Inspection on 21/07/09 for Kenilworth Care Home

This inspection was carried out on 21st July 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenilworth Care Home 01/08/07

Kenilworth Care Home 03/08/06

Kenilworth Care Home 21/12/05

Kenilworth Care Home 20/04/05

Kenilworth Care Home 15/09/04

Kenilworth Care Home 21/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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: Kenilworth Care Home Duncan Place Loftus Saltburn TS13 4PR     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: Katherine Acheson     Date: 2 1 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 31 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 31 Information about the care home Name of care home: Address: Kenilworth Care Home Duncan Place Loftus Saltburn TS13 4PR 01287640203 F/P01287640203 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Sunny Okukpolor Humphreys care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 20 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 category: Old age, not faling within any other category - Code OP, maximum number of places: 20 Date of last inspection Brief description of the care home Kenilworth Care Home is a two storey Victorian House, with a purpose built, modern extension to the rear, which is situated in its own grounds, with a spacious garden, accessible to people who use the service. There is a paved entrance to the rear and car parking adjacent to the entrance. The home provides accommodation for 20 older people, both male and female. Thirteen of the bedrooms are located on the ground floor, offering en-suite facilities of toilet and wash hand basin, and are well decorated. First floor bedrooms are accessed by the stairs and/or stair lift. First floor bedrooms do not offer en-suite facilities but they do have a sink. The home has two lounges and a spacious entrance hall with seating, and the dining room is bright and spacious. The Care Homes for Older People Page 4 of 31 Over 65 20 0 Brief description of the care home laundry is located in the basement. There is a telephone available for people who use the service, and the home has a no smoking policy. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is one star. This means that people who use the service experience good adequate outcomes. We have reviewed our practice when making requirements to improve national consistency. Some regulations from previous inspections reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. This unannounced key inspection took place on 21st July 2009. The manager completed and returned an Annual Quality Assurance Assessment, (AQAA). The AQAA is the services self assessment of how they think they are meeting national minimum standards. This information was received before the inspection and Care Homes for Older People Page 6 of 31 was used as part of the inspection process. The reason for the inspection was to see how good a job the home does in meeting the national minimum standards set by the Government for care homes. Numerous records were examined including care records of people living at the home, medication records, risk assessments, complaints and staff records. People living the home, a relative and staff working there were also spoken to. Discussion also took place with the owner of the home and the manager. Before the inspection surveys for people that use the service and surveys for staff were sent out to the home for the manager to distribute accordingly. Surveys sent to people that use the service were asked to comment on care received. Surveys sent to staff were asked to comment on what it was like working at the home and training received. We received three surveys from people that use the service. We received three surveys from staff. Comments in surveys received can be read in the main body of the report. The cost of care at the time of the inspection visit was four hundred and fifty eight pounds and ninety pence a week. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: Although the care files of people that use the service have been developed since last inspection and good assessments were in place, there were not any actual plans of care. A plan of care should be developed for each assessed need and include what the person can do for themselves and help needed. Care plans should include evidence of likes, dislikes, personal choice and preferences. Care Homes for Older People Page 8 of 31 One care file of a person who uses the service was observed to be written in pencil. The manager was advised that records for people that use the service should be written up in ink and a line through any errors. Some improvement is needed in respect of medication practice. Records should be kept of medication coming into the home to enable auditing. Staff should take and record the temperature of the room in which medication is stored to ensure that medication is stored at the correct temperature recommended by the manufacturer. This makes sure that medicine is safe to administer when needed. Hand written entries on Medication Administration Records should be signed and countersigned. Activities and outings are not taking place on a regular basis. The manager advised that this is partly due to staff sickness and holiday. Activities and outings should take place on a regular basis for those people who wish to join in to ensure that their social and recreational needs are met. The homes complaint procedure should be updated with names and contact details so that people know who they should contact if they have a complaint. The homes adult protection procedure should be updated to include contact numbers of Local Authorities to help to ensure that a prompt referral is made and that staff know who to contact if abuse is suspected. The homes induction programme for new staff should be developed to meet with the required standard. Certificates of staff training should be available for inspection to confirm that training has taken place. The manager should achieve an NVQ level 4 in Care to ensure that she is appropriately qualified. Certificates of testing and servicing should be available for inspection to confirm that it has taken place. The registered person should ensure that fire drills taking place at the home involve all staff including night staff to ensure that staff are appropriately trained and know what to do in the event of fire. The registered person should ensure that weekly tests of the fire alarm system take place to make sure that equipment is in working order. 