Inspection on 07/07/09 for Hallaton Manor

This inspection was carried out on 7th July 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hallaton Manor 02/12/09

Hallaton Manor 03/06/08

Hallaton Manor 11/07/07

Hallaton Manor 01/06/06

Hallaton Manor 19/10/05

Hallaton Manor 07/07/05

Hallaton Manor 15/03/05

Hallaton Manor 27/07/04

Hallaton Manor 25/02/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Bernards Cranoe Road Hallaton Market Harborough Leicestershire LE16 8TZ     The quality rating for this care home is:   one star adequate 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: Carole Burgess     Date: 0 7 0 7 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. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 30 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: St Bernards Cranoe Road Hallaton Market Harborough Leicestershire LE16 8TZ 01858555271 01858555332 elainefarrall@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : St Bernard`s Hallaton Manor Limited care home 41 Number of places (if applicable): Under 65 Over 65 0 41 0 0 41 0 past or present alcohol dependence dementia learning disability mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 41 0 6 41 0 33 Nobody falling within the category LD may be admitted to the home when there are 6 persons already accommodated in that category. Nobody falling within the category PD may be admitted to the home when there are 33 persons already accommodated in that category. The maximum number of people who can be accommodated is: 41. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any Care Homes for Older People Page 4 of 30 other category - Code OP Physical Disability - Code PD : over the age of 40 years Alcohol dependency - Code A:over the age of 40 years Mental disability - Code MD:over the age of 40 years Learning disability - Code LD:over the age of 40 years Dementia - Code DE(E):over the age of 65 years. Date of last inspection Brief description of the care home St Bernards (now known as Hallaton Manor) is a care home providing personal care and accommodation for up to forty-one older persons, who may have additional care needs including mental disorder, dementia, past or present alcohol dependency and learning disability. The home is a large converted country house, which is situated in beautiful countryside approximately one mile from the village of Hallaton. Accommodation is on two floors that can be accessed via stairs or a passenger lift. The rooms are single occupancy with en suite facilities. There are a variety of sitting rooms and a dining room, with a separate facility for those residents wishing to smoke. The home has ample gardens and outside areas that includes a small but wellappointed gymnasium. Minibus transport is available for residents. The Statement of Purpose, Service Users Guide & last Inspection Report are available (these provide information on how the home is organised and what services they provide). The Statement of Purpose and Service Users Guide are provided for any prospective residents and their families. At the time of the inspection the Registered Manager said that fees were from £655 per week, depending if the resident was social service or privately funded, and was dependant on the level of care required. There are extra charges for hairdressing, chiropody, newspapers and any additional care time if residents are accompanied to hospital. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate 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: The quality rating for this service is 1 Star. This means the people who use the service experience adequate quality outcomes. We as it appears throughout the Inspection Report refers to Care Quality Commission. The focus of the inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who use the service and their views of the service provided. The previous key inspection was undertaken on 3rd June 2008. Care Homes for Older People Page 6 of 30 The site visit was unannounced and took place over six hours. We selected three residents and tracked the care they received through a review of their records, discussions with them (where possible), other people who use the service, visitors, the care staff, and observation of care practices. We spoke with staff members regarding the training and support they received. Planning for the inspection included assessing notifications of significant events, a review of the Annual Quality Assurance Assessment (AQAA) sent to the CQC by the service. Surveys were sent to the homes residents, relatives, staff and health professionals to provide feedback to CQC but non were returned prior to the inspection. We have not received any complaints about the service from the public but Leicestershire Social Services are unhappy about some aspects of management and care and have issued a notice to remedy a breach in the core contract, and a formal suspension of placements - dated 10th July 2009. What the care home does well: What has improved since the last inspection? What they could do better: The homes Statement of Purpose must be revised to reflect all of the elements detailed in Schedule 1 Care Homes Regulations 2001 to ensure that people have all the information they need to help them decide if the home is the right one for them. People who move into the home must have a comprehensive care needs assessment (reflective of the Care Management plan provided by the placing authority where this is appropriate) that shows that the home is able to meet all of that persons health and social care needs. Each person who lives in the home must have a comprehensive, individual care plan which fully reflects their health, personal and social care needs. People who are non weight bearing, and may be at nutritional risk, must be weighed regularly to ensure that that their nutritional needs are met, and where necessary professional advice must be sought. Arrangements must be made to consult with service users (or their representative) about their social interests, and make arrangements to enable them to engage in appropriate local, social and community activities. Care Homes for Older People Page 8 of 30 The Registered Person/s must ensure that information and documents in respect of working in a care home,as required in Schedule 2, Care Homes Regulations 2001, and are made available for inspection. The Registered Person/s must ensure that management and administrative roles and responsibilities are clarified. The Registered Person/s must develop a system for reviewing and improving the quality of care provided in the home. People who live in the home should be provided with regular opportunities to express their opinions and have choice and control over their day-to-day lives in the home. All staff should receive restraint training as soon as possible so that they can be confident that they can manage people safely who have challenging behaviors. There should be a training matrix that identifies mandatory training and other staff training needs so they can be planned for in a timely manner. Monthly, recorded visits should be made by the Registered Provider, or a nominated person who is not directly concerned with the home, in accordance with Regulation 26, Care Homes Regulations 2001, and be available for inspection to ensure that the home is being managed effectively. Staff should receive regular, recorded formal supervision, at least six times a year, to ensure that staff have their training needs identified and are able to provide safe and effective care for the people who live in the home. 