Inspection on 14/10/08 for Ramping Cat House Nursing Home

This inspection was carried out on 14th October 2008.

CSCI 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ramping Cat House Nursing Home 09/08/07

Ramping Cat House Nursing Home 04/07/06

Ramping Cat House Nursing Home 19/01/06

Ramping Cat House Nursing Home 10/10/05

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ramping Cat House Nursing Home White Hill Burford Oxfordshire OX18 4EX     The quality rating for this care home is:   zero star poor 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: Kate Harrison     Date: 1 4 1 0 2 0 0 8 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 © (2008) 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: Ramping Cat House Nursing Home White Hill Burford Oxfordshire OX18 4EX 01993822088 Telephone number: Fax number: Email address: Provider web address: rampingcat@atlantishealthcare.co.uk Name of registered provider(s): Name of registered manager (if applicable) Jane Pocock Type of registration: Number of places registered: Atlantis Healthcare Ltd care home 15 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: On admission persons should be aged 60 years and over Date of last inspection Brief description of the care home The Ramping Cat House is a care home with nursing, registered with CSCI to provide accommodation and services to 15 individuals. The home is situated in open countryside on the edge of the Cotswolds, near to Burford. Accommodation is provided in single rooms over two floors, with a stair lift providing access to the first floor. The manager and a team of nursing and care staff provide care, plus a part time cook. The present owner acquired the home in July 2005, visits regularly, and has plans to improve and extend the accommodation. 0 Over 65 15 Care Homes for Older People Page 4 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: 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 inspection was an unannounced Key Inspection, and took place over 8.5 hours one day. This inspection was a thorough look at how well the service was doing. It took into account the homes detailed self assessment document, the Annual Quality Assurance Assessment (the AQAA referred to in this report), and any information we received about the service since our last inspection. We saw most areas of the home and looked at records and documents relating to the care of the people living there. We asked the views of the people living in the home through our surveys and those who could talk with us o the day of our visit, and their views are reflected in this report. We discussed the running of the home with the registered manager, saw recruitment files, policies and procedures used in the home and we checked how the medication is managed. The fees for this home range from 493 to 750 pounds per week. Care Homes for Older People Page 5 of 28 The last inspection of this service was on 09/08/2007. What the care home does well: What has improved since the last inspection? What they could do better: 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 7 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 8 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Pre-admission assessments are carried out before people are admitted to the home, but the home does not provide people living in the home with all the information they are entitled to about the home. Evidence: We looked at the records of two individuals to check the homes admission procedures. We saw that both individuals had been assessed by the local authority, and that a senior person from the home had visited the individuals and carried out a preadmission assessment of their health and welfare needs. At our last inspection in August 2007 we recommended that the homes statement of purpose be updated to include all the necessary information, and the registered manager said this had not happened. One recently admitted person said that she had not seen the homes service user guide, and we saw an incomplete version of the service users guide during our visit. Requirements are made in this report that the Care Homes for Older People Page 9 of 28 Evidence: statement of purpose and the service user guide be updated so that people who come to live in the home are aware of what the home has to offer, what services and facilities they can expect, and how they can make their complaints and concerns heard. Care Homes for Older People Page 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have their healthcare needs met, but there is a lack of personalised care planning and limited understanding of the rights of people living in the home. Evidence: We looked at the care records of two people, and saw that the home uses a commercially available documentation system. Risk assessments were carried out to highlight the risks to the health of both individuals. The assessments included risks about moving and handling, pressure wounds and nutrition. The risk assessments for both individuals showed that the risks were medium, and we saw that both individuals needed help with personal care and in moving about, but there were no care plans to manage how the risks would be minimised. One individual had fallen twice after admission to the home, but there was no risk assessment carried out or a care plan in place to minimise the risks. One individual had one care plan, and this was about how to manage pressure damage. The registered manager said that since moving to the new documentation system the homes custom was to verbally update staff members Care Homes for Older People Page 11 of 28 Evidence: about changes to the way care needed to be delivered. We discussed the need to document the detail of how care was to be delivered with the registered manager, so that people in the home were cared for according to their assessments, and according to how each person wanted their care to be delivered. We saw no evidence that the home discusses with individuals how they would like their care to be delivered, and we did not see that there is a system for detailing individual preferences, for example about how people want to be cared for during bathing or showering. A requirement is made about care planning in this report. The registered manager said that the home is introducing the nationally evidenced based nutrition assessment tool as soon as the necessary documentation comes. We saw that people are registered with a general practitioner and that other healthcare professionals visit the home. One visiting general practitioner said that the home provides the best nursing care compared with other care homes s/he deals with. We looked at how medication is