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Inspection on 12/10/09 for Michaelstowe Hall Residential and Nursing Home

Also see our care home review for Michaelstowe Hall Residential and Nursing Home for more information

This inspection was carried out on 12th October 2009.

CQC found this care home to be providing an Poor 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 24 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

The entrance hall and communal rooms in Oaklands are well decorated and comfortably furnished. Staff were observed to be friendly and welcoming in their approach with residents and their relatives.

What has improved since the last inspection?

Two satisfactory references are now obtained for new staff prior to employment at the home. The laundry rooms had been tidied and although in need of redecoration were well organised with shelving and clothes rails for sorting linen and personal clothing.

What the care home could do better:

There is insufficient information readily available in the home for potential residents and their representatives. There was no copy of the previous inspection report on display in the entrance of the home. Assessments are not sufficiently robust. Care plans have been recorded as having been reviewed but there is no monitoring to ensure recommendations have been actioned. For example one resident`s review instructed staff to refer to the GP for antibiotics but several months later this had still not been actioned. The standards of personal care and healthcare are poor, particularly in the nursing unit (Greenlands). Clear evidence of neglect was observed on the second day of the visit to the home with one resident found lying in faecal stained sheets for several hours and no record of any care being carried out for approximately six hours. Progress previously made to strengthen communication with healthcare professionals had regressed. Residents with specific healthcare needs had not been promptly referred to the GP or tissue viability nurse. Instruction from a GP to regularly monitor a resident`s blood pressure had not been actioned. Standards for end of life care were poor. Care plans frequently did not record residents` wishes following death or their preferred place of care. Most residents in Greenlands who had high dependency needs were isolated in their rooms with their doors closed and no access to a call bell. There were a number of shortfalls in medication found. One resident who was self medicating had no lockable facility for storage of their medication which is a risk to others who may access their room. Risk assessments were recorded but did not demonstrate how the risk was to be minimised. For example one resident was prone to falls but the risk assessment stated what was to be done in the event of a fall rather than how to reduce the risk of a fall. There is a lack of choice for residents and a lack of stimulation. Residents who are able have a programme of activities they can take part in and some can go on outings. However this relies on the support of volunteers. There are no therapeutic activities, for example hand massage for those people being nursed in bed. This means that residents in Greenlands have little stimulation or interaction with other people. The meals comprise homely type food that most residents enjoy. However there is inadequate monitoring of nutritional intake and poor recording of output. There is a lack of action taken following an identified weight loss. One relative told us that their loved one had lost weight and now they have snacks provided. However the snacks recently introduced are not offered to residents and therefore rely on residents who are able to request something themselves. There are insufficient slings available for individual use and recommended made to purchase additional slings at the previous inspection had not been actioned. Hoists had not been upgraded as also required at the previous key inspection. Complaints are not investigated to the satisfaction of complainants and there was no record of complaints available for inspection. One relative told us that the manager wrote their concerns down but no action was taken and they would then need to tell someone else. There had been ten safeguard referrals made none of which had been referred by the home. Infection control standards are of concern. Hand gel was provided in the sluice room for staff use but they was not available for individual use or in key clinical areas. One resident had an MRSA infection. However there was no notice to indicate this and no provision of gloves and aprons in the room. Whilst the malodorous smell had been removed from the identified rooms at the previous inspection, there remained a smell of urine in some areas of the home. Sheets and towels were thin and frayed and stocks were low. Relatives told us that the bedding was not changed frequently enough and they therefore took the laundry home for laundering themselves. There was no pandemic plan to be used in the event of an outbreak of infection. The acting manager was not aware of the infection control policies and procedures. Information provided to the home on swine flu had not been shared with staff. Staffing levels were inadequate to meet the needs of residents on both units. The one registered nurse on duty on Greenlands Unit was also providing management cover for the whole of the care home which is unsafe practice and does not ensure that the nursing needs of residents can be appropriately met. There was a lack of staff support and staff supervision was inadequate. There were few staff meetings held and staff did not feel confidant to use whistle blowing procedures for fear of reprisal from management. There was no registered manager and we were informed that the current manager had given their notice. The one registered nurse on duty was also acting as manager which is unsafe practice. There had been no formal c

Key inspection report Care homes for older people Name: Address: Michaelstowe Hall Residential and Nursing Home Ramsey Road Ramsey Harwich Essex CO12 5EP     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: Diana Green     Date: 2 1 1 0 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 38 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 38 Information about the care home Name of care home: Address: Michaelstowe Hall Residential and Nursing Home Ramsey Road Ramsey Harwich Essex CO12 5EP 01255880308 01255880907 Michaelstowehall@btconnect.com none Handylodge Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 84 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: Persons of either sex, aged 40 years and over, who require nursing care by reason of a physical illness/disability (not to exceed 10 persons) Persons of either sex, aged 55 years and over, who require care by reason of dementia (not to exceed 15 persons in woodlands unit) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 15 persons in Woodlands unit) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 