Inspection on 22/09/09 for Mersey Parks

This inspection was carried out on 22nd September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mersey Parks 30/10/07

Mersey Parks 12/06/06

Mersey Parks 04/12/05

Mersey Parks 28/06/05

Mersey Parks 28/02/05

Mersey Parks 27/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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: Mersey Parks 99 Mill Street Liverpool Merseyside L8 5XW     The quality rating for this care home is:   two star good 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: Jeanette Fielding     Date: 2 4 0 9 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 26 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 26 Information about the care home Name of care home: Address: Mersey Parks 99 Mill Street Liverpool Merseyside L8 5XW 01517094791 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): pollardj@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 150 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The registered person may provide the following categories of service only: Care home with nursing: Code N, to people 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: Code OP (maximum number of places: 60). Dementia over 65 years of age: Code DE(E) (maximum number of places: 90). The maximum number of people who can be accommodated is: 150. Date of last inspection Brief description of the care home Mersey Parks is a purpose built home, built approximately fifteen years ago. The home comprises five separate buildings, each having a separate management and staff structure. One of the houses, Sefton, is currently closed and care is therefore provided in four houses. The home is registered to provide care for people aged over 65 years. Springfield House provides general nursing care, Princes House provides personal care, Care Homes for Older People Page 4 of 26 0 0 Over 65 90 60 Brief description of the care home Greenbank House provides nursing care for elderly people with dementia and Stanley House provides personal care for elderly people with dementia. Each house provides thirty bedrooms together with lounge and dining areas. Mersey Parks is close to local shops and amenities and is located within a short car/bus ride to Liverpool City centre. The fees charged by the home are from 390 to 702 pounds per week depending on the level of care required. Care Homes for Older People Page 5 of 26 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: two star good 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 key inspection was undertaken on three consecutive days over a period of twenty three hours. As part of the inspection process, each of the four houses of the home which are currently operational were viewed including many of the service users bedrooms. Assessments and care plans were inspected together with staff records and certification to ensure that health and safety legislation was complied with. Observation of the interaction between staff and people who live at the home provided further evidence of the actual care given. The care files of thirteen service users were case tracked to evaluate their care. Discussion took place with the Responsible Individual, Care Services Manager, unit managers, nurses, care staff, service users and visitors to the home. The registered manager had completed an Annual Quality Assurance Assessment form prior to the inspection to give additional information regarding the home. Care Homes for Older People Page 6 of 26 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 26 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 26 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. Comprehensive assessments are undertaken on all prospective service users to ensure that the home can meet the individuals, health and social care needs. Evidence: The home provides a full information pack for prospective service users. It includes details about the services and facilities available through BUPA and those available at Mersey Parks. These are issued to all prospective service users or their families and are readily available in the foyer of the administration building. The details about Mersey Parks now needs to be updated to reflect changes that have taken place within the home. Information is also available about funding and advocacy. The home produces a newsletter and these are also available on request. All prospective service users are fully assessed prior to their admission. These assessments are undertaken by the unit manager or a suitably trained person to establish the needs of the service user to confirm that the home can meet those Care Homes for Older People Page 9 of 26 Evidence: needs. The pre-admission assessments of service users recently admitted to the home were inspected and were found to be detailed and informative. Information is gathered from the service user, their family and healthcare professionals who have been involved in their care. A specific form is completed which includes information about health needs, abilities and social needs together with details about individual preferences. This information is used to prepare the initial plan of care which provides information for the staff team. The preadmission assessments for service users who have recently been admitted to the home were inspected and all were found to contain full information to demonstrate that the home can meet their individual needs and preferences. Prospective service users and their relatives are welcome to visit the home to view rooms available and to meet with staff and other service users prior to making a decision regarding their care provider. The home does not offer intermediate care. Care Homes for Older People Page 10 of 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are provided with health and personal care in a way that shows respect for their privacy and dignity. Evidence: Individual care plans are prepared for each service user by the house managers. Each house provides for a specific care need and the unit managers are each responsible for their own houses. Care plans are initially prepared based on the information gathered at the pre-admission assessment, and then built on and updated as more information is gathered about the service user or as their care needs change. All care plans are reviewed on a monthly basis and whenever the needs or condition of the service users change. All service users are fully reassessed every six months and family members are encouraged to take part in the review process. Regular