Inspection on 11/08/09 for Kelvedon House

This inspection was carried out on 11th August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kelvedon House 15/12/07

Kelvedon House 09/10/06

Kelvedon House 20/10/05

Kelvedon House 23/05/05

Kelvedon House 28/10/04

Kelvedon House 16/06/04

Kelvedon House 05/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for older people Name: Address: Kelvedon House 10 Clarkson Road Wednesbury West Midlands WS10 9AY     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: Mandy Beck     Date: 1 1 0 8 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: Kelvedon House 10 Clarkson Road Wednesbury West Midlands WS10 9AY 01215057775 01215057775 info@kelvedonhouse.co.uk www.kelvedonhouse.co.uk Mr Sarwan Samrai,Mrs Shindo Kaur Samrai Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Nicola Deakin Type of registration: Number of places registered: care home 48 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia learning disability old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 48 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 48, Learning disability (LD) 13, Old age, not falling within any other category (OP) 48, Physical disability (PD) 6 Date of last inspection 48 13 0 6 Over 65 0 0 48 0 Care Homes for Older People Page 4 of 32 Brief description of the care home Kelvedon House provides residential care and accommodation for up to forty eight people. The Home is situated approximately a quarter of a mile from Wednesbury town centre, on main bus routes and close to the M6 motorway system. It is located close to easily accessible public transport routes to local areas and surrounding towns. There is car parking with additional parking on the main road. The accommodation is provided on three floors. Each person has their own bedroom with en suite facility. There are no shared rooms in this home. There are lounges and dining rooms, toilets, bathrooms and a shower. There is also a sensory room for people to use and a hydrotherapy pool. There are no dedicated smoking facilities in this home. The range fees for this home is currently between £424 and £1600 per week. This does not include extra services such as hairdressing, newspapers or chiropody. People should contact the home directly for this information. 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 an unannounced inspection carried out by one inspector and one local area manager over one day. The home did not know we were visiting. We looked at all the information we have received, or asked for, since the last key inspection August 2007. This included information about how the service has managed any complaints. What the service has told us about things that have happened, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last twelve months and relevant information from other agencies We spent time talking to some of the people who use the service and to the staff who support them. We looked in depth at the care of three people who use the service. This is part of our case tracking process and helps us to make judgements about the homes abilities to meet peoples needs. We sent surveys to the home and to the people who live there. Their comments have Care Homes for Older People Page 6 of 32 been included in the report. We have also asked the home to provide us with an Annual Quality Assurance Assessment (AQAA). The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. 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: 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 8 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 9 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will have all the information they need to make a decision about living in the home. They can feel assured their needs will be assessed before they move in. Staff will need more training however if they are to understand and meet peoples needs. Evidence: The home has a statement of purpose and a service user guide. Both of these documents give people most of the information they will need when making a choice about living in the home. We have recommended the home includes details of the fees that people are expected to pay for residency. This will mean that people will have up to date knowledge of all aspects of the service they can expect from the home. We looked at the care of three people who had been recently admitted to the home. We saw that in each case people had been assessed by the home prior to their admission. The home had also obtained copies of the care managers assessment in all but one of the peoples care file. This information should provide the basis for care planning in the home. This will give both the person and their family an opportunity to Care Homes for Older People Page 10 of 32 Evidence: ask any questions and to make sure the home can meet their needs. We also spoke to staff on duty about the training they receive. Alot of the staff who work in the home have had no training in either dementia care or learning disabilities. One member of staff said Ive done a very broad awareness of dementia but thats all, another said I have no training I am picking it up as I go along. This is concerning because the home is registered to provide this type of specialist care. We spoke to the manager about this and she told us the home has arranged training for all staff in dementia and we are trying to do the same for the learning disabilities. The home does not provide intermediate care facilities. Care Homes for Older People Page 11 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples healthcare needs are being met but the home must improve its record keeping so that people at not placed at risk of harm or injury. Medication practises are mostly safe but some improvements are needed. Evidence: We looked at the care plans