Inspection on 13/11/08 for Shardlow Manor

This inspection was carried out on 13th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shardlow Manor 22/01/07

Shardlow Manor 15/11/05

Shardlow Manor 26/11/04

Shardlow Manor 14/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Shardlow Manor 111 London Road Shardlow Derby Derbyshire DE72 2GP 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 assessment of the service. We call this full assessment a ‘key’ inspection. Lead inspector: Steve Smith Date: 1 3 1 1 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. They reflect the things that people have said are important to them: 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) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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: Shardlow Manor 111 London Road Shardlow Derby Derbyshire DE72 2GP (01332)792466 01332792466 tpopowycz@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Kevin James Popowycz, Mrs Tracey Jane Popowycz Ms Emma Salt Care Home 28 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration Category(ies): old age, not falling within any other category Additional conditions: Number of places (if applicable): Under 65 0 Over 65 28 1. The registered person may provide the following category/ies of service only: Care home only Code PC 2. The maximum number of service users who can be accommodated is: 28 to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category Code OP Date of last inspection: Brief description of the care home: Shardlow Manor is a Care Home registered to provide personal care and accommodation for up to 28 people in the category of older persons. The Home is situated in the village of Shardlow, which is located on the main A6 route from Derby to Loughborough. The Home has a front garden patio area, and a car park. Shardlow Manor has 22 single rooms, 17 have en-suite facilities and 3 double rooms. A variety of lounge and dinning room space is provided. The accommodation is on two floors, and there is a chairlift for access to the first floor. The Commissions Inspection reports are Care Homes for Older People Page 4 of 28 2 2 0 1 2 0 0 7 displayed in the entrance area of the Home. On the day of this visit to the Home the range of fees was 360 pounds to 420 pounds per week, excluding hairdressing, private chiropody, toiletries and newspapers. Details of previous inspection reports can be found at the Home, or on the Commission for Social Care Inspections website: www.csci.org.uk 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 How we did our inspection: The focus of inspections, undertaken by the Commission for Social Care Inspection, is upon outcomes for people and their views of the service provided. This process considers the Homes capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that needs further development. This inspection visit was unannounced and took place over a period of approximately 8 hours. In order to prepare for this visit we looked at all of the information that we have received, or asked for, since the last key inspection of the Home, which took place on 22 January 2007. This included: The Annual Quality Assurance Assessment. This is a document completed by the Care Homes for Older People Page 6 of 28 Registered Providers of the Home that focuses on how well outcomes are being met for people using the service. What the service has told us about things that have happened in the service. These are called notifications and are legal requirements. The previous Key Inspection Report, and the results of any Other Visits that we have made to the service in the last 12 months. Relevant information from Other Organisations, and what Other People have told us about the service. Surveys returned to us by people using the service, from the relatives of those staying in the Home, and from the staff working in the Home. For this inspection of the service the Commissions Residents questionnaire (a survey mentioned above) was sent to 10 people staying in the Home, and 1 was returned. Ten questionnaires were also sent out for those staying to pass on their relatives, if they thought this was relevant; one was returned. Ten questionnaires were also sent to staff, but none were returned. During this visit to the Home case tracking was used as a system to look at the quality of the care provided. This involved the sampling of a total of four peoples records, being a cross-section of people staying in the Home. Discussions were held with those people, if they were able, together with a number of others, about the care and services the Home provided. Their care plans and care records were also examined, and their private bedrooms and communal facilities were seen. Discussions were also held with any relatives that were visiting during this visit to the Home. In addition, discussions were held with the Manager of the Home about its general operation. Discussions were also held with staff about the arrangements for peoples care, and also about the staffs recruitment, induction, deployment, training and supervision. Care Homes for Older People Page 7 of 28 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 Care Homes for Older People Page 8 of 28 following this report, you can contact them using the details on page 4. The report of this inspection is available 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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All new people moving to the Home were appropriately assessed prior to their admission, so that they were assured that their needs would be met. Evidence: The Registered Providers had provided a good statement of purpose for the Home together with a Residents Guide, which informed people staying in the Home, and their relatives, of what the Home provided. The Guide was well completed, although did not include details of where a copy of the last Inspection Report, completed by the Commission, could be obtained. The Guide also did not include the views of those living in the Home on what it was like to live there. In the Annual Quality Assurance Assessment, completed by the Manager, she wrote We encourage visits prior to admission of prospective residents. We also send out brochures and the statement of purpose to the prospective residents, and always carry out the pre-needs assessment. We give verbal feedback and written confirmation of the possibility of a placement at the home to the prospective resident. In the questionnaire, completed by the one person living in the Home, they said that they were happy with the admission procedure, which was also confirmed in the relatives questionnaire. The records of four people staying in the Home were examined during this visit and a Care Homes for Older People Page 11 of 28 copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, were available to examine. This ensured that peoples legal rights were protected. When new people were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each person, copies of which were seen. The Manager also assessed all people sponsored by Social Services Depts. If the person was self-funding from the outset, the Manager completed her own summary of needs, which were also seen during this visit. Standard 6 does not apply to this Home. 