Inspection on 20/10/09 for Heathfield Care Home

This inspection was carried out on 20th October 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heathfield Care Home 11/05/10

Heathfield Care Home 16/11/08

Heathfield Care Home 26/07/06

Heathfield Care Home 08/12/05

Heathfield Care Home 27/06/05

Heathfield Care Home 02/11/04

Heathfield Care Home 22/05/04

Heathfield Care Home 10/10/02

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for older people Name: Address: Heathfield Care Home Main Road West Wittering Nr Chichester West Sussex PO20 8QA     The quality rating for this care home is:   zero star poor 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: Elaine Green     Date: 2 0 1 0 2 0 0 9 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 31 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 31 Information about the care home Name of care home: Address: Heathfield Care Home Main Road West Wittering Nr Chichester West Sussex PO20 8QA 01243511040 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: heathfield@tesco.net Intercare Orthopaedic Services Limited care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 21 The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category : Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Heathfield Care Home is a privately owned establishment registered with the Care Quality Commission to accommodate up to twenty service users in the category of old age (OP). There is also a variation for one named person in the category of Physical Disablement (PD). The establishment is a detached property set in its own attractive grounds. Situated six miles from Chichester and two miles from West Wittering village. The registered provider is Intercare Orthopaedic Services Ltd. Mrs J Ovington is a director and registered manager responsible for the day-to-day management of the Care Homes for Older People Page 4 of 31 Over 65 21 0 1 6 1 1 2 0 0 8 Brief description of the care home home. The responsible person on behalf of the company is Dr Mayank Gupta. Fees at the time of the inspection are £550.00 - £650.00 a week. A Statement of Purpose and Service Users Guide is available to reference. Care Homes for Older People Page 5 of 31 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: zero star poor 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: An Unannounced visit was made to this home on the 20th October 2009. Before the visit to this service we looked at all the information we have received from the home. The Registered Manager was not available on the day we visited the home so the assistant manager facilitated the site visit element of this inspection. We looked at information about the people who live at the home and how well their needs are met. We looked at other records that must be kept and checked that staff had the skills, knowledge and training to meet the needs of the people they support and care for. We also saw into the communal areas of the home, some of the bedrooms, the kitchen and the laundry. We checked what improvements had been made since the last visit and before we left we told the assistant manager what we had found. Care Homes for Older People Page 6 of 31 The outcomes for the people who live in this home are poor, adequate and good. The overall rating for this home is poor which is a no star rating. A warning letter has been sent to the provider in relation to the regulations that were found to be breached at this inspection. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: An immediate requirement was made on the day of the site visit to the home in respect of staff not working in the home prior to satisfactory security checks being completed. We have since received confirmation that this requirement has been met. A requirement was made in respect of this at the last inspection and the fact that shortfalls have been identified in this area again is being dealt with separately. The registered person must make sure that the Service User Guide and Statement of Purpose is kept up to date and contains all the required information. The registered person must ensure that new service users are admitted only on the basis of a full assessment to which the person considering moving into the home their representatives and relevant professionals have been party. The registered person must ensure that a service users plan of care is holistic and generated from a comprehensive assessment which drawn up with each service user and provides the basis for the care to be delivered and this must be kept under review. The registered person must ensure that robust risk assessments are completed for people to identify those at risk and appropriate interventions must be put into place to reduce any risk identified. These assessments must be kept under review. The registered person must ensure that the homes policies and procedures for the handling and administering of medicines are followed at all times. In particular clear guidelines must be obtained for when as and when medication can be administered. The registered person must ensure that peoples interests are recorded and that they are given opportunities for stimulation through leisure and recreational activities in and Care Homes for Older People Page 8 of 31 outside the home which suit their needs, preferences and capacities. The registered person must ensure that the home introduces a quality monitoring system that is robust and that measures if the home is achieving its aims and objectives. Where shortfalls are identified corrective action must be taken. The registered person must ensure that staff receive formal supervision a minimum of 6 times a year and this must be documented. The registered person must ensure the health safety of welfare of the people who live and work at the home. Environmental risk assessments must be completed, cleaning products must be stored appropriately, the temperature of all hot water outlets must be tested monthly, communal flannels must not be used. 