audits of the care plans ensure that they are up to date at all times. Detailed information is recorded to inform staff of the care required and of more specific details about how that care is to be delivered. Information is also recorded regarding individual preferences such as preferred time of rising or going to bed, daily routines and likes and dislikes. Dietary preferences are recorded together with preferred gender of the person to provide Care Homes for Older People Page 11 of 26 Evidence: personal care. Spiritual needs and preferences are recorded and any specific communication requirements. Detailed risk assessments are undertaken and comprehensive risk management plans are prepared to remove or reduce any potential risks. Moving and handling equipment, assisted bathing aids and pressure relieving equipment are available in the home and are used following a detailed assessment of need. All staff have been given training in the use of equipment to ensure that service users are protected. All accidents are recorded and the registered manager undertakes a review of accidents on a monthly basis. A sample of thirteen care plans were inspected across all four houses to evaluate the care required and to ensure that the appropriate level of care was provided. The home uses a dedicated system for recording information and it was evident that staff were following the procedures for recording that information. Care plans for service users who display challenging behaviors would benefit from additional information to ensure that staff are made fully aware of the actions to be taken in specific circumstances. Staff spoken to during the inspection were able to demonstrate that they had full knowledge of each service users needs and individual preferences. Daily records are completed by the staff and provide evidence of the actual care provided. These records provide evidence that the healthcare needs of the service users are met. Specific charts are maintained where the needs of the service users identify these as necessary i.e. turning, fluid intake and dietary intake. A high number of incidents have been reported to CQC in relation to aggression displayed by service users which has impacted on other service users. Discussion regarding this took place with the Care Services Manager and the Regional Manager. The management should consider reviewing the staff numbers and/or deployment of the staff to provide additional supervision of service users who display aggression to ensure the protection of all other service users. In all units, staff were observed in their interactions with service users. All staff were seen to speak and deal with service users in a respectful manner. Privacy and dignity were respected by the staff. Some members of staff spoken to during the inspection said that they had recently been moved from one house to another due to one of the houses being closed. The explained that it was taking time to get to know the service users that they were now caring for and had not had the opportunity to read the care files. Three members of staff said that they were not happy with the changes. Care Homes for Older People Page 12 of 26 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. There is a lack of social activities which means that service users do not have the opportunity to participate in stimulating or meaningful activities of their choice. Evidence: The home employs three activities co-ordinators although, at present, one is currently off sick. The records of activities show that very few activities are provided, and that only a small number of service users have one to one time with the co-ordinators. These one to one sessions are primarily spent chatting, with no stimulating activities being provided. Each house displays a programme of activities but there is no evidence to suggest that these events take place or that service users are stimulated. Care staff organise specialised events within each house and service users are involved in the preparations. A recent event was themed on a cruise, with each house providing stimulation based on a particular country. Service users said that they enjoyed this event and confirmed that they had been involved in the preparations. Staff are currently preparing for the Christmas event. Service users spoken to said that there was nothing for them to do during the day. One activities co-ordinator was observed to spend time with a small group of service users and was showing them photocopies of old photographs of the local area. There was no opportunity for the service users to discuss the pictures or to comment on their memories of the areas. Care Homes for Older People Page 13 of 26 Evidence: The care file for one service user states that they enjoy playing musical instruments but no provision is made for this. One care file states that the service user requires one to one stimulation but had only three sessions with the co-ordinator over a period of one month, each just being chatting. The care files inspected identify individual preferences in relation to activities but there is no evidence to suggest that these have been taken into consideration when preparing the programme. Meals are prepared in the main kitchen by qualified chefs. The menus show that a choice of meals is offered and that a varied and balanced diet is provided. Menus are produced in written and pictorial format to enable service users to choose their meals in a format appropriate to them. The chef confirmed that service users can choose alternative meals to those identified on the menu. Service users can take their meals in the dining areas, lounge or their own bedroom as they wish. Dining tables were attractively laid with tablecloths and condiments. The meals served during the inspection looked and smelled appetising. Special diets are provided where necessary and discussion with the chef confirmed that details about all special diets are available in the main kitchen. Service users can request a cooked breakfast, cereal of their choice, porridge, toast and marmalade and hot drinks. Individual packs of sauces and jams were available but the home is changing the provision of condiments to small containers. Service users said that they enjoyed their meals but in the survey sent out by CQC, one service user reported that the meals were not horrible. The survey was anonymous and so it is not possible to speak with the service user to enable their choices to be identified. Each house has a small kitchenette where snacks