Inspection on 11/11/08 for Mandeville Grange

This inspection was carried out on 11th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mandeville Grange 04/02/10

Mandeville Grange 23/10/09

Mandeville Grange 23/11/06

Mandeville Grange 29/12/05

Mandeville Grange 28/09/05

Mandeville Grange 14/03/05

Mandeville Grange 10/08/04

Mandeville Grange 28/01/04

Mandeville Grange 21/01/03

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Mandeville Grange 201-203 Wendover Road Aylesbury Buckinghamshire HP21 9PB     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Joan Browne     Date: 1 1 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. 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. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Mandeville Grange 201-203 Wendover Road Aylesbury Buckinghamshire HP21 9PB 01296435320 01296397509 mcsmand@googlemail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mandeville Care Services Limited Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 31 Number of places (if applicable): Under 65 Over 65 31 old age, not falling within any other category Additional conditions: 0 The maximum number of service users to be accommodated is 31. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Mandeville Grange Nursing Home is situated on the outskirts of Aylesbury Town, which provides a variety of shops and other local amenities. The home provides nursing care for up to thirty-one service users, who are accommodated on two floors of the building. All floors are accessible by stairs, a passenger lift or stair-lift. Registered nurses and carers staff the home. Care Homes for Older People Page 4 of 28 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 unannounced site visit which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection (CSCI) was undertaken by Joan Browne on 11 November 2008 and lasted for approximately eight and a half hours. The last key inspection on this service was completed on 23 November 2006. The CSCI Inspecting for Better Lives (IBL) involves an annual quality assurance assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection process and is referred to in the report. The information contained in this report was gathered mainly from records kept at the Care Homes for Older People Page 5 of 28 service and information contained within the AQAA. We also looked at care plan documentation, staff recruitment files, training records, medication documentation and health and safety records. A tour of the premises was conducted and two visitors to the establishment were spoken to. Comment cards were sent to the home to be distributed to people using the service, health care professionals and staff members. Their comments have been reflected into the report. Six requirements and five recommendations of good practice were issued on this visit. Please see health and personal care outcome area, environment outcome area, staffing outcome area and management and administration outcome area for full disclosure. Feedback was given to the manager during the inspection. The fees for this service range from 525.00 pounds to 705.00 pounds. There are additional charges for chiropody, hairdressing and newspapers. We (The Commission) would like to thank all staff and people using the service who made the visit so productive and pleasant on the day. What the care home does well: What has improved since the last inspection? What they could do better: To ensure that all aspects of peoples health care needs are supported in a detailed care plan. To ensure that all staff comply fully with the safe administration, recording, handling and safe keeping of medication in the home. Care Homes for Older People Page 7 of 28 To ensure that the premises are kept in a good state of repair externally and internally. To ensure that staff employed are suitable to work with vulnerable people and there is a clear audit of the process by which individuals are recruited. To ensure that the arrangements for checking the fire panel are reviewed in line with best practice guidelines. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. 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 28 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 28 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. Prospective peoples needs are assessed prior to admission to ensure that the home is able to meet their diverse needs. Evidence: Information in the homes annual quality assurance assessment (AQAA) reflected that the home ensures that each service user has an individualised pre-admission assessment to ascertain whether the home can meet their needs. We case tracked two people recently admitted to the home and evidence was seen confirming that preadmission assessments were under taken prior to their admission. The two individuals were funded by a placing authority and a summary of the care management health and social care assessment was seen. The manager explained the admission process. She said that one of the registered nurses or herself would visit prospective service users in their homes, residential or hospital setting to carry out the assessment. A copy of the service users guide and brochure is given to them. Wherever possible Care Homes for Older People Page 10 of 28 Evidence: service users and relatives are encouraged to visit the home prior to admission. The home encourages comments from prospective service users and their relatives and acts upon them as appropriate. Care Homes for Older People Page 11 of 28 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. The home ensures that care plans and