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 31 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 31 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. Assessments of people who are to use the service are carried out before they move into the home to ensure all needs can be met. Evidence: The manager said that people who are to use the service are assessed before coming into the home. They firstly receive an assessment from a Social Worker. This assessment is forwarded to the home for the manager to review and determine if needs can be met at Kenilworth. The manager said that where possible she will then visit the person at home or in hospital to carry out a further assessment. This further assessment allows the manager to introduce herself and enables people to ask questions about Kenilworth. If a person is funding their own care an assessment is usually only undertaken by the manager of Kenilworth. Care Homes for Older People Page 11 of 31 Evidence: People are encouraged to visit the home before they move in. The manager advised that a brochure and statement of purpose are given to people to help them to make an informed choice. The care files of people that use the service that were looked at during the inspection did contain evidence of assessment. Care Homes for Older People Page 12 of 31 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 who use the service are well looked after. Although care files of people that use the service contain good assessments, care plans need to be developed to help to ensure health and personal care that people receive is based on their individual needs and preferences. Some improvement is needed in medication record keeping which will help to ensure safe practice. Evidence: The care files of three people were looked at during the visit. Files contained a detailed assessment of needs and moving and handling assessments. One file contained a detailed history that the family had put together. This contained important and interesting information about the person including place of birth, childhood, marriage, family, holidays, likes, dislikes and medical history. This same file also contained a write up of the daily routine that the person liked to follow. This included evidence of personal choice including when the person liked to get up, go to bed and what they liked to do during the day. Each file looked at contained an assessment of activities of daily living. Assessments looked at during the visit contained good detail . An example of this was one persons assessment highlighted that to help them to be independent Care Homes for Older People Page 13 of 31 Evidence: with eating they needed their food to be cut up and a plate guard attached to the plate. Another assessment in respect of bathing identified that a safety harness needed to be used whilst bathing to stop the person from overbalancing. Although good assessments were in place and care files contained lots of information there were not any actual plans of care. One assessment identified a person as needing help with bathing and stated, One carer to assist. A plan of care should be developed for each assessed need and include what the person can do for themselves and help needed. Care plans should include evidence of likes, dislikes. personal choice and preferences. One care file of a person who uses the service was observed to be written in pencil. The manager was advised that records for people that use the service should be written up in ink and a line through any errors. People who use the service looked well cared for and staff whilst attending to people showed respect in their actions and in the way they spoke. The Inspector spent a good part of the inspection working at a table in one of the lounge areas. One staff member was seen to be looking at a local newspaper and discussing events in Loftus with the person that uses the service. Staff were attentive quickly bringing a drink for a person when they were asked. There is clear evidence of the involvement of GPs, District Nurses and other healthcare professionals such as Chiropodists. People living at the home confirmed that if they were feeling unwell, the GP would be called. People spoken to during the visit and surveys received were complimentary about life in the home and care received. Comments made included, The staff are very caring, we have a laugh and they will do anything for me This is the best home that I have been in. I have been in two others. The staff here are beautiful I am as happy as a sand boy, it is a life and you have to live it They look after her very well. They laugh with her. Staff are so kind and I am so grateful During the inspection arrangements for receiving, storing, administering, recording Care Homes for Older People Page 14 of 31 Evidence: and disposing of medication were observed and examined. The manager advised that care staff who are responsible for giving out medication have received appropriate training and have had their competency checked. Examination of records highlighted that some improvement was needed in respect of record keeping. Medication Administration Records are written up for each person using the service by care staff on a monthly basis, however were not signed or countersigned. The homes supplying pharmacist delivers medication to the home on a weekly basis. The Manager advised that she checks the medication to ensure that the correct medication has been supplied, however does not keep a record of what has been received. Medication was appropriately stored and although the room used for the storage of medication felt cool there was no record of room temperature kept. Care Homes for Older People Page 15 of 31 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. Food provided is enjoyed by people who use the service. Recreational activities and outings are not taking place on a regular basis and as such people who want to are not given opportunities for stimulation which suits their needs and preferences. Evidence: The manager said that a care staff member who works at the home is responsible for planning and arranging activities. At the time of the inspection this care staff member was off sick and as such activities were not taking place as often as usual. The manager said that people that use the service like to take part in bingo, sing-a-longs, dominoes cards and jigsaws. A company called Motivation and Co visit the home on a monthly basis. They organise games and encourage reminiscence among people that use the service. Also taking place on a monthly basis is an arm chair exercise class. This involves gentle exercise and stretches. In the nicer weather staff take people that use the service out for walks or sit in the pleasant enclosed garden area. The manager advised that a daughter of a person who lived at the home who was part of a singing duo sang to people that use the service. Care Homes for Older People Page 16 of 31 