Inspection on 22/09/09 for Parkview Rest Home

This inspection was carried out on 22nd September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Parkview Rest Home 23/09/08

Parkview Rest Home 19/10/07

Parkview Rest Home 12/06/06

Parkview Rest Home 27/10/05

Parkview Rest Home 20/07/05

Parkview Rest Home 17/03/05

Parkview Rest Home 02/08/04

Parkview Rest Home 13/02/04

Similar services:

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Abbey The

Grayling

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Cranworth Close Registered Care Home

Muston Road (70)

The Cornerstone

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Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for older people Name: Address: Parkview Rest Home 7/8 North Park Road Heaton Bradford West Yorkshire BD9 4NB     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Stephen Marsh     Date: 2 2 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 29 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 29 Information about the care home Name of care home: Address: Parkview Rest Home 7/8 North Park Road Heaton Bradford West Yorkshire BD9 4NB 01274544638 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Susan Linda Crabtree,Mr Stewart Leonard Crabtree care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia learning disability old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Park View is a detached building that provides accommodation for twenty-three people requiring residential care. Bedrooms are located on both the ground and first floor of the building and a passenger lift has recently been installed to assist people with mobility problems to reach the accommodation and facilities on the first floor. The home is adjacent to Lister Park in the Heaton area of Bradford. It is close to local Care Homes for Older People Page 4 of 29 Over 65 4 2 16 1 0 0 0 0 2 3 0 9 2 0 0 8 Brief description of the care home amenities and a bus route. Level access is available to the rear of the property along with a small car park. Well kept gardens are to the front of the home where people can sit and enjoy the good weather. The current fees for the service range from three hundred and seventy five pounds per week to five hundred pounds per week. A full list of charges can be obtained by contacting the home direct. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of this service was the 23 September 2008. Since then we have improved our practice when making requirements to improve national consistency. Some requirements from previous inspections may have been deleted or carried forward as recommendations, but only when it is considered that people that use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The inspection process included looking at information we have received about the service since the last key inspection, as well as this unannounced visit to the home, which was carried out by two Inspectors between 10:00 and 18:00 hrs. The methods we used during this inspection included looking at records, observing staff at work, talking to people living at the home and visitors, talking to the manager and staff and looking around the property. Before the visit we had provided some Care Homes for Older People Page 6 of 29 people living at the home,staff and other health care professionals with survey questionnaires so that they could share their views of the service with us. We received ten questionnaires back from people living at the home and six from staff. No questionnaires were returned by health care professionals. The information provided by people living at the home and staff has been used as evidence in the body of the report. The home had also completed and returned their Annual Quality Assurance Assessment (AQAA) form and the information provided has also been used as evidence in the body of the report. The AQAA is a self assessment form that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. The purpose of the visit was to assess what progress the home had made in meeting the requirements made in the last inspection report and the impact of any changes in the quality of life experienced by people living at the home. Feedback was given to the manager, area manager and provider at the end of the visit. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: The home must only provide care and support to people in the categories shown on the registration certificate. If the home is considering changing the registration to enable them to admit people with past or present alcohol dependency they must be able to clearly evidence that the staff have the training, skills and experience to meet their needs. They must also consider the impact this change in registration will have on other people living there. Staff need to be more vigilant when managing medication so that people living at the home can be confident that it is being stored, administered, and disposed of appropriately. Complaint and safeguarding policies and procedures must be followed at all times so that people can be sure that complaints are taken seriously and they are protected from any form of abuse. Staffing levels should be reviewed to make sure that there are always sufficient staff on duty to meet peoples personal care needs and to provide them with more Care Homes for Older People Page 8 of 29 opportunities to participate in a wider range of social and leisure activities both within the home and the wider community. For staff that do not speak or read English as their first language all policies and procedures should be produced in a language they understand. This will make sure that they do their work safely and do not put themselves or others at risk. Staff should have formal one-to-one supervision with their line manager on a regular basis to make sure that they receive the support they need to carry out their roles effectively and in the best interest of people living at the home. Effective quality assurance monitoring systems should be put in place so that shortfalls in the service are identified sooner and not through the inspection process. All records relating to fire safety should be dated and maintained in good order so that people can be confident that the premises are safe and staff are aware of the procedures to be followed in case of a fire. Risk assessments both for the environment and to make sure safe working practices are being followed should also be reviewed on a regular basis so that peoples health and safety is not put at risk. 