accompanying risk assessments are reviewed monthly but further work is needed to ensure that any health problems identified for people using the service are supported by a plan of care detailing how these needs should be met. The homes medication practice should be reviewed to ensure that it fully complies with best practice guidelines. Evidence: The care of three service users was case tracked. Evidence seen indicated that individuals nursing needs had been assessed allowing them to be entitled to a contribution to fees from the national health service. The care plans and accompanying risk assessments such as moving and handling, falls, tissue viability and nutritional screening had been reviewed on a monthly basis. There was evidence that service users weights were being monitored monthly for those who were not bed-bound. The home does not have the appropriate scales to monitor those residents weights that are nursed in bed. Consideration should be given for the appropriate scales to be purchased. We noted in the pre-admission assessment details and the care Care Homes for Older People Page 12 of 28 Evidence: management summary assessment for two individuals that health problems had been identified. For example one individual was diagnosed as having dementia and a second person with Parkinsons disease. There were no health action plans in place detailing how staff should be meeting the identified needs. We noted that the standard of recording in the care plans especially the night care plans depended on which member of staff was completing them. We noted that tippex correction liquid was used to correct entries recored in error in one particular care plan. This is not good practice and should be reviewed because the plans can be used in a complaints investigation or a coroners inquest. The home has a general practitioner (GP) who visits the home regularly as and when required. Health care professionals that responded to the Commissions survey said that the staff regularly consult members of the multidisciplinary team such as the primary care trust, specialist nurses, physiotherapists, occupational therapists, speech and language therapists for advice and act upon it to improve individuals health care needs The home has a medication policy and procedure in place. We were told that there were no service users that had been assessed as having the capacity to self-medicate. The medication administration record (MAR) sheets were examined and there were no unexplained gaps noted. We observed that medication for a particular service user had not been administered for two days. The explanation given was that the pharmacist did not deliver the medication. Since the key inspection the Commission has received a copy of a statement from the pharmacy supplier confirming that medication for Lansoprazole 15mg and Bendroflumethiazide 2.5mg was not delivered to the home as they were out of stock. We observed the trained nurse administering the lunch time medication and we noted that she had signed the MAR sheet on at least two occasions before offering the medication to service users. This practice must be reviewed to ensure that medication is administered in accordance with the nursing and midwifery council (NMC) guidelines. The controlled drug cupboard was checked and the controlled drugs were found to be managed correctly and accurately recorded. We noted that the cupboard was being used to store non medical items and other valuables. The homes staff should consider reviewing this practice. Staff were observed respecting service users privacy and dignity. All personal care is provided in service users bedrooms. A health care professional who responded to the Commissions survey said that they always find the staff approachable, friendly and thoughtful towards the service users. A second health care respondent said when visiting the home they have felt that all staff are respectful of individuals privacy and dignity. Care Homes for Older People Page 13 of 28 Evidence: The home works closely with the local hospice and provides care to service users in the last phase of their lives. A health care professional who responded to the Commissions survey was complimentary on the palliative care that the home provides to people in the last phase of their lives. On the day of the site visit a relative had visited the home to thank staff for the care and attention they had provided to a loved one that had recently passed. Care Homes for Older People Page 14 of 28 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 ensures that wherever possible it provides social and cultural activities to meet peoples diverse needs. The food provided is wholesome and staff offer people requiring assistance with feeding in a sensitive manner. Evidence: The home employs an activity person five days a week. A four week activity programme was displayed in the home to inform service users what was on offer. Activities on offer were word games, quizzes, reminiscence and ball games. One service user spoken to said that he enjoyed the ball games. The home also employs a therapist who visits the home weekly and offer hot stone treatments and nail care. There is also a music to movement session every Friday facilitated by an outside facilitator. The activity person maintains a record of what activities people like to participate in and this is updated regularly. Service users birthdays are celebrated with a home made cake and a party. Family and friends are given the option to attend the party if they wish to. People who responded to the Commissions survey said that the home provided them