Inspection on 30/10/08 for Holmewood Residential Care Home

This inspection was carried out on 30th October 2008.

CSCI found this care home to be providing an Adequate 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmewood Residential Care Home 11/10/07

Holmewood Residential Care Home 14/12/06

Holmewood Residential Care Home 26/01/06

Holmewood Residential Care Home 13/05/05

Holmewood Residential Care Home 10/01/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Holmewood Residential Care Home Holmewood Lamplugh Road Cockermouth Cumbria CA13 0DP     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: Diane Jinks     Date: 3 0 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Holmewood Residential Care Home Lamplugh Road Holmewood Cockermouth Cumbria CA13 0DP 01900828664 01900821958 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Melanie Gilmore Type of registration: Number of places registered: Lakeland Care Services Ltd care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The home is registered for a maximum of 26 service users in the category of OP (old age, not falling within any other category). Date of last inspection Brief description of the care home Holmewood offers accommodation and care for up to 26 older adults. The home is decorated and furnished to a good standard, is pleasant and comfortable. All of the bedrooms are for single occupancy, but one can be used for two people sharing if requested, they are spacious and individually decorated and furnished. All of the bedrooms have an en-suite toilet and bath or shower. The home has several communal lounges and a dining room. There is a passenger lift, a platform lift to assist with three stairs, handrails, grab rails and a range of equipment to assist people in their day-today lives. The home is set in large well-maintained gardens, including a vegetable 0 Over 65 26 Care Homes for Older People Page 4 of 30 Brief description of the care home garden seating areas and a large car park. Further information about the home and the services provided can be obtained from the manager at Holmewood. 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 inspection of this service takes into account all of the information we have received since the last inspection. We sent surveys to some of the people that live and work at this home in order to obtain their views about Holmewood. The inspection included a visit to the home. We looked at a variety of the records that the home is required to maintain. We looked around the home to assess the general environment and living accommodation provided to people that use this service. During our visit to the home we spoke to some of the people that live and work at Holmewood, including the manager and the owner. The manager also completed an annual quality assurance assessment (AQAA) and returned this to us. The information recorded in the AQAA provides us with information about the service and helps us to check the information we gather during the visit to the home. Care Homes for Older People Page 6 of 30 Care Homes for Older People Page 7 of 30 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. Care Homes for Older People Page 8 of 30 The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are generally provided with sufficient information about the home before they move in. Assessments are made of their health and social care needs and this helps to make sure that the home will be suitable and able to meet their requirements. Evidence: The home produces a statement of purpose and service user guide. These documents give information about the home and the services it can provide. They are available in one written format for prospective residents and their families. Copies of the documents are also available in the home. People are able to visit the home prior to admission. Admission to the home is initially for four weeks, this allows time for the resident and staff to decide whether Holmewood is suitable and able to meet their needs. People thinking of moving into the home have their health and social care needs assessed prior to admission. This also helps the manager to decide whether the Care Homes for Older People Page 11 of 30 Evidence: home will be suitable and whether the staff have the skills necessary to meet the requirements of the prospective resident. Where referrals are made by the local adult social care team, the manager obtains a copy of the social workers assessment. There are arrangements in place should anyone need to be admitted to the home in an emergency, but this type of admission is avoided wherever possible. People using this service told us that either they or their family representative were given enough information about the home before they decided to move to Holmewood. 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. People using this service generally have their health and social care needs met appropriately. Gaps in recording processes mean that care needs may sometimes be overlooked by staff. Evidence: During our visit to this service we looked at a sample of care records for four of the people that live at Holmewood. The care plans record details of each persons health and social care needs and provide some information of how those needs will be met. Care plans have been agreed and signed by the individual or their representative. Care staff told us that they have access to this information and that the care plans give a fairly accurate reflection of each persons care needs and requirements. This means that people using this service generally know what type of care and support to expect from care staff. The records demonstrate that people are encouraged and supported to remain as independent as possible. Preferences and choices are recorded alongside individual personal care requirements. Dietary assessments and assessments of the risks related to poor mobility (pressure Care Homes for Older People Page 13 of 30 Evidence: care) are included in the care plans. There are some specific instructions recorded for staff to follow, such as obtaining regular urine samples or adding fibre to diets but there are no reasons recorded to suggest why these might need to be done. District nurses come into the home to treat people for a variety of illnesses and one person in particular receives attention for pressure care. There are others living at the home that have been identified at risk from falling or may sometimes demonstrate behaviour that may be challenging. Care plans do not contain any instructions for staff to help them manage or monitor such situations appropriately. Where there are incidents/accidents recorded relating to people using this service, care plans and risk assessments have not been reviewed and updated. These shortfalls may at times compromise the safety