Inspection on 04/02/10 for Greetwell House Nursing Home

This inspection was carried out on 4th February 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greetwell House Nursing Home 26/08/09

Greetwell House Nursing Home 04/09/08

Greetwell House Nursing Home 05/09/07

Greetwell House Nursing Home 07/11/06

Greetwell House Nursing Home 05/04/06

Greetwell House Nursing Home 16/01/06

Greetwell House Nursing Home 13/10/05

Greetwell House Nursing Home 09/03/05

Greetwell House Nursing Home 13/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 10/04/2010.

Key inspection report Care homes for older people Name: Address: Greetwell House Nursing Home 70 Greetwell Close Lincoln Lincs LN2 4BA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Dawn Podmore     Date: 0 4 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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 CQC 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 29 Information about the care home Name of care home: Address: Greetwell House Nursing Home 70 Greetwell Close Lincoln Lincs LN2 4BA 01522521830 01522521830 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Dr Sharaf Abd El Monem Salem Name of registered manager (if applicable) Type of registration: Number of places registered: care home 25 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of people who can be accommodated within the home is: 25 The registered person may provide the following category of service only:- Care Home with nursing - Code N To people of the following gender: Either Whose primary needs on admission to the home are within the following categories:- Old age, not falling within any other category - Code OP Physical disability - Code PD - maximum number of places 1 Date of last inspection Brief description of the care home Greetwell House Nursing Home is a privately run, twenty-five bedded, Gothic-style property situated in a quiet residential area in the centre of Lincoln, opposite Lincoln County Hospital. There is a regular bus service into the city and a shopping centre within half a mile. The home is a two-storey, Victorian building, which has been Care Homes for Older People Page 4 of 29 Over 65 25 0 0 1 Brief description of the care home adapted and extended to provide personal and nursing care for up to twenty-five people of both sexes over the age of 65 years. The home is currently accommodating one resident over the age of 60 years with a physical disability. Residents are accommodated in sixteen single rooms and six shared rooms. Two staircases and a passenger lift give access to the upper floor. Communally, there are three bathrooms, a shower room and three toilets. There is a garden to the side of the property and a limited car parking area to the side and rear of the property, in addition there is on-street parking. The manager confirmed that weekly charges made by the home for care ranged from £360 - £550 depending on peoples assessed needs. Information about the service, including the a copy of the previous inspection report, fees and the homes facilities, is available from the managers office. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was announced shortly before our visit and was undertaken by two inspectors. It took any previous information held by C.Q.C about the home into account. Throughout this report the terms we and us refers to the care Quality Commission (CQC). In April 2009 the provider had returned an Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans for improvement over the next twelve months. The content of the AQAA was used at the last key inspection in August 2009 and this visit. Prior to this inspection we also sent out surveys to residents, relatives and staff, 20 of which were returned in time to be included in this report. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they received through the checking of Care Homes for Older People Page 6 of 29 records, discussions with them and the staff who care for them, and observation of care practices. A partial tour of the home was also conducted, which included looking at some bedrooms, communal areas and bathing and toilet facilities. Documentation was sampled and the care records of the three people being tracked were examined. We spoke with 5 residents, 3 relatives and 4 members of staff. They shared their views about how the home operated on a day to day basis and the care and facilities provided. On the day of the visit 11 people were living at the home. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Although there has been improvement in care planning records over the last twelve months, more information and guidance for staff is needed to make sure they are fully aware of their role in supporting people. The plans should be more person centred so that they tell staff about peoples individual preferences in more detail. All files should also indicate that people have been involved in planning and evaluating their care, if this is not possible the reason should be recorded. Information collated about peoples social needs should be developed into individualised care plans that tell staff how they need to support them so that they can continue to follow their interests. The recruitment of staff must be more robust so that people can be confident that staff are suitable to work with vulnerable people. This includes obtaining appropriate written references from their last employer. Staff should receive regular supervision and an annual appraisal. This will help to ensure they are provided with adequate support and guidance. The owner needs to record his visits to the home at least once a month. This will then provide a regular overview of how the home is operating and any issues that need attention. Fire safety checks must be carried out regularly and the results recorded. This will ensure that the systems are working correctly and thereby protecting the people who live and work at the home. Other areas that would benefit from some attention include the following. Assessments that help to determine if people are at risk of things like pressure damage or falls should be evaluated regularly so that any changes can be identified and Care Homes for Older People Page 8 of 29 appropriate actions taken. The assessment and care planning process should take into account legislation such as the Mental Capacity Act and Deprivation of Liberties. Staff should receive training in this subject so that they are aware of their role in assessing, recording and protecting peoples rights and choices. The exterior of the building has flaking paint so the owner should consider repainting it so that people are living in a well maintained environment. The areas around the home also need to be tidy so that it offers people a litter free environment to walk and sit in. Staff training should be audited to make sure that they have all received the training they need to carry out their job. The owner should make further enquirers about arranging for people to have their own bank accounts. This will enable them to accrue interest on any savings they have. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a detailed admission process in place which helps to make sure that the home can meet the needs of the people admitted. Evidence: The home provides people with information to help them decide if it is the right place for them to live. The Statement of Purpose and the Service Users Guide have been updated to include details about the new acting manager. There have been no recent admissions to the home, but the deputy manager described a satisfactory process that included a detailed assessment of peoples needs. Potential residents are also encouraged to visit the home before making the decision to move in permanently. Although people could not fully recall what process had been followed when they came to live at the home the majority said that they received enough information for them Care Homes for Older People Page 11 of 29 Evidence: to make an informed decision. Relatives also confirmed that people had been provided with the terms and conditions of living at the home. The manager said that although people come to the home for short stay placements the home does not provide intermediate care. 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. Peoples needs are being met by staff who understand these needs and deliver care in a respectful manner. However shortfalls in care planning records could lead to peoples needs not being fully met. Evidence: We looked at the care records of 3 people living a the home choosing people with different needs. They contained information about what care and support each person needed and some of their individual preferences. However there were gaps in one of the files we sampled. For example it did not tell staff about how to meet their personal care and hygiene needs, such as bathing, hairdressing and nails care. However daily notes and observation sheets demonstrated that these had been provided. In a separate file there was information about the persons social preferences, but this had not been formulated into a care plan to inform staff about their role in supporting them in this area. Care plans had been evaluated, but this was not always on a monthly basis. Where plans had been devised they did not always provide sufficient information and Care Homes for Older People Page 13 of 29 Evidence: guidance about how to meet the identified needs. For example one plan said assess to control anxiety levels, however it did not go on to say how this should be done. Assessments for potential risk areas, such as manual handling and risk of falls, had been carried out but they had not been evaluated regularly to monitor for any changes. A daily record of how people were progressing had been maintained in good detail describing how they had spent their day and any changes in their condition. Each file sampled contained a blank mental capacity assessment form, but there was no information available in care plans to determine if people could or could not make decisions themselves. This is new legislation that is aimed at protecting peoples rights and choices. Although the manager had received training in this subject other staff had not. People had access to outside health professionals such as doctors and other health professionals. Peoples health care was being monitored and we saw equipment, such as pressure relieving mattresses, in use. Staff were knowledgeable about the people they supported and how they preferred their care delivering. We saw them speaking to people with respect and considering their preferences when providing support. People told us that they were happy with the level of care delivered. One person said I get the care I need. Another commented they look after me very well, my personal hygiene needs are always met. A relative told us, care workers work well for general caring, such as keeping patients very clean and physically cared for. The home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. There is a system in place that allows the manager and deputy to audit the medication system and identify any shortfalls. A recent recording error had been addressed immediately and action was being taken to minimise the risk of it occurring again. The pharmacy that supplies the home has not checked to make sure that systems are robust and are being followed since March 2009. At that visit they reported no issues. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a varied activities programme which people enjoy. They receive a nutritious and varied diet that meets their individual preferences and health requirements. Evidence: The home does not employ a designated person to provide social activities. After talking to the people who live at the home the management team have devised a programme of stimulation which care staff facilitate. The daily programme was displayed on the notice board. Each resident had a personalised form identifying their interests and preferences. Records and peoples comments showed that activities provided included: crafts, watching TV, indoor games, such as board and card games, barbeques and trips to local pubs and shops. On the day of the inspection some people were watching television while others were making Valentines cards. Three residents were also attending the funeral of one of their friends who had lived at the home. Planned events included a Chinese New year celebration and a clothing party. People told us that they were happy with the programme of activities and that there Care Homes for Older People Page 15 of 29 Evidence: were now more staff available in the afternoons so that they could go out. One person said that they always went to church on a Sunday and stayed for coffee afterwards. When asked if the activities suited them someone who returned a survey answered negatively, but did not go on to give any details as to why. At lunchtime the atmosphere in the dining room was calm and relaxed. The menu planned for the day had been changed, but people were still given a choice of main course. One person told us, you do get a good dinner here and another said, the foods okay. A relative commented that although parts of the menus had improved over time they felt that the teatime options could be better. Out of the nine people who returned surveys 6 said that the meals always met their needs, one said usually and the other two said that they sometimes did. At the last visit by the Environmental Health Officer the kitchen was awarded a 4 star rating for the cleanliness and organisation of the kitchen, the highest rating being 5 Star. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are protected by clear policies and procedures for handling complaints and allegations of abuse. Evidence: The home has a complaints procedure, which is displayed in the home and included in the Service User Guide. This is given to people when they come to live at the home. No areas of concern had been raised with the home or us, but a system was in place should any complaints be made. No concerns were raised and in the main people said that they knew how to make a complaint and would be comfortable highlighting any issues. The home has procedures concerning the protection of vulnerable adults. Staff had received training in this subject and at the last key inspection in August 2009 they demonstrated a satisfactory knowledge of what to do if they suspected abuse could be occurring. . Care Homes for Older People Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable and homely environment, but some areas are not adequately maintained and decorated. Evidence: We took a partial tour of the home looking at some bedrooms and communal areas. We also looked at the bathroom identified at the last visit as needing some attention. The general atmosphere of the home was welcoming and homely. Bedrooms had been personalised by the resident or their relatives with photographs, mementos and small items of furniture. The bathroom had been refurbished and redecorated. Although the home was generally maintained to a satisfactory level some areas looked shabby and out dated. Bedrooms with en suite facilities have a shower curtain separating them from the bedroom area. These were too small to totally enclose the area off, therefore peoples privacy and dignity could be affected. At the last inspection visit it was highlighted that the exterior of the building was in need of repainting. The owner told us that although quotes had been obtained no action had been taken yet. The outside area also looked untidy with litter collecting in the shrubs, this means that people do not have a well maintained place to walk and sit in finer weather. Care Homes for Older People Page 18 of 29 Evidence: People told us that they were happy with their rooms and complimented the home for its homely atmosphere. Comments included: they keep the home clean, the home is always fresh and clean and its a very homely place. Separate staff are employed to maintain the cleanliness of the home. There were no unpleasant odours detected during the visit and all areas looked clean and tidy. The home has access to 2 handymen, on the day of our visit they were preparing a bedroom for redecoration. Care Homes for Older People Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to recruit staff, however some areas are not robust enough to ensure peoples safety. People are supported by a knowledgeable staff team who understand their needs and have in the main received appropriate training. Evidence: Records and observations showed that there was sufficient staff on duty to meet peoples needs. People raised no concerns about the number of staff on duty and said that they felt that there were usually enough staff available to meet their needs. Staff confirmed that they felt that the current staffing levels were satisfactory. Observation showed that staff supported people in a calm and relaxed manner and they had time to sit and talk to them. One member of staff told us there are plenty of staff in the afternoon to do things with people. We looked at the files of 2 new staff, both contained an application form, 2 written references, proof of identity and C.R.B. (Criminal Records Bureau) certificates. However in one file neither of the references were from their last employer. The other file did contain a reference from the persons last employer, but this job had only lasted a month and was not a care position. New staff had received a basic induction. The record regarding nursing staff induction Care Homes for Older People Page 20 of 29 Evidence: was just a list, for example medication system explained. There was no evidence of what had been discussed, the depth of the information provided, or that the nurse had been assessed as competent to take charge of the home. The home has a training programme which includes essential subjects such as manual handling, protection of vulnerable adults from abuse, fire safety, medications and basic food hygiene. More specialist training such as wound management had also taken place. Although the acting manager has attended a training course about the Mental Capacity Act and Deprivation of Liberties, which are aimed at protecting people rights and choices, there was no evidence that other staff had received this training. The company encourage staff to complete an N.V.Q (National Vocational Qualification) in care. Information provided showed that 5 staff have attained an N.V.Q. and 3 others were currently doing the award. People said that they were happy with the way staff supported them. One person said. I could not fault the carers, nurses or staff as they are all like a great family team and very friendly to people. Most staff said that they received the training they needed but two people indicated that they would like more training. The files we looked at for new staff failed to demonstrate that their training needs had been fully assessed. Care Homes for Older People Page 21 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Leadership and guidance are provided to staff on a day to day basis, however some systems are not robust enough to ensure full protection to residents. Evidence: The home has not had a registered manager for over a year. There is a new acting manager, Mrs Angela Lacey, who was formally the registered manager at Greetwell House. The previous acting manager has taken the post of deputy. People told us that the manager and deputy were helpful and supportive. They praised the home and the care provided. When asked what the home did well their comments included: everything, it is a very homely place, I find residents and staff