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.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users do not have all of the information they need to ensure that they can make an informed choice about if the home is the right one for them. Evidence: The Statement of Purpose & Service Users Guide do not contain all of the required information and needs significant improvement, to comply with Schedule 1 Care Homes Regulations 2001. This means that people who may be considering moving to the home do not have all of the information they need to decide if the home is the right one for them. This was noted and discussed with the care manager during the last inspection, 3rd June 2008, and a requirement made. The three care plans reviewed contained a basic pre-assessment and a more comprehensive assessment by the placing authority. The pre-assessment completed by the home lacked detail in relation to peoples personal preferences, and did not Care Homes for Older People Page 11 of 30 Evidence: provide an individual, person centered approach to demonstrate that they could meet peoples health and social care needs. A small number of people were privately funded and they had been provided with individual contracts (terms & conditions) of residency so that they were aware of what services were to be provided. The home does not provide intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal and social care needs are not fully reflected in their individual plan of care. Evidence: Three care plans were reviewed. Those seen were basic and contained the minimum of information, both for care planning and for the risk assessments. Information was disseminated in different files making it difficult to follow through the rational behind care planning, interventions and outcomes. For example: a person with a resolving pressure ulcer did not have a pressure ulcer care plan, and there was misinformation in the care plan about an indwelling catheter which had been removed/fallen out (this was unclear. Although the daily log (in a separate file) stated that the catheter was no longer in situ on 24/06/09 the care plan stated draining well on 28/06/09. However, there was a completed turn chart to show that carers had regularly moved the persons position and provided food and fluids. Another person who had challenging behavior had a risk assessment which instructed Care Homes for Older People Page 13 of 30 Evidence: care staff to observe for trigger factors but did not say what these were or how to manage them. In some cases people, who require them, had not had nutritional assessments (although this was in the process of being implemented) and people who may be at risk of weight loss, and were non-weight bearing, had not been weighed as there were no sit on scales in the home. This lack of detail, misinformation, and lack of essential equipment, could place residents at risk. Visits by health professional such as the GP were logged in a separate file and had not been transcribed into the persons care plan to ensure that recommendations and treatments were addressed. Medication management was satisfactory. All senior care staff who dispensed medicines had received training, and were booked for an update on 04/08/09. The Registered Manager was advised as good practice to ensure that Controlled Medications were counted and recorded at each staff handover. The home had recently purchased a new medication fridge. However, there was neither temperature probe nor daily recordings of temperatures to ensure that medicines which needed refrigeration were kept at the required temperature.This was discussed with the Registered Manager who assured us that this would be addressed. Those people spoken with who were able to give an opinion said that they were well cared for. A relative said that he was satisfied with the care and that his mum was well cared for. We also spoke with a visiting Social Worker from London who said that she was generally happy with the care and that her service user clean, well cared for and looked much better. However, she also felt that the care plans and risk assessment were very basic and could be improved. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at St Bernards (Hallaton Manor) do not find that the lifestyle in the home matches their expectations and preferences, and does not satisfy their recreational needs. Evidence: The home does not have a dedicated activities organiser. One carer of the five carers working on the morning shift is nominated to do activities in the afternoons. On the day of the visit no specific activities were observed. People spent time in their own rooms, walked, sat and chatted and some watched TV. There did not appear to be an organised daily programme of activities. However, there were weekly/monthly organised activities such as an organist every six weeks, film show every six weeks (the home have a new DVD player)some outings and shopping in near-by towns, visits to the local village for coffee or a visit to the small museum and organised trips to Foxton Locks and Rutland Water for a small number of people. However, people told us that these were infrequent and for a small number of people only. One younger resident (a lady in her 50s said that there was little done to interest her and that it was not recognised that she preferred 60s music such as The Beatles & Care Homes for Older People Page 15 of 30 Evidence: Rolling Stones, and that the home did not cater for people within the younger age group but lumped everyone together as old and only interested in stuff from the war years. This was discussed with the manager who appeared not to