Inspection on 25/11/09 for Marjorie Cobby House

This inspection was carried out on 25th November 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marjorie Cobby House 03/12/08

Marjorie Cobby House 03/01/07

Marjorie Cobby House 07/02/06

Marjorie Cobby House 12/08/05

Marjorie Cobby House 18/02/05

Marjorie Cobby House 16/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Marjorie Cobby House St Peters Crescent Selsey West Sussex PO20 0NA     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: Liz Palmer     Date: 2 5 1 1 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 27 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 27 Information about the care home Name of care home: Address: Marjorie Cobby House St Peters Crescent Selsey West Sussex PO20 0NA 01243605334 01243605334 june.lawrence@westsussex.gov.uk www.westsussex.gov.uk West Sussex County Council care home 34 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 34 The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (OP) Physical disability (PD) Date of last inspection Brief description of the care home Marjorie Cobby House is registered to provide care and accommodation for up to 34 people over 50 years of age for short stays or rehabilitation. There are no permanent or long stay residents accommodated at the home. The home is located near to the centre of Selsey, West Sussex and the accommodation is on two floors served by a passenger lift. There is a courtyard garden, which is well maintained. All residents have their own room although none have en-suite facilities and there is a range of communal space including a separate room for residents who smoke. Part of the premises is dedicated for the rehabilitation service and suitable kitchen facilities are Care Homes for Older People Page 4 of 27 0 3 1 2 2 0 0 8 0 34 Over 65 34 0 Brief description of the care home provided. Residents are referred by health and social services and therefore are subject to a financial assessment to determine the fee payable by them. Rates therefore vary between 89.90 and 451.00 per week depending on the outcome of the financial assessment. Care Homes for Older People Page 5 of 27 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 inspection included a site visit to the home over a period of 5.5 hours, from approximately 10.00am to 3.30pm. During this time three staff were spoken to and the duty officer and registered manager assisted with the inspection. Three service users were met and spoken to privately, others were observed and spoken to during the inspection. Care plans, medication records, policies and staff records were sampled. Other information used to make judgements about the standard of care in the home included the homes Annual Quality Assurance Assessment (AQAA) that they completed and returned to us. We also looked at the last inspection report and other information received by us since the last inspection including notifications of any events in the home. We sent out 10 staff surveys and 10 service user surveys. One Staff survey was returned to us. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 7 of 27 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 8 of 27 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. Current arrangements for assessing people before they move in are mostly thorough enough to assure people their needs can be met. A review of the process would ensure that this would apply to all those are admitted. Evidence: The homes AQAA states; We only accept an admission to the home when all the correct paperwork has been received. Support hospital discharges and help prevent admission. Respond to the needs of the people using the service, by ensuring that a comprehensive social work assessment has taken place before a referral to the home is made. During the inspection we looked at five pre admission assessments. Four of them had a West Sussex Adult Services statement of need assessment which had been completed prior to admission. A care plan is then drawn up by the home. We saw that enough detail was written into the assessments for the home to make a decision about whether or not the person needs could be met there. These details included a medical history, reason for admission, social and employment history, next Care Homes for Older People Page 9 of 27 Evidence: of kin, the persons strengths and needs relating to their personal care and any dietary needs and preferences. One of the assessments we looked at related to someone who had been admitted as an emergency from a hospital accident and emergency department. The duty officer told us they should not be here, we do not ever refuse. The assessment for this person was not as detailed as the others due to the emergency situation. No one who knew the person well was available to support them. There was nothing in the assessment to indicate their needs could not be met in the home, however, after two days records showed that the placement was not suitable. The manager told us that it was not true that they never refuse admissions and that based on what they knew about this person it was a suitable admission. Alternative accommodation had been found for the person and they were moving the following day. The manager is currently reviewing the assessment process after a number of hospital admissions were noted by us. Care Homes for Older People Page 10 of 27 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 have their personal care needs met in a way that respects their views and upholds their right to privacy. Details of how peoples rehabilitation needs are met is not always clear. Improvements need to be made to the medication procedures to ensure people always have the medication they need and it is administered by people trained and competent to do so. Evidence: We looked at four care plans. Two were for people on respite in the home and two were for people who were staying on the rehabilitation unit. All the care plans were seen to contain up to date