Inspection on 15/12/09 for Pendale Retirement Home

This inspection was carried out on 15th December 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pendale Retirement Home 13/07/10

Pendale Retirement Home 04/05/10

Pendale Retirement Home 02/03/10

Pendale Retirement Home 02/09/09

Pendale Retirement Home 14/07/08

Pendale Retirement Home 16/08/07

Pendale Retirement Home 09/06/06

Pendale Retirement Home 10/03/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report Care homes for older people Name: Address: Pendale Retirement Home 6/8 Greystoke Place Blackpool Lancashire FY4 1NR     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: Wesley Cornwell     Date: 1 5 1 2 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 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Pendale Retirement Home 6/8 Greystoke Place Blackpool Lancashire FY4 1NR 01253342191 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Pendale Care Limited care home 23 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care home only: Code PC, to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP. The maximum number of service users who can be accommodated is 23. Date of last inspection Brief description of the care home Pendale Care Home provides 24-hour care and accommodation to 23 older people of both sexes. The home is situated in a residential area in the south of Blackpool and is close to the sea front. There is a small parking area for visitors at the front of the building. The home has 23 single bedrooms all with an en-suite facility. The ground floor comprises of two lounges and a dining room with the front lounge overlooking the Solarium Gardens and the promenade. The home has a passenger lift, which people can use independently. The home has a Statement of Purpose and Service User Guide providing information about the care provided, the qualifications and experience of the owners and staff and the services residents can expect if they choose to live at Care Homes for Older People Page 4 of 30 Over 65 23 0 0 2 0 9 2 0 0 9 Brief description of the care home the home. A copy of the Service User Guide and most recent inspection report is available from the owner to help people make an informed choice whether to move into the home. The range of fees at the home are two hundred and seventy seven pounds and twenty pence to three hundred and nineteen pounds and forty one pence covering all aspects of care, food and accommodation. The Home owner provided this information on the 5th February 2010. Hairdressing is provided free of charge unless people wish to make their own arrangements. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced visit was undertaken by two Inspectors as part of the homes key inspection. The visit commenced at 9.30am and took place over 6 hours. During the visit we spoke to three people who live in the home, three staff members and the acting manager. Staff and care records were examined and a full tour of the premises was undertaken with the acting manager. The homes financial records were not available for inspection. The outcome from the last key inspection was the quality rating for this service was 2 stars. This meant the people who were using the service experienced good quality outcomes. An Annual Service Review (ASR) was undertaken for this service in July 2009. During the review we contacted the home owner to enquire about the fees being charged to the people who live at the home. We were told by the home owner a major Care Homes for Older People Page 6 of 30 safeguarding incident had occurred at the home after an allegation of financial irregularities had been made by a person living there in August 2008, which involved a senior staff member. The home owner hadnt informed the Commission or any other agency about the allegation. The lack of information provided to the Commission and reporting to other relevant agencies demonstrated a lack of judgment and serious omission on the part of the home owner. Prior to the Annual Service Review taking place the owner of the home had completed an Annual Quality Assurance Assessment form (AQAA) providing information about the service they are providing for their Annual Service Review. The AQAA is a self assessment and data set, which providers are asked to complete each year and is one of the main ways that we obtain information about how they are meeting outcomes for people they support. There was no reference in the AQAA to the suspension of the senior staff member. This incident was referred to the local social services department to be investigated through their safeguarding procedures. As part of the safeguarding investigation we undertook an announced inspection at the home. Due to the nature of this inspection the owner of the home was given notice that the inspection was taking place to ensure the documentation that we needed to inspect would be available. A representative from the local authority was present during the inspection. During this focused inspection we looked at the records relating to people whose personal monies were being being retained by the home. Other records relating to accommodation charges were not available in the home. The records seen were in a state of disarray and it was not possible to audit these effectively in the home. As a result of this copies of records and receipts were taken from the home for further analysis. We informed the home owner that she must ensure that there is a clear understanding within the home when an incident needs to be referred to the Local Authority as part of the local safeguarding procedures and they are open and transparent when discussing incidents with external agencies. This will ensure that the people in her care are safeguarded from potential abusive practices. We also requested that the homes financial records must be well maintained and kept securely at the home and available for inspection. The outcome of the investigation was that the person had been financially abused and the homes procedures had not safeguarded the persons financial interests. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: People who move into the home must be issued with a written contract explaining their terms of residence. Copies of the contracts must be retained at the home and be available for inspection. This will confirm people have been informed of the fees they are to pay and the services they can expect on their admission. The homes complaints procedure should be amended to advise people that all complaints received will be responded to within a maximum of 28 days. This will make people aware that the home takes complaints seriously and they will be responded to appropriately. Care Homes for Older People Page 8 of 30 The home owner must ensure the Commission is notified about any incidents that occur within the home such as the death of a person living at the home, serious injury to a person living at the home and the action that has been taken, any event in the home that seriously affects the well being of people in her care. This includes any allegation of misconduct by the registered person or any person who works at the home. This will confirm that the home acted appropriately and in the best interests of the people in their care. The home owner must ensure that there is a clear understanding within the home when an incident needs to be referred to the Local Authority as part of the local safeguarding procedures and they are open and transparent when discussing incidents with external agencies. This will ensure that the people in her care are safeguarded from potential abusive practices. People employed to work at the home should be provided with training on recognizing abusive practices and how to follow the homes safeguarding procedures. This should ensure the people in their care are safe and protected from potential abuse. Accommodation on the first and second floors looked neglected and the general appearance on both floors were dark and gloomy. A redecoration and refurbishment programme should be implemented to provide a pleasant and comfortable environment for people to live. Staff working at the home must have all relevant information in place including a Protection of Vulnerable Adults (POVA) check and two written references before they commence their employment. This will confirm they have been recruited properly and provide protection for the people in their care. The home owner is reminded that all records required by regulation must be retained at the home and be available for inspection at any time. The home owner must be able to demonstrate at all times that efficient systems to ensure the effective safeguarding and management of money and valuables of the people in her care are in place and the homes record keeping ensures their financial interests are safeguarded. 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 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission and assessment procedures were clear to ensure the care needs of people were met. Evidence: We looked at the care plan records of two people and found they had full assessment information in place including their religious/cultural and relationship needs. The assessment had identified the nutritional needs of the people and risk assessment information advising staff members of the action to be taken to minimize identified risks and hazards. The staff member responsible for the preparation of meals told us they are provided with information about people with special dietary needs and these are accommodated. The people we spoke to said they were very happy with the care being provided and told us their needs were being met. One person said, They are looking after me really well. Another person who had lived at the home for a number of years told us they Care Homes for Older People Page 11 of 30 Evidence: were happy with their care and liked living at the home. Following the recent unannouned inspection undertaken at the home in September 2009 we asked the home owner to ensure all financial records including contracts entered into with the people in her care to be retained at the home and be available for inspection. The acting manager told us she did not have access to this information and we were unable to establish if people had been issued with a written contract explaining their terms of residence and the services they can expect on their admission into the home. This home doesnt provide intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Promotion of health is taken seriously, peoples welfare is closely monitored and health needs were met. Evidence: Individual records are kept for each person with a plan of care setting out the action that is needed to be taken by staff to ensure all aspects of health, personal and social care needs of people living at the home are met. Significant events had been recorded and daily entries made setting out the care given. The care plans were structured and were being reviewed with the people or their relative,advocate and updated to reflect any changing needs and these were being actioned as required. During the random inspection undertaken at the home in September 2009 we asked the home owner to make a record on care plans about the arrangements in place for handling the personal allowances of the people in their care and for the person to sign their care plan confirming they agreed to these arrangements. The two care plans we looked had not recorded this information. Care Homes for Older People Page 13 of 30 Evidence: The records of two people were looked at and these described their healthcare needs. Discussion with staff members on duty confirmed they were fully aware of the healthcare needs of people living at the home and these are monitored and kept up to date. Entries on care plans showed good communication between the home and healthcare professionals. Daily entries made on care plans showed staff members were following the instructions of healthcare professionals and an appropriate level of care was being provided. Observation of practice and examination of care plan records confirmed staff were meeting the diverse needs of the people in their care. Discussion with staff members confirmed they were aware of the needs of the people in their care and the level of support that needed to be provided. They told us they were happy with the training they had received and felt competent to undertake their duties. We spoke to people about the care they were receiving and were told the staff are very attentive and caring. One person said, The staff are very caring and cant do enough for you. The routines are relaxed and the staff kind and helpful. Another person told us the staff were polite and respectful and he didnt feel he could be looked after better anywhere. The staff members responsible for the administration of medicines had received training to ensure they had basic knowledge of how medicines are used and how to recognize and deal with problems in use. Medication practices observed during the visit were safe and good records had been maintained confirming people received their medicines as prescribed by their doctor. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Evidence: Routines observed during the visit appeared flexible with people having the freedom of the home and being able to choose whether to use the communal areas or remain in their own room. One person we spoke to said, The staff are very polite and respectful. I am very happy with my care and dont feel I could be looked after better anywhere. I have the freedom of the home and come and go as I please. I go out most days to the shops and choose to spend time in my room reading and watching television. We spoke to people about the arrangements in place for receiving their visitors and were told they were happy with these. Although we didnt see anyone visiting the home the manager told us there are no restrictions in place and people are welcome to visit at any time. We spoke to people about the arrangements in place for social activities and they told us they were happy with these. During the afternoon we observed the staff organizing Care Homes for Older People Page 15 of 30 Evidence: several individual activities. These were arranged through the choice of the individual person and included playing cards, dominoes, completing a puzzle and one person having some beauty treatment. One person who was hard of hearing was approached by the manager using help cards listing the various activities to choose from. The manager told us this allowed the staff to ask the person discretely if they would like to choose an activity without everyone in the lounge hearing. The lady chose dominoes and beat all three staff members. People spoken to confirmed they enjoyed the food provided by the home. The staff member responsible for the preparation of meals was able to confirm they had information about people with special diets and personal preferences and these were being accommodated. One person commented, The food is very good and you get plenty to eat. I think the cook is good. There is always something on the menu I like. Meal times were served in a relaxed and unhurried manner. Staff members were observed being very attentive to the needs of people who required assistance. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home are not safeguarded from abusive practices by the homes procedures. Evidence: The home has a complaints procedure, which we were told is issued to people on their admission. The procedure was also on display in the hallway but wasnt titled and wasnt easily accessible as it was placed alongside other documentation. The acting manager was informed the procedure should be clearly titled and placed in a prominent position for the attention of the people living in the home and their visitors. We also noticed that people were not being informed of the timescale the home would work within to respond to any complaints they received. The acting manager was informed the procedure should be amended to advise people that all complaints received will be responded to within a maximum of 28 days. This will make people aware that the home takes complaints seriously and they will be responded to appropriately. Since the last key inspection a major safeguarding incident has occurred at the home after an allegation of financial irregularities had been made by a person living there in August 2008, which involved a senior staff member. The home owner did not inform the Commission or any other agency of the allegation at the time and this only came to our attention when we contacted the home owner during their Annual Service Review in July 2009 to enquire about the fees being charged to the people who live Care Homes for Older People Page 17 of 30 Evidence: there. Please see the Management and Administration section for further details. We spoke to the acting manager about her knowledge of safeguarding issues and the procedures to be followed should an incident of abusive practices be brought to her attention. The acting manager was able to demonstrate an understanding of the procedures she would need to follow to ensure the people in her care are protected from abuse. The staff member we spoke told us she wouldnt hesitate to report to the manager any abusive practices she may witness but demonstrated a limited knowledge of the procedures that should be followed and told us she had received no training on safeguarding procedures. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home which would benefit from an ongoing refurbishment programme. Evidence: The lounge and dining areas have been maintained to a good standard and decorated for the comfort of the people living there. The acting manager told us the lounge chairs and dining room tables had recently been replaced and the carpets are cleaned on a regualr basis to maintain standards. The people we spoke to were happy with the standard of accommodation provided and said they felt at home. A tour of the building highlighted that the home would benefit from an ongoing refurbishment and redecoration programme. Bedrooms located on the first and second floors looked neglected and in need of refurbishment. The seals to some double glazed windows at the front of the building had gone and misted over restricting people from being able to look outside. Furniture and paintwork were old and most carpets were worn and required replacing. Some beds were in a poor condition. The general appearance on both floors were dark and gloomy. The home owner told us during completion of the homes Annual Quality Assurance Assessment form (AQAA) that she recognizes the need for refurbishment in the accommodation being provided on the first and second floors and said this would be implemented as finances allow. The bedrooms which were being occupied had been personalized with people being Care Homes for Older People Page 19 of 30 Evidence: encouraged to bring their own belongings on their admission into the home. The rooms were single occupancy and provided en-suite facilities. The people we spoke to were happy with their rooms and said they had the choice of spending time on their own or in the lounge areas. The homes call bell system was tested during the visit and found to be in good working order. The people we spoke to told us the staff were responded quickly if they requested assistance. Hot water temperatures were checked throughout the home and found to be delivering water at a safe temperature in line with health and safety guidelines. It was observed during the visit the home was clean and free from offensive smells. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures are not robust potentially placing people at risk. Evidence: Staffing levels were sufficient for the number of people living in the home. The people we spoke to during the visit told us they were happy with their care and said they were well treated by the staff. They told us the staff were available when they needed them and they were treated with kindness and patience. One person said, I have lived here for a number of years and I get on well with the staff. I am well cared for and have no complaints. The staff member we spoke to showed a good understanding of their role and responsibilities and felt the staff worked well together to ensure the individual and collective needs of the people in their care were being met. The care practices we saw during our visit confirmed people were being well looked after. The records we saw confirmed staff members have access to a training and development programme ensuring the people in their care are being supported by a well trained and competent staff team. In addition three of the seven staff members have achieved National Vocational Qualifications (NVQ) ensuring people are in the safe hands of qualified and competent staff. Care Homes for Older People Page 21 of 30 Evidence: We looked at the records of two staff members employed to work at the home since the last inspection and found that they both commenced their employment before a Protection of Vulnerable Adults (POVA) check and Criminal Records Bureau Disclosure had been completed. One person had no references in place and their application form hadnt been completed fully by not providing an employment history as is required for all care workers. These records are required to confirm their suitability to work with vulnerable people and reduce any potential risk of harm to the people in their care. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not well run. Evidence: The homes acting manager has been in her post since October 2008 and she has completed a National Vocational Qualification (NVQ) in Care at level 3. The acting manager told us she is hoping to commence training for an NVQ level 4 in care and a relevant management qualification in the new year. She has attended some training since her appointment including attending training with the local authority about the Mental Capacity Act deprivation of liberty safeguards which had provided guidance for providers on their duties and responsibilities to apply for authorization if they felt it was in the best interests to deprive someone in her care of their liberty. The people we spoke to confirmed they had choice of movement, were able to make their own decisions about their lifestyle and their civil rights were being safeguarded. The acting manager was informed during the visit that she must apply to be registered with the Commission as she is running the home on a day to day basis. Care Homes for Older People Page 23 of 30 Evidence: Since the last key inspection a major safeguarding incident has occurred at the home after an allegation of financial irregularities had been made by a person living there in August 2008, which involved a senior staff member. As discussed previously in this report the home owner did not inform the Commission or any other agency of the allegation at the time and this only came to our attention when we contacted the home owner during their Annual Service Review in July 2009 to inquire about the fees being charged to the people who live there. The lack of information provided to the Commission and reporting to other relevant agencies demonstrated a lack of judgment and serious omission on the part of the home owner. It was evident that safeguarding policies were in place and available at the home indicating the procedure to be followed should an allegation of financial abuse be made. These procedures were not followed. We referred this incident to the local authority for investigation through their safeguarding procedures. The outcome of the investigation was that the person had been financially abused and the homes procedures had not safeguarded the persons financial interests. As part of the safeguarding investigation we undertook an unannounced random inspection at the home after which we informed the home owner she should familiarize herself with the Care Homes Regulations so that she has a clear understanding of her responsibilities. We also made requirements about the process for running the home being open and transparent with all incidents that occur in the home including allegations of abuse being reported without delay. We also requested that all financial records must be well maintained and kept securely at the home and available for inspection. There were no financial records available for us to inspect and the acting manager told us she did not have access to these. A petty cash tin was being retained in the office from which money can be used for the expenditure of provisions and purchases made on behalf of people living at the home for newspapers and toiletries etc. The manager told us she didnt retain the key for this and we were unable to examine its contents. The manager has in place quality assurance systems to gather the views of the people in her care about the service being provided and keep people informed about events being organized by the home. These are presently organized on an informal basis. She was asked to consider introducing more formal arrangements in the form of organized meetings with minutes being retained. She was also asked to give consideration to introducing satisfaction questionnaires for the people in her care and their visitors so they may make provide their views on the service being provided. A self assessment form that the Commission had asked the home owner to complete before the Annual Service Review undertaken in July 2009, provided information confirming facilities and equipment were being maintained as required by health and Care Homes for Older People Page 24 of 30 Evidence: safety legislation providing a safe environment for people to live. The completion of the self assessment form was also an opportunity for the home owner to tell us about the allegation of financial irregularities which had been made by a person living there in August 2008, which involved a senior staff member and the action they had taken. Care Homes for Older People Page 25 of 30 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 37 17 Financial records must be well maintained and kept securely at the home and availble for inspection. The finacial interests of people are safeguarded by the homes accounting and finacial procedures. 24/09/2009 Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 2 5A People who move into the 23/01/2010 home must be issued with a written contract of residence with copies retained at the home. This will ensure people know the services they can expect if they move into the home. 2 7 17 The arrangements in place 01/02/2010 at the home for handling the personal allowances of people must be recorded on their care plan with their signature confirming they have agreed to these. This will confirm people are happy and have agreed to the arrangements in place. 3 16 22 People must be informed their complaint will be responded to within 28 days and informed of any action that is to be taken. 11/01/2010 Care Homes for Older People Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure complaints are handled well and people feel listened too. 4 18 18 People employed by the 23/02/2010 home must be provided with training on recognizing abusive practices and how to follow the homes safeguarding procedures. This should ensure the people in their care are safe and protected from potential abuse. 5 19 23 An ongoing refurbishment programme must be implemented to improve the environmental standards being provided. This will ensure people live in a well maintained and comfortable environment. 6 29 19 People who work at the 08/01/2010 home must be recruited properly and have all relevant information in place before they commence their employment. This will reduce the risk of employing anyone who is unsuitable to work with vulnerable people. 22/03/2010 Care Homes for Older People Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 31 9 The person in day to day control of the home must apply to be registered with the Commission. This will ensure the home is being run for the benefit of the people who live there. 25/02/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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