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Inspection on 19/02/09 for Hollybank House

Also see our care home review for Hollybank House for more information

This inspection was carried out on 19th February 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This is a good service. Discussions with several people who live at the home, a relative and several members of staff showed that people are happy with the service being offered and received. A number of positive comments were received from people living at the home, and these included: "The staff are very good, they always talk to me a polite way, I`m very happy here." "They (the staff) always knock on my door before they come in, and ask me if I`m alright." "The staff always ask us, not tell us what to do. I like that, `cos that`s how it should be isn`t it." "I like the food, it`s very nice, and we always get a choice," and "Very good, very good indeed." The building is very comfortable, with a number of historic features which add to it`s homeliness. Outside there are sheltered sitting areas, and fine views. There are also plenty of activities, and these include occasional trips out in to the community.

What has improved since the last inspection?

Since the last key inspection: two new conservatories have been completed, which offer bright and spacious sitting accomodation. Six new en-suite bedrooms have been created. The patio has been relaid. Two new profiling beds have been purchased. Two bedrooms have had new carpets. A new freezer and microwave have been purchased for the kitchen.

What the care home could do better:

No statutory requirements have been made as a result of this key inspection. However eight good practice recommendations have been made. These relate to: Carrying out a risk assessment for the stairs in the identified bedroom. Ensuring there is more detailed, and clearer information in the care files related to people`s wishes at the time of their death. The documentation for reviewing care plans should be amended to ensure more information is captured. Documentation in care files should be completed, for example life histories, rather than being left blank. Soft diets should be presented in a way that allows different food s to be identified, rather than mixing everything together. Formal meetings for the people who live at the home should be introduced, and take place on a regular basis. Every member of staff should receive formal supervision a minimum of six times a year. Staff training in safeguarding adults should be provided through stand alone training, rather than just as part of an induction course or National Vocational Qualification (NVQ).

