Inspection on 19/11/08 for Herondale

This inspection was carried out on 19th November 2008.

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

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

Other inspections for this house

Herondale 21/02/08

Herondale 10/10/06

Herondale 28/11/05

Herondale 07/07/05

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Herondale 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jill Brown     Date: 1 9 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Herondale 175 Yardley Green Road Yardley Birmingham West Midlands B9 5PU 01217531653 01217714188 home.her@mha.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Methodist Homes for the Aged care home 36 Number of places (if applicable): Under 65 Over 65 36 36 dementia mental disorder, excluding learning disability or dementia Additional conditions: 0 0 That the home can accommodate one named service user under 65 years of age with dementia. That the home can accommodate up to 36 older people over the age of 65 years with dementia or who have a mental illness and may also be infirm. (DE(E)) and (MD(E)) Date of last inspection Brief description of the care home Herondale is a purpose built; two storey home that is registered to provide care to 36 residents for reason of mental health problems, but predominantly specialise in dementia care. It is situated in a residential area within the boundary of Heartlands Hospital; it is close to shops, local amenities and is accessible to public transport systems. There is adequate parking to the front of the building with a large enclosed garden to the rear, which has a patio and seating for use by residents when weather permits. The home is divided into four wings or house groups spread over the ground and first floors. The first floor is accessible by the stairs or a passenger lift. Each house Care Homes for Older People Page 4 of 30 Brief description of the care home group has its own lounge, dining area, kitchenette, a bathroom, a communal toilet plus nine en-suite bedrooms. The en-suite facilities consist of a toilet and shower facility and are of sufficient size for residents with mobility problems. There is a range of equipment for moving and handling residents plus pressure relief equipment for residents at risk of developing pressure sores. A passenger lift gives access to all areas in the home and there is wheelchair access to the front and rear of the building. The main kitchen and laundry area are situated on the ground floor, which are staffed separately. The weekly fees are available on request, persons may wish to obtain more up to date information from the home. 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. A random inspection was undertaken in July 2008 when visited the home without notice as a result of a complaint and we found that the home had not performed well in some areas. We then visited the home again unannounced in November to look at the majority of the National Minimum Standards (A key Inspection). The report is about both of these visits. The home gave us information in an Annual Quality Assurance Assessment (AQAA) before the key inspection. The AQAA shows how the home rates their performance in Care Homes for Older People Page 6 of 30 the areas set out in this report. During the inspection 3 peoples care was case tracked, this involves looking at all the records about this person and how the home manages their care and we looked at another persons care records. We looked at a number of peoples medication records. We spoke to 2 of the people whilst we were there. The people in this home have problems with their memory and so we spent some time observing what life was like for them in the home. We looked around parts of the building and viewed the health and safety checks that had been undertaken. We looked at staff records. We sent 30 comment cards to the home for relatives, health and social services professionals and staff but received only 2 replies both from relatives. What the care home does well: What has improved since the last inspection? What they could do better: Assessments varied in the amount of detail available and in one instance was not sufficient to give good care. Records were not clear about when the home received information. People do not visit the home before admission and the home needs to look at how information can be given to them. Although care plans are in place sometimes the recording on them is not consistent. Care Homes for Older People Page 8 of 30 This means that signs that a person is unwell and responses to unexplained minor injuries can get missed. Improvements were still needed on plans for diabetes and behaviour to ensure that signs, individual to the person, were identified to show the person was unwell or confused. People were not weighed regularly and changes could indicate that a person is not well. Staff did not always have the results of checks with Protection of Vulnerable Adults list, National Midwifery Council or Criminal Records Bureau checks before starting work and this could put people at risk. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People needs are assessed before they come to stay at the home but information is not always sufficient to give assurance that the home is aware of and able to meet their needs. Information is available to people but needs to be presented in a way that people who are not visiting the home before admission have a chance to see what the home offers. Evidence: The homes Annual Quality Assurance Assessment stated they have a detailed Statement of Purpose and Service User Guide for people or their relatives to look at before they consider the home for a placement. We looked at the information that was collected before people came into the home and Care Homes for Older People Page 11 of 30 Evidence: found that people have an assessment of their needs. Assessments seen varied in their content some provided comprehensive information about the person but others were largely incomplete and provided minimal information about the person and their care needs. For example important information that the person wore hearing aids and details about the persons next of kin were missing. Assessments were also available from Social Workers and the Primary Care Trust but it was not always evident that this information was available before the person came to live at the home. We showed the manager the information available about one person and they agreed, in this instance, that the information available was insufficient. We were told that people do not visit the home due to their dementia before they come to stay. We advised that the home explore suitable ways of giving people information about the home become they come to stay. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care records lack consistency, detail and were not personalised enough meaning that people may not have the care that they want or need on occasions. Medication administration was good and this ensure that peoples health is protected. Evidence: We undertook a random inspection in July and were concerned that people had poor outcomes especially in the areas of the management of continence, behaviour and falls. We found that these areas had improved however there was further work that could be done to ensure the home was meeting all peoples needs. People have a plan of care. These plans are based on their individual needs, choices and capabilities. Staff record against each plan of care, such as plans to maintain healthy skin and health promotion, every shift. We found that there is considerable duplication in these entries although in other areas concerns are not consistently recorded or action taken. One example of this was a person who had a urinary Care Homes for Older People Page 13 of 30 Evidence: infection which was detailed in three different areas of the care plan. Although concerns were identified in these recordings a Doctor was not contacted for two days. On occasions care plans were not updated to reflect the persons changing needs. One person was identified as being at risk of pressure sores and had developed a pressure sore to their heel but their plan of care had not been changed to tell staff what other actions they needed to undertake. There was however a separate plan that detailed what dressings the person needed applying on the pressure area. Records of this person showed there was a need for staff to contact the persons doctor for further advice but we could not find that this had been done. The manager and two other senior staff have had additional training to manage and care for pressure sores. People living at the home frequently have health conditions that can mean they become upset and can challenge people verbally and physically or, a wish to leave the home or do not want to take food and medicines. We found that care plans and risk assessments do not give sufficient information how to manage this and do not always detail any individual triggers for peoples behaviour. This could mean the home is not able to meet all of a persons needs. Two people whose care records we looked at had diabetes. We found that there were some instructions to raise awareness of low blood sugar but nothing to highlight what symptoms people with a high blood sugar may show. We also advised that staff discussed with the persons doctor what blood sugar boundaries would be acceptable for the individual and actions that should be taken if blood sugar was outside these acceptable levels. The Annual Quality Assurance Assessment (AQAA) stated that there is planned training for diabetes and maintaining good hydration for people. We also found that people are not weighed as frequently as needed. Two people had no weight recorded at all and another person had only been weighed once despite living at the home for eight months. Weighing people particularly those with dementia can identify any problems with their the persons health and wellbeing. The home had, at the random inspection, not responded well to falls and at this inspection we found that the management had put in place measures to ensure that people are monitored following a fall. Accident records followed up suggested this was working well and this should ensure that people receive the appropriate medical assessment if needed. The home has generally appropriate systems in place to store and administer medicines that demonstrate that people have the medicines they are prescribed for. All medicines are given by qualified nurses who have additional training in the safe Care Homes for Older People Page 14 of 30 Evidence: management of medicines. There are regular audits undertaken by both the local Primary Care Trust and Pharmacy with the manager identifying an action plan to address any issues identified. Records for the disposal of most medicines were available with the exception of those medicines that people had refused. We advised that there should be records for the appropriate and safe disposal of all medicines to give greater assurance that there are safe systems in place. We found that controlled medication is normally appropriately stored although this was not the situation for a person who had recently come into the home and needed strong pain relief. We discussed this with the home manager who immediately remedied this. Walking around the building some medicinal creams were found that had been open longer than the 28 days recommended to prevent bacterial contamination and these were removed. Interaction observed between people living at the home and staff was not always as good as it could be. We saw staff feeding a person without making any attempt to talk to them and left them without offering them a drink after their breakfast. Another resident was left whilst the staff member was feeding them to help another person and then never returned with the rest of the breakfast and the person was not given a drink for another hour. However we also saw some good interactions between staff and people again at a meal time. People were guided from place to place appropriately if they were walking. People were dressed appropriately with co-ordinated clothing and appeared to have they hygiene needs met. 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. People in this home can be assured that the service will try and find appropriate activities and food to meet their needs. People have visitors and relatives who can be involved in the persons care if appropriate. Evidence: An activities co-ordinator is available at the home 2 days per week. Since starting at the home earlier in 2008 she has looked at the social and occupational needs and past interests of the people living in the home. She has also looked at the personal care needs of people to find out when and how individual time can be spent with the person in the way that they can tolerate. There is a reflexologist available for 7 hours a week and a music therapist is also employed on a part time basis. There is external entertainment that comes into the home on a routine basis. The home is starting to quantify the amount of positive interactions or activities that people have and a target has been set of the minimum number of interactions they expect. Recording of the number of activities has yet to be bedded into the homes daily records and the separate nature of these records increases the number of places that staff have to Care Homes for Older People Page 16 of 30 Evidence: record. There was some