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 31 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 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information provided to people considering moving into the home does not provide sufficient detail to enable them to make an informed decision about whether the home is able to meet their assessed needs and is right for them. Evidence: We looked at the homes Statement of Purpose and Service User Guide this had been updated to reflect that respite care can be provided but it did not detail the number of staff employed, their relevant qualifications or experience. The copies we saw were dated May 2008 however the assistant manager told us that the contents had been reviewed and updated since then. We looked at the preadmission assessments for three of the people who live at the home. None of these assessments covered all the areas that are required to be assessed. The only risk assessments that had been completed for each person was a moving and handling assessment. One of these moving and handling assessments Care Homes for Older People Page 11 of 31 Evidence: stated that the person was prone to falls however no falls risk assessment had been completed to show how this risk could be minimised. There were limited or no details recorded in relation to preadmission assessments for social interests, hobbies, religious and cultural needs. None of the assessments we saw included nutritional screening assessments or assessments that identify those at risk of developing pressure sores. We spoke to a relative of a person who lives here who told us that they had spoken to the manager prior to their relative being admitted to the home and the health care professionals involved with their relatives care. They were happy that their relative had been able to move into this home on a permanent basis and with the care that the home was giving them. They told us they were very pleased with the assessment process and that their relative and themselves had been involved in the decision to move into the home. However they also told us that they had not seen or been involved with completing the paper work for the assessment or care planning process for their relative. Care Homes for Older People Page 12 of 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not based on comprehensive assessments and do not provide the guidance that staff need to follow to ensure that people are supported safely and consistently. The homes procedures in relation to the management of medicines is unsafe. Evidence: We looked at the care plans for 4 of the people who live in the home. These are based on the initial assessment and none of them covered all the areas they are required to. For example other than the initial moving and handling assessments no other assessments had been completed. Each person did have a personal hygiene care plan in place however the ones we saw were identical and had not been individualised for the individual, they stated Offer assistance with all hygiene needs, mouth care including teeth and or dentures, promote individual where possible. Wash and cream feet and lower legs daily. In another persons care plan it stated that continence records should be kept on a daily basis but records showed that this had not taken place. Care Homes for Older People Page 13 of 31 Evidence: Accident forms relating to one person showed that they had had a number of falls over the last 12 months however neither the care plan or the moving and handling risk assessments had been reviewed or updated. None of the care plans we saw had been reviewed on a monthly basis and none had a falls risk assessment in place. People were seen to be treated with dignity and respect by staff on the day we visited the home however, peoples preferences in relation to how they receive support are not documented. One persons preferred term of address is recorded and another persons likes and dislikes in relation to food was recorded but these details had not been recorded for everyone. Peoples wishes on death and dying had not been recorded on the care plans we saw. Daily records are not kept. The home does however record progress notes that detail clinical information about a person on regular but not daily basis. Records relating to personal hygiene given and continence records are kept for some people but no daily recording is in place to show how someone has spent their time or how they are feeling. Since our visit the manager has written to us to state reviews of care have been undertaken monthly by senior carers and that this was available. We looked to the records relating to medication and saw that when prescribed creams had been applied that these had been ticked for and not signed for by staff as is required. There were no guidelines in place for when as and when or PRN medication could be given or for how long for. For example, one persons prescribed medication stated it could be give when this person was distressed however there was no guidance for staff to follow in relation how they would know this. The assistant manager explained to us that this person suffers from hallucinations which cause them distress and this is why they had been prescribed this medication but there was no mention of these hallucinations on the persons care plan or for under what circumstances this medication could be given. There were some gaps