46 persons in Oakland Unit) Persons of either sex, aged 65 years and over, who require nursing care by reason of a Care Homes for Older People Page 4 of 38 Over 65 15 46 23 15 0 10 physical illness/disability (not to exceed 23 persons) Staffing levels to be reviewed within 6 months of registration. The registered person must not admnit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 The total number of service users accommodated in the home must not exceed 84 persons. Date of last inspection Brief description of the care home Michaelstowe Hall provides personal and nursing care with accommodation for up to 84 older people and can accommodate 10 service users aged 40 years and above with a physical disability. Michaelstowe Hall is owned by a private organisation named Handylodge Ltd. The home is located in the village of Ramsey, Harwich, Essex. The home was opened in 1995 and is a 3 storey Victorian building. The home is divided into 3 separate units: Oaklands, which provides personal care only, Greenlands, which provides personal and nursing care and Woodlands which provides dementia care. There are 64 single rooms including 60 with en-suite toilet facilities and 14 shared rooms, all with en-suite toilet facilities. There is a passenger lift. The home has large attractive gardens overlooking open countryside and a courtyard garden accessible to wheelchair users. Michaelstowe Hall is accessible by road and has good bus links. Parking is available in the car park. The fees range from £390.39-£496.69 for nursing care with other costs indicated by individual needs. Additional costs apply for hairdressing, newspapers and chiropody. This information was provided to CQC on 10/12/2009. 1 4 1 0 2 0 0 8 Care Homes for Older People Page 5 of 38 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: The quality rating for this service is zero star poor service. This means that people who use this service experience poor quality outcomes. This unannounced inspection took place on 12th & 21st October 2009. Two inspectors including a pharmacist inspector were present on the first day of the visit to the inspection. All of the Key National Minimum Standards (NMS) for Older People, and the intended outcomes, were assessed in relation to this service during the inspection. This report has been written using accumulated evidence gathered prior to and during the site visit, including the homes Annual Quality Assurance Assessment (AQAA). The Annual Quality Assurance Assessment (AQAA), which is required by law to be completed by the service, is a self assessment that focuses on how well outcomes are being met for people using the service. This was not received by the due date and a reminder letter was therefore sent before the completed AQAA was received from the registered provider. Information received in the AQAA provided us with some detail to Care Homes for Older People Page 6 of 38 assist us in understanding how the registered persons understand the services strengths and weaknesses and how they intend to address them. The inspection process included reviewing documents required under the Care Home Regulations. A number of records were looked at in relation to residents, staff recruitment and training, staff rotas and policies and procedures.There was no manager on duty on either days of the visit to the service. The one registered nurse was also covering the manager position. Time was spent talking to residents, their relatives, the registered provider who attended for part of the first day of the visit to the service and to staff as their time allowed. Care Homes for Older People Page 7 of 38 What the care home does well: What has improved since the last inspection? What they could do better: There is insufficient information readily available in the home for potential residents and their representatives. There was no copy of the previous inspection report on display in the entrance of the home. Assessments are not sufficiently robust. Care plans have been recorded as having been reviewed but there is no monitoring to ensure recommendations have been actioned. For example one residents review instructed staff to refer to the GP for antibiotics but several months later this had still not been actioned. The standards of personal care and healthcare are poor, particularly in the nursing unit (Greenlands). Clear evidence of neglect was observed on the second day of the visit to the home with one resident found lying in faecal stained sheets for several hours and no record of any care being carried out for approximately six hours. Progress previously made to strengthen communication with healthcare professionals had regressed. Residents with specific healthcare needs had not been promptly referred to the GP or tissue viability nurse. Instruction from a GP to regularly monitor a residents blood pressure had not been actioned. Standards for end of life care were poor. Care plans frequently did not record residents wishes following death or their preferred place of care. Most residents in Greenlands who had high dependency needs were isolated in their rooms with their doors closed and no access to a call bell. There were a number of shortfalls in medication found. One resident who was self medicating had no lockable facility for storage of their medication which is a risk to others who may access their room. Risk assessments were recorded but did not demonstrate how the risk was to be minimised. For example one resident was prone to falls but the risk assessment stated what was to be done in the event of a fall rather than how to reduce the risk of a fall. There is a lack of choice for residents and a lack of stimulation. Residents who are able have a programme of activities they can take part in and some can go on outings. However this relies on the support of volunteers. There are no therapeutic activities, for example hand massage for those people being nursed in bed. This means that residents in Greenlands have little stimulation or interaction with other people. The meals comprise homely type food that most residents enjoy. However there is inadequate monitoring of nutritional intake and poor recording of output. There is a Care Homes for Older People Page 8 of 38 lack of action taken following an identified weight loss. One relative told us that their loved one had lost weight and now they have snacks provided. However the snacks recently introduced are not offered to residents and therefore rely on residents who are able to request something themselves. There are insufficient slings available for individual use and recommended made to purchase additional slings at the previous inspection had not been actioned. Hoists had not been upgraded as also required at the previous key inspection. Complaints are not investigated to the satisfaction of complainants and there was no record of complaints available for inspection. One relative told us that the manager wrote their concerns down but no action was taken