Inspection on 06/01/09 for Queens Care Centre

This inspection was carried out on 6th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queens Care Centre 15/01/07

Queens Care Centre 20/10/05

Queens Care Centre 13/05/05

Queens Care Centre 14/12/04

Queens Care Centre 14/07/04

Queens Care Centre 24/03/04

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Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Queens Care Centre Millard Lane Maltby Rotherham South Yorkshire S66 7NA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sue Turner     Date: 0 6 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. the things that people have said are important to them: They reflect 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. 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 Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Queens Care Centre Millard Lane Maltby Rotherham South Yorkshire S66 7NA 01709818181 01709769756 queenscarecentre@msn.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Christopher Stephen Nicholson Type of registration: Number of places registered: Z.A.K. HealthCare Limited care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The service may admit up to 4 persons between the age of 55 to 65 years. Date of last inspection Brief description of the care home Queens Care Centre is situated in Maltby within a short walking distance of all local amenities. The home is attached to a Health Centre from which the Registered Person operates his GP practice. The home accommodates older people that require 24-hour personal care. It is a purpose built home with accommodation situated on two floors; the first floor is accessible by a lift and staircases. All bedrooms are single occupancy with the exception of four double rooms, which at present have single occupancy and will remain so whilst occupied by the existing service users. There is an intention that in the future these rooms may be used for wheelchair users that need additional space (as opposed to double occupancy). There are two lounge areas, both of which accommodate dining areas and a kitchenette. The home has a non-smoking policy for Care Homes for Older People Page 4 of 28 Over 65 40 0 Brief description of the care home both staff and residents. There is a pleasant, sheltered garden/patio area in front of the building. The home is owned and operated by Z.A.K. Healthcare. The current fee is 353 pounds per week or 50 pounds per night. Further information is available in the home?s service user guide that is available both in written and CD-rom formats; these can be obtained from the Queens Care Centre. Care Homes for Older People Page 5 of 28 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. This was an unannounced key inspection carried out by Sue Turner, regulation inspector. This site visit took place between the hours of 8.00 am and 2.40 pm. The registered manager is Chris Nicholson who was present during the site visit. The manager was given verbal feedback during and at the end of the site visit. Care Homes for Older People Page 6 of 28 Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. We received seven from people and three from staff. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Nine staff, three relatives and six people living in the home were spoken to. One professional visited the home and they were also spoken to. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in January 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the care home does well: What has improved since the last inspection? What they could do better: The service provided at Queens Care Centre is of a good standard and everyone involved with the home should be proud of this. So that people health, safety and welfare is not put at risk, peoples care plans and daily records should give more detail. People should be asked about what they like to do in their spare time. The activities programme should include peoples individual preferences. If people have participated in activities this should be recorded in their care plan. The account sheet to record peoples finances needs to be changed so that it is clearly understood by staff who make entries on the accounts. The fire risk assessment should be updated and reviewed to reflect the changes made due to the building work. Staff must make sure that fire doors are not obstructed at any time. When people or their relatives raise concerns about the home this should be recorded in the complaints log. Any appropriate action should also be taken. We acknowledge that the provider and manager continue to evaluate and monitor the service and make any changes necessary to ensure that the home continues to provide Care Homes for Older People Page 8 of 28 the good service that is presently offered. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 28 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 28 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. The home provided sufficient information to inform people about their rights and choices. People were encouraged to visit the home, look around and meet other people staying there. Evidence: The home had a Statement of Purpose (SOP) and Service User Guide (SUG). These were available for people living in the home and anyone who may be considering living in the home. The SUG was also available on a Compact Disk (CD), which some people said they preferred. Before people stayed in the home they were assessed by a social worker. The manager also carried out a pre assessment by visiting people in their own home or hospital. This meant that everyone could be assured that the home could meet the persons needs. People were invited to visit the home, try out the meals and spend time meeting the staff and seeing the services available. Any information collated from the needs Care Homes for Older People Page 11 of 28 Evidence: assessment would then form the basis for the care plan. When staff were asked, are you given enough information about people to enable you to care for their individual needs. Two staff said always and one said usually. One staff said, Any new information relating to my job and service users is