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hollybank House Chesterfield Road Oakerthorpe Derby DE55 7LP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Rob Cooper     Date: 1 9 0 2 2 0 0 9 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 27 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 27 Information about the care home Name of care home: Address: Hollybank House Chesterfield Road Oakerthorpe Derby DE55 7LP 01773831791 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Miss Margaret Ann Bradley care home 44 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 service users who can be accommodated is 44. The registered person may provide the following category of service only: Care home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical disability - Code PD (Max 4 places) Date of last inspection Brief description of the care home Hollybank House provides for up to 40 older persons, including nursing care for up to 20 older persons and up to 4 service users with physical disabilities aged over 50 years. The original house, formerly a private dwelling, was converted and extended for the purposes of registering as a care home. Accommodation is organised over two floors, with access to the first floor via stairs and a shaft lift. There is choice of Care Homes for Older People Page 4 of 27 Over 65 44 0 0 4 Brief description of the care home communal lounge and dining space to the ground floor and adequate numbers of bathrooms and toilets with adaptations to assist those service users with mobility problems. There is level access to the gardens. There are 24 single bedrooms and 9 double, including 3 single and 2 double rooms, which have en suites. Fees range from: £345.52 to £550 per week, depending on needs (information provided by the Registered manager) Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit as part of the key inspection process, so that no one at Hollybank House knew that the inspection visit was going to take place. The visit took approximately six hours through the middle of the day, with one inspector present. In preparing for this inspection, the information that the Commission holds about this care home was reviewed, this included looking at the last inspection report, the inspection record, considering any complaints or concerns that have been made about the service, and reviewing any notifications made relating to incidents that affect the well being of people living at Hollybank House. Care Homes for Older People Page 6 of 27 The methods used during this key inspection and site visit were to visit Hollybank House, where a method called case tracking was used; this involved identifying four people who live at the care home and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of the home, looking at the activities on offer, and talking to three residents, one relative and three members of staff about the quality of the service, and their experiences of living and working at Hollybank House. As part of the inspection methodology the Commission for Social Care Inspection sent out an Annual Quality Assurance Assessment (known as an AQAA), this allows care homes like Hollybank House to self assess their service. Information provided by the home helped to form the judgements in this report. We also sent out ten surveys asking for views and information to people who live at the home, five to relatives and five to staff. Unfortunately none were returned in time to inform this report. The registered manager Alison North provided much of the information during this key inspection visit. On the day of this inspection there were thirty-seven people living at Hollybank House. People who might want to live at Hollybank House can obtain information about the home direct from them, and this would include seeing previous inspection reports prepared by the Commission for Social Care Inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking 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 8 of 27 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 9 of 27 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. People, who live at Hollybank House, and those who would want to, have access to detailed information about the services on offer, which allows those people to make an informed decision about whether the home can meet their needs. Evidence: Both the statement of purpose and service user guide for Hollybank House were seen during the inspection visit. These documents contained a great deal of useful information about the care home, and were available in a large print format. The information available would allow people living at the care home, and those who might wish to in the future, to make an informed choice about living at Hollybank House. Discussions with three people who live at the home showed that they had been given copies of the service user guide, and copies were seen in the peoples bedrooms. The foyer of the home also has a poster with details of the last inspection report on display. Care Homes for Older People Page 10 of 27 Evidence: As part of the case tracking process four people who live at the care home were identified, and their files were seen, each one either contained an agreement from Social Services to fund their placement, a private contract or a copy of the terms and conditions of residence. Each of the four files that were seen contained a formal assessment of need. The assessments were a mixture of in-house assessments and formal assessments completed by professionals. The assessments were based on the Activities of Daily Living, and gave a good indication of an individuals needs. In their AQAA they said: A full needs assessment embraces all of a persons daily living needs. Hollybank House does not offer intermediate care, and therefore this National Minimum Standard was not assessed. Care Homes for Older People Page 11 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their personal care given in a professional and caring manner by the staff, which means that individuals are having their needs met. Evidence: Each of the files that were seen contained a plan of care, which identified personal goals and identified peoples needs and how to meet them. Evidence was seen that care plans were being reviewed regularly, although the review form being used does not capture all of the information, or show how the judgement was reached. There were daily entries by care staff, to record progress and any issues relating to an individuals care. However some of the documentation had not been fully completed, for example the life history, and the results of investigations, which meant that there were gaps in staff knowledge, which potentially could affect the ability of staff to meet peoples needs. All of the files that were seen contained health care plans. The plans included information relating to health care professionals such as visits to the doctor, or by the nurse, and any hospital visits. A mobile optician (Healthcall) provides a service to Care Homes for Older People Page 12 of 27 Evidence: people living at the home. A mobile chiropodist also visits the home, and some people are registered with a local dentist. Everyone living at Hollybank House is registered with one of the local GP services. Three people were asked about seeing the doctor, and they all said that the staff would get them a doctor if they were unwell, and if they needed one. During the inspection visit a local GP called at the home, and he was seen to take time to talk to a relative about their relatives health. Afterwards the relative said that the family