on the medication administration records so it was not always clear if the medication had been administered or not. When we looked at the medication administration records it was not always clear why medication had stopped. The assistant manager explained that this was usually as directed by the prescribing GP but records had not always been signed to this affect. The homes own policy in relation to the administration of homely remedies lists the remedies that may be given to people who live in the home without a prescription provided the GPs consent had been obtained. The home had a large store of Care Homes for Older People Page 14 of 31 Evidence: communal homely remedies including paracetamol however no GPs had been contacted to give their consent for them to be administered. One person had signed a consent form to say they would manage their own medication however, no assessment had taken place to show that they were able to do so safely. Care Homes for Older People Page 15 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has no evidence that they support people to participate in activities that they enjoy or provide them with the social integration and mental stimulation suited to their capacities. Visitors are welcomed into the home and people are supported to exercise choice and control over their lives. The arrangements for the provision of food ensures mealtimes are relaxed and enjoyable and people are provided with a choice. Evidence: When we visited the home one person was meeting with their relatives in the dining room whilst 6 others were watching the television. We asked to see records relating to how people spend their time however there were no records relating to activities to be seen in the home or any form of social activity plan or record in peoples care plans. One persons assessment did show that they enjoy story tapes, music and watching football however the care plan did not show how or when these things would happen for this person or if they needed any support to access the pastimes they enjoyed. People can have visitors and there is an area in the hallway where people can meet with visitors or they can use their own rooms. We saw relatives visiting the home and they told us that they are always welcomed into the home. Care Homes for Older People Page 16 of 31 Evidence: There is a notice board for people in the hall way of the home. This details information for people they they may find useful e.g there was a leaflet from the holistic therapist who visits every 2nd Tuesday in the month, details about the mobile library, a mobile shoe shop, a taxi number, the local Age Concern Advocacy service contact details and the local Catholic Parish Church mass times. Copies of the service user guide, statement of purpose were also available in the hallway along with the last report. Copies of the residents newsletters for February 2009 and June 2009 and minutes of meetings also held in Feb 2009 and June 2009 were in a folder in the hallway. A list of dates for your diary showed that there were plans to hold a Residents meeting in October, poetry and prose in November and both an Old timers Christmas show and a carol service to be held in December. There is a hairdressing sink in part of the communal area of the home and a hairdresser visits the home on a regular basis. The home has a 4 weekly menu. The assistant manager told us that the menu had been discussed at the residents meeting that had been held the week before we visited the home and that some people had put forward new suggestions for the menu. We saw that there were lots of fresh vegetables and fruit in the store cupboards and the food served on the day we visited was hot well presented and home made. People who live in the home told us that they are asked what they would like the night before. They also told us that there is an alternative to the main meal and if they did not want that either they could ask for something else instead. Some people had alcohol with their meals and they told us that whilst this it was their own personal wine or beer that the home keeps this for them. We saw that the home keeps records of what food is ordered but not of how much people eat. Care Homes for Older People Page 17 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes policies and procedures in relation to the safeguarding of adults is safe. The homes policy and procedure in relation to complaints ensures that people are listened to and responded to within a reasonable timescale. Evidence: The home has obtained a copy of the local protocol for how to raise a safeguarding alert with the local authority. Staff induction training covers how to recognise abuse. Management have attended workshops run by the local authority on safeguarding adults and have cascaded this information to the staff team. The homes complaints policy and procedure is made available to all the people who live in the home. The policy states the timescale in which they will respond to the complainant. The contact details for the Care Quality Commission in the complaints policy and procedure are included in the policy and the Assistant Manager stated that these need to be updated. Care Homes for Older People Page 18 of 31 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 is clean and hygienic. Evidence: We saw all areas of the home. We saw into some bedrooms that were vacant and some that were being used. The vacant rooms were clean and had all the required furniture and fittings. The rooms that were being used were clean and had been personalised, people are able to bring their own furniture. We saw the open plan dining room / lounge area. This is domestic in character and the dining