always passed onto me and my colleagues by the manager. People were asked Did you receive enough information about the service so you could decide if it was the right place for you. Seven people said Yes. One professional said, The staff are very good at welcoming people into the home and helping them to settle quickly. Care Homes for Older People Page 12 of 28 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. A range of health care professionals visited the home to support peoples care. Medication procedures protected peoples health and welfare. In the main the health and personal care needs of people were met in a way that maintained their privacy and dignity. Evidence: Each person that lived in the home had an individualised plan of care. These were checked for four people. Care plans contained basic information about peoples health, personal and social needs. Care plans seen were not written in a person centred way. They focused on the tasks necessary to care for the person. There was no information about what the person themself felt their needs were and how they would prefer these needs to be met. The manager said that he had recognised that the care plans used were not suitable and needed to be updated. He said that he was in the process of arranging staff training in how to write care plans in a person centred way. Staff completed daily records at the end of each shift. Those seen were short brief comments, often repetitive. They didnt detail how people had spent their day, what Care Homes for Older People Page 13 of 28 Evidence: diet they had, if they had joined any activity or had visitors. Care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that dentists, GPs, opticians and chiropodists visited as requested. When asked Do you receive the care and support you need. Two people said always, four said usually and one said sometimes. When asked Do you receive the medical support you need. Five people said always and two said usually. One visitor raised some concerns about the help and assistance his relative received from the staff. Their relative needed assistance with a health problem which they believed not all staff were able to deal with. This was passed on to the manager who arranged to meet with the relative to look at their concerns. The manager was asked to arrange training for staff in how to care for people with this particular health problem. Risk assessments were completed. These were seen on peoples files when a risk to a persons moving and handling or health and safety had been identified. Relatives said, Some staff are good others arent so good. There is always assistance and help from the staff whenever my mum needs it. Mum is well looked after, the staff are very observant. Staff are pleasent and helpful, they let me know if anything is wrong with my relative. Medicines were securely stored in locked trolleys within locked cupboards. Medication Administration Records (MAR) checked were completed with staffs signatures. Controlled Drugs (CD) were kept securely stored. Staff recorded CDs in a CD register. This was checked and found correct. Staff said they had completed an in depth training programme before they were allowed to administer medications. Refresher training was provided each year. There was evidence that managers and senior staff were auditing medication procedures. At the previous inspection it was reported that it was the homes policy that a photograph of each person is attached to the medication file to ensure that the correct medication is given to the correct person. Some files were missing photographs and therefore this is carried forward into this report, but has been moved to a recommendation. People and their relatives said that staff treated them with respect and provided personal care and support in a way that maintained their privacy and dignity. Staff were observed showing empathy and patience when dealing with people. Care Homes for Older People Page 14 of 28 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. People were able to maintain contact with family and friends. A limited range of activities was on offer. Further activities and outings would promote choice and maintain peoples interest. Meals were of a good quality. Evidence: People said they were able to get up and go to bed when they chose. They were seen to walk freely around the home if able. One relative said, Mum was very spolit at home so I thought she wouldnt settle here but she has, shes very happy. We observed people being offered hospitality and made to feel comfortable whilst visiting their loved ones. An activities co ordinator worked each morning, Monday to Friday. On the day of the visit people were involved in a sing song and music and movement. People were asked are there activities arranged at the home that you can take part in. Four people said always and three people said usually. People said, We have bingo, quizzes, darts and bowls. We have been out to the theatre. The activities worker didnt keep a record of what activities or outings had taken place Care Homes for Older People Page 15 of 28 Evidence: or any that were planned. There werent any posters in the home advertising what was available. People said they didnt know what they would be doing until they were taken to the activities lounge. Peoples care plans didnt record if people had taken part in any activity or what they would prefer to spend their time doing. We observed people during breakfast. People were asked their food and drink preferences and staff were very supportive. People were able to maintain their independence during meals. If people needed assistance this was offered. Tables were set nicely with tablecloths and matching crockery. When people surveyed were asked do you like the meals. Two people said always, two people said usually and three said sometimes. People said, Were always offered a choice at mealtimes. The food is good. I have no complaints about the meals here. There should be a drinks machine so we can get a drink when we want, but not one we have to pay for. Im a very faddy eater. If I dont like whats on the menu I ask for an alternative. I enjoy my meals but can never