with activities but some choose not to participate. The two relatives spoken to during the inspection confirmed that they were able to Care Homes for Older People Page 15 of 28 Evidence: visit at any time and staff always made them feel welcome. Service users are made aware of their rights to bring personal possessions with them if they wish to such as, small pieces of furniture, curtains and bedding providing they are flame retardant. They are also able to purchase sky television within their own rooms. If requested the home would offer information to service users on how to contact external agents for example, advocates who will act in their interests. The home provides three meals daily with unlimited snacks and drinks throughout the day and night. Special diets are catered for such as diabetic, vegetarian and liquidised meals. A choice of meals are provided and service users and relatives spoken to said that the meals provided were of a high standard. However, a respondent to the Commissions survey said that the quality of the food varied. Suppers were usually better than the lunches. We were told that the chef would provide an alternative if individuals did not like what was on offer.Staff were observed assisting those service users who needed assistance in a sensitive and discrete manner. Care Homes for Older People Page 16 of 28 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. The home has policies and procedures in place to ensure that people who use the service are able to express their concerns and are protected from any potential risk of abuse. Evidence: The home has a complaints policy and procedure in place. People who responded to the Commissions survey said that they were aware of the homes complaints procedure. One respondent said that they have never had to make a complaint. Information in the homes quality assurance assessment (AQAA) stated that the home had not received any complaints within the past twelve months. The Commission has not received any concerns or complaints about the service. The home has a whistle blowing procedure which staff are made aware of. All staff are expected to undergo training in the safeguarding of vulnerable adult at induction which is ongoing. We were told that updated training for four staff in the safeguarding of vulnerable adults was eminent. Staff spoken to were aware of the action to be taken if an allegation of abuse was made. The Commission has not been notified of any safeguarding referrals, made to Social Services under their procedures. Care Homes for Older People Page 17 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally clean and tidy but consideration is needed to ensure that any identified hazards are risk assessed and action is taken to eliminate or minimise them. Evidence: The building is an Edwardian house with an extension providing a variety of rooms for service users. We were told that the home has a programme of maintenance and renewal of the fabric and decoration of the premises. However, the maintenance programme was not available for the inspection purpose. The manager said that when rooms become vacant they are re-decorated. The grounds were tidy, attractive and accessible to service users. There is a patio area with seating and an awning, which provides space for service users to socialise if they wish to. Information in the annual quality assurance assessment (AQAA) stated that the home was working closely with the fire service to ensure that the environment meets regulations and maintain maximum safety for service users. We were told that additional fire doors had been fitted also hold open devices in the agreed locations. Service users are encouraged to personalise their bedrooms and some had chosen to do so. We noted that relatives had raised concerns at a relative meeting about the state of the curtains and bedspreads in some of the bedrooms. We were told that an order had been placed for new curtains, lounge chairs and bedspreads. The manager Care Homes for Older People Page 18 of 28 Evidence: said that since the last key inspection twenty-seven divan beds had been replaced with profiling beds and four bedroom windows had been replaced. Since the key inspection the home had submitted copies of invoices to substantiate that thirty chairs for the lounge and approximately twelve dining chairs and some bedroom chairs had been purchased in March 2008. We noted that an over flow pipe in the old wing was leaking onto the conservatory roof causing the roof to be wet and discoloured. The guttering appeared blocked and required cleaning. A requirement is made for the overflow pipe to be remedied and the guttering cleared. We were told that the storage space in the home was limited. As a result bathrooms and toilets were used to store the hoists and trolleys during the day and they are removed to the corridors at night so that service users are able to have access to these areas. In the interest of safety it is recommended that the storage of equipment in bathrooms, toilets and corridors should be risk assessed for the risk they present to the people using the service and action taken to minimise any identified risk. We noted that the temperature on the hot water tap for the wash hand basin in the old wing bathroom registered 60 degrees Celsius. There was no thermostatic controlled valve fitted to the tap. It is required that a risk assessment is carried out for the risk it presents to the people using the service and action taken to minimise any identified risk. The home has an infection control policy, which staff are aware of. Alcohol gel is available