information about peoples needs and preferences. Care plans were individualised and included risk assessments and manual handling assessments where appropriate. One of the care plans for someone admitted for rehabilitation contained a personal exercise programme to be completed three times daily. When I asked staff about this they were unsure of when this was to be done. One said a physiotherapist comes in to do it. Care Homes for Older People Page 11 of 27 Evidence: Three people were spoken to about their experience of the service. They all said their health and personal care needs were met and their privacy was respected. Those on rehabilitation said they had improved and were looking forward to going back home. All residents are registered with a temporary General Practioner (GP) and daily records showed any concerns about their health and well being are followed up. People said they could see a doctor of they needed to. At the last inspection we made a requirement regarding the recording of medicines received into the home. They have introduced a system for this and the requirement is met. We also made a requirement for the safe storage of Controlled Drugs and we saw that a Controlled drugs cupboard was available however it was not fixed to the wall according to the requirement of the legislation. We observed the duty officer giving out the lunch time medication in the dining room. The medicines are taken out of the cupboard on a lockable trolley. Tablets are then dispensed to small pots and given to the residents. We noted that the duty officer signed the medication record before giving the medication to people. This is considered an unsafe practise because if someone refused their medication the record would be wrong. We also noted that a resident, described by the duty officer as constantly in pain had not been receiving one of her pain killers. We were told that the home had run out the previous day. A repeat prescription had been requested but not yet received. The manager was unaware of this situation and told us that people are always admitted with a 28 day prescription so he could not understand how this had happened. The manager said she would sort this out immediately. During the inspection we saw that some medication, supplied to the home in a monitored dosage system, is then transferred from the original pharmacy supplied and labelled container and placed by a member of the staff, on a daily basis, into another container for later administration by a night carer. The manager told us this is done because the night carers are not trained to administer medication. This is an outdated and unsafe practise and is not in line with best practise as described in The Handling of Medicines in Social Care, produced by The Royal Pharmaceutical Society of Great Britain. This practise was also described as frequently associated with medication errors in a report by the Department of Health, Building a safer NHS for patients. Since our inspection the home has informed us that they have ceased the practise of dispensing medication to secondary pots and the person who had run out of their pain killers now has them. A futher visit was made by the pharmacist inspector on the evening of the 16th December 2009 to check medicine management. We noted that the practice of dispensing medicine into pots to give later had stopped. Care Homes for Older People Page 12 of 27 Evidence: Since our first visit we had received a notification of an error relating to medicines. This was being investigated. The home has good systems and understanding in place around medicine use. It has good record keeping for audit and will deal with issues if they arise for example, the assistant manager had identified that for one person medicine had not been signed as given. She had made a note to herself to investigate this. We investigated this together and found that this medicine was infact not given as their own records allowed an easy check on this. The assistant manager told us that she will investigate this further. Several charts were hand written. These were not signed and dated by the person writting them to take responsibility and accountability. We checked this information against the labelled supply and saw that the information was accurate. To protect the resident against possible harm from inaccuarte transcribing of information the home is advised to check the accuracy of hand written charts before comencing their use. We saw three medicines prescribed to be given only when needed. However there were no guidelines for staff in the care plan on when to give this medicne to ensure consistency. Two people were managing their own medicines. There was a signed consent and a risk assessment on the ability of the resident to manage their own medicine. The resident had a lockable area to store their medicine. The home did not have a detailed individual procedure on how they manage this self administration in the care plan. There were two examples where medicine were prescribed as a variable dose and the actual amount given to residents was not recorded. This had been done in the past but had slipped recently since they had introduced double signatures for giving medicines since the recent error. This meant that there was no space left on the chart to record the amount given. We informed the staff that this information must be recorded. Records around receipts and disposal of medicine were kept. The controlled drugs register is kept and stock levels corresponded to the record in the register, however some training is needed on how to record the information in a robust way. We saw lines being left blank in the register. This is not in line with guideline for good record keeping on controlled drugs. Care Homes for Older People Page 13 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home promotes independence and encourages people to do as much for themselves as they can. Activities are on offer and peoples choices are respected. People say the