and drinks are prepared. A supply of additional snack foods, bread, milk and other items are stored in the kitchenettes to provide service users with snacks and drinks during the day or night on request. The food is transported to the individual houses in heated trolleys and is served direct to the service users by the senior person on duty. Staff were observed to assist service users with their meals where necessary. Meals were unhurried and staff sat with service users and assisted them in a dignified manner. Staff coats and personal items were noted in the kitchenette on Stanley House and should be removed. Relatives and friends are free to visit service users at any time and each house has been provided with a small lounge area where they can meet. Service users are free to meet with their visitors in one of the communal areas or in their bedroom as they wish. Relatives spoken to said that some of the staff were extremely welcoming. Care Homes for Older People Page 14 of 26 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. Service users and relatives are able to complain about the home and action is taken to respond to their concerns. Evidence: The home has a comprehensive complaints procedure and details of how to make a complaint are displayed in foyers throughout the home and is detailed in the service user guide. The home maintains full records of complaints made and these records show that all complaints have been fully investigated and that the outcome is given to the complainant. Fifteen complaints have been made in the last twelve months and all have been dealt with in a timely manner. Three service users said that they would speak with the house manager if they had any concerns and four said that they would speak with their relatives. Staff spoken to confirmed that they were aware of the procedure to be followed in the event of a complaint being made, but in the surveys sent out by CQC, two respondents said that they would not know what to do. This has identified a training need for staff in relation to the complaints procedure. All staff have been given training on the protection of vulnerable adults during their induction training and additional training and updates on this have also been given. Evidence of this training is held on the staffs individual files and in the minutes of staff meetings. Staff spoken to were able to demonstrate that they were aware of the different types of abuse and would report any concerns to the house manager or registered manager. The home has a comprehensive whistleblowing policy which has Care Homes for Older People Page 15 of 26 Evidence: been issued to all staff. A new managing customer expectations policy has been introduced and training will be given to staff with regard to this. Policies and procedures are readily accessible to all staff. Records held by CQC confirm that the registered manager has reported all incidents to CQC and to Liverpool Safeguarding Unit when necessary. A high number of referrals to Safeguarding have been made, primarily in relation to the aggression displayed by service users. Care Homes for Older People Page 16 of 26 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. Every effort has been made to provide service users with a pleasant and homely environment in advance of the planned programme of improvements for the home. Evidence: Mersey Parks is a large, purpose built home which provides five separate houses for care provision and a central building for administration, catering and laundry services. At present, one of the houses, Sefton, is closed and so only four houses are operational. Each house is on a single level and provides full access to people who have mobility difficulties or require the use of a wheelchair. Ramps provide ease of access and three houses are accessed via a covered walkway. It is evident that relatives and staff have been involved in personalising service users bedrooms. All service users are encouraged to bring pictures, photographs and items of memorabilia in to make their room homely and to reflect their lifestyle. Some bedroom furniture has now become worn and faded. Decor is generally good and staff spoken to said that they tried hard to keep the houses clean and pleasant and were looking forward to the commencement of the improvement programme. Care Homes for Older People Page 17 of 26 Evidence: The home employs maintenance personnel to attend to repairs and general maintenance. Plans are in place for the programme of redecoration and refurbishment to be implemented but no specific date has yet been set for the commencement of this. Princes House. There was a lack of paper towels and waste bins in toilets and bathrooms. One bathroom, 35, was noted to have a stained bath mat and a dirty towel. No plugs were provided for the bath or washbasin and the extractor fan was not working. Staff stated that this bathroom is not used but there is no notice indicating this. One area of the home was noted to be malodorous and particularly unpleasant. Stanley House. One bathroom and one toilet were noted to be malodorous. Springfield House. There was a lack of bins and staff stated that these had been ordered and their delivery awaited. Vacant bedrooms require to be thoroughly cleaned, rubbish and clothing removed and made available for new service users. The linen store was extremely untidy and contained a supply of lumpy pillows. Some lumpy pillows were found on beds and require to be replaced. A large supply of unnamed clothing was seen in one of the storage areas. Efforts should be made to return the clothing to the correct service users. The cleaning trolley is stored in the room which has now been designated as a staff changing area. Greenbank House. The furniture in rooms 16 and 20 require to be thoroughly cleaned as it is soiled and dirty. The sluices are extremely malodorous and this has impacted on the corridors, bedrooms and communal areas. Staff stated that this is due to the sluicing machines which are not in use. Confirmation was received from the Care Services Manager that the problems caused by these machines are to be addressed. Staff spoken to said that they had sufficient equipment in each unit to meet the needs of the service users. Aids and adaptations are provided together with assisted bathing facilities. Each house has a small, secure garden area which can be accessed from the lounge and from the patio doors in some bedrooms. Improvements have been made to the gardens to provide service users with a safe environment. Plants