for staff to carry on their person and for relatives to use on entering and leaving the home. On the day of the visit the home was clean and hygienic. A number of respondents to the Commissions survey said that the home was always fresh and clean. One respondent said that it always smells a bit when you enter the building but bedroom is fresh. A requirement was made at the previous inspection for individual hoist slings to be provided for service users who needed them. The manager said that all service users now have their own individual slings. We observed that the laundry assistant was transporting service users clean laundry in a wheelchair. This practice pose a risk of cross infection and should be reviewed. The laundry room is situated away from where food is stored, prepared and cooked. It is equipped with a washing machine with sluicing facility to meet disinfection standards and a drier. The room walls and floor of the laundry were in a satisfactory condition. Care Homes for Older People Page 19 of 28 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 home ensures that staff are trained and skilled to meet people using the service diverse needs. Weaknesses in the homes recruitment procedure need to be addressed to ensure that only staff that are suitable to work with people using the service are employed and there is a clear audit of the process by which they were recruited. Evidence: The home employs a multi-cultural staff team to meet service users diverse needs. The staff roster was examined. There was one registered nurse and seven carers on duty. The manager said that the number was reduced in the afternoon to one registered nurse and six carers. During the night there are three carers and one registered nurse on duty. The call bells were answered promptly. People who responded to the Commissions survey said that the staff were always or usually available when needed. The annual quality assurance assessment stated that within the last twelve months seven staff had left the homes employment. The home does not normally use agency staff but have had to depend on agency staff within the past three months to cover some shifts. Some staff who responded to the Commissions survey said that the service could improve by employing more staff and by improving the wages for health care assistants. We were told that ten of the fifteen care assistants that the home employs hold the Care Homes for Older People Page 20 of 28 Evidence: national vocational qualification (NVQ) in care at level 2 or above. This mean that the home has met the standard that 50 Percent of care staff hold the NVQ qualification. Four staff recruitment files were examined. All files contained a completed application form, two references, and terms and conditions of employment. Interview notes to verify that face to face interviews had taken place were seen. Weaknesses in the homes recruitment procedure were noted. For example, there was no evidence that the references obtained were followed up with a telephone call to verify the identity of the referees. In one particular file there were gaps in the individuals employment record and there was no written evidence that the gaps were explored at the interview. In a second file the references obtained were not from the most recent employer. One staff member was working with a PoVA first check but there was no written evidence that the member of staff was working under the supervision of a qualified and experienced person until the full criminal record bureau (CRB) disclosure had been obtained. In three of the files there was no photographic evidence to confirm proof of identity. A discussion was held with the homes training officer. She confirmed that all staff are inducted on commencement of employment and are required to attend mandatory training and regular updates. A training matrix was in place and it gave a comprehensive guide to staffs training requirements and when updates were due. Certificates of mandatory training undertaken by staff were seen. We were told that two members of staff had undertaken train the trainer training in infection of control. The manager said that these individuals will now be facilitating in-house training in infection control. The home is part of a cluster group and staff have been benefiting from the training that is on offer. Staff who responded to the Commissions survey said that their induction covered everything they needed to know to do the job. Care Homes for Older People Page 21 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home aims to provide a consistent service to ensure that the service is managed appropriately. The frequency of fire safety checks need to be improved to ensure that people using the service and staff safety is protected and promoted. Evidence: Since the last inspection the home has appointed a new manager. A full time operations manager was also appointed to support and assist the homes manager. The manager has been working in the home for over ten years as the deputy manager and has many years experience working in a nursing home setting. She does not hold the registered managers award certificate but intends to undergo training to achieve this qualification. The manager has not yet started the registration process with the Commission. A group of trained nurses, carers and ancillary staff support the manager in the day- to- day operation of the home. The manager said that she reports to the operations manager and that there were clear lines of accountability in the home. She updates her knowledge and skills by attending periodic training. The manager