and well being of people using this service. Individual records show that people have access to health care professionals when needed, such as the doctor, community nurses, optician and chiropodists. Aids and adaptations such as air mattresses and walking frames are obtained when needed. Some people told us that staff help them to attend appointments at the hospital or clinic if their families are not able to help. We looked at a sample of the medication records and the storage arrangements for medicines kept at the home. At previous visits we have found that medicines were stored in a very warm room. This problem has now been addressed. We found that medicines were stored in an organised, tidy manner and at suitable temperatures. There are some arrangements in place for the storage of controlled medicines (medicine that is at risk of being mis-used). The law relating to how this type of medicine is stored has changed and the current arrangements in place at the home do not comply with this. The manager must make arrangements to ensure that this type of medicine is stored correctly. We made further checks on these medicines. The records had been maintained accurately and consistently signed by two people when the medicine is administered. Medication records were found to be completed accurately. Where changes to medication prescriptions had been made by the doctor, this was clearly recorded on the medication record sheet and in the persons individual care plan. Photographs of residents are included with their medication records to help with identification and reduce the risk of medication being given in error. There is a policy and procedure in place at the home regarding the administration of medication. Staff attend training and refresher training in this subject to help ensure that they can carry out this task safely and competently. Some staff have completed the distance learning course via a local college and other training and refresher training is provided by an external training company. Care Homes for Older People Page 14 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 using this service are supported and encouraged to enjoy a full and stimulating lifestyle and make choices about their daily lives. Evidence: The people we spoke to told us that there is a very good activities/entertainment programme provided by the home. People using this service are able to choose whether they join in the activities or not. One person told us I love the minibus trips, bingo, dominoes, party and entertainment evenings and coffee mornings. The monthly entertainment programme is very good. I like the notice board in the entrance hall with everything on. The local clergy visit the home on a frequent basis to perform religious services for those residents who wish to attend. Residents at Holmewood are supported in maintaining their own personal hobbies and interests too. People using this service are able to go out alone, subject to a safety assessment. These assessments are an area that the manager needs to improve upon so that they are detailed and up to date. This will help to make sure that people using this service are safe and protected as far as practicable. Visitors to the home are made welcome and residents may receive their visitors in one of the communal areas or in their own room for more privacy. Care Homes for Older People Page 15 of 30 Evidence: The people we spoke to told us that the food is very good at Holmewood. There is always plenty of choice and sufficient food is served. People are able to choose an alternative if there is something on the menu they dont like or dont want. Although there are set times for the serving of meals, there is some flexibility and people can make choices about where they eat and when they eat their meals. There are hot and cold drinks available throughout the day, together with snacks and fresh fruit. We sat in one of the lounges for part of our visit to the home. A member of staff came in to ask if anyone wanted music on, but everyone said no. Some people were reading newspapers, others just sitting or dozing, some residents are able to mobilise independently and come and go as they please. A member of staff popped in and out of the room several times but there was little interaction. It was generally quiet in the lounge the ladies that were sitting in there said it was usually like this and they like it. One person said that they often like to have a chat but that it was quiet today. There is another lounge where the television is usually on and some people were sat in there too. We observed lunch being served. People were helped to the table if they needed assistance. There was a choice of meals and drinks - we observed good portion sizes and that plenty of vegetables were served with the meal. Where people needed assistance with their meal, staff provided this discreetly and sensitively. People were chatting and the event appeared to be a sociable one. The kitchen at the home has recently been awarded five stars (excellent) for food safety and hygiene by the local council. Care Homes for Older People Page 16 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. There is a lack of understanding and staff training regarding safeguarding procedures and how they work. These shortfalls potentially place people using this service at risk of harm or abuse. Evidence: There is a complaints process in place at the home. People using this service are aware of it and a copy is available and displayed in the home. There is a process in place for recording concerns, compliments and complaints. Some of the people who use this service told us that they would go to Melanie (the manager) straight away and that any complaints are dealt with pronto. There are policies and procedures, including the local authority guidance, in place at the home to help ensure the protection of vulnerable adults (abuse), but these are not always followed as they should be. We spoke to some of the staff that work at the home and looked at staff training records. Staff could not recall receiving training in the protection of vulnerable adults, although one person thought that they may have seen a video about it last year. Staff training records do not confirm that all staff have received this important training and the records relating to staff induction training do not indicate that adult protection training is covered. The manager told us that she hopes to make improvements to this over the next 12 months to ensure that all staff have completed adult protection training. Some of the discussions we had with staff, together with the records we looked at Care Homes for Older People Page 17 of 30 Evidence: during our visit to the service, demonstrate that staff do not have a clear understanding of abuse, adult protection