second day of the inspection we noted that the carpet was being replaced. We were informed that the carpet in the laundry area was also due for replacement. There has been a repeated requirement on at least 2 occasions addressing the replacement of the carpet in the laundry area. The ceiling of the communal areas was also being freshly painted on the day that the carpet was being changed. Care Homes for Older People Page 20 of 30 Evidence: The bedrooms of residents were homely and personalised as many residents/relatives brought personal items/possesions of the residents. All residents said that they like their rooms and were satisfied with the standard of decor. We noted that bedrooms are decorated as and when they become vacant. As the home had a few vacancies at the time of the inspection we did note that at least one bedroom was being fully redecorated. The radiators that we saw had covers on them to protect people who may become in prolonged contact with these, from burns. The manager confirmed that all radiators that residents have access to, have covers to ensure the safety of the residents. Care Homes for Older People Page 21 of 30 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. The home provides adequate level of staffing to meet the needs of residents, but the standard of training was not as good as it could have been. Although the standard of recruitment has improved, the procedure is still not being applied as robustly as it should. Evidence: Staffing has not changed in the home and staff continue to have fixed duties every week, which suits their individual circumtances and seems to work for the home. The manager said that there are 3 members of staff from 08:00-09:00 and 5 members of staff from 9:00-13:30. Out of the five members of staff, 2 are responsible for cleaning, 1 is responsible for cooking, serving lunch and washing, and 2 provide care to residents. There are three members of staff from 13:30-18:00, two of which are directly allocated to look after residents. From 18:00-22:00 there are three members of staff to help residents go to bed. At night there is one waking and one sleeping member of staff. We discussed the response of the home in relation to staffing when the needs of residents increase such, as when there are residents who are disorientated to time and place and who can therefore be at risk of falls and injury. The manager stated that whenever necessary she would ensure that there are enough staff on duty to ensure Care Homes for Older People Page 22 of 30 Evidence: the safety of residents. In cases when there are long term changes in the dependency of residents, the manager said that she would discuss the needs of the residents with their relatives/representatives. We looked at the personnel files of three members of staff. They all had two references and evidence that a CRB check had been conducted. They all had evidence that they were eligible to work in the UK except for one where there was a written note instead of a copy of the document that shows that the relevant person is eligible to work in the UK. We found that two members of staff had gaps in their work history. One person had a significant gap that was in excess of ten years. We noted that all new staff were offered induction in the home and that they had also started the common induction standards as per Skills for Care. We looked at the training records of four members of staff. We found that staff have not always been kept up to date with mandatory training. For example none of the members of staff were up to date with fire training. Two of the four members of staff whose records were checked, were not up to date with manual handling training. Care Homes for Older People Page 23 of 30 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 manager is experienced and familiar with the needs of the residents. She runs the home in a smooth manner. The home does not yet have a formal system to address the quality of the service that it provides, to make sure that it always provides a quality service. Health and safety issues in the home are appropriately addressed to ensure the safety of residents Evidence: There has not been any significant changes in the management of the home, apart from the manager stating her wishes to have a deputy manager in place to support her in managing the home. She has an Advanced Management in Care qualification but she does not yet have a qualification in care. She has however worked and managed the home for many years and is aware of the needs of the residents who are accommodated in the home. Care Homes for Older People Page 24 of 30 Evidence: Quality Assurance is carried out mostly on an informal basis. The manager keeps an active presence in the home and talks to residents and to visitors to the home to check if they are satisfied with the care and support that the residents receive. She says in the AQAA that she plans to develop Quality Assurance in the home. She added that the home enjoys a good reputation in the local community and that residents are refered to the home by GPs, healthcare professionals and other people who have had contact with the home. The home does not keep any money for residents. Expenditures that are made on behalf of residents are invoiced monthly with their bill. Personal possessions of residents are recorded when residents are admitted to the home. We looked at the maintenance records of the home and noted that the maintenance of equipment was carried out as required and that most of the maintenance was up to date. There were gas safety certificate for appliances that use gas, an electrical wiring certificate and a portable appliances test certificate. There was evidence that lifting equipment was maintained and tested as required. Records showed that fire drills were held, but there has not been a fire drill at night. It is recommended that one be carried out. There was evidence that fire detector tests were carried out although not always on a weekly basis. There were records to show that the water temperature at outlets to which residents had access to, is checked at least monthly to make sure that the temperature of the water did not rise above 43 degrees centigrade.A weekly health and safety check is also carried out. The home had an up to date fire risk assessment and fire emergency plan. While touring the home we noted that some window restrainers could be easily disabled to enable the windows to be fully open. This is potentially a risk to some residents. The retrainers must be of a type that can only be disabled with a special key or tool as per guidance from the Health and Safety Executive (see Health and Safety Executive Website). Care Homes for Older People Page 25 of 30 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 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 That residents have a 27/01/2009 preventative action plan in place when risk assessments has identified that their safety may be at risk. To demonstrate that the home is taking action to ensure the safety of residents 2 29 19 All applicants must have all the appropriate checks before they are offered employment in the home including a full work history, to make sure that there are no gaps that have not been accounted for. To ensure that residents are fully protected by the recruitment procedure of the home. 28/01/2009 3 30 18 All members of staff must have annual mandatory training such as fire training and manual handling to make sure that they are 28/01/2009 Care Homes for Older People Page 27 of 30 fully competent to care for residents. Staff must be fully trained to make sure that they can look after residents as safely as possible 4 33 24 The home must have a 28/01/2009 quality assurance system that can be used to measure the quality of the service that it provides. To make sure that the service always provides a quality service. 5 38 13 Restrainers that are 28/01/2009 provided to prevent windows from fully opening must be of a type that can only be disabled by a special tool or key to make sure that the restrainers cannot be easily disabled and therefore putting residents at risk. To make sure that residents are not at risk from falling from the window. 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 7 That residents/relatives sign the care plans to show that they have been involved in the drawing up and review of care plans. It is strongly recommended that training be provided to staff in end of life care to increase their confidence in addressing this subject. Documentary evidence must be kept in the personnel file to Page 28 of 30 2 11 3 29 Care Homes for Older People show that people who work in the home are eligible to work in the UK. 4 5 31 38 The manager should consider having a qualification in care. It is recommended that a fire drill be carried out at night. Care Homes for Older People Page 29 of 30 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. 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