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 the 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 health and personal care needs of people using the service were being met. Evidence: Four records of people staying in the Home were examined, or case tracked, to ensure that suitable records were being maintained. Satisfactory initial assessment records were made by the manager, during her first visit to the potential new people in their own homes or hospital placements. This was found to be followed up by individual plans of care and risk assessments for each person whose files were looked at. However, the space provided, on the form used by the Home for the individual plan of care was very limited, and so the information recorded was equally limited. For example, - (The Resident) needs assistance of 1-2 carers to wash and dress morning and night, although no information was provided on what the 2 carers were to do for the person. However, comments from people using the service supported that their needs were being met. A formal six monthly review of care was only found in one of the files. Good daily records were maintained by the Homes staff. The Home also completed a monthly review of care, but in the main this review simply said Continue with agreed plan of care. It was therefore not a review that could be shown to the person, whose review it was. Staff were observed talking and assisting people in the lounges and dining rooms. This Care Homes for Older People Page 13 of 28 was seen to be done very positively, with a relaxed atmosphere, which was enjoyed by the people staying in the Home. In the Annual Quality Assurance Assessment, completed by the Manager, she wrote We provide a good standard of care to residents with high levels of need using the multi-disciplinary team around us to continue to support and care for people who are at the end of life. We have a team of District Nurses and GPs who help us to provide specialist equipment etc. We have good relationships with these people and also our local pharmacist, who provides an excellent service. We ensure all agencies offer a good service with foot-care, dental and haircare. We communicate well with families in a realistic and sensitive manner. At the time of this visit to the Home, this was found to be the case. The records of peoples health needs were observed and a good record was found to be maintained. All medication and the method of distributing it to people staying in the Home was examined. This showed that a well maintained record was kept. However, the following issues needed to be addressed: A small number of medications were found in the blister packs, which the Medication Administration Record (MAR) sheets indicated had been given to those staying in the Home. The symbol O was used on the MAR sheets in a number of places. At the foot of each MAR sheet it indicated that this symbol was to be defined. However, the symbol was not defined by the staff, and it was used to indicate different things in a number of cases. Discussion was held with people staying in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and had a strong sense of well being. One person said - Staff always do things my way, they always come when I press the buzzer - another said - I cannot grumble, staff are very good. All staff were observed to be very caring in their dealings with people in the Home, and spoke to them in a caring, friendly manner. In the one questionnaire available the person had written that staff listened and acted on what she said - ... most of the time. She also said that staff were available whenever she needed them. Staff were also spoken with, and they were able to describe very positive ways of assisting people within the Home. 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 the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples preferred lifestyles were respected by the Home, and people were given a wholesome and appealing diet in pleasant surroundings, that enhanced their well being. Evidence: In the Annual Quality Assurance Assessment, completed by the Manager, she wrote We offer flexibility around choices & preferences, residents can personalise their own rooms. Visitors can call at any time and see a resident on a one to one basis as there is open visiting in the home. We offer small outings for residents and recognise their religious needs. This was confirmed by conversations with those staying and with staff. People staying in the Home were asked about the activities provided. Those spoken with said that regular activities took place. They said that such activities as painting, card making, dominoes, cards and bingo took place. It was also said that at events such as Christmas and Easter etc special events were arranged. People also said that outing were planned, such as Christmas shopping, and that on such occasions wheelchairs were available to all, as they were not expected to walk the considerable distances around the shops. Staff were also asked about the activities provided, and in addition to those already listed, they said that monthly trips were arranged through the summer, and that trips to public houses were arranged in the winter months. They also said that fetes were arranged twice a year, and that events such as baking, pat a dog and reflexology were also provided. Staff said that all of these events were arranged by the Activities Coordinator who worked at the Home two full days each Care Homes for Older People Page 15 of 28 week. People staying in the Home said that they decided when they got up and went to bed. One person said - I get up when I want to - I have breakfast in bed - and another said - I get up and go to bed when I want to, and when I ask for help, they help me. People also said that - I have a bath once a week, which is OK for me - and - I have one bath a week, and I do exercises to keep my joints moving! Relatives and friends of people staying in the Home were able to visit at any time, and could always be seen in private. One person said - We can come to my bedroom or stay in the