and flowers have been provided and the staff of each house have been actively involved in providing a pleasant garden area. Seating is provided and service users were observed to be using the gardens. Care Homes for Older People Page 18 of 26 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 has a robust recruitment policy to ensure that service users are provide with care by appropriately trained and competent staff. Evidence: The home employs qualified nurses, Senior care assistants and care assistants to provide care and support to the service users. A bank of staff are employed to cover sickness and annual leave and, on occasions, agency staff are employed. The home has a robust recruitment procedure. All prospective staff are required to complete an application form prior to being called for interview. Two references and taken and checks are made through the criminal records and protection of vulnerable adults bureaux. Staff files were inspected and all were found to contain full information as required. Details of training courses are recorded in the files and this provided evidence that a high number of training events are offered to all staff. The files for recently employed staff provided evidence that induction training is given. At present, 55 percent of the care staff hold NVQ qualifications and additional staff are currently working towards these. Training is given to the qualified nurses to ensure that they have the skills and knowledge to provide the specialist care necessary. Surveys were sent to staff by CQC and a good response was received. In the surveys, staff expressed concerns about the number of staff on duty in each of the houses. Care Homes for Older People Page 19 of 26 Evidence: They stated that when a member of staff goes off sick, staff are moved from another house to cover, thereby leaving the second house short of staff. One respondent was not happy with the recent changes in the home, requiring them to work in a different house due to one of the houses closing. Some of the respondents reported that they felt supported in their work, but some reported that they were not. In discussion with the staff at the time of the inspection, some said that they were not happy with moving to another house but understood the reason for it. Staff spoken to had a clear understanding of their role and said that they enjoyed their work. They confirmed that a high number of training events took place and all confirmed that they enjoyed the training and learned from it. Staff said that the service users were not provided with stimulating activities and felt that more could be done. They were extremely enthusiastic about the plans for Christmas activities and had a high number of ideas about how these could be arranged. One member of staff offered to take a day off for the activities so that she could come into the home in her own time so that the care of the service users would not be compromised. A high number of incidents have been reported to Safeguarding in relation to aggression of service users. The number of staff on duty in each house should be reviewed to ensure that service users are supported and supervised according to their individual needs and behaviours. Staff meetings are held on a regular basis and minutes of the meetings are held. These meetings provide an opportunity for open discussion and the dissemination of information. Staff are given supervision on a regular basis and annual appraisals are undertaken. Service users spoken to described the staff as caring, helpful and kind. In the survey forms sent by CQC to service users, one respondent said that there were never enough staff. Care Homes for Older People Page 20 of 26 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. There is a high level of management support within the home to oversee and improve the running of the home and the care of service users. Evidence: Since the last inspection, there has been a change in the management of the home. The new manager is a qualified nurse and is experienced in the management of care services. An application to register the manager is to be submitted to CQC. The manager is supported by senior management within BUPA. Regular audits on all aspects of the home are undertaken on a regular basis. Each house within the home has a care manager who is responsible for the day to day running of the house and the care of the service users. The manager meets with all house managers on a daily basis to ensure that she is made aware of all issues and to disseminate information. The home is supported by a national team of Quality and Compliance Officers whose Care Homes for Older People Page 21 of 26 Evidence: role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. Polices and procedures are regularly reviewed and updated where required. The home has an annual internal and external customer satisfaction survey and the findings are used to identify where improvements can be made. Health and safety meetings take place on a regular basis and the records held in the home provide evidence that all issues are addressed. The premises and equipment within the home are checked on a regular basis and certification of this is held. Where possible, service users or their relatives deal with personal financial matters. The home has an interest bearing bank account for service users which they can use on request. Care Homes for Older People Page 22 of 26 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 23 of 26 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 12 16 A programme of suitable and meaningful activities is to be prepared based on service users choices and abilities. To provide stimulation to the service users 20/11/2009 2 31 8 An application to register a 20/11/2009 manager of the home should be submitted to CQC. To take responsibility for the running of the home. 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 16 Training on the procedure to be followed in the event of a complaint or concern being made should be given to staff where necessary. Efforts are to be made to ensure that all offensive odours are removed. The staffing levels should be reviewed to ensure that Page 24 of 26 2 3 26 27 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 sufficient staff are provided at all times to meet the needs of the service users and to ensure their protection. Care Homes for Older People Page 25 of 26 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 26 of 26 - 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!