and they would then need to tell someone else. There had been ten safeguard referrals made none of which had been referred by the home. Infection control standards are of concern. Hand gel was provided in the sluice room for staff use but they was not available for individual use or in key clinical areas. One resident had an MRSA infection. However there was no notice to indicate this and no provision of gloves and aprons in the room. Whilst the malodorous smell had been removed from the identified rooms at the previous inspection, there remained a smell of urine in some areas of the home. Sheets and towels were thin and frayed and stocks were low. Relatives told us that the bedding was not changed frequently enough and they therefore took the laundry home for laundering themselves. There was no pandemic plan to be used in the event of an outbreak of infection. The acting manager was not aware of the infection control policies and procedures. Information provided to the home on swine flu had not been shared with staff. Staffing levels were inadequate to meet the needs of residents on both units. The one registered nurse on duty on Greenlands Unit was also providing management cover for the whole of the care home which is unsafe practice and does not ensure that the nursing needs of residents can be appropriately met. There was a lack of staff support and staff supervision was inadequate. There were few staff meetings held and staff did not feel confidant to use whistle blowing procedures for fear of reprisal from management. There was no registered manager and we were informed that the current manager had given their notice. The one registered nurse on duty was also acting as manager which is unsafe practice. There had been no formal consultation with residents or their relatives since the previous key inspection and there was no annual plan available. Information received in the AQAA was brief and lacked detail of how the registered persons intended to improve outcomes for residents. Notifications of serious illness and adverse incidents were still not reported to the commission despite this being a requirement at the previous key inspection. Risks of hot water and fire safety (door closures) had not been addressed. There were no reports available from the registered provider visits as required under regulation 37. 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. Care Homes for Older People Page 9 of 38 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 10 of 38 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 11 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People planning to live at Michaelstowe Hall cannot be assured they will receive all the information they need to enable them to make a decision or that their individual needs will be fully assessed prior to admission. Evidence: There was no statement of purpose or service user guide on display in the nursing unit (Greenlands unit) of the home. The nurse in charge stated that they had been shown a copy of the documents. However an admission checklist was seen that was signed by a resident confirming they had been given a service user guide. Copies of the statement of purpose and service user guide were provided by the administrator later during the inspection. The service user guide was brief and did not include all the information required (i.e. contract, terms and conditions, fees, complaints procedure etc.) There was no copy available of the previous key inspection report on display for visitors information to enable them to gain an insight into how the service was meeting the Care Homes for Older People National Minimum Standards or Care Homes Care Homes for Older People Page 12 of 38 Evidence: Regulations 2001. The admission procedures were discussed with the nurse in charge who confirmed that they had not admitted any service users to the home. They did state, however that in the event of a new admission, a pre-admission assessment would be undertaken either in hospital or at their home to ensure their needs could be met. However it was not clear how this could work in practice as there was only one nurse on duty and the home could not be left without a registered nurse. In addition the one registered nurse was also the acting manager for the whole home including the residential unit (Oaklands Unit). Pre-admission assessments were viewed for five residents. All contained an assessment form that included all elements as detailed under this standard. However it was evident during the inspection that residents with a mental disorder had been admitted for which the home is not registered to provide care. This indicates that a full assessment had not been undertaken prior to admission. The home does not provide intermediate care. Care Homes for Older People Page 13 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Michaelstowe Hall cannot be assured that their personal and healthcare needs will be met. Arrangements for medication storage must be improved to ensure the security and quality of medicines in use. People may be put at risk by not being given medication as prescribed by their doctor. Risk assessment and risk management plans need to be improved to safeguard people living at the service. Evidence: Two relatives spoken with in Oaklands confirmed they were aware of the care plan but only the initial care plan and were not clear if this had been reviewed. They told us that communication was a problem, for instance, they were not informed when there had been a change in the key worker. They told us the care is fine. Its the administration. However they also told us they needed to remind staff to carry out personal care tasks, for example cleaning dentures. Five residents care records were viewed during the site visit. Records were inconsistently recorded. One resident was spoken with and evidently had a mental disorder for which the home is not registered to provide care. This had been highlighted during a recent review undertaken by a social worker following concerns raised. Care Homes for Older People Page 14 of 38 Evidence: Evidence of the residents or representatives agreement was seen in each of the care plans viewed. Nutritional risk assessments were undertaken and reviewed with weight monitoring also undertaken one to two monthly provided residents were able to use the scales. However one resident had lost 2.4kgs in two months but no action had been taken. The records instructed staff to carry on with routine care. Risk assessments were seen for risks associated with manual handling, use of bedrails, tissue viability and nutritional risk. However these were not sufficiently detailed. For example a risk assessment for falls did not detail how the risk was to be minimised, but only the action to be taken in the event of fall. Records were seen in residents rooms for recording personal care and continence. However the standard of entries seen were poor, stating pad changed rather than whether the pad had been wet or soiled which would