remember what Ive had. Care Homes for Older People Page 16 of 28 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. Complaints and safeguarding policies and procedures were in place. In the main people and their relatives felt confident that any concerns they may have would be listened to. A number of concerns raised by one relative had not been recorded in the complaints log. Staff were aware of their responsibilities in regard to complaints and safeguarding, so helping to ensure that people were protected. Evidence: People and their families had been provided with a copy of the homes complaints procedure. This detailed who to speak to at the home or, if preferred, external to the home to make a complaint, should they wish to do so. Seven people were asked Do you know how to make a complaint. Five people said yes, one said no and one person didnt answer. One Person said , I tell the staff and they sort it. Relatives said, I have never had any reason whatsoever to complain. If I needed to speak to someone I would see the manager. I havent used the complaints procedure but I am aware of it. The home had a complaints log book. No complaints had been recorded in this since the last inspection. One relative said they had raised a number of concerns/complaints with the manager and staff about their relatives care. These concerns should have been recorded in the log book. This would have provided evidence that the manager Care Homes for Older People Page 17 of 28 Evidence: had taken the relatives concerns seriously and acted accordingly. This was discussed with the manager on the day of the visit. We had not received any complaints about the home. The AQAA said that staff had completed training in dealing with complaints and adult safeguarding. Staff confirmed this. Staff spoken to were aware of their role and responsibilities in dealing with any alledged safeguarding incidents. The home had copies of and were working with the revised South Yorkshire protocols for adult safeguarding.People spoken to said they felt safe living in the home. Care Homes for Older People Page 18 of 28 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 home was maintained to a good standard, was clean and fresh smelling. Procedures for the control of infection were in place which promoted peoples health and welfare. Evidence: The home was in the process of being extended. Major building work was being carried out around the perimeter of the home. Due to this some people had been moved to rooms that were not being affected by the extension work. People said they were happy with the changes to their rooms. The manager had taken positive steps to ensure that people were comfortable and safe during the extension work. A rolling programme of redecoration and refurbishment was also underway. Since the last inspection new furniture, carpets and decorating had been completed. In the main lounge there was a large screen television that people were enjoying watching. The manager said that he had identified the areas that were in need of further work and this would be completed as funds became available. All areas of the home were clean and pleasant smelling. Homely touches were provided in communal areas and bedrooms were personilised and comfortable. People said that they had all they needed in their rooms. The toilets and bathrooms were adequate. Seven people surveys returned, were asked Is the home clean and fresh. Six people said always and one said sometimes. One relative said they had raised concerns about the Care Homes for Older People Page 19 of 28 Evidence: temperature in the ground floor lounge/dining room. They said the room was often very hot. The manager had identified on the quality assurance audit that concerns had been raised and that a new pump had been fitted to the central heating. This hadnt improved the problem and the manager was asked to look at other ways to make sure the temperature in the room was maintained at a comfortable level. We acknowledge that this may be made better as changes to rooms are made as part of the extension work. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. The laundry was in need of refurbishment and redecoration. The manager said a new laundry was being provided in the new extension. Behind the washers and dryers there was a thick layer of dust and fluff, which posed a fire hazard. When this was brought to the attention of the manager he arranged for the handyman to clean the area. This was done immediately. Staff had undertaken training in infection control. Care Homes for Older People Page 20 of 28 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. Sufficient staff were provided to meet the needs of people. The recruitment information obtained for staff was sufficient to adequately protect the welfare of people. Staff had completed training that ensured they had the competences to meet peoples individual needs. Evidence: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. On the day of the site visit staffing numbers were at an acceptable level. Staff said that the manager ensured that staffing levels were kept at an acceptable level. They said that when people were sick or on holiday, other staff were called in. They also said that rotas were arranged so that the needs of people living in the home could be met. Three relatives were spoken to. Two said that there always seemed to be enough staff around and one relative said there wasnt enough staff. The manager had undertaken a review of staff training and had identified the shortfalls. Mandatory training had been booked and further training in specialized topics for example dementia was being delivered. The AQAA stated that Rotherham Council had provided them with a substancial amount of money to use for staff training. Three staff surveys were returned. When asked did your induction cover what you needed to know when you started the job, all three staff said very well. Care Homes for Older People Page 21 of 28 Evidence: Staff also said they were receiving lots of training which was relevant to their role. Staff were able to talk about the various training courses that they had attended which included, Moving