areas is large enough to accommodate all the people currently living at the home. We saw into the laundry which has large industrial type machines. The home was clean and tidy and there were no odours. There is a communal area at the end of the hallway that connects the en suite or villa accommodation on the ground floor. This area has a hairdressing sink, a range of seating and an organ. Care Homes for Older People Page 19 of 31 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. The homes recruitment practises are not safe. Staff complete inductions and receive the mandatory training needed to fulfil their role. Evidence: We looked at the records relating to the recruitment of 4 members of staff. We saw that the application forms do not ask for the persons previous work history. References have been provided but have not been checked for authenticity. The assistant manager stated some overseas staff were recruited through an agency and that the agency had obtained the references. One person had been employed by the home in the past but had then returned to their home country for 12 months. This person had recently been employed again by the home but no checks had been undertaken, no application form had been completed and new references had not been sought. An immediate requirement was made on the day of the site visit in respect of this person working in the home without a PoVA first check being completed. The home has confirmed with us that this person would not be working in the home until confirmation that this check had satisfactorily been completed. Additionally they would not be deployed to work in the home unsupervised until the recruitment process had been fully completed. A requirement has been made in respect of people working in the home following a robust recruitment process. Staff rotas do not show designation of staff member or the capacity in which they are Care Homes for Older People Page 20 of 31 Evidence: are working. Call bells were only heard on two occasions during visit and they were answered straight away. As previously stated the numbers of staff employed and their qualifications are not stated in the homes Statement of Purpose or Service User Guide. We asked to see the induction that is completed by staff. We were told that 2 members of staff have completed the skills for care induction and that they has been sent off to be verified and so that certificates could be issued. Another member of staff is in the process of completing this induction and keeps the work book with them. We asked to see the training records for the staff working in the home. The home has a training matrix in place and this showed that most staff have completed the mandatory required within the timescales. We were told that those staff that had not completed the mandatory training they need for this year had not done so because they had been on holiday at the time that the training took place. Care Homes for Older People Page 21 of 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the qualifications and experience needed to run this home however the procedures adopted by the home and the lack of monitoring of the homes own performance, place people at risk. Evidence: We were notified as is required of the registered managers absence from the home for more than 28 consecutive days on two occasions this year. The notification sent to us regarding their most recent absence from the home informed us that that the registered manager would be back in post from the 1st of October 2009. However, the registered manager was still not back in post at the home when we visited on the 20th of October. The home now publishes the results of their own quality assurance, which is based on questionnaires and these are available to view in the hallway at the home. However the homes quality assurance does not asses the homes performance in relation to meeting the National Minimum Standards. Shortfalls have been identified in Care Homes for Older People Page 22 of 31 Evidence: association with assessments, care planning, medication, staff recruitment, staff supervision and health and safety and have been highlighted throughout this report. In addition, not all the requirements made a the last inspection have been met. We looked at staff supervision records for five carers employed at the home none of which had had supervision on a regular basis and the supervisions that had been recorded were observations of practise. The assistant manager told us that all care staff have had an appraisal this year. The manager Ms Ovington has written to us following the visit to state that supervision has been documented but may have been misinterpreted as training. The assistant manager told us that the home is not involved with the management of the finances for anyone who lives in the home. We were told that since the last inspection the home has taken advice on moving and handling and that staff have received moving and handling training. We saw that the homes cleaning products were not kept in a locked cupboard and were left out in the laundry room and in the sluice room both of which were unlocked. We noted that the way the home currently uses flannels for personal care could be seen to be problematic and misinterpreted although they are taken from rooms each day after use and washed, they are not named for each person for example. We saw records that indicated that the home tests the hot water temperature of 2 outlets in the home monthly. The manager has written to us stating that this is on the advice of the health and safety executive . We were advised on the day of our visit that the home had recently been visited by the fire department and as a