Inspection on 16/11/09 for Philips Court

This inspection was carried out on 16th November 2009.

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

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

Other inspections for this house

Philips Court 22/12/08

Philips Court 19/02/08

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for older people Name: Address: Philips Court Bluebell Close Sheriff Hill Gateshead Tyne & Wear NE9 6RL     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Suzanne McKean     Date: 1 6 1 1 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 27 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 27 Information about the care home Name of care home: Address: Philips Court Bluebell Close Sheriff Hill Gateshead Tyne & Wear NE9 6RL 01914910429 01914913428 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd care home 75 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 75 The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Dementia Code DE, maximum number of places 75 Mental Disorder, excluding learning disability or dementia, Code MD, maximum number of places 75 Date of last inspection Brief description of the care home Philips Court Nursing Home is a 75 place facility. It has a 15 place unit,which provides personal care and two 30 place units which provide nursing care for predominantly people with dementia. The two nursing units are located at one side of the home, with the personal care unit being at the other side of the home. The reception area, a large communal room and Care Homes for Older People Page 4 of 27 Over 65 0 0 75 75 2 2 1 2 2 0 0 8 Brief description of the care home office are located at the centre of the home. Each unit contains dining rooms, lounges, bathrooms, toilets and bedrooms. Philips Court is a purpose built home that stands in its own grounds. The home is near to the Queen Elizabeth Hospital and located within a recently built residential area. It is within close proximity to a range of local amenities and facilities such as shops and churches.There are bus stops nearby which link with the main regional centre of Gateshead. The fees payable range from: Local Authority £438 Nursing £449 plus Free Nursing Care £106.30 Private £492.25 plus Free Nursing Care £106.30 Private Nursing £685.10 and includes the Free Nursing Care element Not included in the fee rates are personal items, clothing, newspapers and some outings. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services 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 quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit, we looked at, information we have received since the last key inspection visit on 22nd December 2008. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The providers view of how well they care for people. The views of people who use the service and their relatives, staff and other professionals. Care Homes for Older People Page 6 of 27 The Visit. An unannounced visit was made on 16th November 2009 by three inspectors, which lasted nine hours. During the visit we:- Talked with people who use the service, relatives, staff, the manager and visitors. Looked at information about the people who use the service and how well their needs are met. Looked at other records, which must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit. We told the manager what we found. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: The manager and senior staff must undertake Protection of Vulnerable Adults training with the Local Authority, which will better prepare them to take on the roles specific to the way that safeguarding is managed in this area. Care Homes for Older People Page 8 of 27 Although it is acknowledged that the home is staffed in line with the numbers and dependencies of the people living there there are times when additional pressures are placed on the staff because of the complex needs of the residents. A review of staffing levels and staff deployment should be carried out to make sure that there are enough staff to provide good support for the residents who need assistance. It is recommended that the manager look at ways of making the food intake charts more detailed regarding quantities so that the calculation of food intake can be more accurate. Although the opportunity for people living in the to engage in meaningful social activities has been improved it is recommended that the way that the residents on the first floor are supported to live active and meaningful lives is reviewed when the additional activities hours are provided. It is recommended that all staff are given the opportunity to attend external Protection of Vulnerable Adults training so that they will be aware as to how the homes policies and procedures fit in with the Local Authority Safeguarding strategy. It is recommended that all staff are given Deprivation of Liberty and Mental Capacity Act training so that they will be aware of the way that these issues are relevant to the people living in the home. Accident recording in the home is good, however the way that the accidents in the home are looked could be further improved to highlight to staff where themes risks are greater so that they can be fed more effectively into preventative strategies. 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 27 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 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clear information is available about the service and a good assessment of need before admission makes sure people can be confident that their needs can be met . Evidence: Southern Cross Corporate Statement of Purpose and Service User Guide is readily available and a copy is given to each person or their representative. The assessments which are carried out by the home, the information from the care managers, and the assessment information from the nurse assessors are used to form the pre admission assessments. This makes sure that the home can be confident that they can provide the care needed before a placement is offered. Assessment information is clear and provides sufficient information to ensure people are admitted when the home is sure they can meet someones needs. Care Homes for Older People Page 11 of 27 Evidence: Care plans also