evidence of peoples care files that they had attended music therapy sessions. We sent 30 surveys for relatives to complete if they wished and surveys to health and social care professionals and staff of the home. We received only 2 surveys in total back and these were from relatives. Both relatives were happy with the service they received. One commented I feel that they provide my mother with a caring environment ...They provide activities such as my mother can participate in such as hand massage and music therapy. People could walk around unrestricted from place to place on each of the floors. At the previous inspection we had been concerned about the baffle lock not restricting a person living in the home taking another person down the stairs. This issue has been resolved as the person has moved from the home. This needs to be kept under review for both the potential risk to people from this behaviour, compliance with deprivation of liberty and discussed with the fire service. The same is true for any process where doors are locked. We looked at the kitchen on the day of the inspection and found it clean and well organised. Despite the cook not being at the home arrangements had been made for a home cooked meal to be provided. Menus were available and there was a move to get these to be more accessible for people living in the home. A picture representation of the actual meal may assist in this. We looked at the food provided at the lunch and found that turkey and leek pie or cheese and onion pasties were the choice with vegetable choices of courgettes, cauliflower and broccoli. We discussed that perhaps a person may not like pastry and a different choice be available. The home has available produced pureed food for those people unable to eat solid foods. The food was presented well and people observed eating appeared to enjoy it. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although there are procedures in place to listen to complaints and concerns sometimes the method of recording and monitoring of these mean there are delays in responding to people. Evidence: A random inspection was undertaken in July 2008 as a result of a complaint and found that the majority of issues raised were upheld. We found the home did not have a robust enough system to ensure that complainants felt they were listened to. Please see standards 7, 8, 18, 19 to 26. We have found at this inspection that many of the issues were now being attended to. Not all checks on staff are completed before they start work and could put people in the home at risk (see standard 29) We have received no complaints since the random inspection. The 2 people who responded to surveys had no complaints about the home. We had been concerned at the random inspection that incidents between people living at the home were not reported under the homes safeguarding procedures. The home did respond and refer one safeguarding to the local social services office. The home has started referring people however the homes method of recording on care plans can Care Homes for Older People Page 18 of 30 Evidence: mean that important issues get lost. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the benefit of a home that has a layout and space to meet their needs. Refurbishment is needed in some areas to ensure that people have a comfortable homely environment Evidence: The home is purpose built so rooms are a reasonable size and they have good furniture. When we visited in July 2008 we found that the environment was not meeting peoples needs. The intention was to refurbish the home following an expansionand as a result the home was looking very worn and tired in places. However the expansion was put on hold and refurbishment plan is being brought forward. In July 2008 we had found that beds that have special mattresses to promote healthy skin were not set up appropriately, that bed rails were not fitted as required and areas of the home were unclean. The organisation has responded appropriately reviewing the mattresses and replacing these where necessary and a number of special profiling beds have been purchased. We viewed two bedrooms on each unit and found that in these rooms the appropriate equipment was in place. One person was in bed most of the time and we found that they had a high- low bed, they were dressed, looked very comfortable and measures had been taken to ensure that risks had been minimised. Care Homes for Older People Page 20 of 30 Evidence: Peoples bedrooms varied in the amount of personal ornaments and pictures on display but it was clear that family or other people that were close to the person helped them choose items that were meaningful. One bedroom seen showed that the persons religious beliefs had been catered for. The home was cleaner than at a previous inspection and there was more attention to ensuring that the bathrooms remained safe for people to use. Whilst the home was generally clean and fresh there was a bedroom that needed some attention to odour control. One bedroom also had a plug in air freshener next to the bed. Use of air fresheners need risk assessing as there can be difficulties with continued use. We looked at the homes laundry this was working well. However the manager informed us that they intend to improve the laundry systems to promote good infection control and to increase the space available. Some carpets needed replacing throughout the units however this is also part of the homes refurbishment plans. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to ensure that people have their needs met. Staff receive training to ensure that they can meet peoples needs appropriately. Staff did not have all the checks required undertaken in a timely way and this means that people cannot be assured that new staff are save to work with them. Evidence: We received rotas for this home and found these did not accurately show the people on duty for the day of the inspection. The rota did not indicate when the manager was on duty or, in the managers absence, who was in charge of the home. The rotas showed that there was a 1 to 4 ratio of staff to people living in the home. Day staff generally work from 8am to 8pm and there is usually 2 nursing staff seven care staff and a manager on duty. These staff are are deployed so there are two staff on duty in each unit. At night there are four care staff and one nurse on duty. In addition to this there is an activities co-ordinator, a music therapist, administrator reflexologist, chaplain, domestics and catering staff working a variety of hours. This was seen to be enough staff to manage the needs of the people. Care Homes for Older People Page 22 of 30 Evidence: At the time of the inspection 78 per cent of staff had an National Vocational