and the procedures that should be followed when abuse is suspected. We found that the home does not always inform us or social workers of events which affect the well-being of people using this service. Checks such as criminal record bureau (CRB), protection of vulnerable adults (POVA) list and references are made on prospective staff. There are gaps in these checks and the home does not follow procedures regarding the recruitment and employment of people who may have a criminal record. Care Homes for Older People Page 18 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service live in a safe, warm and comfortable environment, which is well maintained to a good standard. Evidence: The home is well maintained, decorated and furnished to a high standard. However, the manager told us that further improvements could be made by having a more formal maintenance programme. The people we spoke to told us that the home is always warm, clean and tidy. The home employs housekeepers to help make sure the home is always clean. These staff have undertaken training to help them carry out their jobs efficiently and effectively. There is a laundry at the home, which the provider said had recently been refurbished and re-equipped with new machines. A laundry assistant is employed at the home, although there are occasions when care staff undertake some of these tasks. One person made particular comments on the standard of the cleaning and laundry service at the home and said it was excellent. There are a variety of communal areas that can be used by people that live at Holmewood, including comfortable lounges, a designated smoking room for those residents who wish to smoke, a dining room and a communal bathroom with specialist bathing equipment for those residents who may not be so mobile. All the rooms at the home are for single occupancy and have en-suite facilities, Care Homes for Older People Page 19 of 30 Evidence: including a bath or shower. People are able to bring items and treasured possessions into the home with them. This helps to make their own personal rooms more comfortable and homely. The home is equipped with aids and adaptations to assist people to access the various parts of the home as independently as possible. There is a lift to the first floor. There have been some issues with this over the past few months and residents are able to use the lift with the assistance of a staff member if they wish. We made a brief visit to the kitchen, which was found to be clean, tidy and well organised with the chef busy preparing the tea. Outside, the home is surrounded by large, well appointed gardens, which are accessible to people using this service. There are also car parking facilities. The owner told us that he is planning to make better use of the extensive grounds and pathways to make them more accessible to wheelchair users and people who use other mobility aids. Care Homes for Older People Page 20 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. People are generally satisfied that they receive the care and support they need. There are times when they need to wait for staff support and attention. Evidence: There is a staff rota in place at the home and all the staff work regular shift patterns. There were two care staff on duty on the day of our visit and whilst people generally had their needs met, we observed that the staff were very busy all day. We spoke to some of the staff and received comments via surveys from others. Some staff are concerned that a lot of residents are becoming increasingly dependent. They felt that this is not always taken into account when staffing the home and this places more pressure on them. Another member of staff told us it is a struggle sometimes as people are becoming more dependent and less mobile. There are usually only 2 of us on from 7:30am, sometimes about 5 people are already up but the others all need some level of supervision or assistance, although there are one or two that are fairly independent. We also consulted some of the people that use this service and received varied comments from them. Everyone said that they were very happy with the staff and that they are very helpful, kind and friendly. The comments we received do indicate that people sometimes have to wait for attention from staff. Some of the comments included; always excellent care and support. Staff are always available in and around Care Homes for Older People Page 21 of 30 Evidence: the home and they come quickly when I use the call bell. Another person said; although I have to use hoist and wheelchair I never usually have to wait too long to go to the toilet or to bed, which is good as there are more than me use a hoist. We were told; I am very happy with the staff. They never say they havent time if they are busy and they come back as soon as possible, and the staff are alright, they are very kind. They usually attend to me quite quickly but sometimes I have to wait over half an hour, especially at bed time. We looked at a sample of staff recruitment and training records. Prospective staff complete application forms and attend the home for interview. References are obtained and criminal records bureau checks (CRB) and protection of vulnerable adults (POVA) checks are made. These checks help to make sure that people using this service are supported by suitable staff. There are some gaps in the recruitment process, particularly regarding the employment of people who may have a criminal record. We discussed this with the owner and the person responsible for ensuring CRB checks are completed as these matters need to be addressed quickly. Staff told us that they receive regular training and updates. They said that they are offered training in a variety of subjects both in-house and external. They have received training in manual handling, COSHH, malnutrition, basic food hygiene, emergency aid, tissue viability awareness (via the hospital) and are due to attend diabetes awareness training. Some staff could not remember having training in abuse. We found that the training records did not consistently record sufficient information about the training staff have undertaken. It was difficult to assess whether induction training met national training guidelines or that staff received the required amount of annual training recommended. Where new staff claimed to have undertaken some training previously, there was no evidence to support their claims. Care Homes for Older People Page 22 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. The home is generally run in the best interests of the people that live there. There are some gaps in the recording systems, which may at times compromise the health, safety and welfare of people living and working at the home. Evidence: The home is managed by a qualified and experienced