Inspection on 17/09/08 for St Marks Care Home Limited

This inspection was carried out on 17th September 2008.

CSCI 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Marks Care Home Limited 16/09/09

St Marks Care Home Limited 04/09/07

St Marks Care Home Limited 11/09/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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: St Marks Care Home Limited 38-40 Wellesley Road Clacton on Sea Essex CO15 3PW     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: Sara Naylor-Wild     Date: 1 7 0 9 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 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: St Marks Care Home Limited 38-40 Wellesley Road Clacton on Sea Essex CO15 3PW 01255421750 01255435282 sandy@sahadew.fsnet.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) St Marks Care Home Ltd Type of registration: Number of places registered: care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 17 persons) Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 17 persons) The total number of service users accommodated in the home must not exceed 17 persons Date of last inspection Brief description of the care home St Marks Care Home can provide personal care and dementia care for up to 17 people over the age of 65 years. The home has been converted from two private residences. It is on a residential street in Clacton-on-Sea close to the town centre and sea front. Accommodation is provided on two floors, with the upper floor being accessed by a passenger lift. Thirteen rooms are single occupancy and two rooms are shared. Care Homes for Older People Page 4 of 34 0 0 Over 65 17 17 Brief description of the care home Residents have a dining area and two sitting rooms available to them. There is a small garden to the rear of the property and limited off road parking in front of the home. Care Homes for Older People Page 5 of 34 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 last key inspection of this service took place on 4th September 2007. This unannounced key inspection was carried out on the 17th September and the 2nd October 2008. As part of the inspection we checked information received by Commission for Social Care Inspection (CSCI) since the last inspection in 4th September 2007, looking at records and documents at the care home and talking to the manager, Mrs Sandy Sahadew, care staff and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in July 2008 was considered as part of the inspection process and a tour of the premises was completed at the visit to the care Care Homes for Older People Page 6 of 34 home. The service sent us their Annual Quality Assurance Assessment (AQAA) when we asked for it. This contained information about what they felt they did well. Although this information was brief and did not always tell us how the service was seeking to improve the outcomes for people living at the service, beyond their present provision. The manager assisted the inspector at the site visit. Feedback on findings was given during the visit with the opportunity for discussion or clarification. We would like to thank the manager, the staff team, and people living at the service and their relatives for their help throughout the inspection process. The range of fees charged by the service are between 385.00 and 450.00. Additional charges were made for toiletries, hairdressing, private chiropody and privately arranged activities. 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 Care Homes for Older People Page 8 of 34 printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 34 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 34 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. People considering moving into the service cannot be assured that their needs will always be understood by the service before they agree to their admission. Evidence: The services statement of purpose states that when considering the admission of a person new to the home they will take into account the views of all stakeholders such as the person themselves, their family, other people living at the home, care managers and social workers. It also sets out a variety of visits that can be made to the home to familiarise the person with the service and the people living there. There are no clear statements about the service carrying out an assessment of the persons needs and how they determine whether these will meet their criteria of registration. The Annual Quality Assurance Assessment (AQAA) sent to the Commission states that all residents are assessed prior to their admission. Care Homes for Older People Page 11 of 34 Evidence: The assessment details of the two people most recently admitted to the service were considered. The files contained assessments relating to a general holistic assessment, falls, nutrition, behavior, mental health, social and leisure and dependency. In the samples seen at the inspection, only the dependency form had any information entered in to it and this section was incomplete. Another sheet contained a brief description of needs and details of family contacts. Without a full assessment it is not possible to see how the service understood and considered the needs the person under assessment presented and whether the service could be meet these. At the time of the inspection, contracts between the service and the people living there were not available on the premises. Mrs Sahadew attended the CSCI offices at a subsequent date and provided copies of contracts for most people living at the home, there were however some that were not signed by either the person themselves or their representative. The manager cited reasons why this had not been addressed, although for some there was an extended timescale since their admission. Care Homes for Older People Page 12 of 34 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 at the service cannot be confident that staff will understand how to provide support to them in a consistent manner. Generally people living at the home can be assured that they are protected by the services systems for the administration of medication. However people who wish to manage their own medication cannot be confident that they do so only after the risks in their doing so have been fully assessed. Evidence: The care plans of five people were considered as part of the case tracking methodology used in the inspection. As with the initial assessment documentation, there was not a consistent level of detail in the sampled plans, with two people most recently admitted to the service not having any plans of care. Those that were present did not always fully reflect the information gathered in the initial assessment. The plans tended to concentrate on individual issues rather than a Care Homes for Older People Page 13 of 34 Evidence: holistic approach to describing the individuals capabilities and how their daily life should be supported. This method of recording does not provide the reader with a sense of the person as an functioning individual, or reflect current good practice in person centered planning. The manager discussed the progress of care planning since the previous inspection. They outlined the shortfalls they felt were in the existing format of the plans and provided copies of new forms they intended to introduce in the next six months. The staff are responsible for recording in the daily records the events in the persons life for that day and how they have supported them. These were completed regularly with entries against a number system used to identify the element of the care plan being commented upon. Staff were able to demonstrate that they understood peoples needs and were working in a empathic way. From cross referencing with the daily records completed by staff for each person, it was clear that they did not always adhere to the plan of care or reflect how this was being carried out. In one example a persons plan of care stated that they required supervision and support to manager their personal hygiene, as they tended to only wash their hands and face. The daily record for this person repeatedly stated that they had washed and dressed independently and did not provide the reader with an understanding of how staff were monitoring the persons ability. All the care plans that were present had been regularly reviewed and updated where necessary. In order to provide a high quality of support that consistently meets the individuals expectations, preferences and needs the quality of recording in care planning required attention. Only with clear and person centered records that staff report against can the service ensure that they provide the