and risk assessments for three people who live in the home. We found that each person had their own care plans and risk assessments written by staff but the information contained within some of them was not always accurate and at times was potentially dangerous. For example in one persons care plan for risk of choking staff had written pat the person on the back and try to dislodge if not give me a drink, if I am still choking please call for assistance. We spoke to staff on duty and asked them what they would do if someone did choke, it was reassuring that none of the staff said they would offer the person a drink and all of the staff said that they would raise the alarm before attempting first aid. The home must make sure that information contained in peoples care plans is a true reflection of the care they need and of current best practise. This will mean that people are not being placed at greater risk. Care Homes for Older People Page 12 of 32 Evidence: We looked at moving and handling risk assessments and care plans. The plans need to include more information if people are to be moved safely. The home should record the type of hoist to be used and the size of sling for each person on their risk assessment. This will mean that staff are aware of the correct equipment to use for each person. We also spoke to staff about moving and handling training. We were told no I havent had any, I have picked it up as I go along, you watch and learn but I havent had any training yet. The home needs to make sure appropriate training in moving and handling is provided for all members of staff. The home must also make sure that is accurately recording the weight of people living in the home so that any unplanned weight loss or gain can be addressed. In all of the care files we looked at we found no regular recording of peoples weights. In one persons file we found written entries that told us the person was not eating or drinking properly but because the home had not recorded the persons weight it was difficult to determine how much the recent loss of appetite had affected their weight. There are some people living in the home who have challenging behaviour. There were care plans in place for this. Staff were able to tell us the contents of the care plan and how they manage this behaviour. They said we leave people alone, give them space and try to work out what could be bothering them. We did see some evidence the home is beginning to develop the person centred approach to care planning. This means that peoples care will be planned in a way that is personal to them and reflects the individual care and attention they need. The manager also told us that she was aware that care plans and risk assessments needed to be improved and she is already developing further training for staff so this will happen. We also saw the home is supported by visiting professionals such as the district nursing service, community mental health nurses and social workers. People also have access their own doctor when they need it. We looked at medication systems in the home. We have made requirements and recommendations for improvements in this area. The temperature of the medication storage rooms was far too hot and exceeded recommended limits. The home must be able to demonstrate it can keep medication safely for people. The medication trolleys on the ground floor were not secured to the wall when not in use. The manager did tell us that this was being done during the inspection in order to keep peoples medication safe. We looked at the medication administration records (MAR) we found that staff are handwriting onto the MAR but they are not having the entry double checked or signed by another member of staff. We have recommended this is done to reduce the risk of errors in transcribing occurring. When we looked at MAR sheets we saw that people were being prescribed antibiotics and other medications for treatment of short term illnesses such as a urine infection or a chest infection. We then looked in peoples care files and found that there was no Care Homes for Older People Page 13 of 32 Evidence: care plan in place for this. We have said the home must do this, this is because medication may only be part of the treatment for a urine infection and staff would need to be aware of this. We spoke to staff about how they preserve peoples rights to privacy and dignity in the home. Staff were able to give us good examples of when they would do this. They said I try to put my self in their shoes and think how would I feel?. Another person said I try to help people calm down a little bit, it must be embarrassing at times for them letting a stranger wash and dress them. We also spoke to people living in the home who told us I have no concerns the staff are very good. 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. The home needs to develop the activity programme for people to take part in. People are encouraged to maintain contact with their families and friends. Evidence: The home is developing the activity provision it provides. There are some events being organised such as outings to the local park and shopping trips. We saw some people taking part in ball games and skittles during this visit and staff told us we try really hard to fit the activity in, its hard sometimes because the activity person left. The manager told us there are plans to recruit to the activity coordinators post, we are waiting for this to happen. We noted that people on Knowles and Wesley units do take more trips outside of the home and we were told its important that people go out and see others, they dont want to be stuck in the home all day but when the staffing levels are low this is really hard to get done. When we looked at care plans for people on Knowles and Wesley units we saw that most