Inspection on 02/03/10 for Kimbolton Lodge

This inspection was carried out on 2nd March 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 16/05/2010.

Key inspection report Care homes for older people Name: Address: Kimbolton Lodge 1 Kimbolton Lodge Bedford Bedfordshire MK40 2NT     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: Sally Snelson     Date: 0 5 0 3 2 0 1 0 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 30 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Kimbolton Lodge 1 Kimbolton Lodge Bedford Bedfordshire MK40 2NT 01234355918 01234270924 kimboltonlodge@riseway.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Kimbolton Lodge Limited Name of registered manager (if applicable) Ms Julie Elizabeth Stanton Type of registration: Number of places registered: care home 36 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: 36 The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: both, whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Kimbolton Lodge is a large converted house with a two-floor extension added to the back. The home is on a bus route, and in walking distance of the town centre and various amenities. There is parking at the front, and an attractive garden to the rear. The positioning of the extensions has provided small courtyards so several of the rooms have a garden view. Kimbolton Lodge provides both residential and nursing care for a maximum of 36 Care Homes for Older People Page 4 of 30 Over 65 36 0 Brief description of the care home elderly service users. Permanent and respite care is provided, and staff have experience in caring for service users with a range of conditions associated with old age. All of the rooms in the more recently built extension have en-suite facilities. Stairs or lifts access the two floors of the home.There is ample car parking available at the home. Further information can be obtained directly from the home by phone, email, or when visiting. At the time of the inspection the fees varied from £580.00 to £785.00 per week depending on the needs of the person using the service and the room available. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out in accordance with the Care Quality Commissions (CQC) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users views and information received about the service since the last inspection in the form of the Annual Quality Assurance Assessment (AQAA). Prior to the inspection we received back 10 completed questionnaires from residents and four from staff. Only one of the residents had completed the questionnaire themselves, the rest had been supported by staff members. This inspection of Kimbolton Lodge was the first inspection under the new provider. It was unannounced and started at 09.45hrs on 2nd March 2010. On this day the registered manager was on leave so some areas of the inspection had to be finished on the 5th of March when she was available. Care Homes for Older People Page 6 of 30 The registered manager Ms Julie Stanton and the Operational Manager Elaine Baigre were present on the final day and for feed back. During the inspection the care of three people who used the service was case tracked. Case tracking involved reading residents records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home and staff were spoken to and their opinions sought. Any comments received from staff or service users about their views of the home plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: This inspection highlighted a number of concerns that were fed back to the manager and the operational manager. The operational manager made a commitment to supporting the manager to raise the rating of this service. Before the report was produced we had been advised that a number of areas had been addressed. This reports includes requirements which the service must meet in a timely fashion. These included the need for care plans and risk assessments to be in more detail and for staff to ensure that the care recorded on the plans match that provided to the resident. Medication system and procedures must be more robust and residents must have prescribed medication available at all times. The were sufficient staff on duty at any one time but in order to have a full staff complement the service relied on some agency staff. Despite the number of staff employed five of the 10 residents commented that they sometimes had to wait for staff Care Homes for Older People Page 8 of 30 to be available to provide care. Training, development and supervision of staff was inconsistent and staff lacked leadership. Policies and procedures needed to be reviewed , and quality assurance monitoring was not regarded as a core management tool. Four residents told us in their questionnaires that they would appreciate more activities. It was difficult to ascertain if the home was offering a suitable range of activities to met the needs of the residents as there was little documentation about interests and activities recorded. 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 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions were not made to the home until a full needs assessment had been undertaken. The home was unable to provide people with sufficient information to make an informed choice about the home. Evidence: The Statement of Purpose available in the home included some out of date information. We were told that the document was continually under review because it detailed each staff member, their qualification, and the time, in years and months, they had worked at the home; it therefore needed to be altered at least monthly. The document had all the required information but consideration needed to be given to keeping it current. We did not see a copy of a Service Users Guide and we were advised it was with the printer. The manager was not able to locate an old copy and it was apparent that those residents who had been recently admitted had not been Care Homes for Older People Page 11 of 30 Evidence: given this document. The certificate on display did not reflect the new owners. This was being dealt with. The current certificate had a condition that no more than 13 residents with nursing needs could be accommodated. This condition does not appear on the new registration. All of the pre-admission assessments sampled had been completed by the manager, and the