show more accurate monitoring of the residents output. Residents records viewed during the two site visits confirmed that they were registered with a local GP practice and received visits on request. We were informed that district nurses visited to provide nursing care to residents in Oaklands Unit on request. A relative spoken with during the visit to the service confirmed that their loved one received visits from a chiropodist and that staff called the GP when needed. However during the second visit to the service, clear evidence of neglect was observed in the nursing unit. One resident who was being nursed in bed and was confused and unable to call for assistance was observed with faeces on their hands and lying in faecal stained sheets. The resident had a fungating cyst that was being treated and left on an open dressing. The cyst had a strong offensive odour indicating that the would was infected. The room door was closed and there were flies in the room and around the resident. There was no records of any care having been given from 10:40 hours until 16:20hours when this was brought to the attention of the nurse in charge. The care plan stated take period wound swab for as appropriate antibiotic whenever the cyst is discharging and offensive. The care plan had been reviewed monthly. Entries dated 23/06/2009 and 24/07/2009 instructed staff to take a wound swab and refer to the GP for antibiotics. However there was no record of action been taken. The nurse subsequently contacted the GP surgery who confirmed they had received no referral regarding the cyst since 23/06/2009 although the records confirmed the resident had been seen by a GP on 13/08/2009. Most medicines are stored securely for the protection of residents but we saw that where people look after their own medicines in their rooms these were not always locked away and could be accessed by other people and people they were not prescribed for. The risks to people about this had not been assessed for one person and for another the risk assessment was not up to date. The main medicine storage Care Homes for Older People Page 15 of 38 Evidence: areas provide a suitable environment to ensure the quality of medicines in use but on one unit we saw that the temperature of the fridge used to store medicines had been recorded outside the recommended maximum on several occasions without any action taken to investigate the performance of the fridge or the quality of medicines stored there. The failure to store medicines at the correct temperature may result in people receiving medication that is ineffective. The cupboard used to store controlled drugs on Oaklands does not comply with the Regulations. We looked at medication and medication records for several people living in the home and, in general, they were in good order and demonstrate that people receive the medicines prescribed for them. However, we noted that the instructions on the medication for some people indicated that it should be given regularly but the record made when their medication is given shows it to have been omitted as it was not required. It is important that people receive their medication in line with the prescribed instructions. We watched medicines being given to some people at lunchtime and this was generally done well but we saw that one person who was prescribed a medicine on a when required basis for pain was given the medication without being asked if they needed it. We looked at the care plan for one person who has diabetes and this stated that his blood sugar should be monitored weekly, but the record made when this was done was often less frequent than this and there was no recorded target level of what the blood sugar level should be. We also looked at a care plan for one person who regularly refuses their medication and, although the care plan noted that this had been discussed with the residents doctor and a decision made to take the residents blood pressure daily, the records showed that this had not been done since 9th September 2009. One person is prescribed continuous oxygen therapy but the care plan did not indicate the flow rate the equipment should be set to, nor was there a risk assessment or risk management plan in place for its use. On the second day of the visit to the service there were three care staff on duty. A number of residents room doors were closed with care staff attending at intervals to provide personal care. Between visits by staff, three residents who were unable to use the call bell system were observed left alone with no evidence of any stimulation, for example television or music playing. The care records of one resident who had communication difficulties were viewed. There was no record of any visits being made Care Homes for Older People Page 16 of 38 Evidence: by staff for several hours to provide drinks or to check if they were comfortable. Personal care was observed to be provided in private in residents rooms. However there were frequently no staff in evidence to monitor and supervise residents. Care staff were observed to enter rooms without knocking and were evidently rushed indicating they would not have sufficient time to uphold dignity. Some rooms included personal items of furniture but others were bare and a number had no lockable facilities to enable residents to keep their personal items and valuables safe or for safe storage in the event that a resident chose to self medicate. Care Homes for Older People Page 17 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Michaelstowe Hall have limited opportunities for social activities and community contact resulting in some experiencing isolation. There are limited choices of food and not enough emphasis on ensuring nutritional needs are met. Evidence: The home employed an activities coordinator who worked five days per week. A social activities programme was seen on display in both Oaklands and Greenlands Unit with a variety of activities on offer. Several residents were observed taking part in a social activity in Oakland unit during the visit to the service. A relative told us that the social activities and entertainment are good and gave an example of an event the previous week when an entertainer encouraged the residents to sing along with them. They also told us their loved one uses a walking stick and would like to walk a bit more but no one offers to help. Outings were arranged weekly for a small number of residents who were able. Trips were arranged by the activities coordinator with the use of the bus owned by Friends of Michaelstowe Hall and supported by volunteers. The activities coordinator said that they did go to see residents who were nursed in bed in Greenlands unit. However apart from infrequent visits by the coordinator to individual residents there was no social activity support for residents in Greenlands unless they were able to go to Oaklands unit. The care plan of one resident who was confused and Care Homes for Older People Page 18 of 38 Evidence: was being nursed in bed