Evidence: Comments made by people spoken to during the inspection and in surveys received in respect of activities and outings included, The exercise classes are very good , I like to join in I would like to do more sometimes I get bored There isnt much entertainment, I do not think that there are any funds The home could do more social activities I love the activities The manager said that the home support people that use the service to practice their religion. A Priest from the local Roman Catholic and a representative form the local Church of England church visit on a regular basis. She said that a number of people went to church at Easter. The manager was asked if people had been on any trips out or visits to restaurants or pubs. She said that people that use the service preferred in house entertainment. The hairdresser visits the home every Monday, a charge is made for this service. Visitors are made to feel welcome at any time. One relative spoken to during the visit said, It is like coming home, where mum is home is. All of the family visit. We all feel part of a community and are always welcomed. The lunchtime of people that use the service was observed. The lunch time menu of the day was fish, chips and mushy peas and for dessert there was rice pudding. The manager said that alternatives to the menu are offered at each meal time. Meal time was relaxed with people enjoying the food that is provided. Tables were appropriately set, salt and vinegar was available. People were given a glass of juice or water and a cup of tea. Staff were observed to be supporting and encouraging those people who needed help. People spoken to during the inspection and surveys received spoke positively about the food. comments made included, The food is very good and always well presented Care Homes for Older People Page 17 of 31 Evidence: The food is very nice, if I dont like something they offer me something else The food is varied and appetising You have nice roast beef on a Sunday with Yorkshire pudding Care Homes for Older People Page 18 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are confident that their complaints would be listened to, taken seriously and acted upon. Staff receive adult protection training which helps to ensure safety of people that use the service. Updating of the homes complaint and adult protection procedure would help to ensure that the appropriate people are contacted when needed. Evidence: The home has a complaints procedure, however this needs to be updated to include names and contact details of who to complain to. The complaint procedure does inform people of their right to contact Local Authorities if they have a complaint. The manager said that there have not been any complaints in the last twelve months People spoken to during the inspection and surveys received said that they felt that they could approach the staff or manager to raise any concern/complaint that they may have and that they would be listened to. The home has an adult protection policy/procedure which details action that staff should take if abuse is suspected. The procedure would benefit from being updated to inform of Local Authority telephone numbers to help to ensure that staff know who to contact if abuse is suspected. Care Homes for Older People Page 19 of 31 Evidence: The manager said that staff receive adult protection training on induction and on a regular basis thereafter. She said that she and two other staff have recently attended safeguarding training provided by the Local Authority and that staff are currently in the process of completing an adult protection work book Care Homes for Older People Page 20 of 31 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. The standard of the environment is good providing people that live there with an attractive, homely and comfortable place to live. Evidence: Kenilworth is registered to provide care to twenty older people. The home is a two storey Victorian House with a purpose built modern extension to the rear. The home has a spacious garden. There are thirteen bedrooms on the ground floor of the home that have an ensuite facilities, which consist of a toilet and hand wash basin. The remaining bedrooms are on the first floor of the home and can be accessed by stairs or a passenger lift. Bedrooms on the first floor of the home do not have ensuite facilities, but they do have a sink. The home has a spacious entrance hall with seating, two lounges and a dining room. During the visit the Inspector walked around the home with the manager. The lounges were homely with good quality furniture. Bedrooms of people that use the service that were looked were nicely decorated, had appropriate furniture and were personalised. Since last inspection the ground floor corridor has benefited from redecoration and new carpets. The last inspection of the service highlighted that the kitchen doors were held open with items that would not allow the doors to close in case of fire. The cook had Care Homes for Older People Page 21 of 31 Evidence: advised that doors were held open because it was do warm in the kitchen. The manager said that an air cooling device has since been fitted to the kitchen. The last inspection of the service highlighted that the home were having problems making sure that there was always hot water available for people to have a bath. The manager advised that this problem is now resolved. On the day of the inspection hot water was available in bathroom areas. The homes laundry is situated in the basement. Appropriate laundry facilities were in place. The laundry walls and floor have been painted since last inspection to enable cleaning. The manager said that the there are plans to put new flooring in the laundry. On the day of the visit the home was clean and odour free. Care Homes for Older People Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes recruitment procedure is good, which helps to ensure that people are protected. Although mandatory training is provided to staff Inadequate induction training could impact on the care given to people that use the service. Evidence: At the time of the inspection visit there were fifteen people using the service. Staffing rotas looked at during the visit informed that there are three care staff on duty during the day and evening and two care staff at night. In addition to care staff on duty the manager works five days a week supernumerary. She said that there have been occasions of late because of staff sickness and holidays that she has been counted in the numbers worked rather than being in addition to. Seventy seven percent of care staff working at the home have achieved an NVQ level 2 in care or equivalent. Records were available to confirm that the manager