said that Care Homes for Older People Page 22 of 28 Evidence: she intends to hold regular relatives, service users and staffs meetings to ensure that individuals views are listened to and acted upon. She also said that she operates an open door policy which enable service users and relatives to discuss any relevant care issues. The home sends out satisfaction surveys to relatives and service users and these are analysed to ascertain where improvements could be made. Information in the homes annual quality assurance assessment (AQAA) stated that the home was aiming to review and improve on the quality assurance system within the home. Regular visits in line with Regulation 26 of the care homes regulations are carried out by the proprietor or the operations manager. The homes AQAA was returned to us by the date it was requested. All sections were completed and the information gave a reasonable picture of the current situation within the service. The home manages a small amount of money handed in by relatives for service users. We were told that the finance person deals with service users money. Receipts were provided for all money handed in. The controlled drug cupboard was found to contain a purse belonging to a service user. The nursing staff have access to a safe to store service users valuables in the nurses office therefore, there is no need for service users property to be stored in the drug cupboard. This practice should be reviewed. The annual quality assurance assessment (AQAA) data set reflected that all equipment in the home requiring maintenance had been carried out and was up to date. We were told that extensive work on the passenger lift was recently undertaken. A random selection of the homes fire safety records revealed that a fire risk assessment for the building had been reviewed in April 2008. A fire evacuation plan for the building was in place and this was updated in October 2008. We noted that the fire panel was checked monthly instead of weekly as recommended by best practice guidelines. The emergency lighting should also be checked monthly. This practice must be reviewed to ensure that best practice guidelines are fully complied with. We saw evidence that fire drills were regularly taking place during the day time. Consideration should be made to ensure that the night staff are involved in regular fire drills as they would need to know what to do if there is a fire. We observed that staffs practice in food handling and safety was not consistent. Opened packets of food and sauces in the refrigerator were not labelled and dated so that they are used within the recommended time scale once opened. A recommendation is made to ensure that opened packets of food and sauces are dated and labelled. Care Homes for Older People Page 23 of 28 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 24 of 28 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 Health problems identified 15/12/2008 must be supported by a care plan detailing how staff should by meeting the identified needs. This is to ensure that all aspects of individuals health needs are met. 2 10 13 Staff must ensure that best 15/12/2008 practice guidelines are followed when administering medication to people using the service. To ensure that there is a safe medication practice in the home and all staff adhere to it. 3 19 13 The wash hand basin tap in the old wing bathroom must be risk assessed for the risk it presents to the people using the service and action taken to minimise any identified risk 15/12/2008 Care Homes for Older People Page 25 of 28 To ensure that people using the service safety is promoted. 4 19 23 The guttering in certain areas on the roof must be cleaned to prevent damage to the premises. This is to ensure that the premises are appropriately maintained in a good state of repair externally. 5 29 19 The proprietor must review the homes recruitment practice in line with the current regulation and guidance issued by the Commission for social care inspection. To ensure that staff employed are suitable to work with vulnerable people and there is a clear audit of the process by which persons were recruited. 6 38 23 It is required that the local fire service officer is contacted reqarding the frequency of checking the fire panel and the emergency lighting and act on any recommendations made. This is to ensure that people using the service and staff safety is promoted and protected and best practice guidelines are complied with. 15/12/2008 15/12/2008 15/12/2008 Care Homes for Older People Page 26 of 28 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 To comply with best practice guidelines staff should ensure that arrangements are in place to enable people using the service to have their medication as prescribed. To comply with best practice guidelines tippex correction liquid should not be used in the care plans to correct entries recorded in error. Staff should ensure that non-medical items are not stored in the controlled drug cupboard. In the interest of safety the storage of equipment in bathrooms, toilets and corridors should be risk assessed for the risk they present to the people using the service and action taken to minimise any identified risk. Consideration should be given to review the practice of transporting clean laundry in wheelchairs belonging to people using the service. Opened packets of food and sauces should be labelled and dated to ensure that they are used within the used by timescale once opened. 2 7 3 4 10 19 5 26 6 38 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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