nurse where a nursing place was required; they were of a good quality and the information gained was used to inform the care plans. Each of the residents had a signed contract, a copy of which was stored in the home. The ability of the staff team to meet the assessed needs of the residents will be discussed in the staffing section of this report. Kimbolton Lodge did not offer intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents had care plans that included basic information necessary to deliver the persons care, but they were not detailed or person centred. In some cases the plans did not reflect the care that was delivered. Medication systems did not always follow good practice or safe practice guidelines. Evidence: We looked at the records the home kept for three people using the service, including two who had been admitted in the last four months. The care plans we saw gave staff guidance on the help and support each person needed with most aspects of their care. Some, such as a plan for feeding a resident via a tube, (PEG), were in sufficient detail, however others needed more detail about the way the care was to be provided. For example needs help with dressing did not convey to the reader how the resident liked to be supported. In order to ensure the information was relevant and up-to-date old plans needed to be archived or altered. For example, we saw a plan for the care of the site of a Care Homes for Older People Page 13 of 30 Evidence: pacemaker that had been fitted two years previously. This plan advised the carer on the treatment of the wound site, which was now healed and was not relevant to this persons care. We were also aware that plans of care had not been written for all aspects of the care provided. A resident with a rash, that was being treated by the GP, did not have a care plan for the treatment of this condition. By reading other documentation and talking to staff we were able to ascertain that this resident had been referred for specialist treatment, but it was not apparent how and what treatment should be given. We were also concerned that the care file did not detail that certain processes, referred to in the care plans, had been carried out. A resident with wounds on three areas of her body, had plans for how frequently and with what products the wounds should be dressed, but there was no evidence that this had taken place. The manager told us that this would be recorded in the diary. This was in breach of data protection and also did not provide a consistent record of care. However for the purposes of case tracking and ensuring the safety of this resident we were able to establish that the correct care was being provided. It was also apparent that care plans were not always followed by staff. For example we looked at a plan of care for eating and drinking included a letter from a speech and language therapist who had visited and advised the use of a beaker without a lid for fluids and the use of a tea-spoon for pureed food at mealtimes. At lunchtime we observed this person being fed a pureed diet via a tea-spoon, but her drink was in a beaker with spout and there was a straw in the spout. Staff told us that this resident found this the easiest way to take fluids, but it was not reflected in her plan of care and appeared to the reader that specialist advice was not being followed. The plans also referred to the goal, or the aim of the treatment, and comments like achievable did not indicate how the treatment was to be evaluated. All of the plans, including those with very old information had been reviewed regularly. However we did not see that people had been asked to sign their care plans to agree that this was the care they wanted and needed. There were some risk assessments in place but more were needed, and like the care plans they needed to be written in more detail. We saw information that a resident needed a hoist but no assessment to determine the size of the sling to be used with the hoist, or risk assessments for these pieces of equipment and their use. In two files a score had been recorded as part of a nutritional assessment suggesting that this person had not lost weight and had a BMI in a particular range. We did not see a Care Homes for Older People Page 14 of 30 Evidence: record of a regular weight to correspond to the review of the assessment. The manager confirmed these were done but was unsure where they were recorded. We looked at medication records (MAR charts) held for the nursing and residential residents. In both areas there were gaps on the records (that is, no signatures to confirm that the medication had been given and no code to explain if the medication had not been given, why not). The person administering the medication must confirm, by signing their initials, that the medication has been administered, or they must use a code to explain why the medication was not administered. We found it difficult to reconcile the medications that were prescribed with a variable dose because of the way the exact dose given was recorded making the page look very confusing. Where we attempted to reconcile boxed or bottled medications these were not always correct. We were also aware that for two peoples medication was recorded to be out of stock. This is not acceptable and auditing processes should ensure that this does not happen. This was dealt with as soon as senior staff were made aware of our findings. People we spoke with had no concerns about the way staff treated them. They told us staff respected their privacy and dignity, and we observed staff knocking on bedroom doors, and making sure doors were closed when any personal care was being carried out. Many people had information about their end of life wishes. Care must be taken that if a family is making a decision on behalf of a relative about care that this decision it is supported by a mental capacity assessment confirming it is a best interest decision. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It was difficult to ascertain if the home was offering a suitable range of activities to meet the needs of the residents as there was little documentation about interests and activities recorded. The food in the home was of satisfactory quality, well presented and met the dietary needs of people who used the service. Staff were trained to help those individuals who need help when eating and were sensitive in their approach. Evidence: On the day of the inspection we did not witness any activities taking place, although residents did tell us about the activities that took place, and appeared satisfied with what was arranged for them. We saw a number of activities advertised, such as entertainers and clothes shows coming into the home. These were advertised for the residents and their families. The operational manager advised us that a new activity person had been appointed and that she had a number of different ideas for group and personal activities. We saw some recorded information about peoples past interests and hobbies, but we did not see any plans for activities for individuals. Residents told us that their visitors were made welcome. We also saw that community Care Homes for Older People Page 16 of 30 Evidence: groups such as church groups and choirs were frequent visitors into the home. The main lounge was a thoroughfare for staff and throughout the day we saw staff interacting with those residents sitting in the lounge as they passed through. The inspection covered lunchtime. This was an unhurried occasion and people who needed support were fed first allowing carers to spend time with the residents in the dining room. The meals served appeared nutritious and were well received by the residents. There was one main meal advertised, but people were offered a choice of alternatives. We were disappointed that food that needed to be pureed had been pureed together so it looked unappetising. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The outcomes of complaints from individuals were not always fully recorded. There were policies and procedures for safeguarding people but people could be at risk if the correct procedure were not undertaken. Evidence: The complaints procedure gave simple guidance about how people could raise a concern. Clear timescales had been included in the procedure so complainants would know when the manager of the home would respond to them. We looked at three complaints made to the home since the last inspection. A central file included information of the complaint, evidence of investigation but no responses to the complainants. The manager told us that the complainants had all been spoken to about the complaint and this had been recorded in the residents file. We were confident that the complaints detailed had been dealt with correctly, but this process was not recorded in one place. The manager had received safeguarding of adults (SOVA) training but was hesitant in her reply when asked to respond to a scenario. However there was evidence that incidents that could be considered possible abuse had been reported. The manager had ensured that all staff had been trained to understand the various forms of abuse and how they could recognise these and respond. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Kimbolton Lodge provided a clean homely environment for people to live in. Evidence: The home was clean and tidy and homely throughout. Since the last inspection the provider for this home had changed. There had been some alterations, such as wet rooms being created where bathrooms that were not widely used had been, some new flooring, and the necessary work to fire doors to meet regulation. The operational manager had plans for refurbishment of the home, particularly the dining room which she described as being tired. People using the service were supported and encouraged to make their rooms personal. One resident, with an interest in gardening, was particularly pleased that her room overlooked the garden and that she had access into the garden. In the past the home had a separate nursing unit, but in order to integrate staff, residents were accommodated in the most suitable available bedroom for them. There were attractive gardens surrounding the home and ample car parking for staff and visitors. Protective clothing, gloves and hand washing facilities were provided. Cleaning Care Homes for Older People Page 19 of 30 Evidence: schedules were in place and domestic and clinical waste was disposed of satisfactorily. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were consistently enough staff available to meet the needs of the people using the service, however there was a reliance on agency staff which could compromise consistency of care. Training had been provided and was planned but it was not obvious how the training was managed. Evidence: The home had sufficient staff on duty at all times, but at least four of the residents who completed questionnaires in advance of the inspection told us more staff were needed as they had to wait for care. Staff told us that only having duty rotas a week in advance did not always make it easy for them. The operational manager had been aware of this and had instructed the manager to produce rotas one month in advance and to offer part-time staff some additional shifts before using an agency. This was in order to provide residents with greater continuity of care. The home operated with one nurse and seven carers in the morning when at capacity, and one nurse and five cares in the afternoon. If the home was not full the staffing levels were altered to reflect this. As already stated the home only provided nursing care for up to 13 service users. If this was to alter staffing ratios would need to be considered, particularly in relation to the number of nurses on duty. Care Homes for Older People Page 21 of 30 Evidence: The AQAA advised us that 17 of the 26 staff had NVQ to level 2 or above and a training record showed that staff received updates on mandatory training. A newly created training matrix indicated to us that the manager was aware when staff needed to have updates to their training but it was apparent that more specialist training such as managing a PEG feed or diabetes was necessary. There was no evidence that the training programme reflected the staffs needs as it was not informed from staff supervision sessions. To ensure compliance with recruitment we sampled three staff files, looking particularly at staff recruited since the last inspection. As with other documentation these files were being tidied up to make them easier to use. The files included all the required documentation and checks, and confirmed that the manager was recruiting and starting new staff in accordance with regulation. All new staff completed an induction programme but it was not well recorded and did not evidence that it covered all areas of care. This was particularly concerning where staff had not worked in care before. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Training, development and supervision of staff was inconsistent and staff lacked leadership. Policies and procedures needed to be reviewed , and quality assurance monitoring was not regarded as a core management tool. Evidence: The evidence in the previous sections of this report indicate that the manager of this home works hard but has not been able to raise the quality rating. The manager has worked at Kimbolton Lodge for more than 20 years and has been registered as the manager for the last three. Throughout that time she has struggled with some aspects of management, but shown competence in others. The manager had a history of working long hours and not delegating work. In this time outcomes that reflected the hours she worked were not achieved. During the inspection the operational manager showed a commitment to working with the manager and the newly appointed deputy to raise the standard of the service provided. A plan of responsibility had been devised Care Homes for Older People Page 23 of 30 Evidence: for all senior staff and the operational manager was to audit the outcomes. The staff team spoke highly of the manager and showed her respect, but at times she did not appreciate that she was in charge of the team and not merely one of the team. The home had some systems in place for checking that the service they provided was of a good quality, and was what people wanted. This must be built upon to show that the service is reactive to the needs of the residents. Staff, residents and relatives meetings are held at intervals, but more are needed. We did not speak to any relatives during this inspection but in the past relatives we spoke with said they find this useful, but they also feel the manager is approachable and available at anytime. All sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the service, but there was limited detail about the areas where improvement was needed and how this was to be managed. The Regulations (Regulation 26) require the provider to visit the home at least monthly, and to write a report of the visit. This is so that we can be sure the provider knows what is going on in all areas of the running of the home. A copy of the report must be sent to the manager, and be available for inspection. The manager showed us that these reports had been completed and were used to make improvements. We noted that many of the concerns raised in this report had been identified in the previous months report. The home keeps a small amount of cash in safe-keeping for some of the residents. We checked the cash balance and the transaction record for two people and it was all correct. Care must be taken that the money paid to the visiting hairdresser is receipted individually in order to provide an audit trial and that residents have access to their money when they want it. Staff supervision sessions were not taking place at regular two monthly intervals. It is important that these sessions are structured and recorded and inform the training plan for the home. Records showed that tests of the fire alarms had been carried out. Care Homes for Older People Page 24 of 30 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 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 This refers to Regulation 15 (1) Details of any care to be carried out by staff must be documented. This ensures that staff have the information to provide all the necessary care. 04/04/2010 2 7 15 This refers to Regulation 15 (2) The information in the care plans must be current and altered as care needs change. This ensures that consistent care is provided 04/04/2010 3 8 14 This refers to Regulation 14 (2) Staff must ensure that peoples health is reviewed regualrly and that any measures needed to 04/04/2010 Care Homes for Older People Page 26 of 30 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 promote health are provided. This ensures that the an assessment for the correct treatment is on-going. 4 9 13 This refers to regulation 13(2) Medication audits must be carried out and action taken as appropriate. 01/04/2010 This is to ensure that the recording, handling, storage, administration and disposal of medication are satisfactory. 5 18 18 This refers to Regulation 18(1)(a) Any staff on duty must be aware of how to manager an allegation or suspicion of abuse. This ensures that people are kept safe and appropriate action is taken 6 30 18 This applies to Regulation 18(1) There must be evidence that staff have received training that equips them to meet 01/06/2010 01/05/2010 Care Homes for Older People Page 27 of 30 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 the assessed needs of the residents. This includes induction training. This ensures that all staff on duty can met the assessed needs of the residents. 7 32 9 The service must have a clear sense of direction and leadership. This will support the home to raise it rating. 8 33 24 Robust audit processes must 01/05/2010 ensure that a quality service is being provided. This ensures that all involved in the service have an opportunity to influence change and that best practise is achieved at all times. 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 01/06/2010 1 1 The manager should ensure that the Statement of Purpose and the Service User Guide are kept under review so that they accurately reflect the current position of the home. People should be encouraged and supported to read their care plans and agree them. Activities should reflect people interests and hobbies. A record of activities should be included in the care plan. 2 3 7 12 Care Homes for Older People Page 28 of 30 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 4 5 15 16 Food that has to pureed should be done so in separate portions. The outcome of a complaint investigation should be stored in the central log along with information as to how the complaint was investigated. All staff should receive meaningful regular supervision sessions. 6 36 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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