follows good recruitment procedures. Three files of staff working at the home were examined. Appropriate references were on file as was evidence of Criminal Record Bureau checks. One survey received stated, All the staff are very caring and show concern about the wellbeing of residents. The staff appear happy and to our delight there is not a big Care Homes for Older People Page 23 of 31 Evidence: staff change over so he/she is used to all the people caring for her Records were available to confirm that staff working at the home receive induction, however this did not meet with the required standard as set by Skills for Care. A training matrix was available for inspection which detailed that mandatory training had been provided to staff. Three staff files were examined at random during the visit, however not all certificates were available on staff files looked at to confirm that training had been provided. Care staff spoken to during the visit said that they had received training. Care Homes for Older People Page 24 of 31 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. Quality assurance monitoring systems are in place to help to ensure that the home is run in the best interest of people that use the service. Insufficient testing of the fire alarm system and carrying out fire drills that does not involve all staff working at the home could compromise safety. Evidence: The manager has many years of experience of working in a residential care home setting. She has achieved an NVQ level 4 in Management and is to commence and NVQ level 4 in Care in September. The manager said that she had attended numerous training events during the last twelve months in order to keep herself up to date. Appropriate quality assurance monitoring systems are in place. Surveys are sent out to people that use the service on a yearly basis to make sure that they are happy with the home and the care that they receive. Surveys were last sent out in August 2008. The manager said that as the home is only small she is able to meet and chat with people that use the service and relatives on a daily basis. Care Homes for Older People Page 25 of 31 Evidence: The home looks after Small amounts of money for people who use the service. Each person has an individual record, which details money held and transactions. A sample of health and safety records were examined. A certificate was available to confirm that the homes fire extinguishers had been serviced. Gas appliances had been serviced in March 2008 and records were available to confirm that there had been repairs to the gas boilers and hot water in June 2009. The Provider advised that he is in the process of arranging a further service of gas appliances, however didnt do so until the problem with hot water had been resolved. The Provider advised that the homes fire alarm system had been tested, however was unable to locate the certificate to confirm that this was the case. The deputy manager said that water temperatures are taken and records weekly, however was only able to locate water temperatures that had been taken up until January 2009. She said that water temperatures after this date were in a separate file. Records were available to confirm that tests of the fire alarm system are on average carried out weekly, however due to staff shortages had not be carried out since 13th June 2009, however there were records to confirm that two fire drills involving staff had taken place after that date on 21st June 2009 and 29th June 2009. The manager advised that fire drills are used as additional fire training for staff. Records identified that fire drills were taking place during the day and as such night staff were not participating. Care Homes for Older People Page 26 of 31 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 27 of 31 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 15 The registered person must 30/10/2009 ensure that people that use the service have a plan of care for each assessed need in respect of health and welfare. Care plans need to include what the person can do for themselves, assistance needed, likes, dislikes, evidence of personal choice and preferences. This will help to promote Independence, ensure that care needs are met and that care is delivered in such a way that is acceptable to the person. The registered person must 13/10/2009 ensure that all new care staff who are not qualified to NVQ level 2 in Care complete an induction that meets with the required standard. 2 30 18 Care Homes for Older People Page 28 of 31 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 to ensure that staff are appropriately trained to meet the needs of people using the service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 The registered person should ensure that care records for people that use the service are written up in ink and a line through any errors. The registered person should record the temperature of the room in which medication is stored to ensure that medication is stored at the correct temperature recommended by the manufacturer. This makes sure that medicine is safe to administer when needed. Hand written entries on Medication Administration Records should be signed and countersigned. The registered person should keep a record of medication coming into the home to enable auditing. The registered person should consult people that use the service about a programme of activities help to ensure that it meets with their social and recreational needs. The homes complaint procedure should be updated with names and contact details so that people know who they should contact if they have a complaint. The homes adult protection procedure should be updated to include contact numbers of Local Authorities to help to ensure that a prompt referral is made and that staff know who to contact if abuse is suspected. Certificates of staff training should be available to confirm that training has taken place. The manager should achieve an NVQ level 4 in Care to Page 29 of 31 2 9 3 4 5 9 9 12 6 16 7 18 8 9 30 31 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 ensure that she is appropriately qualified. 10 38 The registered person should ensure that fire drill taking place at the home involve all staff including night staff to ensure that staff are appropriately trained and know what to do in the event of fire. The registered person should ensure that weekly tests of the fire alarm system take place to make sure that equipment is in working order. Certificates of testing and servicing should be available for inspection to confirm that it has taken place. 11 38 12 38 Care Homes for Older People Page 30 of 31 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 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!