managed in the home. All the medication is kept securely, and nobody manages their own medication. The home has an arrangement in place for a local dispensing surgery to deliver the medication, and we saw that all medication coming into the home is recorded. We checked the system for recording the administration and disposal of medication, and these were satisfactory. There is a contract in place with a commercial firm to manage the disposal of medication. We saw care staff and nurses deal sensitively with individuals during our visit, but we also saw that staff members do not always knock on individuals doors before entering, and noted that they are not usually consulted about their care. No rooms are shared at the home. Care Homes for Older People Page 12 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have limited opportunities to influence the way the home operates, and the home does not actively consider how the routines of the home can be adapted to meet their needs. Evidence: The home has an activity schedule, but the activities organiser left some time ago and although the manager said the post had been advertised, it has not been filled. Care staff are now responsible for providing any 1 to 1 activity in the morning, and communal activities in the afternoon. During our visit although an activity was shown on the schedule it did not happen, and in the afternoon people were grouped together in the lounge around the television showing a film. There are no outings planned. The registered manager said that some days people are not interested in the activity planned, and choose not to have it, and she mentioned activities that are not written on the activity schedule, such as occasional visits from a Pets as Therapy dog and handler. One person recently admitted to the home said that she saw an activity happening one day, but nobody invited her to join in, and she was not sure if she was allowed to. She was not aware of the activity schedule, and said she thought she might like to take part in some. There are opportunites for individuals to use the Care Homes for Older People Page 13 of 28 Evidence: garden as they want, and one individual said she enjoyed being in the garden as often as possible. There are examples of how the routines of the home at times do not take into account the wishes of people living in the home. One individual discussed how changing the homes routine to accommodate her having a towel in her room by the wash basin would make her daily life easier, but although she had asked to have one, the homes routine was not changed. The manager does not have a routine of seeing all the people living in the home and discussing what life is like for them on a regular basis, so is not always aware of the issues that affect them. We discussed the importance of this exercise with her. Christian religious services are held regularly in the home to suit the people living there. Visitors are very welcome in the home, and the manager said she sees relatives regularly. People told us that they enjoyed lunch at the home. They said that the vegetables are fresh and the meal is wholesome and satisfying. The registered manager said that as the cook is not in the home in the evening the supper consists of sandwiches and soup, and the care staff are usually responsible for this. We saw no evidence that the people in the home have been consulted about a choice of hot food in the evenings and this needs to be addressed. There are no meetings organised for people living in the home or their relatives to have their say about how the home operates. Care Homes for Older People Page 14 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are safeguarded from harm through the homes procedures and staff training, but they do not all know how to make their complaints known. Evidence: We saw the complaints procedure displayed in the home, but our details were not included as is required by the Care Homes Regulations, and the registered manager said this would be amended. One individual who was living in the home for several weeks was not aware of the complaints procedure, and this was discussed with the registered manager. The homes AQAA shows that 1 complaint had been received and responded to within 28 days, and we have received no information about complaints made to the home since our last ispection. Since our last inspection the manager has acquired the necessary information regarding Oxfordshires safeguarding procedures, and is aware of what to do in the event of suspicions or allegations about abuse. The staff team has attended training about afeguarding vulnerable adults, and the home has policies and procedures about the subject. The manager agreed to review the procedure so that the staff team could easily understand what they need to do in the event of suspicions or an allegation. Care Homes for Older People Page 15 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management has not recognised or responded to the need to keep the home clean, hygienic and safe, and this presents risks to the safety of the people living there. Evidence: We saw the communal areas of the house including the upstairs bathroom and downstairs shower room. Cleaning equipment was stored in the bathroom, including a red mop and bucket, in full view of anyone taking a bath. There were two large bins, one by the side of the bath, and another for soiled pads by the head of the bath with a very dirty lid. The bath was very dirty, with soap scum and lime scale stains. The tap area was very dirty with a bolted on holding bar that was rusty and dirty, with soap and lime scale stains. The toilet was very dirty with excrement stains, and the bowl had heavily stained limescale. The raised toilet seat was stained and dusty. A frame around the toilet was very dusty and dirty. The areas behind the bath and toilet were very dirty, and the vinyl-type floor covering had several white paint marks. There were old notices on the wall and these need to be removed as they make the room look more institutional than necessary. The manager agreed that it looked like it had not been cleaned for at least one month. The downstairs shower room also needs deep cleaning, including the tiled areas. The communal bathroom and shower room do not provide a clean relaxing Care Homes for Older People Page 16 of 28 Evidence: place for people to bath and shower in, and this must be addressed. We saw that other areas of the communal spaces also needed cleaning and updating. Two chairs in the nurse station area are shabby and ragged and need to be recovered or replaced. We understood that the cramped and shabby lounge mentioned in our last report has not