Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 18/01/10 for Mavesyn Ridware House

Also see our care home review for Mavesyn Ridware House for more information

This inspection was carried out on 18th January 2010.

CQC found this care home to be providing an Poor 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People tell us they like living at the service and tell us they are well cared for. Comments from people using the service include: `they look after us` and `good care and attention`. People also tell us they get on with the staff with comments such as: `Staff are very kind`, `Good care team`. People are provided with a choice of meals. We found the service to be welcoming and homely offering people a pleasant place to live.

What has improved since the last inspection?

There has been some improvements in the care planning process with staff now being more involved. Improvements have been made to the arrangements for administering medication including the introduction of system for auditing medication.

What the care home could do better:

Care plans still need further development particularly in relation to the needs of people with more complex needs such as dementia and mental heath. There are health issues that need to be addressed to make sure all people`s health care needs are being met. These include making sure people have the chance to have dental checks. The service needs to make sure that everyone working at the service is fully aware of the inter agency safeguarding procedures including the agreed process for referring incidents to the local authority. The service needs to make sure that staff have the knowledge and skills to meet people`s needs relating to their mental health including dementia. Staff files need to be able to demonstrate that staff have had all the necessary pre employment checks. The service needs to have proper record keeping arrangements in place in all cases when they are involved in people`s financial matters. The service needs to ensure that Health and Safety issues are addressed including records of fall audits, making sure training is completed and that checks on fire equipment are undertaken. Regular fire drills should also be completed. We also made a number of recommendations.

Key inspection report Care homes for older people Name: Address: Mavesyn Ridware House Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB     The quality rating for this care home is:   zero star poor 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: Jane Capron     Date: 1 8 0 1 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) 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 30 Information about the care home Name of care home: Address: Mavesyn Ridware House Church Lane Mavesyn Ridware Near Rugeley Staffordshire WS15 3RB 01543490585 01543490585 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mavesyn Ridware Residential Home Ltd care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 21 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 21 Physical disability (PD) 8 Dementia (DE) 6 Date of last inspection Brief description of the care home Mavesyn Ridware is located off a public transport route near to Armitage and Handsacre. It provides care and accommodation to 21 older people. The service stands in its own grounds with stunning views, the gardens are well maintained and offer appropriate seating areas for the people who use the service. The service has a large Care Homes for Older People Page 4 of 30 Over 65 0 21 0 6 0 8 1 3 0 2 2 0 0 9 Brief description of the care home lounge, conservatory and separate dining room. Bedrooms are single occupancy and some have an en-suite facility. The current range of fees are not included in the Service User Guide. People are advised to contact the home directly for this information. The most recent inspection report is available from the home upon request. 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: zero star poor 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 took place over a 12 hour period with two inspectors. The service did not know we were visiting. Prior to the visit we had information from the Annual Quality Assurance Assessment that the service had sent us in July 2009. This is a document that the service completes that tells us about the service they provide, improvements they have made and how they intend to improve the service in the future. We also looked at information that the service sends us about incidents that have occurred. These are a legal requirement. We also looked at information we have about any complaints or safeguarding incidents that have occurred. We received surveys from eight people living at the service, two relatives and seven staff members. At the service we looked at how the service is meeting peoples health and personal care needs and whether peoples privacy and dignity is respected. We also looked at whether people can live the life they want and whether choice is promoted. We looked at how the service is protecting people and whether there are systems in place to listen to the views of people. As part of this inspection we looked around the service Care Homes for Older People Page 6 of 30 including a sample of bedrooms. During the inspection we spoke to people that live at the service, staff and the manager. 