manager. She is assisted in her duties by the deputy manager and the owner of the home, who is a regular visitor at Holmewood. The manager has actioned and implemented many of the requirements and recommendations that we made at the last inspection of this service. The owner of Holmewood and the manager try to ensure that the home is run in the best interests of the people that live there. They carry out quality assurance audits, involving the people that use this service and their relatives, in order to identify areas for further improvement. Staff records show that staff supervision and appraisal regularly takes place. This helps to make sure that staff work safely and have their care practices monitored. Some of Care Homes for Older People Page 23 of 30 Evidence: the staff that participated in this inspection of the service confirm that they receive supervision and are able to discuss things with the manager. Some said that they generally felt fully supported by the care manager but others said that there are times when the manager does not always seem to act on things we tell her. We looked at a selection of records that the manager is required to keep by law. The manager told us that all of the policies and procedures in place at the home have been reviewed and updated where necessary. Staff were up to date with their fire procedures training and records in relation to the maintenance of fire detection and fire fighting equipment were also up to date. There is a fire risk assessment in place at the home and this is reviewed annually. The manager told us that there are service contracts in place to ensure that items such as the central heating systems, boilers, electrical appliances and the passenger lift are well maintained and serviced regularly. We looked at the accident book and the communication book kept at the home. We found that there are several incidents that should have been formally reported to us and to social workers for further consideration. This was discussed with the manager and the owner of the home during our visit. Failure to report such incidents may place people using this service at risk from harm or injury. Although some risk assessments have been carried out there are some areas that need to be improved upon, particularly where people go out of the home alone, have been identified at risk from falling or those that may sometimes display behaviour that can be challenging. Detailed risk assessments help to reduce the risk of accidents or situations occurring. Safe systems of work plans provide staff with information on how to manage situations safely and help to reduce the risk of harm or injury for both staff and residents. Care Homes for Older People Page 24 of 30 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 7 15 People using this service 01/12/2007 must have a comprehensive and up to date plan of their care needs and requirements. The plan must set out in detail the action that needs to be taken by staff to ensure that all aspects of their health and social care needs are met and the outcomes achieved. Any changes to the service users needs must be clearly recorded in the plan. (Previous timescale of 31/01/07 not met). 2 29 18 The staff recruitment 01/12/2007 practices and procedures used at the home must be reviewed to ensure that people using this service are protected from any risk of harm. Amendments must be made in line with current legislation and good practice to ensure that proper checks are made and references obtained prior to staff working at the home. (Previous timescale of 31/01/07 not met). 3 37 17 Records must be maintained 31/12/2007 Page 25 of 30 Care Homes for Older People and up to date to help ensure that people using this service are kept safe and receive the care and support they need. This includes staff recruitment records, training records, care plans and health and safety risk assessments. (Previous timescale of 31/01/07 not met). Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 People using this service must have a comprehensive plan of how their care and support needs will be met and managed safely. Care plans provide the basis to ensure appropriate care and support is give to each individual. Where people have specialist needs, clear strategies and plans must be in place to help ensure that staff manage situations safely. 15/12/2008 2 9 13 Arrangements must be 31/12/2008 made to ensure that medicines liable to mis-use (controlled drugs) are stored in accordance with current legislation. There are legal requirements for the storage and administration of this type of medicine. Care Homes for Older People Page 27 of 30 3 18 13 Arrangements must be made to ensure that people using this service are protected from suffering harm or abuse. People using this service must be safeguarded from abuse, neglect and harm. All allegations or incidents of abuse must be followed up promptly and relevant authorities notified. 15/12/2008 4 29 19 You must ensure that there are robust recruitment and selection procedures in place, which include a policy on the recruitment of exoffenders. People using this service must be protected as far as practicable from people who may be unsuitable to work in a care setting. 15/12/2008 5 37 17 The records required to be kept by regulation and in relation to the protection of people using this service must be maintained accurately and up to date. Accurate record keeping helps to ensure that the rights and best interests of people using this service are protected and promoted. 31/12/2008 6 38 37 You must ensure that the Commission for Social Care Inspection is notified of any event that adversely affects the health and well being of 15/12/2008 Care Homes for Older People Page 28 of 30 any person using this service. You are required by law to notify CSCI of such events. This information helps to inform the judgements made by CSCI regarding the quality of the service. 7 38 13 You must make sure that people living and working in the home are protected as far as practicable from the risk of harm or injury. People living at the home must be supported safely at all times. Safe systems of work procedures help to promote safety and further reduce the risk of harm or injury. 15/12/2008 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 27 You should review the current care and support needs of people using this service. This will help to make sure that there is a sufficient number of experienced and competent staff on duty at all times. You should make sure that all staff employed at the home receive appropriate training in accordance with the aims and objectives of the home and to meet the changing needs of people living at the home. 2 30 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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