very friendly and they are always there when I need them. Relatives told us, a great standard in every way and I think they are alright as they are, they all seem to work as a team, it is a second home to me. When we asked what could be improved some people said nothing while others Care Homes for Older People Page 22 of 29 Evidence: highlighted some areas that could be enhanced. One person said that few more permanent staff would be advantageous so that less bank staff were used, although they also said this had recently improved. A relative said that they would like to be informed about any changes in their mothers condition straight away rather than staff leaving it for the manager to contact them. Another said that she would like some staff to be a little more reassuring when their relative was upset. Staff spoke positively about working at the home. Their comments included: I love it here and this is an excellent home to work in, with a good management team in place, and they are very approachable. They said that the home was person centred and homely and that it was a very friendly place to work. They also identified some areas that could be improved. These included up-dating and enhancing the environment, particularly the exterior of the home, more outings for residents, and communication. Although staff said that they felt that they were well supported by the management team, records failed to evidence that regular structured supervision sessions or annual appraisals had taken place recently. The home has a quality assurance system so that they can gain the views of the people who use the service. The deputy manager said that she had recently sent surveys out to professionals who visit the home but none had been returned. However the last surveys sent to residents and relative was July 2008. Some meetings had taken place, but these were not carried out on a regular basis with the last one being in May 2009. The home owner, or his representative, is required to visit the home monthly and complete a report detailing their findings and how any concerns or issues are to be addressed. Although some reports were available these had not been completed on a regular basis. The content of the reports we looked at did not fully cover the areas required. There is a system in place for residents monies to be held in safe keeping by the home. This includes keeping a running total of all transactions and obtaining receipts and two signatures. Some monies have been deposited into a joint bank account which is managed by the owner. He told us that he had been unable to arrange for individual bank accounts so that residents can accrue interest on their savings. The home has health and safety polices and procedures to guide and instruct staff. There is also a programme in place to service and maintain equipment on a regular Care Homes for Older People Page 23 of 29 Evidence: basis to make sure that it is in good working order. Information provided in the AQAA demonstrated that regular checks on equipment, such as hoists, had taking place. We looked at the fire safety folder and found gaps in the recording of things like weekly fire alarm and emergency lighting testing. The owner said that responsibility for this was to be given to the handymen to make sure that checks were carried out consistently. Care Homes for Older People Page 24 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 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Care plans must be in sufficient detail to enable care staff to provide comprehensive care. They must include all individual care needs, choices and preferences. This will help to make sure that staff have access to all the information and guidance they need and can therefore meet peoples needs 05/04/2010 2 29 19 The process for recruiting staff must be robust and include undertaking all essential checks This will help to protect people living at the home from unsuitable people being employed. 01/03/2010 3 33 24 The quality assurance system must be used constantly to gain the views of the people who use the 26/04/2010 Care Homes for Older People Page 26 of 29 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 service and evaluate the policies in place. This will help to make sure that the home is operating at an acceptable level . 4 36 18 There must be a system in place for staff to receive regular supervision and appraisal. This will help to ensure that staff are adequately supported in carrying out their job. 5 37 26 Monthly visits to the home must be made by the proprietor and a report completed detailing their findings and any actions to be taken to address any issues found. This will provide an ongoing evaluation of how the home is operating and any areas that need addressing. 6 38 23 Fire safety checks must be carried out regularly and recorded consistently This will ensure that the systems are working correctly thereby protecting the people who live at the home. 01/03/2010 08/03/2010 05/04/2010 Care Homes for Older People Page 27 of 29 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 Risk assessments for subjects such as pressure damage and nutritional status should be evaluated regularly. This will ensure that any changes in peoples condition are detected promptly and minimising actions can be taken. 2 7 The care planning and the assessment process should include reference to the Mental Capacity Act and Deprivation of Liberties and the effects it has on residents lives. This will help to make sure that peoples rights and choices are protected. The owners environmental audit and business plan should include the exterior of the premises, including the paintwork. This information can then be used to prioritise the work needed which will help to make sure that people live in a well maintained environment. 3 19 4 30 Staff should receive appropriate training in relation to the Mental Capacity Act 2007 and Deprivation of Liberties. This will give them a better understanding of their role in supporting people appropriately. 5 30 The induction programme provided to nursing staff should be comprehensively recorded. This will help to demonstrate that new nursing staff have received all the information they need to enable them to take change of the home. 6 30 The manager should review the training provided to each member of staff to make sure that everyone has received appropriate training. This will enable her to plan for future training needs. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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