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 9 of 29 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 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is admitting people outside the categories they are registered for without being able to evidence that staff have the skills to meet their needs and without taking into account the views and feelings of other people living there. Evidence: Information provided by the area manager shows that the service user guide for the home has recently been updated and now provides people with the information they need to be able to decide if the home can meet their needs. At the current time the information is only available in English but the manager confirmed that it would be made available in different languages and formats on request. Records show that peoples needs are assessed before they move into Park View either in their own home or temporary place of residence. The needs identified during this pre-admission assessment visit form the basis for the initial care plan, which is completed on admission. Care Homes for Older People Page 11 of 29 Evidence: People are invited to visit the home before admission to see at first hand the facilities provided, meet the staff and other people living there and stay for a meal if they wish to do so. People are also able to move in to the home on a trial period if they are still undecided. This is good practice and shows that people are supported throughout the admission process. The manager confirmed that the home will admit people on an emergency basis, however, wherever possible the Social Services assessment of need is obtained either before or on admission. We looked at the pre-admission assessments completed for the last person admitted to the home for respite care and found that it provided good information. However, we were concerned that the the main reason for admission was the due to alcohol abuse, which had lead to self neglect. We also noted that two other people living at the home had past or present alcohol dependency problems. The home is not registered to care for people under this category and therefore in the best interest of the individuals concerned and other people living at the home this situation must be reviewed. If the home is considering changing the registration to enable them to admit people under this category they must clearly be able to evidence that the staff have the training, skills and experience to meet their needs. The home must also take into account the impact this will have on other people living there. Care Homes for Older People Page 12 of 29 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. Care records provide accurate and up to date information, which means that people receive the level of care and support they require to meet their personal, health and social care needs Evidence: Care plans are in place for all people living at the home and are initially generated from the information provided by the Social Service Care Management Team or the assessment of needs completed by the manager. Wherever possible care plans are drawn up with the involvement of the person using the service and/or their relatives and form the basis for the care to be provided. The four care plans we looked at were completed to a good standard and were being reviewed at least monthly to make sure that they accurately reflected the level of care and support required by the individual. The information provided was generally person centred and gave clear guidance to staff on how to meet peoples needs. Moving and handling and nutritional assessments are routinely carried out for all new Care Homes for Older People Page 13 of 29 Evidence: admissions and risk assessments are also completed where areas of potential risk to peoples generals health and welfare are identified, which is good practice. All people living at the home are registered with a general practitioner and are supported in having access to the full range of NHS services. The input of other healthcare professionals is clearly recorded in the documentation available, which shows that staff are seeking advice if they have concerns about peoples health. The home has also introduced the key worker system, whereby everyone living at the home has a named member of care staff as their key worker who is responsible for providing them with information and support throughout their stay. Survey questionnaires returned by people show that they are happy with the care and support they received and said that staff always treated them with respect. Comments included I like living at Park View - there is always someone available if I need help or assistance and the manager and staff are friendly and always take time out to talk to me, which is brilliant. We reviewed the medication system in place and found that generally medicines are managed safely. However, we did have concerns that one person had not been given their medication as prescribed for a number of days because of some confusion between senior staff. Staff must therefore be more vigilant when managing medication so that people living at the home can be