received any updating attention. This lounge has a good aspect on the garden, though one set of windows need repainting as the paint is peeling and it looks shabby. Other windows also need repainting in different areas of the home. The homes laundry is managed by the day care staff, and the registered manager said that all care staff had completed a distance learning course about the control of infection. We saw that laundry was sorted on the laundry floor, and the registered manager explained this was usual practice. As the floor is of concrete and not impermeable, this is not good practice as the floor is not cleaned after each sorting of the laundry. It is difficult to see that the staff team understand the principles of infection control when the bathrooms are in a poor hygienic state and the laundry is treated in a way that will encourage the spread of infection. The staff team need to take a training course that will give them an effective understanding of the principles of infection control. The home has no regular cleaning staff, and the care staff are expected to do the cleaning tasks that cannot be carried out at night, such as the cleaning of individuals rooms. Night staff are expected to clean the communal areas, including the bathrooms, but there is no schedule of cleaning, or effective auditing programme to monitor how the work is carried out. At our last inspection visit a requirement was made that sufficient staff must be on duty to manage the cleaning and laundry needs in the home, but this requirement has not been met. Although the numbers of people living in the home have decreased since our last inspection visit, it is clear that the home is not meeting the needs of the people currently in the home to have a clean hygienic place to live in. Also at our last inspection visit, we made a requirement that staff members receive the training appropriate to the work they are to perform, and there was no evidence that they had received the necessary training to carry out the cleaning of the home. The manager said that she did not have the programme of routine maintenance and renewal of the fabric and decoration of the home but it was agreed that she could have 48 hours to produce the programme. There is no maintenance person on site , but the registered manager said that she could arrange to have maintenance issues such as plumbing and electricity attended to by local people, and during our visit a locksmith was in the home. The night staff had reported a broken lightbulb in the hall by the nurse station and steps, and this had not been replaced, as an electrician had not been called. We discussed the storing of an oxygen cylinder in an alcove upstairs, without a warning notice, and the registered manager said she would discuss this with the Care Homes for Older People Page 17 of 28 Evidence: pharmacist. The alcove also included flammable materials and the registered manager agreed to dispose of them. We noted that the room for one individual did not adequately meet her needs, because since her admission her needs have changed, and now she uses a wheelchair to get around the home and her room. This was discussed with the manager who agreed to review her needs, and to take the necessary steps to meet her changing needs. The expected extension to the home has not started and now has no expected start date. Care Homes for Older People Page 18 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of enough trained staff to carry out all the necessary work in the home may put the health and welfare of people living in the home at risk. Evidence: People living in the home told us that the staff team are good and caring, and one person said the best thing is their cheerfulness, and their ability to make a good atmosphere. One person said that generally the team know what they are doing. We discussed the staffing situation in the home with the registered manager . She said that several members had left including the cleaner and the activities organiser. No one suitable came forward following advertising for the positions, and the home has a policy of not using agency staff, so the posts remain unfilled. For the nine people living in the home there is one nurse and two carers working in the mornings, and one nurse and one carer in the afternoons. There is a cook from 8am until 1pm daily. Recently the registered manager has worked as the nurse on duty, as one nurse is on annual leave, and as another nurse is starting annual leave this month, expects to continue until the middle of November working as the duty nurse. This means that she is not able to carry out all her management duties, and this effects the smooth running of the home and ultimately the welfare of the people in the home. The care staff, as well as managing their caring duties, organise and carry out activities, the management of the laundry, cleaning of the home and the organising Care Homes for Older People Page 19 of 28 Evidence: and presenting of the evening meal. As we saw that all the tasks are not completed satisfactorily and this affects the people living in the home we served the notice mentioned in the previous section. The homes induction training programme has improved, and is now to the Skills for Care standard. There is a staff training programme, that provides all the mandatory training for staff, and we saw the certificates of training in several staff files. Of the five care staff employed two hold the National Vocational Qualifivcation (NVQ) Level 2 in Care, three more are enrolled, and one has started doing the NVQ Level 3 programme. We looked at four staff files to check the homes recruitment process. At our last inspection visit we made a requirement that the home must obtain confirmation of all the information required before employing people to work at the home. We saw that all the information was available for three of the people we checked. For one person who had started work at the home in 2005 and left in 2006 and was re employed in July 2007 we could not find any of the information about the recent checks or any of the necessary information. We saw all the documentation about the first employment and the registered manager said that she had been very mindful of the requirement we made, and had made sure that she had all the information necessary and had carried out all the checks required. She said that the only place the information would be stored would be in the filing cabinet in the nurses area, and although she spent 15 minutes searching the documents were not found. We agreed that the registered manager could have a further 48 hours to produce the documents. Care Homes for Older People Page 20 