people spent their time in the home either watching television or colouring in books. The staff did show us the sensory room which is very well equipped for people use and they said it works really well, they (people living in the home) seem to really enjoy it. The home also has a hydrotherapy pool which has yet to be registered but is fully equipped for people to make use of. There is a fully qualified pool attendant and swim Care Homes for Older People Page 15 of 32 Evidence: teacher in post ready to begin water treatments as soon as the room is registered for use. People are encouraged to have visitors when they choose. We saw evidence to show us that other people go out with their families, go to the shops and maintain links with the local community. As part of our case tracking process we looked at peoples bedrooms to make sure they were fully equipped and people had the opportunity to personalised them. We saw meal times in the home during this visit. The tables had been laid and the dining room looked like a pleasant place to eat. Staff were seen to assist people in a discreet and sensitive manner. The home operates a four weekly menu and there is always two choices for each meal. Staff also told us if they dont like whats on the menu then we can always make something else. One person chose to eat their meals in the comfort of their own room, they told us the food is very nice but I wish it was a bit warmer when it gets to me. The manager was made aware of this comment during the inspection and will be looking into it on behalf of the person. 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 living in the home can feel confident their views and concerns will be listened to and acted upon. Staff will need further training in safeguarding procedures if people are to be protected from harm. Evidence: The home has a complaints procedure in place and this can be found in the service user guide. A copy of this is also kept in each persons bedroom for their information. The home responds positively to complaints and takes steps to address peoples concerns. The home has investigated two complaints since it reopened in March 2009. We saw the home has kept clear records of the complaints and of the investigations carried out in relation to this. We have received one anonymous concern about the service. We have looked into this during this inspection. As a result of the information we have received we have recommended that gloves and aprons should be freely available for staff use in infection control. We also looked at the homes systems in place for the protection of vulnerable adults. We call this safeguarding. We spoke to staff about their knowledge of what is abuse and how they would report allegations to. We were told I havent had any training yet but I would go and tell the person in charge. Other staff were unsure about what they would do and it is likely that staff may take matters into their own hands. We have recommended that staff have further training and guidance in safeguarding so that people can be confident they will be protected from harm and that staff will act appropriately should any allegation of abuse be made to them. Care Homes for Older People Page 17 of 32 Evidence: The home does not use any forms of restraint at present. There are no bed rails in use or lap straps for wheelchairs. Some of the doors in the building have a coded lock in order to keep people safe. We looked at recruitment practises and found the home is taking steps to prevent unsuitable people from working with vulnerable adults. This includes required checks against the Protection of Vulnerable Adults list (PoVA) and a Criminal Records Bureau disclosure (CRB). 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 excellent 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 purpose built, well maintained and clean home. Evidence: The home has been purpose built and it provides very good accommodation for people to live in. We looked around most of the home during this visit. We saw that there are good sized lounges for people to sit in, dining rooms are spacious and pleasantly decorated. We looked at some peoples bedrooms, we saw that people have taken the opportunity to decorate them to their own taste and the home has helped accommodate this. Some peoples bedrooms have been fitted with over head tracking for hoists, this making moving and handling people easier and less intrusive. There are way finding markers throughout the home, each door has a sign that has large print description of the room, braille and a picture. These signs will aid peoples recognition whilst walking round the building. There is a sensory room on the ground floor which has specialist lighting, music, padded seating and other equipment designed to calm or stimulate peoples senses. Staff told us its really nice in here when people come in you can see them relax. At present it is only the younger adults living on Knowles and Wesley units that can take advantage of this room. The home should consider using it for people who are living in other areas of the home as well. This type of sensory room has been beneficial to people with dementia in helping reduce agitation and promote relaxation. Care Homes for Older People Page 19 of 32 Evidence: The home also has a garden for people to enjoy, we were told I would like to go more often but sometimes there arent enough staff and the weathers bad. The hydrotherapy pool is currently not in use. The home has a fully equipped hydrotherapy pool for people to use and it is hoped it will be registered for use in the very near future. We looked at the systems in place for management of infection. We saw the laundry and have made some good practise recommendations, such as making sure gloves and aprons are readily available at all times. We have also said that the laundry door should remain shut at all times so that the risk of scalds from the hot pipes we saw is reduced. We spoke to staff during this inspection who told us they had taken part in infection control training. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home needs to keep staffing levels under review in order to make sure peoples needs are being met. Staff need further training so they can be confident they understand and can meet peoples needs. Evidence: We looked at staffing levels in the home and found that improvements could be made. We looked at the staff rotas and saw that one member of staff had been off sick but the home had not made arrangements to cover this absence. We saw there were two staff on duty on Knowles and Wesley Units, however the needs of the people living on these units would suggest that another member of staff would be beneficial. Most of the people on these units need two people with them at all times to meet their needs, such as getting them dressed, using the hoist, walking and going out on trips. When staffing numbers are reduced this puts added pressure on staff and also means that peoples choices are reduced. We spoke to staff who told us we would like to be able to do more with people but when the numbers are low its really difficult. The home must keep this under review. We looked at the recruitment processes in the home. We saw the staff files of four people. All of them contained the required information and security checks such as previously mentioned Protection of Vulnerable Adults (PoVAfirst) and CRBs. This means the home has systems in place to prevent unsuitable people from working with vulnerable adults. Care Homes for Older People Page 21 of 32 Evidence: We spoke to staff about training opportunities in the home. We were told I had to sort some of my training out before I started, I havent done my NVQs yet but the home will get me enrolled. The home manager told us that all care staff will be supported in completing their National Vocational Qualifications (NVQ). We have also seen the home has put in place further dates for staff to take part in training such as dementia care training, moving and handling and first aid. We looked at the training records for some staff. We spoke to several staff on duty during the inspection who confirmed they have yet to take part in training and keep their knowledge and skills up to date. New workers are not supported through an induction at present that meets the Skills for Care common induction standards. This induction will provide staff with the basic skills needed for completed their NVQ training. Staff have told us they have had no training in dementia care or learning disabilities since starting work at the home. Care Homes for Older People Page 22 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. The home will need to make improvements so that is can demonstrate it is run in the best interests of the people living there. Evidence: The home is managed by Nicola Deakin. She is a registered nurse and has the qualifications required for a manager. We were told the manager is approachable and will help if we are stuck. The manager is aware of the shortfalls we have identified with the service delivery in this report. The home has also been recently inspected by Sandwell contracts and monitoring department. As a result of that inspection the manager has put an action plan together to make improvements to the record keeping systems in the home. We have said the home must manage the poor record keeping, improvements in medication systems, activities and staffing levels. At present the home does not have a quality assurance system in place. This means that there is no formal way for the home to evaluate the quality of the service they are providing. This will need to be addressed in order for people to know the home is being run in their best interests. Care Homes for Older People Page 23 of 32 Evidence: The manager is aware that this will also need to be actioned. The home has yet to return their completed Annual Quality Assurance Assessment (AQAA). This has been requested and the home will tell us in this document about the improvements to the service they intend to make over the next twelve months. We spoke to staff about their understanding of the Mental Capacity Act 2005 deprivation of liberty safeguards. Some of the staff did not know if there was a copy of the code of practise available or where it is. The manager told us that some staff have received training about the Mental Capacity Act 2005, however when we spoke to staff they told us they did not understand this or had had training. We did not find evidence during this inspection that people were deprived of his or her liberty without an authorisation but awareness of the deprivation of liberty safeguards is low enough to make this a possibility. We saw that the home does have satisfactory systems in place for the safe keeping of peoples money. The home does not act as appointee for any of the people living in the home and will only manage small amounts of money for people. We looked at the way the home promotes peoples health and safety in the home. We have said that staff training must be improved so that all staff know and understand current best practise in relation to first aid, moving and handling, infection control and health and safety. All safety certificates in relation to the building and the maintenance were up to date. Staff confirmed when we spoke to them they had recently had fire training and a dire drill. Care Homes for Older People Page 24 of 32 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 25 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 3 14 The home must make sure that each person has an assessment of their needs and a copy of this assessment is obtained before the person moves in. This is so people can be confident the home understands and can meet their needs before they move in. 30/10/2009 2 4 12 The home must make sure that staff have training in dementia care and learning disability. This is so staff will be able to recognise and understand peoples needs in relation to their condition. 