confident that it is being stored, administered, and disposed of appropriately. We recommended to the manager that all members of staff receive additional medication training and that a more suitable place is found to store the drug trolley as at the present time staff have to walk through the kitchen to access it. Following the visit we received written conformation that all senior staff had updated their training on the safe storage, administration and disposal of medication and the drug trolley had been relocated within the home. People living at the home can therefore be confident that medication is now being given as prescribed. Care Homes for Older People Page 14 of 29 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. The home could provide more opportunities for people to participate in a wider range of appropriate social and leisure activities both within the home and the wider community. Evidence: The manager confirmed that people are encouraged to make choices and decisions about how they spend their time whilst living at the home. Peoples personal interests are recorded in their care plan and wherever possible they are supported by staff to follow their own daily routines. The home does not employ an activities co-ordinator therefore in house activities and trips out are organised by the care staff. For people that dont like to join in group activities time is made to engage with them on a one-to one basis. Survey questionnaires returned by people indicate that while some activities and outings take place at the home it depends on staffing levels and what other duties they have to undertake . Comments included I would like to go out more but there is not always staff available to assist me and we need more outings. The manager said that people do go out for walks in the local park with staff usually at the weekend Care Homes for Older People Page 15 of 29 Evidence: and join in any events organised in the park throughout the year. In addition, some in house activities are arranged by the care staff and a music for health session is held at the home on a monthly basis. Information in the self assessment form does however show that the manager acknowledges that more community based activities could be organised for people wishing to participate and in the longterm the home would like to employ an activities co-ordinator. The manager confirmed that people are encouraged to continue to attend their place of worship if they wished to do and on the day of the visit a representative from a local church held Communion at the home. People spoken with said that they were able to see visitors in their own rooms if they wished to do so and family and friends were always made to feel welcome and offered light refreshments when they visited. During the visit we had the opportunity to have lunch in the dining room and the meal served was tasty, well cooked and well presented. Staff were observed to help people if they required assistance to eat their meal and plate guards were provided if appropriate. The meal was unhurried and there was good interaction between staff and people living at the home. Survey questionnaires returned show that people feel that the food is always good and their preferences are taken in to account when menus are planned. Comments included there is always a good choice at meal time and I have no complaints at all about the standard of meals provided - I enjoy all my meals. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure that complaints are dealt with appropriately and people are protected from any form of abuse. However, at times policies and procedures are not being followed which might put people at risk. Evidence: There is a complaints procedure in place and information provided in the self assessment form shows that the home has received two complaints since the last inspection visit. The manager confirmed that both complaints had been investigated and dealt with within the timescale set out in the complaints procedure. A record of the outcome of the investigation was recorded in the complaints register. However, the manager had failed to keep a copy of the letters sent to the complainants following the investigations to evidence good practice. Questionnaires returned by people living at the home and their relatives clearly show that they are aware of the complaints procedure and would have no problem at all in approaching the manager if they had any concerns about the standard of care being provided. Adult protection (safeguarding) policies and procedures are in place and training records provided by the manager show that all staff have received training in the recognition and reporting of allegations of abuse. However, we had concerns that there was no written evidence to show that two entries made in the daily reports we Care Homes for Older People Page 17 of 29 Evidence: looked at that might have been safeguarding issues had been fully investigated. The manager confirmed that she had carried out investigations but acknowledged that she had not documented her findings or sought advice from the Bradford Social Services Safeguarding Team. This is unsafe practice which might put people at risk. Survey questionnaires returned by staff indicate that they are aware of the homes policy on whistle blowing and knew what to do if they suspected that people were being abused or working practices at the home were not in the best interest of the people living there. Care Homes for Older People Page 18 of 29 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. Park view continues to generally provide a comfortable and homely place for people to live. Evidence: The home provides accommodation for twenty-three people in both single and double bedrooms. Since the last inspection a passenger lift has been installed to assist