lounge, its as we choose - another said - I usually see my relatives in the lounge, but I could go to my bedroom if I wanted. The staff spoken with also said that relatives could visit at anytime. It was said that people could chose where they wanted to see their relatives, in one of the lounges, or in the persons bedroom. One person staying in the Home said that - If I wanted to go out to the shops or visiting someone from the Home would take me. Two people said that they enjoyed the communion services that were held in the Home on a monthly basis. One person also said that they were able to vote in national and local elections via a postal vote. People staying in the Home were able to say that the Home provided good meals and that - They always come around in the morning and ask what you want for dinner and tea. At tea time we can have something on toast, cobs, crisps... - another person said - Two choices are always provided, and an alternative is provided if you dont like either. At tea time you can have sandwiches, toast and honey, spaghetti with chicken nuggets - food is good and fresh. Staff also confirmed this. People and staff said that drinks and snacks were always provided between meals, and that people could also ask for additional drinks at anytime. Mealtimes were never rushed, which was witnessed during this visit to the Home. 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 the 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 made to the Manager were addressed to meet peoples needs. The protection policies and procedures provided meant that people staying in the Home were well protected. Evidence: People spoken to said that if they had a complaint to make they would tell the Manager - I would tell (the Manager). I had to do this once and it was all sorted out I was pleased with the result - and another person said - I would tell (the Manager) or a senior member of staff. I have raised a complaint and I was happy with how it ended. The Commission had not received any notice of complaint since the last visit to the Home, in January 2007. Since that visit in January 2007, the Manager had recorded one complaint, which was reviewed and found to have been resolved satisfactorily. The policies and procedures for both written and verbal complaints were reviewed and were found to be satisfactory. The Registered Providers complaints procedure detailed that all complaints would be responded to by the Manager within at least 28 days. In the Annual Quality Assurance Assessment, completed by the Manager, she wrote We deal with complaints effectively and we ensure that all our staff are POVA trained. I and senior staff have been trained to discuss concerns about complaints and protection with individual staff members during supervision and residents care reviews. Care staff supported this when they were spoken with. The Registered Providers had a Safeguarding Adults procedure that included a Whistle Blowing policy, which staff spoken with were aware of and had undergone training for. This meant that a procedure was in place to allow staff to inform the Manager of any Care Homes for Older People Page 17 of 28 inappropriate actions by other staff. The Manager said that she had a copy of the Dept of Healths policy called No Secrets, but did not have a copy of the Public Interest Disclosure Act of 1998. The Manager confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. Staff said that they understood that people staying in the Home might, on occasion, show challenging behaviour, but were not able to say that they had received training on the how to manage such behaviour. The Manager said that the Registered Providers had not provided a policy stating that staff could not benefit from peoples wills, which, when the staff were spoken with, was also confirmed by them also. 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 the 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 well maintained throughout, providing all people staying in the Home with a safe, comfortable environment in which to live. Evidence: A tour was made of the public areas of the Home, and included many of the bedrooms of people staying in the Home. The Home was most pleasantly decorated throughout, and the lounges and dining rooms was pleasant to sit in. The bedrooms seen provided sufficient space and provision for each person staying in the Home. The Registered Provider had also provided appropriate furnishings in almost all locations seen during this visit. Bedrooms were also very pleasantly decorated, by each person, with pictures of their lives prior to moving to the Home. Toilets were easily available to everyone staying in the Home, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. In the Annual Quality Assurance Assessment, completed by the Manager, she had written -We maintain a high standard of cleanliness and ensure the home is odour free. We redecorate regularly to retain a homely atmosphere throughout. We also encourage residents to personalise their bedrooms. During the past 12 months the Care Homes for Older People Page 19 of 28 Registered Providers have installed a new heating system in the home, they have also provided a new refrigerator and dishwasher in the kitchen, and have arranged for the exterior of the home to be redecorated. During this visit to the Home most of this was seen to have been done, although one bedroom visited did suffer with a poor odour, as commented on below. 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 the 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 good level of care staffing was provided to meet the needs of people staying in the Home. Recruitment practices were followed when recruiting new staff, so that Residents welfare was safeguarded. Evidence: Levels of care staffing were examined for the 3 weeks beginning 23 October 2008. This showed that a good level of staffing was being provided. The Annual Quality Assurance Assessment completed by the Manager said that - We provide a high staff/resident ratio. At the time of this visit to the Home it was found that over 50 of care staff held a qualification of at least NVQ level 2 in Care; 14 of a total of 20 care staff. Of those 14 members of staff 4 held an NVQ level 4 and 3 held an NVQ level 3. Both staff who were interviewed said that they already held at least an NVQ level 2 in Care. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all necessary information had been obtained. The history of employment of one of the new staff members had only been taken over the previous 10 years, and not back to when they had left school. All other information was found to be satisfactory. Care staff spoken with were able to confirm that they had been given copies of the General Social Care Councils code of conduct and practice. The Manager said that all new staff were provided with induction and foundation training, which was confirmed by staff spoken with. She also said that all care staff were provided with at least three paid days training a year, which again was confirmed by staff. All staff also had an individual training and development assessment and profile. Care Homes for Older People Page 21 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 the 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 management arrangements at the Home were sufficiently robust to ensure that residential care was maintained at a positive standard. Evidence: The Manager was found to be appropriately qualified to manage the Home, having an NVQ level 4 qualification in Care and Management. The Manager said that the Registered Providers visited the Home on at least a weekly basis, but they did not complete the statutorily required inspections of the Home on a monthly basis. She said that this had been done in the past, but had not been carried out for some time. The Manager was not able to produce an annual Quality Assurance plan for the Home, which reflected the aims and outcomes for people staying there. However, surveys had been undertaken, and published, of peoples opinions of the operation of the Home. Residents Meeting were found to be regularly held at 6 monthly intervals and minutes were produce. The opinions of peoples families and friends, and of GPs and District Nurses etc, were obtained, via questionnaires, and during formal reviews of each person staying in the Home. In the Annual Quality Assurance Assessment the Manager said - Staff in the Home work as a team, and ensure that they communicate well with one another and with management. Care Homes for Older People Page 22 of 28 The Home held a number of accounts of peoples personal money. Two of these were examined and it was seen that this was managed effectively for those staying in the Home. However, advise was given on the amount of money it was appropriate for the Home to hold for each person. Staff members were asked about the supervision they received from the Manager or other senior staff in the Home. They said that this was done on approximately a 2-3 monthly basis, when their own needs, and the needs of those staying, were discussed. The Manager confirmed that supervision was provided by herself or senior staff, for all care staff working in the Home. Records of supervision were also seen. The training provided for all staff was examined. This showed that the training required by regulation on Moving and Handling, Fire Safety, First Aid, Food Hygiene and Infection Control was up to date. However, it was found that no senior staff had been trained as qualified First Aiders to ensure that at least one person with this qualification was on duty day and night. The results of these training needs was confirmed by examination of the Homes records, by the Registered Provider of the Home. In addition to the above areas of mandatory training, the Manager said that training was offered in the Management of Medication, Safeguarding and dealing with Challenging Behaviour, Continence Awareness, Care of the Dying, Dementia, Bereavement and training in NVQ levels 2, 3 and 4. From copies of the Registered Providers maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. The Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Care Homes for Older People Page 23 of 28 Are there any outstanding requirements from the last inspection? Yes 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 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. 7 15 Plans of care must be completed in sufficient detail to ensure that staff know how they are to provide care to people staying in the Home. This is to ensure that the detail of the care is fully recorded and can be acted upon by staff. 28/01/200 2. 9 13 When staff used the symbol O on the Medication Administration Record sheets they must always define its meaning. This to ensure that information provided on the MAR sheets is clearly understood by all. 28/01/2009 3. 29 19 All the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as 28/01/2009 Care Homes for Older People Page 25 of 28 amended during 2004, must be obtained when appointing new staff. This is to ensure that new staff recruited are suitable people to provide care in the Home. 4. 31 26 The Registered Providers must ensure that the Home is inspected on an unannounced basis, at least once each month. This must be done to met the requirement listed in Regulation 26(4) & (5). 28/01/2009 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 1 The Residents Guide should include details of where a copy of the last Inspection Report, completed by the Commission, can be obtained, and the opinions of those staying in the Home on what it is like to live there. The Residents Guide should inform those staying on how contact can be made with the Commission, the local Social Services Dept and the local Health Authority. Monthly reviews of care should contain significant detail of the previous months activities for the person concerned, positive and negative. The review should also be shown to the person, or their representative, for them to comment upon, have their comments added to the report and to be signed by them. The Manager should formally review each persons plan of care and risk assessment at 6-monthly intervals. The formal review should include the person themselves, their Care Homes for Older People Page 31 of 32 representative and, if appropriate, their other relatives, the Manager and other involved staff. One of these reviews could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the person. 2 1 3 7 4 7 Care Homes for Older People Page 26 of 28 5 18 6 7 18 18 8 33 The Registered Providers should provide a policy which states that staff are not able to benefit from, or assist those staying in the Home, in the making of their wills. They must then ensure that all staff are aware of this. All staff should receive training on dealing with challenging behaviour, in line with safeguarding adults from abuse. The Registered Providers should obtain a copy of the Public Interest Disclosure Act of 1998, to aid the management of Safeguarding Adults issues. The Registered Providers and Manager must complete an annual Quality Assurance plan for the Home. 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. ©This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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. 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