were always kept well informed about matters to do with health and welfare. Boots the chemist provides Hollybank House with their medication. An inspection of the homes medication systems showed that medication is handled safely. Administration records were seen and found to be complete. No one living at the home currently self-medicates. All aspects of the medication procedures that were seen showed a clear audit trail for medication, and indicated that people living at the care home were safe. Discussions with three people who live at Hollybank House, and observation of the staff working with people generally showed that the staff treated them with respect and dignity. This included observing staff knocking on peoples doors before entering, and speaking in a respectful manner. Comments received from people living at the home included: The staff are very good, they always talk to me a polite way, Im very happy here. They (the staff) always knock on my door before they come in, and ask me if Im alright. In their AQAA the home said: Privacy and dignity are actively promoted within the home in line with policy and training. Each persons file that was seen had an end of life care plan, covering different aspects of the individuals wishes at the end of their life. However in several examples the details were brief, or not specific, which meant that staff would not be clear about what was happening or who to contact at the time of a persons death. Care Homes for Older People Page 13 of 27 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 have a lifestyle that reflects their cultural, social and religious interests, and needs, and there is clear evidence that their social care needs are being met. Evidence: Discussions with three people who live at the home identified that there were plenty of activities arranged, these ranged from activities in the home such as bingo, table topped activities (games and puzzles), and keep fit exercises. There is also a knitting circle and a crochet group, and several examples of their work was seen around the home. Outside entertainers, also came into the home, with sing-a-long type activities are very poplar. There are also trips out, in the local area, including shopping trips, lunches and visits to the pub. The home make use of Amber Valley Transport who have a bus with a lift, so those people with mobility problems, can also get out into the community. There is an activity co-ordinator working at Hollybank House, and discussions with her identified that there was a mixture of group activities and individual one to one sessions. Among the entertainment brought in to the home have been: singers, and musicians, and people living at the home are encouraged to be involved in choosing the entertainment. Several visitors were seen during the inspection visit, and one relative was spoken Care Homes for Older People Page 14 of 27 Evidence: with. This relative said that they and their family were always made welcome by the staff, and they were kept up to date with changes in their relatives condition, or any information about activities they might have taken part in. The relative said that there were open visiting times, and sometimes they had eaten a meal with their relative, and joined in activities that were happening in the home. Staff were observed to see how well they interacted with the people who live at Hollybank House, and whether choices were being offered. This was seen to be a positive situation with choice offered particularly around drinks and activities. Staff demonstrated how choices were offered and recorded at meal times, and the activity co-ordinator talked about how activities were organised, and choice was offered, including taking feedback from people taking part in activities. Discussions with two people indicated that they both thought they had control over a lot of things in their lives, with comments such as: The staff always ask us, not tell us what to do. I like that, cos thats how it should be isnt it. I like to go to bed about 9 oclock, so I ask the staff to take me. On the day of this inspection visit there was a good choice of meal on offer including a vegetarian option if required. Several people living at the home require a soft diet, and observations of these meals showed that they had been mixed together, rather than seperating out into the different food types (for example meat, potato and the different vegetables. Information related to peoples likes and dislikes was seen in the kitchen. All of the people spoken with said good things about the food with comments such as: I like the food, its very nice, and we always get a choice, and Very good, very good indeed. The relative who was spoken with also said that the food was very nice, and they had on occasions stayed for lunch, and it was very good quality and quantity. Care Homes for Older People Page 15 of 27 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. People are safe, as a result of the policies, procedures and systems that are in place, and people living at the care home and their relatives are confident that their complaints will be taken seriously and dealt with. Evidence: Hollybank House has received one complaint since the last key inspection. A review of the complaint showed that it had been dealt with in line with the homes complaints procedure, which is on display in the foyer, and also forms part of the service user guide. Discussions with two people who live at the home indicated that they knew who to complain to, and how to complain, although neither of them had ever needed to. Discussions with a relative about the complaints procedure identified that they would speak to the manager, and they felt confident that she would deal with the complaint, although so far, this had not been necessary. In their AQAA Hollybank House said: There is a simple and clear procedure policy encompassed within the service user guide regarding complaints. A review of the staff training records in relation to safeguarding adults, showed that the majority of the twenty six care staff had undertaken this training, although for many staff this has been part of either induction training or a National Vocational Qualification (NVQ) course. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering people greater protection against abusive practice, while also making sure that the staff understand Care Homes for Older People Page 16 of 27 Evidence: the correct policy and procedure to follow if abusive practice is found. Three members of staff were asked about safeguarding adults training and they said they were aware of the issues, and had undertaken this training, two as part of their NVQs. Hollybank house has made one safeguarding adults referral since the last key inspection, and this was discussed with the manager, and the actions taken reviewed, this showed that the policy had been followed correctly. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, clean, well maintained and comfortable home, with their personal possessions around them, Evidence: A partial tour of Hollybank House showed that it was comfortable and well maintained, with good quality fixtures and fittings. The home is a converted farm house dating back to the 17th century, with several features such as a date stone in the lounge (1655) which adds to the homely feel of the building. Discussions with several people who live at the care home showed that they thought that it was comfortable and meets their needs. Several bedrooms were seen, and these were well personalised, and homely, although one bedroom is accessed by a short flight of stairs, from the bedroom door down into the bedroom - another feature. However there is no risk assessment in place with regard to the stairs or the person who sleeps in that bedroom. All of the people who were spoken with said they felt they had everything they needed, and that they thought their bedrooms were comfortable and the home was well equipped. New conservatories have been added since the last key inspection, and these make light airy sitting areas. Domestic staff were seen cleaning in different parts of the home during this inspection visit, and discussions with staff showed that there were systems in place for cleaning, and that Hollybank House had a good supply of cleaning materials. The building was Care Homes for Older People Page 18 of 27 Evidence: found to be clean, and smelt fresh. In relation to cleaning they said in their AQAA: The home is homely, welcoming and clean. The maintenance is performed by a maintenance person. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have been recruited professionally, and are trained to do their jobs, which means that the people who live at the care home are safe, and have staff who are able to meet their needs. Evidence: The staffing rota for Hollybank House was seen and this showed that there was enough staff currently employed to meet peoples needs. Two people living at the care home were asked about staffing levels, and they said that they thought there were enough staff, as did the relative who was spoken with. Two of the three staff members who were spoken with thought the staffing levels were sufficient, although the third thought that sometimes we are short, and could do with more staff. The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. In their AQAA they said that twenty staff had NVQ level II although a review of the staff training records showed that currently there are fifteen, as some staff had left. In addition three staff members are currently undertaking this training, and six staff members have their NVQ level III qualifications, with a further four working towards level IV. The files of five members of staff were seen, to check that they contained all of the information that would show that staff at Hollybank House had been recruited in a Care Homes for Older People Page 20 of 27 Evidence: safe manner, namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that the homes recruitment policy and procedure had worked to protect the people living there. Discussions with three members of staff about their recruitment showed that they had gone through all of the pre-employment checks, and had not started working until those checks had been completed. The staff training records showed that Hollybank House does have a training plan for its staff. The training records showed that staff were receiving the training to help them to do their jobs. Evidence seen in staff files together with course certificates showed that the mandatory traning courses in subjects such as fire, food hygiene and moving and handling had been taking place, and further training was booked in the future. Discussions with three staff members provided evidence of the training courses staff had attended, and gave an insight into the staff training plan at the home. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This is a safe, well-managed care home with good systems for ensuring its quality in place, which means that peoples needs are being met. Evidence: Alison North is the Registered Manager. She is suitably qualified and experienced being a Registered General Nurse, and she has been judged by the Commission for Social Care Inspection to be a fit person to run a care home. Alison became the registered manager in March 2004. Hollybank Houses quality assurance system relies on questionnaires being filled in by people who live at the home, relatives and visitors. Copies of these questionnaires were seen together with evaluation of the results. The home do not currently hold meetings for the people who live there, which means there is no opportunity for people to formally express their views about how the home is being run. Regulation 26 visits (these are monthly audits by a representative of the owners management team) are taking place, with copies of reports seen; these also form part of the Care Homes for Older People Page 22 of 27 Evidence: homes quality assurance system. Hollybank House has a system for peoples small cash needs. This is operated on behalf of some of them by the staff (dependent on individual choice and their ability to manage the money, or relatives involvement). Four peoples finances were checked at random. All of the cash tallied with the records, and receipts were seen, which enabled a clear audit trail of the individuals financial expenditure to be followed. Two people living at the home were spoken with, and both said they could get their money from the staff when they wanted it. One adding: Its safer being locked up by the staff. Hollybank House has a formal staff supervision system in place, in which staff receive supervision, either with the manager or with one of the other senior members of staff. This is usually in a one to one meeting. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. Three members of staff were asked about formal supervision, and they all said they felt well supported, and were receiving supervision sessions, although not on a regular basis. The records show that while staff are being supervised, this is not meeting the National Minimum Standard of six times a year. A range of different health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up to date, which shows that people are living and working in a safe environment. Care Homes for Older People Page 23 of 27 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 24 of 27 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 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 Care plans and related documentation should be complete, with documents such as life histories completed, to give staff a full picture of an individuals needs and care. The form used to record monthly reviews of care plans should be amended to capture more information, and to demonstrate how the judgement was reached. Care plans relating to last wishes, should include more information, and be more specific about who will actually undertake tasks at the time of death. Meals prepared for people who require a soft diet, should have the individual foods softened seperately, so that the individual food colours can be identified, together with textures and tastes, rather than mixing everything together in one lump. Safeguarding Adults training and refresher training should be available to all staff, this should be stand alone traing, and not just offered as part of an induction course or NVQ training. A risk assessment should be carried out on the stairs into the identified bedroom. Page 25 of 27 2 7 3 11 4 15 5 18 6 19 Care Homes for Older 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 7 33 Regular meetings should be held for people living at the home, to give the opportunity for individuals to formally comment on the care they are receiving, and have a voice with regard to how the home is being run. All members of staff should receive a minimum of six formal supervision sessions a year, with a senior member of staff. 8 36 Care Homes for Older People Page 26 of 27 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. Care Homes for Older People Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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