people with mobility problems access the accommodation and facilities on the first floor of the building. All the communal areas including lounges and the dining room are located on the ground floor of the home close to toilet facilities. There is however a smoke room on the first floor of the building. We found the standard of decor and furnishings in all communal areas to be good although some of the lounge and dining chairs required cleaning. We reviewed some but not all the bedroom accommodation and generally the standard of decor and furnishing was good although in one shared room we found that a bed base and head board were not clean and the arms of the two easy chairs in the room were either worn or scratched. We also found that in at least two bedrooms the bed linen was worn and/or torn. This matter was discussed with the manager who confirmed that the home had recently purchased some new bedding but had not yet Care Homes for Older People Page 19 of 29 Evidence: had time to put it in every room. In one bedroom we found that the sling shaft on a mobile hoist looked worn although the equipment had been serviced in June 2009. We looked at a carbon copy of the service record but the writing was not legible. Following a discussion with the manager she agreed to take the hoist out of use until she had contacted the service engineer and made sure the equipment was safe to use. People living at the home and their relatives said that they were satisfied with the standard of accommodation and pleased that they had chosen to live at Park View. Comments included I like having my own bedroom as there is plenty of space for all my things and the home is always kept clean and tidy. The laundry equipment at the home is located on the lower ground floor with the exception of the tumble dryer which is located in a store room in the managers office. Staff therefore have to carry laundry up and down steep stone steps to access the laundry area. The manager said that a risk assessment had been completed for this although it could not be found on the day of the visit. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not always sufficient staff on duty to meet peoples personal and social care needs. The home provides staff with good training opportunities and makes sure that they are clear about their roles and responsibilities. Evidence: The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two written references and a Criminal Record Bureau (CRB) before new staff start work. This makes sure only people suitable to work in the caring profession are employed. We reviewed the recruitment files and found that generally the recruitment policy was being followed although in two instances the procedure had not been as thorough as it should have been. The manager is aware of this and confirmed that in future staff would not be employed until suitable references had been received and any gaps in employment had been explored. Survey questionnaires returned by staff show that the interview process was carried out fairly and they are well supported by the manager. However, feedback from two Care Homes for Older People Page 21 of 29 Evidence: staff show that they feel at times that the home is left short staffed and these occasions they dont always have time to meet peoples personal care needs. Staffing levels must therefore be reviewed to make sure that there are always sufficient staff on duty to care for people properly. To support the care staff the home employs catering staff and a cleaner to make sure that peoples dietary needs are met and the home is clean, tidy and free from offensive odours. However, we raised concerns with the manager as the cleaner is unable to speak or read English and the home relies on a family member to interpret for them if there are issues. The concerns raised were mainly about how the interview process was conducted for someone with no grasp of the English language and how the person was made aware of the health and safety policies and procedures in place when all the documents are written in English. To safeguard the individual and other people living or working at the home we recommended that as an initial step that all policies and procedures relating to health and safety are translated into a language she understands and a risk assessment is carried out to make sure that safe working practices are being followed. The manager confirmed that all new staff receive induction training in line with the Skills for Care Common Induction Standards. These are nationally agreed induction standards designed to help new staff get the skills and knowledge they need to care for people. Following induction there is an expectation that staff will study for a National Vocational Qualification (NVQ) at level two or above depending on the post they hold. Information provided in the self assessment form indicates that out of a permanent care staff team of ten, five have already achieved a NVQ and the remaining five are currently studying for the award. This shows a good commitment to staff training. Feedback from staff indicates that they are generally happy with the level and standard of training provided and were encouraged to take up training opportunities. Staff also felt that the training the receive helps them understand the individual needs of people living at the home and keeps them up to date with new ways of working. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well managed. However, the manager must be more pro-active in identifying shortfalls in the service so that people can be confident that the home is managed in their best interest. Evidence: Mrs Ann Leyland is the manager of Park View although she has still to complete the registration process. Mrs Leyland has many years experience in the caring profession and is currently studying for a recognised management qualification. Mrs Leyland has a positive attitude to the inspection process and during the course of the inspection showed a willingness to work with us to maintain and improve standards at the home. The manager confirmed that one-to-one formal supervision with individual staff does not take place as often as required but as Park View is a relatively small home and she works with the staff on a daily basis she is always available if they have any concerns. Feedback from staff show that they feel well supported by the manager and senior staff team. Comments included it is very easy to approach the manager with any Care Homes for Older People Page 23 of 29 Evidence: problems and we have a good manager who will listen to you and understands the problems we have. There are some recognised quality assurance monitoring systems in place although they need to be developed further so that concerns highlighted in the body of the report are identified sooner and not brought to the attention of the provider through the inspection process. As part of the quality assurance process survey questionnaires are sent to people living at the home, their relatives and other healthcare professionals on an annual basis to assess how well the home is meeting stated aims and objectives. The home holds money in safekeeping for a number of people. Only senior staff deal with peoples personal finances and receipts are obtained for any items purchased on their behalf. We checked the system in place and no concerns were raised. Policies and procedures and risk assessments are in place to ensure the health and safety of people living at the home, visitors and staff. However, some of the risk assessments we looked at had last been reviewed in 2003. We therefore recommended that a full audit is carried out to make sure that that staff are following safe working practices. We had concerns that the cupboard used for storing cleaning material is located in the wall half way down the stairs to the lower ground floor. Staff have to step in and out of the cupborad which opens directly onto the stairs and therefore there is a possibility that someone could fall. It was therefore recommended that the cleaning cupboard is located in another secure area of the home to protect the health and safety of staff. We looked at the fire safety records and noted that there was a fire risk assessment in place and although the area manager said it had been approved by the Fire Safety Officer it was not dated. Records showed that two fire drills had been carried out in 2008 and only one in 2009 up to the date of the visit. On discussing this matter with the manager she said that more fire drills had taken place but they had not been recorded. This was a confirmed by two members of staff spoken with who said that the home had fire drills on a regular basis. Information provided in the self assessment form shows that all equipment in use at the home including the passenger lift and hoists are serviced in line with the manufacturers guidelines, which means that people can be sure they are in good working order. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 29 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 3 14 The home must not admit people outside the categories listed on the registration certificate. So that people moving into the home can be confident that staff have the skills, training and experience to meet their needs. 06/11/2009 2 18 12 Safeguarding policies and 06/11/2009 procedures must be followed at all times. This will make sure that people living at the home are protected from any for of abuse. 3 27 18 Staffing levels must be reviewed. To make sure that there are always sufficient staff on duty to meet peoples personal care needs and to provide them with the opportunity to participate in 13/11/2009 Care Homes for Older People Page 26 of 29 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 a wider range of social and leisure activities. 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 12 More should be done to provide people with the opportunity to participate in appropriate social and leisure activities both within the home and the wider community. A copy of all correspondence sent to a complaintant should be held on file to evidence that the complaint as been dealt with appropriately and resolved to their satisfaction. For staff that do not speak or read English as their first language all policies and procedures should be produced in a language they understand. This will make sure that they do their work safely and do not put themselves or others at risk. Effective quality assurance monitoring systems should be put in place so that shortfalls in the service are identified by management sooner and not through the inspection process. Staff should have formal one-to-one supervision with their line manager on a regular basis to make sure that they receive the support they need to carry out their roles effectively and in the best interest of people living at the home. The cleaning cupboard should be relocated to another secure area of the building so that the health and safety of staff is not put at risk All records relating to fire safety should be dated and maintained in good order so that people can be confident that the premises are safe and staff are aware of the procedures to be followed in case of a fire. Risk assessments both for the environment and to make safe working practices are being followed should be reviewed on a regular basis so that peoples health and Page 27 of 29 2 16 3 27 4 33 5 36 6 38 7 38 8 38 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 safety is not put at risk. Care Homes for Older People Page 28 of 29 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). 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