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: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 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 9 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. People considering using the service are provided with information about the service to help them decide if it meets their needs. People considering using the service have an assessment of their needs to assist the service to decide if they can provide them with the support they need. People with more complex needs may not always have their needs fully met. Evidence: The services Annual Quality Assurance Assessment that was provided to us last year tells us they complete a pre-admission assessment and that people are provided with information about the service. It also states that people are only admitted if the staff have the skills to meet peoples assessed needs. People that responded to our surveys tell us that they feel that they had enough information about the service to decide if they wanted to move there. We did see a Care Homes for Older People Page 10 of 30 Evidence: copy of the Service User Guide and Statement of Purpose at the service although the service tells us that this is not given to people but provided on request. Some elements do need updating and the service acknowledges this. Examination of files shows that the service completes assessments of people being considered for admission to the service. The services assessment document should enable the relevant information to be gained to enable them to decide if they can meet peoples needs. The service tells us that it only admits people if they are confident that the staff have the skills, ability and qualifications to meet peoples needs. Whilst we feel that the service can meet the needs of older people we did feel that the service needs to ensure that staff have further knowledge in supporting people with dementia care and mental health needs to be able to fully meet the needs of these people. We did not see any specific support in place for either of these groups although the service does have the support from health care professionals to advice them in caring for people with these needs. Care Homes for Older People Page 11 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. Peoples health care needs are generally being met but there remain areas to be improved to fully meet peoples needs. People living at the service are treated with respect and dignity. The medication administration procedures are making sure people receive their medication as prescribed. Evidence: The AQAA tells us that each person has a care plan and that the person or their family is involved in its development. It also tells us that staff receive regular health care support and have a choice over how their personal care is provided. An examination of documents confirms that everyone has an individual plan. At our last inspection we saw progress had been made in developing person centred plans and on this occasion we saw that the manager is continuing to try to develop these plans. We did feel however that some plans are confusing as two sets of plans are present in some files. We would advice that the service uses one type of plan and that any old plans are not kept with the current ones. Plans although at times difficult to understand did contain relevant information about peoples individual needs. We did Care Homes for Older People Page 12 of 30 Evidence: however still see there are gaps in some of the information. In some files there is little information about peoples social care needs. Also where people have communication needs, plans should contain detailed information to enable staff to understand how a person communicates. One we saw said communicates in her own way with no specific information about how the person communicates their needs. We also saw gaps in the information relating to peoples mental health and how this affects them and how staff should respond to needs resulting from these conditions. We were somewhat reassured as generally staff could give a verbal update of peoples needs. Plans are being reviewed every month. We saw that peoples care is not always agreed with the person concerned or their relatives. People that use the service do have access to health care services and they are supported by visits to the home by health care professionals. The visiting district nurse told us that she is confident the staff do report individual concerns to them or the doctor. A GP. that responded to our survey said that they feel that peoples health needs are usually met. They commented looks after [people ]well, liaising closely and appropriately with Community Nurses and Doctors. The service did tell us that people do not have regular dental checks and the service must make arrangements to ensure people have this option available. We saw that people at risk of pressure sores are provided with equipment such as pressure relieving mattresses and cushions. We did however notice that one person with diabetes recently admitted for respite care was not having their sugar level taken. The manager subsequently told us that this has been addressed. The service has put in nutritional assessments but we would ask that the service consider the appropriateness of the current system. For example one person was assessed as low risk but other information such as a history of poor eating and having a pressure sore indicated a higher risk level. The service is regularly weighing people. All risk assessments are generally completed but we could not see adequate information that show the actions taken to try and minimise the risks identified. There is evidence to show that the service is meetings peoples personal care needs. We saw that the service was identifying how people should have their personal care needs met and that people have a choice of having a bath or shower. People appeared to be suitably dressed and well groomed. People that answered our surveys tell us that they always or usually receive the care they need and comments include they look after us and good care and attention. Relatives too said that the service always or usually provides people with the support they need. Care Homes for Older People Page 13 of 30 Evidence: We saw that staff spoke to people in a respectful manner and people are complimentary about the staffs attitude. Staff could tell us how they made sure