have recognised that her younger residents needs would be different from those who were considerably older. In addition, there were no individual activity plans, and a significant number of people suffered from dementia but there did not appear to be any specific understanding of, or activities tailored for their specific needs such as daily diaries, memory boxes, reminiscence sessions etc. There were no recorded residents meetings as the manager said that they resulted in residents shouting at each other. She said that she had one-to-ones with residents but again these were not recorded so that residents opinions, any subsequent actions were not recorded or shown to have been followed up. There was nothing to demonstrate that people who live in the home were able to play any part in the day-to day life of the home. People have their religious needs supported by monthly visit from the Church of England and Roman Catholic clergy and two people occaisionally visit the local village church. The Registered Manager said that other faiths would be supported if this was required. One visitor said that he was always made welcome and could visit any any time. The dining area looked clean and well decorated; tables had tablecloths and table napkins. The main lunch was organisied in three sitting which seemed to work well giving carers time to provide discreet and unhurried assistance for those people who needed help. Food looked well presented and there were choices at all main meals. Coffee and Tea were provided at mid-morning and mid-afternoon but there were no biscuits or cakes provided at this time. When asked the Registered Manager said that they did not give out biscuits (although the care manager said that they did) because people wanted too many and then would not eat their tea. We discussed the concept of choice and it was suggested that two biscuits could be provided. The Registered Manager said that she would re-introduce biscuits for the residents at mid-day breaks. The kitchen was clean and the cook had a list of residents requirements on a clipboard in the kitchen so that he was aware of special diets such as diabetic and soft diets. One resident who had a soft diet had the food blended together, rather than keeping each element separate. When discussed with the Registered Manager she said that Care Homes for Older People Page 16 of 30 Evidence: when presented separately the resident would not eat it but this was not recorded in the persons care plan. . Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Evidence: The home had a complaints file and had received only one complaint since the previous inspection. This had been managed appropriately. The complaints policy and procedure needs to be reviewed and updated to include the contact details and role of Social Services in managing complaints, and the new details of the Care Quality Commission. Prior to the inspection visit we have not received any complaints about the service from the public, but Leicestershire Social Services are unhappy about some aspects of management and care and have issued a notice to remedy a breach in the core contract and a formal suspension of placements - dated 10th July 2009. All staff had received Safeguarding Vulnerable Adults training by First Response in the last 12 months, and those spoken with were aware of whistleblowing procedures and how to keep vulnerable people safe. The home had copies of the local policies and procedures for safeguarding. Care Homes for Older People Page 18 of 30 Evidence: Those people who were able said that they felt safe living in the home. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home live in a safe, well-maintained environment. Evidence: The home was clean and fresh except for one room, as identified to the Registered Manager, which had a strong odour of urine and was unsatisfactory and did not uphold the occupants dignity.She assured us that the carpet would be replaced following a discussion with the Registered Provider (owner of the home). There were generic risk assessments for all areas of the home which had been reviewed in 2008/9 to ensure that the home was safe. A member of staff had undertaken Portable Appliance Testing (PAT) training and was able to check small electrical appliances and was also able to provide details of regular fire alarm tests & drills and hot water checks etc. to ensure that the home was safe for the people who live and work there. Although the Registered Manager did not have an actual maintenance and refurbishment plan some new purchases had been made since the last inspection such as: new furniture for the quiet area on the landing (delivered that day); security gates at rear to enclose a secure garden area for the residents; the managers office being upgraded and some rooms had been redecorated. Carpets in two bedrooms and Care Homes for Older People Page 20 of 30 Evidence: carpets to hall stairs and landing had been replaced. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are sufficient in number to meet residents needs but training and recruitment records are not well managed. Evidence: There were thirty-four residents on the day of the inspection visit. During the day there were five carers (not including the Registered Manager) in the morning, and four carers in the afternoon, with one of the morning carers allocated to organise activities (see Outcome 3) and two carers at night. In addition there was an administrator, who sits in an office away from the main building, a cook and ancillary staff. Four staff files were reviewed. These were loose leaf, disorganised and in some cases did not contain all of the information as required in Schedule 2, Care Homes Regulations 2001, such as two written references, recent photographs and birth certificates. Although Criminal Records Bureau (CRB) checks had been completed, proof that this had been done was not, in all cases, readily available for inspection. Staff received induction training, but again in some cases this could not be evidenced in staff files. The Registered Manager provided a list of training undertaken by staff Care Homes for Older People Page 22 of 30 Evidence: during the last six months. Some or all of the staff have undertaken the following training: fire training, first aid, challenging behavior, infection control, moving and handling, dementia awareness, safeguarding vulnerable adults, risk assessment and epilepsy awareness. The Registered Manager stated that nine staff had attained a National Vocational Qualification (NVQ) in Care, Level 2 or 3. The Registered Manager had a list of training undertaken by staff but this was not individualised to identify any deficits in their training needs. All staff had received training in managing challenging behavior but not in restraint. As some residents may, potentially, be identified as having challenging behaviors it was suggested that staff should access this training as soon as possible. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Manager does not provide consistent, effective and co-ordinated leadership. Evidence: The home had a Registered Manager who had worked in care for many years. She had a NVQ 2 and was currently undertaking and NVQ 4/Registered Managers Award. The home lacked a management structure that identified peoples individual roles and responsibilities, resulting in a lack of communication between the management team. Record keeping and care planning was basic and disorganised. This had resulted in information not being shared and/or recorded, and an assumption that staff knew what care was required resulting in peoples wider, health and social care needs not being fully met. Staff had not been regularly supervised (a regular review of staffs personal and Care Homes for Older People Page 24 of 30 Evidence: training needs in relation to their work) to ensure that they continued to update their skills and provide good care for the people who live in the home. The care manager, during the last inspection stated that this was being done more frequently but it was evident that this had not been followed through and there were no written records available to demonstrate that staff supervision had been undertaken. Some records of induction training, mandatory training and training updates were available. These were not consistent nor did the Registered Manager understand the significance of implementing a training matrix that could identify staffs individual training needs, thereby ensuring that people who lived in the home continued to receive a good standard of care. The AQAA was poorly completed, lacked detail and did not provide sufficient information to enable us to make any meaningful assessment of the current state of the home. Regulation 26s were not available. These should be completed by the Registered Provider at least monthly (or by a nominated person if the provider is not in day-today contact with the home) to demonstrate that they maintain a managerial overview and are aware of any shortfalls in management or care practice. In addition, we were concerned that at the end of January 2009, through into March 2009, at a time when the local authority had concerns about the home, the Registered Manager was working in the kitchen for more than seven weeks because the cook had left. She still covers for the cooks day off. We were not made aware of this by the Registered Manager at the time, and it is our opinion that this was a contributory factor to the home being unable to maintain a good standard of management and care planning. Health and Safety policies and procedure and generic risk assessments had been completed to ensure that people live in a safe environment. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 1 4(Schedule 1) The Statement of Purpose 03/08/2008 and Service Users Guide should contain all of the information as stated in Care Homes Regulations 2001, Schedule 1. Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 The Statement of Purpose must reflect all of the elements detailed in Schedule 1 Care Homes Regulations 2001. 07/09/2009 To ensure that people who may be considering moving to the home have the information they need to make an informed choice about where to live. 2 7 15 Each person must have a 30/10/2009 comprehensive, individual care plan which fully reflects their health, personal and social care needs. To ensure that all preoples health, personal and social care needs are identified and met. 3 8 15 People must have appropriate assessments completed, such as nutritional screening, and regularly reviewed, to 30/10/2009 Care Homes for Older People Page 27 of 30 ensure that all of their care needs are identified and appropriate professional support obtained in a timely manner. To ensure that all of their health, personal and social care needs are identified and met. 4 8 15 People who are non weight bearing, and may be at risk, must be weighed regularly. To ensure that all of their nutritional needs are identified and met. 5 12 16 Arrangements must be 30/09/2009 made to consult with service users (or their representative) about their social interests, and make arrangements to enable them to engage in appropriate local, social and community activities. To enable people to experience a lifestyle that matches their expectation and preferences. 6 31 12 The Registered Person/s must ensure that management and administrative roles and responsibilities are clarified. To ensure the smooth running of the home for the benefit and safety of the people who live there 31/08/2009 31/08/2009 Care Homes for Older People Page 28 of 30 7 33 24 The Registered Person/s 30/10/2009 must develop a system for reviewing and improving the quality of care provided in the home. To enable people who live in the home, or their representatives, and other health professional provide the service with feedback to help them identify and improve care. 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 3 People should not move into the home unless the home has completed a comprehensive care needs assessment (reflective of the Care Management plan provided by the placing authority where this is appropriate) that reflects a person centered approach and demonstrates that the home is able to meet all of that persons health and social care needs. People who live in the home should be provided with a regular, recorded opportunities to express their opinions and have choice and control over their day-to-day lives in the home. Monthly, recorded visits should be made by the Registered Provider, or a nominated person who is not directly concerned with the home, in accordance with Regulation 26, Care Homes Regulations 2001 and be available for inspection. Staff should receive regular, recorded formal supervision, at least six times a year, to ensure that staff have their training needs identified and are able to provide safe and effective care for the people who live in the home. Care plans, staff files and records required for the effective and efficient running of the home should be well organised, maintained, up to date and accurate. 2 14 3 31 4 36 5 37 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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