Inspection on 13/07/09 for Jeannette Lodge

This inspection was carried out on 13th July 2009.

CQC 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jeannette Lodge 16/04/09

Jeannette Lodge 12/01/09

Jeannette Lodge 19/02/07

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for older people Name: Address: Jeannette Lodge 15-17 Park Avenue Gillingham Kent ME7 4AS     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sue McGrath     Date: 1 4 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Jeannette Lodge 15-17 Park Avenue Gillingham Kent ME7 4AS 01634852894 01634851647 richardraj@rosedenerch.freeserve.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Golden Slumbers Limited care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 21 The registered person may provide the following category of service only : Care home only (PC) to service users of the following gender; Either whose primary care needs on admission to the home are within the following category ; Old age, not falling within any other category (OP) Dementia (DE) Date of last inspection Brief description of the care home Jeanette Lodge offers residential care to older people. They are registered for 21 service users. The home is registered for Demetia care but manages mild demntia only. The home is a large detached property situated in a residential area and directly opposite an attractive park. The home is close to local shops, bus stops and local amenities. Chatham and Gillingham town centres are approximately one mile away. Accommodation is provided on three floors, the upper floors are accessible by chairlifts. All bedrooms have a call bell point. The home has a large garden, which is accessible for all residents. Care Homes for Older People Page 4 of 32 1 6 0 4 2 0 0 9 21 0 Over 65 0 21 Brief description of the care home Fees are from 323.00 pounds to 408.00 pounds per week. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and regulations and that the outcomes are promoting the best interests of the people living in the home. The actual site visit was carried out by 1 inspector over the course of 1 day. We (the Commission) spent time touring the building, talking to the people living in the home. We also spoke to the manager and staff and reviewed a selection of assessments, care plans, medication records, menus, staff files and other relevant documents. The registered provider was present throughout the inspection. Prior to our visit an Annual Quality Assurance Assessment (AQAA) had been sent to us within the required time limit. The AQAA is a self-assessment, required by law. This assessment focuses on how the service considers they are meeting the outcomes of Care Homes for Older People Page 6 of 32 the people using the service and where it feels it can make improvements. It also provides statistical information about the service. Information from the AQAA has been used in this report where appropriate. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Care Quality Commission (CQC) to be able to make an informed decision about each outcome area. The inspector on leaving the home was satisfied that residents were both safe and well cared for and wishes to thank the manager and her staff for their assistance and hospitality. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: There are still concerns over the management of the service as two Statutory Requirement Notices and three Statutory Requirements made at previous inspections have not been fully complied with. The day to day operations, level of care and social activities remain good. The main issues are about staff recruitment and training and the overall management and leadership in the service. The non compliance with the Statutory Requirement Notices on staff recruitment means that there remains gaps in staff records that has the potential to put people at Care Homes for Older People Page 8 of 32 risk. The non compliance with the Statutory Requirement Notices on quality assurance means that any form of quality assurance has not been completed to ensure the service is meeting its stated objectives. The non compliance with the Statutory Requirements on staff training means that there remains significant gaps in staff training that has the potential to put people at risk. The non compliance with the Statutory Requirements on staff supervision means that there remains gaps in staff supervision that has the potential to 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 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 32 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 32 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 in the home and their families are provided with the information they need to make an informed choice about moving into the home. People who live in the home benefit from an assessment of their needs prior to moving into the home to ensure their assessed needs can be met. People also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. Evidence: We looked at the information provided to people who use the service to find out whether it was detailed and answered all their questions and to find out how the service passed on the information. We viewed three service user files to determine how the home assesses people. The home now has a new statement of purpose and a service user guide. These were viewed and found to comply with the requirements of Care Homes for Older People Page 11 of 32 Evidence: regulation. Evidence was seen the service user guide was now available in all bedrooms. The evidence obtained at this inspection demonstrated that the statutory requirement notice issued after the last visit regarding the statement of purpose and service user guide is now considered as met. The owner confirmed each resident was given a contract or statement of terms and conditions when they were first admitted to the home. Evidence was seen in individual files of such documentation. We spoke with ten people who said they felt well cared for and that staff looked after them well. Documentation seen also evidenced that good care was provided. The owner stated that all residents undergo a thorough assessment completed by either himself or the senior carer prior to admission. Again evidence was seen of such documentation in individual files. Care management assessments were also gathered if funding was to be provided by Social Services. The admission process was discussed with the owner and it was stated that all prospective residents were invited to visit the home prior to admission with a relative or representative. Trial periods were offered after admission and before the final decision to remain needed to be made. The home does not offer intermediate