that peoples privacy is respected and dignity upheld. We saw that the home has a medication policy which is accessible to staff. Medication records are up to date for each person including medicines received, administered and disposed of. There is evidence that the home complies with the administration, safekeeping and disposal of controlled drugs. Staff spoken to have a good knowledge of the medication being administered and the procedures to follow. Monthly medication audits are completed by the senior person on duty however this is not included in the quality assurance document held by the manager. Care Homes for Older People Page 14 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. Some activities are available but more could be provided including for those people with dementia and mental health needs. People are provided with a choice of meals. Evidence: The services AQAA tells us that people are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. It also tells us that there are regular themed evenings and trips out. The service also tells us that there are sufficient staff available to allow time for activities and stimulation. We feel that the information in the AQAA concerning activities does not give us an accurate description of the current situation. We feel that there are limited activities provided and this is the fourth inspection where we have raised concerns over the quality of the lifestyle people can enjoy. The manager tells us that there has only been one opportunity for people to go on a trip over the last year and that there has only been one themed evening. No activities are available in the mornings. The service provides one afternoon of organised activity; movement to music and we saw this was enjoyed by people. The hairdresser also visits once a week. Staff tell us that any other activities are their responsibility and this occurs on a hit and miss basis when they have the time. There are no records of these activities but we are told that they Care Homes for Older People Page 15 of 30 Evidence: include crafts, bingo and dominoes. There is no schedule of activities displayed although we did see a poster stating that a theatre group was due to visit the service. When we raised the absence of activities with the manager she told us that people did not want to take part. We feel that the manager needs to address this issue looking at what activities people wish to do and considering more individual activities. The service provides care to people with mental fraility but the service has not properly developed social care histories to give them a fuller understanding of their previous lifestyle. The service tells us it has not developed any activities to meet these peoples social care needs. One person we spoke to clearly responded to sensory items but none are provided to them by the service. The manager did tell us that there are some reminiscence items but these are not used. In respect of activities we had a mixed response to our surveys. Four said activities are always available whilst two said they are sometimes available. When we asked what the service could do better comments included provide more activities and need few more activities. We also had a relative contact us with some concerns, one of which was that people are left in front of the television with little staff interaction. One staff survey also identified a need to do different activities and to spend more time with the people that live there. We also have some concerns about whether the service is always meeting peoples spiritual needs. We saw that one persons spiritual needs are being met, being visited regularly and the staff responding to their dietary needs. Another person identified as having spiritual needs saw the vicar three times over the last year although this was due to occur monthly. We raised this with the manager and she reported that the vicar did not visit often but she had not considered any other ways of meeting this need. Visitors are welcomed to the service and we saw several during our visit. We saw that people have the choice to spend time in their bedroom or in the communal rooms. People are able to make their bedrooms their own bringing in small items of furniture and personal possessions. The standard of meals was raised at the last inspection. We feel that his has improved. On the day we visited a choice of meals was shown on the menu board. Also the cook tells us that if someone asked for something else they would try and provide it. Drinks and snacks are available throughout the day and night. The manager did tell us that they intend to review the menus and to include people in making choices about the food. People spoken to say they like the meals. Comments include meals good and provides good food. This view was also that of a relative Care Homes for Older People Page 16 of 30 Evidence: who said that the food is good. Some people that need support with eating are provided with it. Peoples weight is being monitored. 