Qualification level 2 qualification in care and records sampled showed that a copy of the certificates wee available. The Annual Quality Assurance Assessment stated that they hope to have 90 per cent of staff to this level soon. A number of staff are taking the NVQ3 this means that staff are trained in the needs of people living in the home. We looked at four staff recruitment records and found that the homes records did not show a robust recruitment practice. We found that one staff file did not have evidence to show that checks with the National Midwifery Council or the Protection of Vulnerable Adults list had been completed before the person started. Another person did not have a Criminal Records Bureau check before they started. This means that people cannot be assured that staff are checked as being safe to work with vulnerable people before they start work. We were unable to see any induction records in the main staff files although the manager assured us that an induction profile is worked on over a period of time and held by the member of staff. She confirmed that these meet the Skill for Care recommended induction areas of knowledge. Similarly we were unable to view any supervision records. Staff receive up date training and some of this training is by computer. We noted that a number of courses were recorded as being undertaken all on the same day. The management should have records to show that people are competent after completing courses. There has been specialist course on dementia, challenging behaviour and on end of life care. Such specialist courses enable staff to understand about the specific needs of people living in the home. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home generally have their needs met but some shortfalls in record keeping and staff recruitment mean that they could be at risk. Evidence: The manager has yet to be registered with the commission. She has yet to complete the Registered Managers Award, the recognised management qualification for managers. We identified at the random inspection some areas where the home needed to make improvements and these are being attended to. However further improvements are required on record keeping because this is affecting both the speed of the response to changes in peoples needs and the robustness of recruitment of staff. The homes Annual Quality Assurance Assessment (AQAA) was completed in a thorough way. It details the homes expected level of performance and the checks and audits that are in place. On occasions the home could not demonstrate that they are Care Homes for Older People Page 24 of 30 Evidence: meeting the performance level documented. However there were clear targets for improvements in the next 12 months. The AQAA documents how the home has changed in response to people living in the home surveyed in the areas of meals and activities; we also found this. We found that staff were having meetings and that individual staff were being given more responsibility to monitor care practices such as continence management and tissue viability and this should help to improve practice. We looked at the records of money and the money held for three people and found that the money held matched the record. We found that receipts were obtained for money spent and there were signatures on the records for any transaction. This means that peoples money was appropriately accounted for. Most people spend money on hair dressing and chiropody. Peoples money was mostly managed by relatives and money was brought in so the home could pay the hairdresser and chiropodist. Some people have their money managed by solicitors or social services. We looked at a number of records about health and safety of the home. We found that the home had good records on gas and fire safety. We found that the record of wiring safety showed that this was unsatisfactory and the home were unable to produce a document of how this had been remedied. We know the home is being refurbished and that the full wiring check is due in April and this should be resolved at this point. 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 3 14 (2) The assessment of peoples needs must be quality reviewed after admission. This is to ensure that they have enough information about a person to provide for all the persons needs. 13/02/2009 2 29 19 Where a person is employed 31/01/2009 with only a Protection of Vulnerable Adults First check evidence must be on file of the results of this check must be on file before the person starts work and a risk assessment must take place to limit the persons contact with people living in the home. This is to ensure that people have safe contact with people living in the home, while checks are progressed. 3 29 19 Appropriate Criminal 31/01/2009 Records Bureau and National Midwifery Council checks Page 27 of 30 Care Homes for Older People must be completed before people start work in the home. This is to ensure that people are safe to work with vulnerable people 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 1 The home should find ways of supplying people who are considering coming into the home with suitable information to assist them about whether this will suit them. Care plans for the management of behaviour should be more individual to the person and contain any triggers to the behaviour. Care plans for diabetes should detail what is appropriate blood sugar for that person and actions to be undertaken if their blood sugar is outside those parameters. People should be weighed regularly as indicated by their clinical need. A system should be put in place to ensue that creams are removed from bedrooms after they have been open longer than 28 days to prevent bacterial contamination. Further effort should be made to maintain communication between staff and people. All situations where doors are locked should be reviewed in line with the mental capacity act and the homes fire risk assessment. There should be a system that ensures that issues of concern are easily identifiable in care records to promote action on them. The homes refurbishment plans should carry on without undue delay. The use of plug in air fresheners should be reviewed and risk assessed as they can be a fire hazard. Rotas should accurately reflect all the people working in the care home. 2 8 3 8 4 5 8 9 6 7 10 13 8 18 9 10 11 26 26 27 Care Homes for Older People Page 28 of 30 12 13 27 38 Rotas should show the hours the manager is working and their absence who is in charge of the home. The home should plan a review of the electrical installation to ensure that it remains worthy and that it fits in with the refurbishment of the home. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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