and Handling, Food Hygiene, First Aid and Fire. A number of care staff had completed the NVQ Level 2 in care and others had commenced the training. The number of staff trained exceeded the required minimum of 50 per cent of the staff team trained to NVQ Level 2 in Care. One professional said The care staff have the right skills and experience to carry out their role well . Three records of employment were checked. These included all of the required information references, certificates of training, health checks and evidence of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check. Application forms recorded peoples previous employment. Care Homes for Older People Page 22 of 28 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. The managers leadership approach benefited people and staff. Quality assurance systems meant that the home was run in the best interests of everyone. In the main peoples health and safety had been promoted and protected. Evidence: The manager had many years experience of caring for older people and had completed his Registered Managers Award (RMA). The manager was hard working, competent and carried out his role to a high standard. He was committed to ensuring that people living in the home were consistently well cared for, safe and happy. One professional said The manager is very supportive when I ring to arrange for someone to stay at the home. Staff said that they found the manager and other senior staff very approachable and could go to them at any time to discuss their work and peoples care. The home did not have anyone nominated to carry out Regulation 26 visits. The provider visited the home on a daily basis to keep himself up to date with the service. Care Homes for Older People Page 23 of 28 Evidence: Staff said he was available for them to speak to should they wish to. Relatives said they were often asked their opinions of the home and the service provided. They said they received questionnaires from the manager which they completed and returned. Staff meetings were arranged. Minutes from these were seen. The manager said that staff were not keen on attending full meetings but preferred to speak to him in supervision and on an individual basis if they had any issues or concerns. Recent resident and relative meetings have not taken place. The manager acknowledged that these should be arranged. The home handles money on behalf of some people. This was checked for three people. Account sheets had been recently changed. There was no column to record peoples financial balance and this had caused confusion. For one person we were unable to establish if the money held for them was accurate. This was pointed out to the manager who said he would address this immediately. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Fire records evidenced that fire alarm checks took place. Staff said that they had received fire training and fire drills. Records of fire drills did not detail the duration of the drill and how staff had responded. We talked to the manager about recording the outcome of fire drills so that staff learned from this. A fire risk assessment had been completed in December 2005. The written risk assessment had not been updated since. The manager said, and we could see that he had updated certain fire procedures due to the building work that was underway. The manager should now update the written fire risk assessment so that it corresponds with the changes made. During the site visit the fire alarm activated. This was a false alarm and staff responded appropriately. A trolley used by the staff was left blocking the fire doors, so the doors were unable to close when the alarm activated. Staff were asked to ensure that the fire doors were not obstructed. Care Homes for Older People Page 24 of 28 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 28 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 16 22 All complaints and concerns raised must be recorded in the complaints log. The record must include the details of any investigation and any action taken. So that people and their relatives and friends are confident that their complaints are taken seriously and acted upon. 14/01/2009 2 35 17 Where the money of an individual is kept in safe keeping there must be a clear written record of all deposits, withdrawals and balances. So that peoples finances are protected from abuse. 14/01/2009 3 38 37 The fire risk assessment must be reviewed and updated. So that peoples safety is maintained. 14/01/2009 Care Homes for Older People Page 26 of 28 4 38 13 Fire doors must be free from 14/01/2009 obstructions at all times. So that peoples safety is maintained. 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 2 3 7 7 8 Daily records should give more detail about how people have spent their day. Care plans should be written in a more person centred way. When a person living in the home has a specific health problem staff should receive training, guidence and information in how to provide the best care for the person. A current photograph of each person should be present on their medication record or personal file. A planned programme of activities and outings should be arranged. People should be made aware of the activities programme. Peoples should be asked their preferences about what they would enjoy spending their time doing. This should be recorded in their care plans. If people are involved in activities and outings this should be recorded in the daily records. Further action should be taken to ensure that the temperature in the ground floor lounge/dining room is maintained at a comfortable level. The laundry room should be kept clean and free from dust and fluff, so that it does not pose a fire risk. Regular resident and relative meetings should be planned. Records of fire drills should detail the duration of the fire drill and the response of the staff to the fire drill. This can then be used to assist in deciding what fire training staff may need to feel confident in what to do in the event of a fire. 4 5 10 12 6 12 7 19 8 9 10 26 33 38 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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