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. People feel able to raise issues and feel that they are responded to. Further action needs to be taken by the service to make sure that people are fully safeguarded. Evidence: The AQAA states that the complaints policy is available in the entrance hall and that notices are around the service. It also says that complaints are listened to and acted upon promptly. We saw that there are copies of the procedure in each persons bedroom although the contact details for the commission were incorrect. The manager was aware of this and said she has plans to update them. The AQAA tells us that peoples views are also obtained through regular forums and one to one meetings. However when we asked about this the manager said that forums do not take place as people do not wish to attend. All except one person that responded to our survey say they know how to make a complaint. Relatives say that they feel the service responds to concerns. The service does not have any system in place to record any complaints or concerns. We advised the service to put this in place so that information about any complaints is readily available and can be audited as part of their quality monitoring. The service tells us that it has received no complaints since the last inspection. We, the Commission, have received a concern from one relative. This person also contacted the service but the manager could not locate the information but did tell us she has taken action to address the issues. Care Homes for Older People Page 18 of 30 Evidence: The AQAA tells us that the service ensures that staff comply with the procedures relating to protecting and safeguarding people. It states all staff have training in the protection of vulnerable adults. The training records show that staff have not had any recent safeguarding training. We spoke to two members of staff and they could tell us about the signs of potential abuse and that if they have any concerns they would refer the issue to the manager. However neither staff member knew what was expected of the manager if they referred an incident. This was the case when we visited last time and we had advised the service to discuss the safeguarding process at a staff meeting. Since the last key inspection there have been two safeguarding incidents one that came to light immediately following this inspection. Both these are in the process of being investigated. One incident does raise some concerns as it was not reported to the manager until some days after the incident indicating that the staff member did not feel confident to report it. We are also concerned that the service did not follow the correct procedure in referring the matter to the local authority. We looked at a sample of staff files as part of this inspection and out of four files three had some gaps in the records. Care Homes for Older People Page 19 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. The service provides people with a pleasant and homely place to live. Evidence: The AQAA tells us that the service is well lit, clean and tidy and smells fresh. It also states that rooms are homely, comfortable and cosy with personal belongings. The home generally provides a welcoming and homely environment for people. The service has suitable communal rooms including a conservatory although we told that this is cold in winter. The service tells us it has plans to improve the heating to make it more comfortable for people to sit in. The service provides suitable bathing and showering areas. We looked at a sample of bedrooms and those that have been redecorated and upgraded are of a good standard. There are about five or six that still need to be upgraded. The service appears to be generally clean and tidy. There are infection control procedures in place and staff spoken to have a good understanding of the importance of using protective clothing to prevent the spread of infection. 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. People can be confident that there are sufficient staff available to provide them with support but cannot always be confident that they have the knowledge to meet more complex needs. Evidence: The AQAA states that the service offers the necessary number and skill mix of staff to meet peoples needs. it also states staff are trained and that pre employment checks are made. The staffing levels remain unchanged since we visited last time having three care staff on duty throughout the day and two staff on duty overnight. Six of the eight people that answered our survey said that staff are always available. Other comments included [staff]good to speak to when I can get hold of them and could do better communication with residents. People generally feel that they are listened to by staff. We also received some positive comments about staff including staff are very kind and good care team. Records show that the service supports people to complete NVQ training. Currently nine out of 13 care staff have achieved an NVQ qualification. The service does provide staff with additional training in such areas as diabetes and medication. As the service does provide a service to people with dementia and mental health the service needs to Care Homes for Older People Page 21 of 30 Evidence: ensure that staff have more knowledge and understanding in these areas. Staff that responded to our surveys say that have training to meet peoples needs. Sampling of four staff files shows there to be gaps in the records of three of them. The file of the most recently recruited staff member had all the necessary checks in place. Other files contained evidence of police checks but lacked some references and information to confirm peoples identifies The manager was advised of the need to adhere to Schedule 2 of the Care Standards Act with regard to record keeping. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be confident that the service is well led and managed and that their safety is always promoted. Evidence: The services AQAA tells us that the management team are very committed to ensuring the health, welfare and safety of the people that live there and the staff. There has been no change to the management arrangements since we visited last. Although the manager is trying to improve the service we are concerned over the level of progress being made. As on the four previous visits there remain concerns over the lifestyle people enjoy. We have also noted some issues over peoples health care support and over the information in some care plans particularly for those people that have more complex needs. There are also concerns over the information in plans to address peoples risk of falls. The manager tells us that she audits the falls but does not