care. Care Homes for Older People Page 12 of 32 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 who live in the home benefit from having clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and the people who live in the home benefit from having full access to all professional health care services as required. People who live in the home are protected by the homes policies and procedures for dealing with medicines. Evidence: We wanted to look at peoples care plans to ensure that their health, personal and social care needs were set out in a way that would enable staff to deliver good care. We looked at three plans to evidence this. Each care plan gave detailed information on the individuals needs and how staff could met these needs. It was noted that people are encouraged to maintain their independence where possible and where not possible full assistance would be offered. The people spoken with confirmed they were aware of their care plans and were Care Homes for Older People Page 13 of 32 Evidence: consulted about the contents on a regular basis. Evidence was also seen that health care needs were well met and that each resident was registered with a local GP had full access to other health care professionals as required. Records of such visits were recorded in the daily notes and it was advised that these be recorded within the care plans on a separate sheet to enable tracking to take place. This would also enable other health care professionals to get a clear idea of any trends of histories if needed. Staff were able to demonstrate a good understanding of skin integrity and care. The senior carer confirmed that no residents in the home had any pressure areas. Specific equipment for the care of skin integrity and tissue viability was seen throughout the home. Moving and handling assessment could be improved and this was discussed with the provider. Medication was still stored in a dedicated medical cupboard in the dining room and there were procedures in place to ensure key safety. There were no gaps seen in the mar(medication administration records) sheets viewed on the day. The home has purchased a new controlled drugs book that was well maintained. The home ordered a copy of the Royal Pharmaceutical Society of Great Britain guidelines of The Safe Administration of Medication for Care Homes on the day of the site visit. As mentioned at the last site visit the manager is still advised to look at the quality of the medication training for staff. It was also advised at the last site visit that PRN protocols be drawn up after consultation with the GP. These had not been completed and a requirement will now be made to that effect. We spoke with many people on the day of the site visit and all spoke highly of the staff and the level of care they received. All of the people looked very well cared for. As at previous visits the majority of the ladies had manicured nails and were wearing coordinating clothing. Examples of very good interaction between staff and residents was seen throughout the inspection and the atmosphere was relaxed and pleasant. It was evident that staff respected privacy and dignity when delivering personal care. Care Homes for Older People Page 14 of 32 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 who live in the home have their social and recreational interest and needs well provided for with a wide range of activities organised. People who live in the home are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. People who live in the home receive a wholesome appealing balanced diet in pleasing surroundings Evidence: We wanted to look at the type of lifestyle experienced in the home and if people were happy with the level of social interaction and level of activities. We also wanted to look at if choices were given to the people and what control they had over their lives. To do this we spoke with nearly all of the people Staff were also spoken with. The people in the home are offered a wide range of activities and entertainments during the day and these are normally arranged by the staff. The owner is involved with the entertainments and often takes residents out to local Church groups and on outings. The local Baptist Church came into the home on a regular basis and the owner also takes some residents to the Church and Rochester Cathedral on a regular basis. Care Homes for Older People Page 15 of 32 Evidence: Professional entertainers were used regularly in the home and a picture board of photos in the hallway showed how much the residents enjoyed these events. At previous site visits relatives had confirmed they could visit at any time and were always made very welcomed by the staff. Staff were seen to offer choices where possible and where not possible full support was seen to be given. Mealtimes were relaxed and not rushed and people spoken with said they had enjoyed their dinner. Records seen confirmed what food residents had taken. Fresh fruit and vegetables were seen in the kitchen. People spoken with said the food was always good and they had a choice on the main meal. Staff confirmed that choices in food and drinks were always available and that the kitchen never closed. Care Homes for Older People Page 16 of 32 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. People who live in the home are protected by a complaints system and residents and relatives feel their views are listened to and acted upon. The home has adult protection policies and procedures to ensure that people are protected from abuse but staff remain untrained. Evidence: We wanted to ensure that all people concerned with the home were aware of the complaints procedure and felt confident their concerns would be listened to and acted upon. We also wanted to ensure all people were protected from any form of abuse. The provider was able to produce a complaints procedure at this site visit. It was basic but did give timescales for any complaint to be dealt with. Those written procedure were seen in the hallway for people to read and was now in the statement of purpose. One person who lived in the home said she had no concerns that any issues she had would not be dealt with. She also stated the owner and staff always listened to what she had to say and that she felt she could easily complain if she needed to. Information given in the AQAA confirmed that the home had received two complaints in the last year. The provider was unable to find any written evidence of how these had been managed or recorded. The provider must now set up a system in which complaints are managed appropriately and recorded correctly. Care Homes for Older People Page 17 of 32 Evidence: Staff have still not received formal training in