was viewed. The care plan stated the resident loves music. Yet during the day of the visit to the service there was no music or TV playing in their room. The resident was observed isolated in their room with the door closed. The personal activities record was viewed and entries were recorded weekly to two weekly and mainly referred to chats. There were only two entries dated 27/04/09 and 8/11/09 that referred to music being played. These stated sang to radio and sang along to radio. This indicated that minimal stimulation was being provided for the resident and almost none that they had stated a preference for. Several relatives were spoken with during the visit to the home and all confirmed they could visit during the day, evenings and at weekends. We were informed that a communion service was arranged for residents and the local church magazine provided to the home. No residents were taken out to church. There was currently no contact with local groups in the area. During the visit to the home residents were observed to be in one of the lounges in Oaklands (the second lounge was not in use) or in their own rooms. In Greenlands Unit most residents were in their own rooms with their doors closed and were being nursed in bed. There was no evidence either from the care plans or observation that they had been offered a choice of how or where they spent their day. Some residents rooms were seen to be personalised with their own belongings (photos, pictures, ornaments etc.). However a number had no personal items and no lockable facility for safe storage of their valuables. There was no information on advocacy services seen on display in the home. The kitchen was viewed and was clean and well organised but the decor was shabby and the equipment was well used and could do with being upgraded. Menus were seen on display in the kitchen and corridors of the home but not in the dining room. We were informed that residents are offered a choice of food the evening before for the main meal of the day. Consequently most residents had forgotten what they had chosen and needed to be reminded and the set menus that were available were subject to change. However during the morning of the visit to the home we were informed that the cook was with a resident discussing their choice for their main meal. Information was received that food stocks were low. Stocks were checked and were observed to comprise a variety of fresh, frozen and dried produce. Fresh fruit and vegetables and fruit juices were also seen in storage. We were informed that only one fresh vegetable was provided daily although there were stocks of frozen vegetables in stock. Frozen food included sausage rolls and pasties that we were informed were given for tea with sandwiches, crackers and cheese and powdered soups. No homemade soups were provided for residents. We received information that no food Care Homes for Older People Page 19 of 38 Evidence: was available for residents during the evenings. We discussed this with a cook who told us that sandwiches are made up every evening for residents. However these were evidently provided on request rather than being offered routinely and we were informed that the kitchen was locked after 7pm although some food was available in a second fridge. One relative told us they had recently introduced snacks in the evenings and told us their loved one had lost weight and they realise it. The lunch-time meal was observed being served to residents in the dining room/lounge of Oaklands Unit on the first visit and comprised chicken pie, mashed potato and cabbage with gravy; one resident was served a cheese salad as their alternative choice. The tables were observed laid with cutlery and condiments but there were no tablecloths or flowers on the tables. Bottles of salad dressing and tomato sauce were observed left out rather than being kept in the fridge as directed on the bottle. Despite being brought to the attention of staff they were still left out on the return visit. The lunch time meal was observed being served in Greenlands Unit during the second day of the inspection. This comprised toad in the hole or sausage rolls with potatoes, fresh broccoli and gravy followed by a desert of home made cherries and almond cake with custard. Several residents were served in their own rooms. When food was being taken to individual rooms, food was left uncovered on the trolley. Some plates were returned with food left on the plate. One resident was seen in their room asleep having eaten very little and remained asleep while the food was left to go cold. A relative told us that their loved one needs help cutting their food up but this is not always offered. Another relative told us that their loved ones meal is served in their room as is their choice but that the cutlery is not always provided complete. A relative told us the food is good but too much is served and it has improved immensely. Care Homes for Older People Page 20 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Michaelstowe cannot be assured their concerns or complaints will be acted upon or that they will be safeguarded from abuse. Evidence: We were informed that the home had a complaints procedure. From information received and discussion with relatives it was evident that written complaints had been made. However there was no record of complaints available for inspection. Several relatives stated they did not know who to speak to if they had a complaint and any concerns they raised were not addressed to their satisfaction. The home had a safeguarding policy and procedures. Staff training records viewed confirmed that all staff had received training in safeguarding adults with updated training provided during March, April and October 2008. The nurse in charge said that they had not received updated training since being employed at Michaelstowe Hall. However they were able to demonstrate a good understanding of the procedures to be followed. A whistle blowing policy was also available. However staff spoken with indicated they did not feel able to use the whistle blowing policy for fear of disciplinary action being taken against them. There had been ten safeguard alerts made in recent months alleging poor standard of personal care, health care and neglect. The homes recruitment procedures were inspected and confirmed that all relevant checks were undertaken prior to appointment. Care Homes for Older People Page 21 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Michaelstowe cannot be assured they will live in a safe, clean or comfortable environment. The standards and practices for infection control place people at risk. Evidence: A tour of the premises was made during the two visits to the home, concentrating on Oaklands Unit on the first visit and Greenlands Unit on the second visit. The entrance to Oaklands Unit was secure with a door entry system in place. The large reception area had a table with visitors book and some information provided. The front of the home was laid to lawn