result has been required to install a new fire escape and the old one is marked as out of use. Work on the new fire escape had not commenced when we visited the home. However the manager has written to us following the inspection to state that this was not the case and that it was Heathfield management that implemented the replacement of the fire escape in conjunction with other building developments. We saw that there is no boundary wall or fence to the side of the property and that the homes open plan garden backs onto other open plan gardens belonging to privately owned properties. There is no risk assessment in place in relation to the safety of the people in the home accessing these garden or for their security. Care Homes for Older People Page 23 of 31 Evidence: Care Homes for Older People Page 24 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 1 5 That the Service Users Guide 28/02/2009 contains all the required information. To ensure that residents and their representatives have all the required information to reference. 2 1 4 That the Statement of 28/02/2009 Purpose is updated to reflect all the required information and the service provided. To ensure that up-to-date information about the care provided is available to reference. Care Homes for Older People Page 25 of 31 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 The registered person must ensure that new service users are admitted only on the basis of a full assessment as specified in schedule 3 which has been undertaken by people trained to do so, and to which the prospective service user, representatives, and relevant professionals have been party. This documentation must be signed and dated. To ensure that the home is able to meet the assessed needs of the individual. 30/11/2009 2 7 15 The registered person must ensure that a service users plan of care is generated from a comprehensive assessment as specified in schedule 3 and that this is drawn up with each service user and provides the basis 31/12/2009 Care Homes for Older People Page 26 of 31 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 for the care to be delivered. Each plan must be reviewed a minimum of monthly and as and when changes occur. To make sure that staff have the guidance they need to follow in order to ensure that support is provided safely and consistently. 3 8 12 The registered person must as specified in Schedule 3 ensure that service users are assessed, by a person trained to do so, to identify those service users who are at risk of developing, pressure sores and appropriate intervention is recorded in the plan of care. To ensure the health safety and welfare of the service users in the home. 4 8 13 The registered person must ensure that service users psychological health is monitored regularly and appropriate restorative care provided. To ensure the health safety and welfare of the service users in the home. 31/12/2009 31/12/2009 Care Homes for Older People Page 27 of 31 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 5 8 16 The registered person must 31/12/2009 ensure that appropriate interventions are carried out for service users identified as at risk of falling. To ensure the health safety and welfare of the service users in the home. 6 8 14 The registered person must as specified in Schedule 3 ensure that Nutritional screening is undertaken on admission and subsequently on a periodic basis, and a record maintained of nutrition. To ensure the health safety and welfare of the service users in the home. 31/12/2009 7 9 13 The registered person must 31/12/2009 ensure that the homes policies and procedures for the handling and administering of medicines are followed at all times. In particular clear guidlines must be obtained for when PRN medication can be administered, service users GPs must give their consent before homely remedies are administered, medication administration records must be completed and signed for to indicate if prescribed Care Homes for Older People Page 28 of 31 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 medicines have been taken or applied, risk assessments must be completed for service users who administer their own medication. To ensure that people receive their medicines safely. 8 12 16 The registered person must 31/01/2010 ensure that service users interests are recorded as specified in schedule 3 and they are given opportunities for stimulation through leisure and recreational activities in and outside the home which suit their needs, preferences and capacities. To ensure that service users are supported to live the life they choose. 9 29 19 The registered person must 30/11/2009 ensure that recruitment practises are robust with all employment checks needed, to be in place before employment commences. To ensure that service users are supported and protected by the homes recruitment policy and practises. Care Homes for Older People Page 29 of 31 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 10 33 24 The registered person must ensure that the home introduces a quality monitoring system that is robust and that measures if the home is achieving its aims and objectives. Where shortfalls are identified corrective action must be taken. To ensure the health and safety and well fare of the people who live and work in the home. 31/01/2010 11 38 13 The registered person must ensure that cleaning products are stored appropriately, and enviromental risk assessments must be completed. To ensure the health and safety of the poeple who live and work in the home. 30/11/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 30 of 31 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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