food is always good and their visitors are made welcome. Evidence: In their AQAA the home states The ethos of the home is to promote independence, and people using the home are fully supported to do this, with a range of activities to help meet their individual needs. Staff are skilled at supporting independence, and helping people who use the service gain confidence. The focus is about what individuals can do, and providing support for things that are more difficult. We respect that people using the service have the right to privacy, dignity and choice. Activities in the rehabilitation unit are provided to support the people using the service to develop or regain the activities of daily living, and enable them to return home safely and with confidence. A notice board at the entrance to the home displays information about forthcoming events. There are quizzes, bingo and regular visits by a hairdresser. Care Homes for Older People Page 14 of 27 Evidence: People spoken to confirmed that they are supported to choose how to spend their time and said they never get bored. Those on rehabilitation said they are encouraged to do as much as they can for themselves and that their activities are focused on them regaining their independence and returning home. Daily records showed that visitors come in and out at varying times. people said their visitors are always made welcome and get offered a cup of tea and can stay for a meal if they book in advance. The AQAA states that dietary needs and preferences of people using the home are managed well. In the dining room meals are taken at a leisurely pace, and staff sensitively support people who need additional help. Monitor food intake for people who may choose to have a meal in their room. Lunch time was observed by us and we saw that food was well presented and served in a relaxed and unhurried manner. Staff were chatty with residents and people said they enjoyed their meal. Care Homes for Older People Page 15 of 27 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 arrangements for complaining ensure people feel able to speak up and be listened to. Safeguarding polices are in place and people are protected by the homes approach to this. Evidence: In their AQAA the home tells us that people using the service, their relatives and carers know the procedure, and are asked to raise any concerns they may have. Three residents spoken to on the day said they could not remember seeing the policy but would talk to the manager or staff if they had any concerns. They said they had nothing to grumble about and were never unhappy. A copy of West Sussex Multi Agency guidelines were seen in the managers office and information about safeguarding was displayed in the entrance. Two of the three staff that we spoke to demonstrated understanding of safeguarding and what their role is in reporting any abuse. A third member of staff said they had not had training recently and were not sure what it was. However, when asked how they would respond if they were told of any or suspected any abuse they knew what to do. There is currently one ongoing safeguarding alert and another one was made by us as a result of the unsafe medication practises in the home, as described in the Health and Care Homes for Older People Page 16 of 27 Evidence: Personal Care section of this report. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have a safe, homely and well maintained environment. Evidence: The homes AQAA states that they provide a safe clean and comfortable environment for people using the service, and provide specialist equipment to meet individual need. During the inspection we saw that the environment was well maintained and comfortable and that specialist equipment and adaptations needed to meet individuals needs were provided. This includes hoists, variable height beds and ceiling tracking hoists. There are four lounges and kitchens located throughout the building. These rooms are homely and individually decorated. There are no restrictions on the use of these and people were seen using them freely during the inspection. People spoken to said they liked the environment and their rooms were kept clean and vacuumed every day. The bedrooms seen were personalised and had suitable equipment, for example a television, bedside light, wardrobe and drawers. Care Homes for Older People Page 18 of 27 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 mix of staff skills and numbers generally meets the needs of those in the home. The home provides suitable training in most areas. Staff say they are well supported, however, are not fully supported by the current arrangements for regular supervision. Evidence: The homes AQAA states that they maintain a flexible staffing level to meet the individual needs of the people using the service. Two of the staff spoken to confirmed this stating that agency are brought in to cover sickness and they are never left short. One member of staff said they sometimes feels like we are left short and are running from one person to the next. The one staff survey returned to us stated that there are sometimes enough staff to meet the individual needs of people. The three people using the service said that staff were marvellous. Two said there were always enough staff to meet their needs and one said they are sometimes short staffed. Those who had used their call bell said it was answered promptly. They said night staff were good and always brought them a drink. At the last inspection we made a requirement regarding criminal record checks being obtained. We saw this requirement to be met. We saw that a new system for recording information about agency staff was in place. This includes confirmation of their identity, criminal record check, experience, training, qualifications and Care Homes for Older People Page 19 of 27 Evidence: references. No new permanent staff have been employed since the last inspection. The three staff spoken to said they felt well supported in their roles. Two