with shrubs and car parking for visitors. We were informed that since the previous key inspection the exterior of the home had been decorated. However the rear of the home (Greenlands) which overlooked open fields looked neglected with weeds, empty hanging baskets and was clearly in need of decorating. On the first day of the inspection the door bell was rung four times before it was eventually opened by the one registered nurse on duty. The telephone was constantly ringing very loudly which was intrusive for residents, most of whose needs were very dependant and were being nursed in bed. Several residents rooms, communal rooms, bathrooms, a shower room, the kitchen and laundry were viewed. The entrance hall, stairs and communal rooms in Oaklands unit had been redecorated within the previous two years and were pleasantly decorated and carpeted. However some individual residents rooms were sparsely furnished and in need of redecoration and radiator Care Homes for Older People Page 22 of 38 Evidence: covers that had been fitted prior to the previous key inspection had still not been painted. Parts of the home were generally clean. However a smell of urine was present in the corridors and some residents rooms. A number of rooms and bathrooms were evidently not in use and had no bins. The bathroom sink used for hairdressing was in needs of descaling and a chair for use by residents was shabby. The home employed a maintenance person and there were systems in place to ensure regular maintenance checks of the home were made. Records viewed and information received confirmed that the home did not comply with all requirements of the local fire and environmental health department. For example room door closures had not been installed. However the maintenance person informed us that an order had been placed for purchase of the door closures. Greenlands Unit was purpose built single storey accommodation. Oaklands Unit had stairs and a passenger lift to enable access throughout the premises. There were grab rails in corridors and aids in bathrooms and toilets whilst available were old and in need of replacement. Action had not been taken to replace hoists recommended for upgrade at the previous key inspection. Call systems were provided throughout communal and individual rooms to enable residents and staff to call for assistance. However several residents were observed during both days of the inspection to be left unsupervised and without access to a call bell. Residents who were not able to use the call systems were observed left in rooms with doors closed which did not facilitate staff to appropriately monitor their well being. There was a smell of urine was present in some residents rooms and corridors of the home. Some residents rooms and en-suites were not adequately cleaned, for example the carpet in one room was heavily stained and in an en-suite, the toilet was stained with faeces and a urine bottle was left half full with urine. In another bathroom the toilet was obstructed by boxes of incontinence products. There was no pandemic plan available in the event of an outbreak of infection. The nurse in charge had no knowledge of infection control guidelines or where these could be found for staff guidance. Staff had personal protective clothing (aprons, liquid soap and paper towels) for use when providing personal care in residents en-suites and bathrooms. However there were no personal protective clothing in a residents room who was confirmed to have MRSA and antibacterial gel was not provided to staff individually for their protection but was only provided in the sluice room. Another residents room had no paper towels for use by staff when providing personal care. The laundry room was large with two washing machines and two driers that were in working use. Washing machines had sluice facilities (able to wash at 65 degrees centigrade for a minimum of 10 minutes) to minimise the risk of infection. A separate room was provided for sorting and ironing residents clothing. This contained a standard iron and ironing Care Homes for Older People Page 23 of 38 Evidence: table, hanging rails and shelving with baskets for organising residents clothing before returning to them. The room appeared well organised with few items of clothing in storage. One relative spoken with said they had previously had problems in laundry not being returned and now took responsibility to launder their loved ones personal clothing. Two other relatives spoken with said that sheets and bed covers were not laundered frequently enough, bedding did not match and personal clothing was not returned. They had therefore also taken responsibility to launder their loved ones clothing themselves. The linen cupboards were inspected. Sheets and towels were observed to be low in stocks and some were frayed and threadbare. We were informed that new stocks of towels and face cloths had been purchased but only new face clothes were evident in the stocks seen. One linen cupboard was very untidy and appeared not to have been cleaned for some time. There were a number of cases and bags of clothing stored on the floor. Some sheets and blankets were observed to be labelled with a healthcare service and a commercial laundry. Care Homes for Older People Page 24 of 38 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels at Michaelstowe Hall do not provide assurance that residents needs can be appropriately met. Evidence: Staffing levels were discussed with the nurse in charge and duty rotas were viewed. These comprised: Greenlands Unit for seventeen residents: Day- 1 registered nurse 2 care assistants ( 1 providing assistance with drinks/meals) Night - 1 registered nurse 1 care assistant Oaklands unit for seventeen residents: Day - 1 senior care assistant 2 care assistants Night - 1 senior care assistant 2 care assistants There was no manager on duty at the time of the visit. The duty rotas were not accurate as one staff member had reported sick and been replaced by another but the duty rota had not been amended to reflect this. In addition there was no provision on the duty rota to indicate the times the manager would be on duty. We were informed that the current manager was on sick leave and the one nurse on Greenlands was also covering the managers position. In addition to the nurse in charge there was one administrator, a maintenance person, four domestic staff, an activities coordinator (first visit only), one cook and two kitchen staff on duty. During the second visit to the home, staffing levels were clearly inadequate to meet residents needs. Staff were rushed when providing personal care to the very dependant residents in Greenlands, were clearly task driven, having no time to spend interacting with residents and were observed to be neglectful in not attending to one resident for several hours. We were Care Homes for Older People Page 25 of 38 Evidence: informed that when there was no senior care assistant on duty, the registered nurse came from the nursing unit to administer