30/10/2009 3 8 17 The home must make sure 30/09/2009 that it records peoples weight on at least a monthly basis. Care Homes for Older People Page 26 of 32 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 This will help identify those people who have unplanned weight loss or gain and to take appropriate action. 4 8 15 The home must make sure that people with short-term health conditions such as your urinary tract infection have a care plan in place to address this. This is so staff will be aware of short-term health needs for people living in the home. 5 8 12 The home must review care plans and risk assessments. Potentially dangerous entries should be removed. This should reduce the risks to people living in the home. 6 9 15 People who require 30/09/2009 medication on an as required basis or PRN must have a care plan that clearly shows when staff will administer this type of medication. This will reduce the risk of inappropriate administration to people. 30/09/2009 30/10/2009 Care Homes for Older People Page 27 of 32 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 7 9 13 The home must take action 30/09/2009 to reduce the temperature in the medication storage rooms. The home must be able to demonstrate it can store medication safely 8 9 18 All staff who administer medication must complete an accredited medication training course. This will give staff the knowledge and understanding they need in order to administer medication safely. 30/11/2009 9 27 12 The home must make sure that there are enough staff on duty throughout the day to meet the needs of the people living in the home. This will mean that peoples needs are being met and they are not being placed at risk by poor staffing levels. 30/09/2009 10 28 12 The home must be able to demonstrate that staff have been trained and have the skills to care for the people living in the home. This will reduce the risk of people being harmed by poor care practises. 30/10/2009 Care Homes for Older People Page 28 of 32 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 11 38 12 The home must make sure that staff receive training in safe moving and handling of people. This will reduce the potential risk of harm to both the people living in the home and the staff. 30/11/2009 12 38 12 Staff who have day to day 30/11/2009 contact with people living in the home must have first aid training. this training should also cover what to do in the event of a person choking. This will reduce the risk of harm to the people living in the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The home should include a range of fees payable by each person for weekly residency in the service user guide. This will give people up-to-date information of the fees liable to be charged. The home needs to continue developing the person centred approach to care planning. This will help both staff and people living at the home get the individual care they need. The home must make sure that medication trolleys are secured to the wall when not in use. The home should keep daily records of the temperature in the medication storage rooms. This will enable them to take action if the temperature is excessive. This will mean 2 7 3 4 9 9 Care Homes for Older People Page 29 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 that medication will be stored as manufacturers recommend. 5 6 9 12 The home must review its storage of controlled drugs to make sure it complies with changes in legislation. The home should consider providing more activity for all the people in the home. This will include more outdoor events. This is so people can retain their links with the local community. The home should make sure that all staff are aware of the location of the local authority guidance for safeguarding vulnerable adults and its contents. All staff should have training in safeguarding vulnerable adults. This is so they can be sure to recognise the signs of abuse, know who to report allegations to and safeguard the people they are caring for. The home should increase the numbers of staff who have training in the principles and practise of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The home should seek further clarification from the Environmental Health Officer about the recording of food temperatures on Knowles and Wesley units. Gloves and aprons should be available for all staff to use in the laundry. This will help reduce the risk of cross infection to people. The home needs to expand upon the support and training staff are given. The current induction process does not meet skills for care standards. This means that staff may not be getting the support they need when they start working in the home. The home needs to develop the Quality Assurance system so that people living in the home are included in the review of the service. Moving and handling risk assessments should include they type of hoist to be used and the size of sling for the person. This will help prevent accidents from occurring. The home should make sure that the laundry doors are closed at all times and that the hot pipes are insulated where possible. This will reduce the risks to the people Page 30 of 32 7 18 8 18 9 18 10 19 11 26 12 30 13 33 14 38 15 38 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 living in the home. 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. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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