said they receive regular supervision and one said they had not had supervision since early spring this year. Records showed that not all staff are receiving supervision on a regular basis. Two night staff were noted as not having supervision since May this year. Another night staff had not had supervision since August this year and the last one recorded before that was in October 2008. Evidence showed that full time day staff were also noted as not receiving regular supervision. Out of the 16 permanent care staff 11 have been trained to National Vocational Level (NVQ) 2 or above. Staff say they have also been trained in all mandatory courses as well as short courses on; palliative care, foot care, and continence care, for example. A sample of certificates were looked at to confirm this. Care Homes for Older People Page 20 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well run by an experienced and qualified manager. Improvements to the monitoring of medication procedures and keeping up to date with current good practise will better protect people. Evidence: Staff and residents spoken to during the inspection all spoke highly of the manager, they said she is approachable and supportive. She has shown us she responds positively to requirements we make and has worked to improve standards in the home. For example meeting all the requirements made at the last inspection has improved the health, safety and welfare of people using the service. However, new requirements regarding medication may mean the manager has not kept herself up to date with current guidance and good practise and may still be putting peoples health and welfare at risk. The homes AQAA tells us that, with regard to health and safety, the appropriate Care Homes for Older People Page 21 of 27 Evidence: checks are undertaken as well as servicing of equipment. Staff confirmed these checks are done and records regarding fire training and safety were sampled and seen to be up to date. The home undertakes its own quality assurance and uses Regulation 26 monitoring visits as part of this. Mostly finances are handled by people who use the service or their advocates. The home will hold small amounts of money for people if they wish, the records and balances for these were not checked on this occasion. At the last inspection a requirement was made regarding the use of foot plates on wheelchairs. There was a wheelchair having footplates adjusted on the day of inspection and staff confirmed that they are always used now. We also made a requirement regarding the use of bed rails and the need for them to be risk assessed. There are currently no residents using bed rails at the moment so we looked at a risk assessment of a recent person admitted who had used them. A brief risk assessment was seen to have been drawn up and the person was moved to a divan bed as part of their preparing to go home. No record of how and when this decision was arrived at was kept. For the purpose of the report the requirement is met, however the manager must ensure all decisions are recorded. Care Homes for Older People Page 22 of 27 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 9 13 In line with Regulation 13(2) 03/01/2009 Controlled Drugs must be recorded and administered in line with legislation. This must happen in order to comply with the law. 2 9 13 In line with Regulation 13 (2) 03/03/2009 all Controlled Drugs must be stored in a cupboard which meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973. This must happen in order to comply with the law. 3 9 13 In line with Regulation 13(2) 03/01/2009 complete and acccurate records must be kept of all medicines received into the home and of all medicines given to people. This must happen so as to show that people get their medicines. 4 29 19 In line with Regulation 19 (1) 03/01/2009 written confirmation must be maintained in the home that CRB disclosures have been obtained for all staff, including agency workers as detailed in CSCI CRB policy guidance issued October 2008. Page 23 of 27 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action This must happen in order that the home can evidence its recruitment practices safeguard people. 5 38 13 In line with Regulation 13(4) 03/01/2009 foot rests must be in place on wheelchairs and used by staff unless it is demonstrated through documented risk assessment this is not in the persons best interest. This must happen to ensure people are not exposed to unnecessary risks. 6 38 13 In line with Regulation 13(4) 03/01/2009 risk assessments must be completed for all people where the decision has been made to use bed rails. This must happen to ensure any risks to people are managed safely. Care Homes for Older People Page 24 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 For han written medicine administration charts to check the accuracy of the information before comencing use of these charts so the the health and welfare of the residents is protected. 31/12/2009 2 9 13 To record tha actual amount given when a variable dose is prescribed by the doctor for medicines so that there is a clear audit of medicines had by the resident 31/12/2009 3 9 13 To fix the controlled drugs cupboard to the wall in accordance with the Misuse of drugs [safe custody] regulations 1973 In order to comply with the law 31/12/2009 Care Homes for Older People Page 25 of 27 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 4 9 13 to have a detailed care plan around the use of medicine prescribed only when needed at times chosen by the residents so that there is consistency and person centered care 31/01/2010 5 30 18 The registered person must ensure a system is in place to monitor that all staff receive regular supervision. This includes night and agency staff. To ensure they are competent to carry out their roles. 14/01/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 26 of 27 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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