record six week reviews with the person, relative,senior home staff and care manager. Care Homes for Older People Page 12 of 27 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. Good care planning and review processes make sure that staff are clear how to care for the needs of residents and the people living in the home are well looked after. Evidence: All residents have an individual care plan, and these are completed to a good standard and show how the care that was being given to the residents. There are relevant risk assessments for the prevention of falls, nutrition, wound care, moving and assisting, continence promotion and mental health status. The plans showed that they are regularly reviewed and updated. The care staff are involved in making sure that the necessary information is in the care plans by keeping the nursing staff informed. This includes the welfare of the residents and their activities and events on a day to day basis. Food and fluid balance records were generally up to date and detailed, however further improvements could be made by making this information more specific eg the quantity or size of the portion. The manager agreed to look at how this could be achieved. There have been recent changes to the care plans to make them more person Care Homes for Older People Page 13 of 27 Evidence: centered and are in line with the organisations most recent documentation guidance, and this is ongoing as there are still some improvements that could be made to answer the how question. A number of assessment tools are in use, and they were reviewed monthly, and were dated and signed by the author. Daily reporting of residents care were good, and the changing health care and mental health care of residents was reviewed and changes to the plan made as necessary. The care plans showed that the residents have access to all NHS services and facilities. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores. The staff have a good knowledge of residents psychological health care needs with evidence of good partnership workings with other professionals. Personal care was given in privacy, and staff used residents preferred name at all times. Staff are respectful/caring and empathetic and work with people with some very complex and at times challenging needs with patience. They respond well to people and interact positively, offering encouragement and verbal support to people all the time. Residents were complementary about the staff in the home and felt that they were able to have privacy in their own rooms and the staff respects that this. A relative said that they felt that the care staff always tried to do give their relative the care she needed and that they would always tell them about how they had been when they came in to visit. The medicines in the home are well managed and safely disposed of as necessary. The treatment room was very tidy and was well organised. The medicines are not given at meal times. This improves the mealtime experience for the residents and prevents the residents from being distracted during this important time. A survey returned from a visiting professional said that the home ensures that the patients in their care are treated with respect and dignity. Care Homes for Older People Page 14 of 27 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. There is a flexible routine and people living in the home are supported to live active and meaningful lives taking into account their individual wishes, abilities and interests. Evidence: There is an activities co-ordinator employed in the home and each person living in the home has his or her social care needs assessed. A care plan is then developed to identify the way they can be supported to live active lives. It is acknowledged that providing effective social opportunities for this client group presents a challenge for all of the staff. However, the staff in the home are aware of the need to be flexible in this. The manager has secured additional funding to increase the activities co-ordinator times from thirty seven hours to fifty hours per week and so she is recruiting staff to fill the additional hours. At the moment there is limited opportunity for people to engage in anything meaningful on the first floor, with a lot of people sleeping or wandering for parts of the day. This will be reviewed when the additional activities hours are provided and should improve as a result. There are good examples of the artwork and crafts produced by the people living in Care Homes for Older People Page 15 of 27 Evidence: the home in the area used by the residents for their crafts and in other places in the building. There are also photographs of trips out and events that have taken place at the home. There is a very pleasant area on the ground floor for residents to spend time either with their relatives or visitors or to come together and have a coffee and chat. During the visit a number of relatives visited the home, all of which were complementary about this facility. A relative said that they felt that the way the staff deal with their relative makes their life better and spontaneous conversations and everyday activities such as looking at a magazine or the television gives them the opportunity to enjoy each others company. Families are also encouraged and supported to take residents out and about. Generally through the day the residents were choosing where they spent their time. A resident described how he chose the things he did like the time he gets up, what and when he eats although he acknowledged that the meal times were set within some limits. A relative said that the staff would keep meals back if the resident was out at meal times and that they would always make sure that they had something when they returned. Although most residents could not have a conversation about how they felt about the home they appeared to be happy as they were smiling with the staff or were enjoying spending time with other residents. Some of the residents were moving around the home and were being supported to do so even when they were at some risk of falling. The lunchtime meal looked well prepared and the residents appeared to be enjoying it. The residents were being given assistance on a 1 to 1 basis if they needed it. There was a positive atmosphere in the dining rooms and the staff were very vigilant about the residents getting choices. Lots of comments could be heard during the lunchtime of which would you like and would you like to try it?. The residents were observed to clear their plates and some were offered alternatives if they did not seem to eat much. Comments made by residents during the meal times included I enjoyed my breakfast, the eggs were lovely and the food is very nice here. The residents bedrooms were personalised reflecting individual choices and preferences. Residents have visitors at any time and are able to use their own rooms, the lounges or communal areas or in the summer the garden area to receive them. Relatives are given information about visiting in the service user guide. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good complaints and safeguarding procedures make sure that the residents are safe and that they are protected from harm. Evidence: The company has a detailed complaints procedure which is easy to follow and it is displayed in the reception area of the home. The relatives spoken to were aware of the complaints procedure but suggested that they tended to express any concerns to the manager during relatives meetings or on an individual basis. The home keeps a detailed record of all complaints received with detail of any investigation and action taken to resolve issues. There have been four complaints since the last visit to the home. Three have been resolved and one relates to replacement of carpets which is still being looked at under the refurbishment plan. Staff have had Safeguarding training with the Company or with Future Strategies. Staff would be able to recognise any sign or suspicion of abuse and said they would have no hesitation in reporting to the manager. The registered manager and senior staff have not yet completed training with Gateshead Local Authority. They need to complete this so that they can be sure they follow the proper procedural guidance as the Authority would take the lead in any investigation in the first instance. Care Homes for Older People Page 17 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in a safe environment with good communal areas, and bedrooms that are personalised and comfortable. Evidence: Philips Court is a purpose built home located in a residential area. The location and layout is suitable for the residents who live there. There are pleasant lounges and dining rooms on each floor. Residents were able to use the entire home as the ground floor has wide corridors and doors and there is a lift to take them to other areas of the home. There has been a lot of thought put into developing the environment to be more dementia friendly. This has been done with regards to current dementia care research, with lots of tactile, brightly coloured, memorabilia and objects hanging etc for people to touch and look at. The garden area is well developed with a sensory planting area, seats and walk-ways. On the first floor an imitation garden area has been created with seating to mimic an outside area for those people who walk about the home. There is a range of television and audio equipment available for people living in the home to use including very large televisions in the lounges which are wall mounted. Resident were watching a popular programme and two spent some time talking about the programme they were watching. Care Homes for Older People Page 18 of 27 Evidence: The corridor are nicely decorated and there is now a number of items to make them more suitable for the client group. These rummage boxes are in place to offer them stimulation as they move around the home and give staff points of interest to engage the residents in. There is no odour evident anywhere in the home. There are bathrooms, shower facilities and toilets near to all communal areas and residents bedrooms. The residents bedrooms are comfortable and decorated to a good standard. Most have been encouraged and supported to bring personal items with them resulting in individualised rooms reflecting personal taste and previous lifestyles. The laundry was generally tidy, and there are suitable laundry baskets and laundry rails to take clean linen and clothing back to residents rooms and linen cupboards. There are sluices on each floor, which are locked when not in use. Sluice disinfectors were in working order. The sluice rooms were clean, tidy and odour free. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff working in the home are employed using effective recruitment and selection practices, and they are given training and support to make sure that they can carry out the work they are being asked to do. Evidence: On the day of the inspection vist there were enough staff on duty to provide the care to the residents. The staffing rotas show that there are sufficient staff identified for each shift period. When sickness and staff holidays occur the Manager usually covers these periods by offering additional shifts to the staff. However, when this is not possible agency staff are being used, late reporting does occasionally result in fewer staff being on duty for short periods. However, there are periods of high activity such as meal times when these numbers are stretched in some areas of the home It may be necessary for this to be reviewed to provide additional cover for the lunch time when the residents require a high level of assistance. The staff are being offered both statutory training for moving and assisting, fire, health and safety and first aid as well as opportunities to undertake more specific training. The records for training are good and the manager is able to identify where any gaps occur and can identify additional training needed. Staff are undertaking NVQ Care Homes for Older People Page 20 of 27 Evidence: level 2 or 3 and the home has an induction and training programme for all staff. The training provided includes, Moving and assisting, fire, food hygiene, food awareness, COHSS, safeguarding, Medication, Yesterday Today and Tomorrow (Dementia Care Training). The Manager said that Infection Control, Deprivation of Liberty and Mental Capacity Act training was to be provided to the staff. This is needed as the staff were very aware of the gaps in their knowledge base. The company has very comprehensive policies and procedures for recruitment and selection of staff. The manager has recently recruited staff to the team and they are offered a good induction package. The new staff are recruited using equal opportunities practices and no staff begins work until the necessary checks have been made on them. References are sought from their previous employers and there work record is looked at to make sure that they are suitable for the work they will be asked to carry out. The manager has introduced an informal process of asking the residents about how the new staff have performed during their induction period. This gives them the opportunity have some input into the induction and training planning process. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good systems in place to make sure that the home is run effectively taking into account the views of the residents and ensuring safe working practices in line with the company policies and procedures. Evidence: The home an experienced and competent manager who is well settled into her role, and is well supported by a strong team of qualified nursing staff, a good administrator and committed staff team. She is an experienced manager and with a long history of working with older people who has the necessary qualifications. There is an extensive quality assurance programme in place. This is a formal process and includes a number of different strategies. The company has a system of audit of all of the areas of provision including care plans, environment, catering, care, and health and safety. There are a number of reports that are analysed centrally. There are regular meetings with the residents and relatives and there are regular Care Homes for Older People Page 22 of 27 Evidence: meetings with the manager and the staff. The records of these contain a wide selection of appropriate topics. The staff meetings are generally on a monthly basis but vary according to the issues in the home. The attendance is good. Staff supervision records indicated that staff are receiving supervising at the appropriate timescales of six per year, the contents of these were not examined on this occasion. However the Manager confirmed that she is satisfied that she is able to use them to make sure that the staff are able to carry out their work safely and effectively. The manager takes the necessary action to ensure the health and safety of the service users through regular tours of the building, risk assessments and recording of action taken to respond to hazards. The staff are aware of the need to maintain a safe environment in the home. This is supported by the policies and procedures examined and by discussion with the Manager. Staff follow the Southern Cross accident policy and accidents incidents are appropriately logged. The staff complete the accident form and the administrator adds this information to the IT system to inform Operations Manager. These statistics are reviewed quarterly. Data is extracted numerically but doesnt seem to be tracked for qualitative information that could be fed back into the Quality Assurance system and used in care planning reviews to ensure more preventative steps are being put in place. The inspectors talked to the manager about using a graph or visual aid to highlight danger spots and use with staff might help them see identify dangerous behavior and can see at a glance if incidents have reduced increased discuss at team meetings reviews. It was agreed that this would allow them to drill down and pick out information by unit, individual, theme, nature of injury etc., so that the information could be better utilised. Records for safe working practices in relation to first aid, food hygiene, moving and handling and infection control were in place and were satisfactory. There are records in place to show the way people living in the home receive support to manager their finances. The personal allowance records show that receipts and two signatures are maintained for all transactions and these could be cross referenced to the computer held records. Regular audits are completed and a random check showed no discrepancies. The administrator had a very good understanding of the processes. Care Homes for Older People Page 23 of 27 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 24 of 27 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 18 12 The manager and senior staff must undertake Protection of Vulnerable Adults training with the Local Authority. This will make sure that will be able to follow the proper procedural guidance as they would need to take the lead in any investigation in the first instance. 07/03/2010 2 27 18 There must be a review of staffing levels and deployment at peak times. This will make sure that the residents are adequately supported and that the staff will have the time they need to provide in a way that is person centered. 07/02/2010 Care Homes for Older People Page 25 of 27 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 8 It is recommended that the manager look at ways of making the food intake charts more detailed regarding quantities so that the calculation of food intake can be more accurate. It is recommended that the way that the residents on the first floor are supported to live active and meaningful lives is reviewed when the additional activities hours are provided. It is recommended that all staff are given the opportunity to attend external Protection of Vulnerable Adults training so that they will be aware as to how the homes policies and procedures fit in with the Local Authority Safeguarding strategy. It is recommended that all staff are given Deprivation of Liberty and Mental Capacity Act training so that they will be aware of the way that these issues are relevant to the people living in the home. It is recommended that the way that the accidents in the home are looked at is reviewed to highlight to staff where themes risks are greater so that they can be fed more effectively into preventative strategies. 2 12 3 30 4 30 5 38 Care Homes for Older People Page 26 of 27 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. 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