medication and that the medication round takes between 30-45 minutes. We were also told by a relative that staff from the nursing unit come to the residential unit to assist their loved one to bed. Clearly this leaves inadequate levels of staff on the nursing unit to safely care for residents. The AQAA informed us that there were 22 care staff employed by the home of which 50 had an NVQ qualification. The recruitment files for three recently employed staff were viewed. All files included evidence that the relevant checks (CRB, two satisfactory references, full employment history, identification etc.) were undertaken prior to appointment. The files also included terms and conditions of employment and evidence of induction to skills for care standards. Evidence that systems were in place for the checking on current Nursing and Midwifery Council (NMC) registration for registered nurses was also seen. The training records were viewed and confirmed that mandatory training in health and safety, manual handling, fire safety etc was provided. A copy of the training matrix was also provided and confirmed that a regular training programme was in place. Since the previous key inspection in-house training had also been provided in diabetes care, nutrition, infection control, food hygiene and dementia care. Care Homes for Older People Page 26 of 38 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. There is lack of leadership and supervision in the home placing residents and staff at risk. Evidence: It is of concern that the home has now been without a registered manager for more than one year. A relative told us there is no-one in charge and it is not clear whether he (the current manager) manages or not. Also stating that any concerns were written down and the next time someone else wrote the same concerns down but no action was taken. The home needs someone to take decisions and ensure it is done. The AQAA informed us that we are disappointed that the manager was not interviewed for registered manager. However two applications were returned to the applicant as they were incomplete. No complete application was received by the commission which is a requirement before an interview can be arranged. On both days of the inspection of the home there was no manager on duty. We were informed that he was on sick leave, although he had previously informed us that he had submitted his notice. The one registered nurse working on Greenlands was also covering the Care Homes for Older People Page 27 of 38 Evidence: manager position for the whole home. One registered nurse is not adequate to meet the nursing needs of residents, most with very high dependency needs without having to also cover the manager position and is considered unsafe practice. Staff employed at the home are therefore without clear leadership and appropriate supervision. From discussion with the administrator and staff it was evident that there was no quality assurance programme in operation. There had been no service user or relative questionnaires distributed and there was no annual plan for the home. The Annual Quality Assurance Assessment (AQAA), a self-assessment which is required by law to be completed by the service and focuses on how well outcomes are being met for people using the service, had not been returned to the Commission by the required date and a reminder letter was therefore sent. Detail provided in the AQAA was brief but included most of the information asked for. Prior to the inspection we sent surveys for distribution to service users and health and social care professional to seek their views on how the service was doing. However no completed surveys were received by the commission. There were no internal audits available for inspection. No registered provider reports (required under regulation 26) were available for inspection. There had been no staff meetings or relatives meetings arranged for some considerable time until recently when prompted by the local authority. One staff member told us there had been some meetings this year but could not remember when. Communication with staff appeared to be mainly in the form of memos rather than face to face meetings. A copy of the staff meeting minutes dated August 2009 were later provided. It was also confirmed that the minutes of the meeting held prior to that were dated June 2008. The arrangements for handling residents monies were discussed with the administrator. We were informed that systems had recently been reviewed in line with the local authority. We were informed that three residents pensions were collected on their behalf. Each resident managed their own monies with support of a relative. The home held the personal allowances for some residents who had a relative to manage their finances on their behalf. The personal allowances and records were inspected for four residents. The amounts of money were present and correct for all four with records of transactions made and receipts held as evidence. The AQAA informed us that staff were empowered and supervision was provided every two months. However we observed numerous memos displayed in the office with instructions for staff. There was only evidence of three meetings having been held with staff in the last fifteen months. This does not demonstrate an open management style nor show that staff are supported in their work. A member of staff also told us they were short staffed and felt there was no support for them. Supervision records Care Homes for Older People Page 28 of 38 Evidence: were viewed and these confirmed that supervision meetings had been held at two monthly meetings. However the records were brief and did not demonstrate that staff were appropriately supported through discussion of care practices or concerns they may have in their work. The care records were held in the staff office in Greenlands in a lockable filing cabinet and in the staff office in Oaklands on shelves. This is of concern as the office door is left open and the room is frequently left unattended. Residents personal information was also seen on the notice board in Greenlands where the door is left open and accessible to the public. Notifications required under regulation 37 had been received by the commission for deaths at the home. However no notifications had been received regarding accidents and incidents. Staff had evidently been completing the notifications which were seen during the visit to the home. However the administrator was not aware these needed to be forwarded to the Care Quality Commission and neither the manager nor registered provider had ensured this was actioned. The home had a health and safety policy and procedures in place for staff guidance. The records confirmed that staff had attended health and safety training following appointment. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g.checks on fire equipment, fire alarms and emergency lighting etc.). The fire alarm was heard being tested during the visit to the home. Care Homes for Older People Page 29 of 38 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 7 15 Care plans must include clear 14/11/2008 guidance for staff to monitor and review residents ability to self care. Without clear guidance for staff residents may not be monitored and their personal and health care needs may not be met. 2 8 37 Notifications of serious illness 21/11/2008 and adverse incidents must be reported to the CSCI without delay. Incidents not reported to CSCI do not ensure close monitoring of residents care nor represent an efficient and effective management. 3 22 23 Baths and hoists must be upgraded as indicated in the servicing reports. Without a safe system for bathing residents they may be a risk of accident or injury. 31/01/2009 4 31 9 The manager must be registered under the Care Standards Act 2000. Without a registered manager effective leadership and supervision cannot be 31/12/2008 Care Homes for Older People Page 30 of 38 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 assured. 5 37 37 Regulation 37 notifications 31/12/2007 must be forwarded to the CSCI for all events that adversely affect the wellbeing or safety of a resident. 6 38 37 Notifications must be submitted for any event which adversely affects the well-being or safety of any service user. Without notifications being submitted it cannot be assured that residents are protected by the management arrangements of the home. 30/11/2008 Care Homes for Older People Page 31 of 38 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 1 5 The service user guide must be reviewed to include all information required. This will enable people planning to live at the home to make an informed decision. 15/01/2010 2 3 14 Residents must not be admitted to the home without a full assessment of care needs. Without a full assessment it cannot be assured that the persons needs can be appropriately met. 31/12/2009 3 7 13 Risk assessments must demonstrate how risks have been minimised. This will safeguard residents. 31/12/2009 4 8 13 Residents must be referred to a GP when there is an identified health need. 31/12/2009 Care Homes for Older People Page 32 of 38 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 ensure they receive appropriate treatment. 5 9 13 Where medication is stored in peoples room there must be risk assessment and risk management plans in place. This will safeguard residents. 6 9 13 Medication must be stored securely, under suitable environmental conditions and medicines controlled under the Misuse of Drugs Act must be stored in accordance with the Act and associated Regulations. This will prevent unauthorised access to medicines, ensure the quality of medicines in use and comply with legal requirements. 7 9 13 Medication must only be given in line with prescribed instructions. This will ensure people receive the medicines as prescribed for them. 8 10 12 Residents must have their 31/12/2009 personal care needs met in a respectful manner without being rushed. 30/10/2009 30/11/2009 30/10/2009 Care Homes for Older People Page 33 of 38 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 ensure their privacy and dignity is upheld. 9 12 16 All residents must be 30/11/2009 enabled to take part in social and therapeutic activities that meet their individual needs and preferences. Residents who do not receive social contact and mental stimulation may become isolated and depressed. 10 13 16 Residents must have more opportunities for involvement with the local community groups. This will enhance residents lives. 11 15 16 Snacks should be prepared and offered to residents in the evening. This will ensure they receive suitable nutrition and are not undernourished. 12 15 17 Nutritional records must be accurately maintained and appropriate action taken when a resident loses weight. This will ensure residents receive adequate nutrition. 31/12/2009 31/12/2009 30/11/2009 Care Homes for Older People Page 34 of 38 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 13 16 22 Complaints must be fully investigated in line with the homes procedures and a record made available for inspection. This will ensure issues of concern are appropriately addressed and used to improve the service. 31/12/2009 14 18 12 Staff must be supported and 31/12/2009 confident to use whistle blowing procedures. This will safeguard residents. 15 19 23 The programme of redecoration must include individual residents rooms. This will enhance the environment for residents. 15/01/2010 16 19 23 The gardens must be appropriately maintained. This will provide a pleasant outlook for residents. 31/03/2010 17 22 16 Additional sheets and towels 15/01/2010 must be purchased. This will ensure residents do not have to use thin, frayed towels and sheets. 18 25 13 Hot water temperatures must be within 43 degrees centigrade. 31/12/2009 Care Homes for Older People Page 35 of 38 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 safeguard residents from scalding. 19 26 13 Malodorous smells must be removed from the home. This will minimise the risk of infection to residents. 20 26 13 Staff handwashing facilities (paper towels and liquid soap) must be provided in all areas where personal care is provided and clinical areas. This will minimise the risk of infection. 21 27 18 Staffing levels must be increased to meet the dependency needs of residents. This will ensure there are sufficient staff to meet residents needs. 22 31 8 A manager must be appointed to the home. This will provide staff with leadership and ensure that the home is appropriately managed. 23 33 24 The quality assurance programme must be developed to include regular consultation with residents 31/01/2010 01/03/2010 31/12/2009 31/12/2009 31/12/2009 Care Homes for Older People Page 36 of 38 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 and their relatives and other stakeholders. This will demonstrate that the quality of care is regularly reviewed and that stakeholders views are taken into account. 24 38 13 Room door closures must be 15/01/2010 fitted in line with fire safety regulations. This will safeguard residents. 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 1 The statement of purpose and service user guide and a copy of the most recent inspection report should be available in the home for residents and their representatives information. To ensure residents are aware of their choices current menus should be readily available. To ensure mealtimes are an enjoyable experience tables should be laid attractively with table cloths, napkins and condiments. To protect the health and safety of residents and staff the home should have a pandemic plan to be used in the event of an outbreak of infection. The systems for staff supervision should be developed to ensure it covers all aspects of practice, the philosophy of care in the home and career development opportunities. 2 3 14 15 4 26 5 36 Care Homes for Older People Page 37 of 38 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. 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