adult protection and the home has already received a statutory notice regarding this. During the inspection the provider was given 48 hours to evidenced training was being undertaken. Staff spoke with had a reasonable understanding of abuse and all that were spoken with confirmed they would always report any concerns to a higher authority. Adult abuse is covered basically in the homes induction programme. Care Homes for Older People Page 18 of 32 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 who live in the home benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. People who live in the home are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. Evidence: The home was decorated to a good standard and since the current owner purchased the home he had invested 50,000 pounds on the internal environment. New carpets have been fitted throughout the home and new chairs provided in the lounge. All of the bedrooms have had new carpets and furniture and were individually decorated with the residents choosing the colours where possible. All had access to a lockable drawer and could have a key to their rooms of they wished. All had new beds and matching bed linen. The provider has recently started to fit new sinks with a tiled splash back to some of the bedrooms. He is intending to complete all the work in the near future. Several residents said how much the home had improved recently and several said they enjoyed the new specialist bath. Several of the bedrooms were viewed and all were well personalised and decorated. Evidence was seen that residents were able to bring in small personal items. Care Homes for Older People Page 19 of 32 Evidence: Evidence was seen that some specialist equipment was provided such as specialist mattresses and cushions but the home does not have a hoist. The home was very clean and fresh and visitors confirmed this was always the case. Care Homes for Older People Page 20 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the benefit from being cared for by staff who have a good understanding of their needs. People continue to be at risk from poor recruitment procedures. People who live at the home continue to be put at risk from poor training. Evidence: We wanted to ensure that sufficient staff were employed, who were suitably trained and had a good understanding of the needs of older people. We wanted to ensure they had been appropriately recruited to ensure the safety of the people in the home. We looked at the rotas which evidenced that the home employs sufficient staff to meet the needs of the people who lived there. Information given in the AQAA confirmed that 6 of the 12 care staff had achieved NVQ to level 2. This was confirmed by training records. The provider was hoping to have more staff enrol on the course this year. On the 13th February 2009 a Statutory Requirement Notice was issued regarding the employment of staff and the provider was required to comply by 12th April 2009. At Care Homes for Older People Page 21 of 32 Evidence: this inspection we found areas such as CRB and POVA first checks had been complied with but other employment checks had not. We found 2 staff files with only one reference. The provider was aware of the gaps and said he was actively chasing the references but that he had not had a response from the person named on the application form. He is advised to ensure two references are always obtained before offering employment. Therefore the Commission concludes that this requirement has not been fully met and further action may now be considered by the Commission. At the last inspection in January 2009 a Statutory Requirement was made regarding staff training. It stated that training must be undertaken in Moving and Handling, First Aid, Fire Awareness and Safe Guarding Adults. The compliance date was 31/03/09. At this inspection dated 14th July 2009, after the compliance date, it was seen that two care staff and two domestics had not completed a moving and handling course; first aid training had not been completed; fire awareness training had not been completed and Adult Protection had not been completed. The provider appearers to have concentrated on health and safety and the role of the care worker training sessions. One senior member of staff had received Fire Warden training. Induction training has improved since the last inspection. The provider was given forty eight hours to evidence that mandatory training had been booked with a reputable training company. This was forwarded to the Commission within the given timescale. The provider must forward confirmation when the courses have been completed by staff. Therefore the Commission concludes that this requirement has not been met and further action may now be considered by the Commission if the required training is not undertaken. During the inspection staff were observed completing their care duties. Direct and indirect observation conformed that staff are diligent and caring and encourage people to maintain their independence where possible. The atmosphere in the home was relaxed and cheerful. Staff were able to display sound caring techniques and good rapport was seen between staff and residents. All of the people who lived in the home who were spoken with confirmed they felt well cared for and that staff were kind and considerate. Comments made included: Care Homes for Older People Page 22 of 32 Evidence: the girls cant do enough for me the girls are so kind I love it here, everyone is so helpful, nothing is too much trouble. It was also observed that all of the people looked smart and well cared for. Care Homes for Older People Page 23 of 32 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. There is the potential of people in the home being put at risk from poor management and lack of supervision monist staff. Sound financial procedures protect people living in the home. Current arrangement now protect the health, safety and welfare of the people in the home and the staff. Evidence: We wanted to look at the skills of the management team and if the service benefited from the ethos, leadership and management of the home. We also wanted to see if the home was run in the best interests of the people who lived there. We also needed to ensure their health and safety was protected and promoted. The registered provider is also the registered manager and although he has made some improvements to the management of the home, still does not fully comply with Care Homes for Older People Page 24 of 32 Evidence: the Statutory Requirement Notices or the Statutory Requirements made from previous inspections. It is commendable that he continues to be involved with the social activities of the people in the