record this. On this occasion we saw some gaps in the employment records. We also have concerns over the time available for management tasks. Over the previous Care Homes for Older People Page 23 of 30 Evidence: month the manager has only one day a week to undertake management tasks. The service provided us with an AQAA in July 2009. Information in this AQAA does not always reflect the current service. For example it states that people have trips out and themed evenings but these only occurred once last year. It also states that resident forums take place but the manager said this did not happen. It is unclear whether these previously took place or whether the AQAA was not providing accurate information. The service is undertaking some monitoring checks on the service. Annual surveys of people and relatives are completed and there is a check list to assess how admissions are completed. The service has started to complete an environmental check on the service. Medication audits are completed but are not used as part of the system for checking the quality of the service. A robust system of monitoring and review would identify many of the areas we have highlighted in this report enabling the service to take action to address them. The service is looking after small amounts of peoples money. We did a check on two peoples money and the amounts balanced with the records. The service did tells us that a care worker is banking money on behalf of a person that lives at the service. In such a situation we would expect the service to maintain appropriate records both to safeguard the person and the staff member. The service has Health and Safety procedures in place. A fire risk assessment has been completed. An examination of the fire records shows that the fire alarm has not been tested for over a month and the emergency lights not tested since October 2009. There were no records of fire drills for 2009. The service provides Health and Safety training but we found gaps in the records including those for fire training. We issued an immediate requirement to address these issues as they are placing people at risk. We have also referred the service to the fire authority. We also observed some trip hazards in the building including a carpet near the lift and trailing TV wires and call bell leads. 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 1 38 23 All staff must have up to 20/01/2010 date fire prevention training. This will make sure that staff are confident in fire safety and will increase peoples protection. 2 38 23 Fire drills must take place on 20/01/2010 a regular basis This will make sure that staff know how to respond in the event of a fire. 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 8 12 Arrangements must be made for people to have dental checks. This will promote peoples oral care. 09/03/2010 2 8 12 The person admitted with diabetes must have the necessary support to monitor their health. This will ensure this persons health is promoted. 01/03/2010 3 18 13 The service must ensure that all staff are fully aware 02/03/2010 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 of the agreed interagency safeguarding procedures including the process of referring incidents to the local authority. This will ensure that staff are aware of their responsibilities and that any potential incidents are properly referred for investigation. 4 29 19 Where there are gaps in the staff employment records the service must take action to address them. This will improve the protection for the people living there. 5 30 18 Staff must have the knowledge and skills to be able to support people with needs relating to mental health issues including dementia care and mental disorder. This will ensure that people with these needs are provided with the support they need. 6 35 13 Where the service is banking 02/03/2010 money for a person a proper record must always be kept. 20/03/2010 03/03/2010 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 This will make sure that everyones financial interests are safeguarded. 7 38 13 The service should record its 10/03/2010 audits on falls within the service including the actions taken to reduce them. This will evidence that the service is taking action to reduce the likelihood of falls. 8 38 13 The service should 16/03/2010 undertake a hazard analysis of the building particularly in relation to slips, trips and falls. This will provide people with a safer environment. 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 Person centred plans should contain all the relevant information to support staff to provide people with the support they need, particularly in respect of people with more complex needs. The service should review it current nutritional assessment document to ensure that it is the most relevant tool for the people it cares for. The service should look at ways of meeting peoples spiritual needs. People should have more opportuntity to take part in activities of their choice both in and out of the service. The Page 28 of 30 2 8 3 4 12 12 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations provision of activities should take account of peoples individual and diverse needs including those people with needs relating to dementia care and mental disorder. 5 16 The complaints procedure should provide the correct address of the Commission to enable people to make contact with it if they wish. The service should ensure that the manager has sufficient time to undertake the management tasks required. The manager must keep up to date with current practices including being competent in such areas as person centred planning, risk management and quality audits. The service should put in place a robust method for reviewing and monitoring the service. 6 7 31 31 8 33 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. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!