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and welfare needs of the people living in the home are compromised by the lack of systematic management in the home. Evidence: The registered manager is skilled and experienced, has her Registered Managers Award and has been in charge of the home for some years. She completed the AQAA document, but gave limited information about what was happening in the home. Where shortfalls were identified, for example employing agency staff to cover abscences, this has not been addressed and the home is operating without enough staff to cover all the necessary work. The registered manager is supported to some extent by Atlantis Healthcares operations manager, but recently the operations manager has been required to run one of companys other homes. This has meant that the organisation has not effectively supported the egistered manager. In response to our requirement about quality assurance processes at our last inspection visit a quality assurance survey was conducted in July 08 asking the views of people living in the Care Homes for Older People Page 21 of 28 Evidence: home and their relatives about the service provided at the home. The registered manager said that although the replies had been received no further action had been taken about collating the results or addressing any issues arising. This was because the operations manager is not available to do it, and she does not have enough time to complete the exercise. As part of the quality assurance process our requirement included the homes annual business and development plan, and the registered manager said that she did not have it, and it was agreed that she could have a further 48 hours to produce it. The planned development of the home scheduled for July 08 has been delayed. The home does not manage or keep any monies on behalf of people living in the home. Since our last visit the formal supervision of staff has improved, and we saw the record of a recent unannounced monthly auditing visit by a representative of the company. The nurse station/office is in the galleried area of the open hallway, and a locked filing cabinet is used to store some of the confidential information about people living in the home and also the staff recruitment information. We saw that some key confidential information about people living in the home is not stored securely, and is available unattended in the hallway, and the registered manager said that as there is no office provided there was nowhere suitable to keep records securely where the staff team could have regular access throughout the day. This needs to be addressed, and the confidential records of people living in the home must be kept securely. The registered manager said that the homes fire risk assessment was up to date, and that fire training is carried out regularly, but the manager is failing to ensure that safe working practices regarding hygiene are carried out in the home. The lack of management hours available to the registered manager has been mentioned in our last two reports, and in our report of August 2007 we made a requirement that she must have sufficient supernumerary time to carry out the additional managerial, supervisory and assessment tasks required of her. During this inspection visit we found evidence that the registered manager is not fulfilling her management duties, for example parts of the home are unhygienic, there is a shortfall in the maintenance of the home, the changing needs of the people living in the home are not recognised and addressed quickly. There is a lack of systematic management in the home, and one result is that there are not sufficient resources available to make sure that the health and welfare needs of the people living in the home are met. Care Homes for Older People Page 22 of 28 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 27 19 Sufficient staff must be on 20/09/2007 duty at all times to meet the physical, emotional and social care needs of all service users. In addition catering, cleaning and laundry staff must be employed in sufficient numbers. All staff must receive training 20/10/2007 appropriate to the work that they perform. That a staff training and development programme is put in place. 2 30 17(4) 3 31 10(3) The registered manager 20/09/2007 must have sufficient supernumerary time to carry out the additional managerial, supervisory and assessment tasks required of her role. 4 33 24 Quality assurance processes must be developed to evidence that the home is run in the best interests of the service user. Including the homes annual business and development plan. 20/10/2007 Care Homes for Older People Page 23 of 28 Care Homes for Older People Page 24 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 22 That the homes complaints procedure be revised to include our name, address and telephone number. That the home give a copy of the revised comlaints procedure to every person living in the home. So that the people living in the home are aware of their right to complain, and are aware of what to expect when they make their complaints known. 31/10/2008 2 1 4 That the homes statement 31/10/2008 of purpose be updated to include all the necessary information, including all the matters detailed in Schedule 1 of the Care Homes Regulations. To make sure that people have all the information they need about the care home. 3 1 5 That the service user guide 31/10/2008 be updated to include all the Care Homes for Older People Page 25 of 28 necessary information, and that the updated service user guide be supplied to all the people living in the home. So that the people living in the home have all the information they need about the home. 4 7 15 That care plans are developed through consultation with the individuals living in the home showing how their individual needs regarding personal and healthcare will be met. So that all the needs of people living in the home are recorded and met, and that people have their needs met in the way they prefer. 5 19 23 That all parts of the home are kept clean and reasonably decorated. So that people living in the home can bath or shower in a clean, reasonably decorated environment. 6 37 17 That all the information relating to people living in the care home detailed in Schedule 3 of the Care Homes Regulations be kept securely. So that people living in the home can be confident that the home respects their confidential information. 31/10/2008 31/10/2008 31/10/2008 Care Homes for Older People Page 26 of 28 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 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 © (2008) 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!