home and has clearly heavily invested in the physical structure and decor of the home, however his managements skills continue to be a concern. All of the people living in the home were very complimentary about the manager and staff said he spends a lot of time in the home. After the last inspection a Statutory Requirement Notice was issued following non compliance of a requirement made in February 2007 regarding quality assurance. The compliance date was 16th March 2009. No evidence could be found that any progress had been made to meet the notice. There was no evidence that the provider had sought any views of anyone connected with the home. Some questionnaires were seen at the last inspection dated December 08 and these were again shown to the inspector. The provider did say that he regularly talks with the people who live there and their relatives and nobody had raised any concerns. There was no system in place that projected dates throughout the year as to when key stages of quality monitoring would take place. The Statutory Notice also required that the Commission be sent a copy of the proposed plan and that clear and dated records of each stage be maintained. This had not happened. The provider was given forty eight hours to evidence a structured plan that would evidence work had been undertaken in meeting compliance. This was forwarded to the Commission in the given timescale. The provider must inform the commission when he has completed full compliance with Statutory Requirement Notice and is again advised to fully read the notice. Therefore the Commission concludes that this requirement has not been fully met and further action may now be considered by the Commission. At the last inspection in February 2009 a Statutory Requirement was made regarding staff supervision. This was reviewed at this inspection. It was found that although the provider had devised a plan of when he intended to complete supervision sessions, this had not been adhered to. There had only been two supervision dates since February. The requirement is six times a year. Further discussion took place about the style and content of supervision in the home and Mr Raj was strongly advised to obtain further training in this field. The provider was given a further forty eight hours to produce evidence that supervision would be planned and adhered to. This evidence was forthcoming and supervision of staff will be viewed at the next inspection. Therefore the Commission concludes that this requirement has not been fully met and further action will now be considered by the Commission at the next inspection. Care Homes for Older People Page 25 of 32 Evidence: At the last inspection in February 2009 a Statutory Requirement was made regarding fire training and drills. The provider said he had issued all staff with a copy of the evacuation procedure. The senior member of care staff had attended a Fire Wardens course but the remaining staff had not received appropriate training. There had only been 1 fire drill for 5 staff since the last inspection. It is recognised that some work has been completed but not all the requirements have been met. The home must provide evidence that all staff have undertaken a fire drill and attended approved fire awareness training. Evidence must be sent to the Commission when completed. Therefore the Commission concludes that this requirement has not been fully met and further action may now be considered by the Commission. At the last inspection a Statutory Requirement was made regarding all necessary maintenance and safety checks be carried out. Evidence was seen this time that this had been complied with and the paperwork and certificates were in place. Window restrainers had been fitted on all windows. Therefore the Commission concludes that this requirement has met and no further action will now be considered by the Commission. Care Homes for Older People Page 26 of 32 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 30 18 The registered person shall, 31/03/2009 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed by the registered person to work at the care home are trained appropriately to the work they are to perform. All staff must undertake mandatory training on Moving and Handling, First Aid, Fire Awareness Training and Safe Guarding Vulnerable Adults. The level of First Aid training must reflect the requirements of the Health and Safety Executive. 2 33 24 An effective quality 31/08/2007 assurance and quality monitoring systems, based on seeking the views of service users, needs to be in place to measure success in meeting the aims, objectives and the statement of purpose of the home. It is recognised that the owner has only been at Jeanette Lodge for five months and is waiting for a suitable length of time so the judgements can be made on the change Page 27 of 32 Care Homes for Older People 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 of ownership. remains open Stautory Requirement Notice was issued following last inspection. Further action to be taken after MRM 3 36 18 The registered person shall 27/02/2009 ensure that persons working at the home are appropriately supervised. In that all staff receive formal supervision at least six times a year. 4 38 23 The registered person shall after consultation with the fire and rescue authority make adequate arrangements for people working in the care home to receive suitable training in fire prevention and ensure regular fire drills are undertaken. In that staff have receive instruction regarding fire drills and are aware of the procedure to be followed in case of fire. 5 38 23 The registered person ensures that safe working practices include fire safety: understanding and implementations of appropriate fire procedures. All staff must be aware of the fire precautions and drills Care Homes for Older People Page 28 of 32 28/02/2009 24/01/2009 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 remainas open. Further action to be taken Care Homes for Older People Page 29 of 32 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 9 13 The registered person shall make arrangements for the recording, safekeeping, safe administration and disposal of medicines received into the home. In that PRN protocols be drawn up in consultation with the GP for medicines that are prescribed as when required. 31/08/2009 2 16 22 The registered person shall ensure that any complaint made under the complaints procedure is fully investigated. In that records are fully maintained of any complaints and how they were resolved. 31/08/2009 Care Homes for Older People Page 30 of 32 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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