staff with a clear understanding of the individuals living at the home and how they can best support them in their daily lives. The management and recording of medication was considered at the visit. The administration of lunchtime medication was observed and the staff demonstrated a clear understanding of good practice. Records relating to medication were examined and these were complete and in good order. They demonstrated a robust system for the receiving, administration and return of prescribed drugs used by people living at the home. The service has a controlled drugs cabinet that meets with the guidance in the storage of these drugs. They maintain a separate log book for drugs dispensed in this category and this was in good order. Care Homes for Older People Page 14 of 34 Evidence: There were four staff who were responsible for drug administration as well as the registered manger, and all these staff had taken part in medication training commensurate with their role. One person living at the home was administering some of their prescribed medications themselves. There was not a risk assessment in place for this person although they had signed a declaration stating that they understood the risks and accepted these. This was discussed with the manager at the inspection and they produced a new risk assessment form for this activity that they stated was about to be introduced to the home. Care Homes for Older People Page 15 of 34 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 at the home can be confident that there are opportunities to participate in activities. They cannot however be assured that these will be tailored to meet their abilities, needs and expectations. People living at the home can enjoy a menu that is varied and caters to their individual preferences. Evidence: The service offers some opportunities for people to take part in activity. There is a weekly diary plan of organised activity that includes puzzles, musical movement and games. Some individuals plans of care contained reference to their preferences in activity and past interests. The quality of the information varied with some people having detailed attention to their social needs such as day center attendance, weekly trips to shops and knitting, whilst others had no entry at all in activity and social interests. The ability of people to participate in organised social activities appeared to limit the way this area of need was considered by the service, although members of staff had Care Homes for Older People Page 16 of 34 Evidence: taken part in training specifically aimed at activities for people with dementia. A person living at the service told us that they would like to live somewhere where there was more to do. From discussion with people living at the home and the manager it was evident that this was an area that required development. People are encouraged to maintain contact with their families and friends and visitors are welcomed at the home at any reasonable time. During the inspection a visitor who attended the home told us that they were made to feel welcome and felt that staff treated them with respect and politeness. Other examples included staff telephoning relatives to inform them of their relations wellbeing. All the people spoken with during the inspection were enthusiastic about the meal provision at the home. One person told us the food is the best thing about this home. The four week menu has been planned according to the preferences of people living at the home, although there are alternative selections on offer at each meal. The menus are varied and provide a range of nutritious values. The cook speaks to each person every morning to ascertain their wishes for the days meals. This record is used both to record what people have chosen and to monitor their nutritional intake. The cook also bakes cakes and pastries for each day, and any specialist diets such as diabetic low sugar alternatives are catered for. Care Homes for Older People Page 17 of 34 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. Most people living at the home can be confident that they will be listened to and their concerns acted upon. They can be assured that the staff understand how to safeguard them from abuse. People with cognitive impairments would be less able to make their concerns known using the complaints system. Evidence: The service has a complaints policy that details the way in which complaints can be communicated to the home and how they will respond. These statements would provide people with cognitive awareness sufficient information about how to raise their concerns or views with the service. As a specialist service for people who are suffering with dementia the providers should consider how people with cognitive impairments are supported to access the complaints procedures. There have not been any complaints received by the service or the Commission since the last inspection. The safeguarding procedures were detailed in the services policy in respect of protecting people from abuse. This set out the seriousness with which allegations of abuse were taken and the responsibility of individual staff and the service in reporting these to the appropriate bodies. Staff have all undertaken Safeguarding training in the Care Homes for Older People Page 18 of 34 Evidence: last 12 months. There have not been any referrals made in relation to safeguarding since the last inspection. Care Homes for Older People Page 19 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home benefit from an environment that is comfortable and homely, but that could be further improved to ensure it supports their independence. Evidence: There was not an annual maintenance plan developed for the service although there had been continued redecoration and refurbish of the premises since the last inspection. This included the communal areas all being decorated, the proposed changes to the kitchen area had been completed and the provision of a serving area for both staff and people living at the home to make refreshments. The manager stated that they planned to decorate peoples bedrooms as the opportunity arose through vacancy or new admissions. Peoples bedrooms seen during a tour of the premises, were pleasant and comfortable with suitable levels of furnishings to meet their needs. People had personalised their rooms with their own belongings. The manager was asked if there had been consideration of how the environment could be adapted to support the independence of people with dementia. This would include the use of colour, signage and materials to provide signposts to people who have difficulty interpreting their environment. The manager said that they were aware of Care Homes for Older People Page 20 of 34 Evidence: research but had not yet considered this in the redecoration programme as there had been such extensive improvements to be made to the fabric of the service in the initial period of new ownership of the home. This should be considered as part of the services annual quality assurance reviews. The home was clean and tidy with no unpleasant odours in any part of the building. One person told us they particularly noted that there were no odours in comparison with other establishments they had visited. The staff had all received training in Infection control. Care Homes for Older People Page 21 of 34 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. People living at the service can be confident that staff in sufficient numbers to meet their needs supports them and who have received training to carry out their roles. Specialist training in dementia care could further improve the level of support they receive. Evidence: The staff rota reflected that the service maintained three staff on duty throughout the waking day, with the manager, housekeeper and cook providing additional support. There was also one staff member awake overnight and one on sleep-in duty every night. The service does not use agency staff instead covering annual leave and other vacancy by giving overtime to the staff team. This did mean that some staff had worked up to 53 hours in one week and the manager should monitor this to ensure that the quality of their support did not suffer as a result. The records relating to the employment of staff were considered at the visit. A sample of documents relating to three staff were seen and included those of the two staff most recently appointed. Care Homes for Older People Page 22 of 34 Evidence: The recruitment records for staff were in order, with completed application forms, evidence of previous employment, identification and qualifications held on the file. Both files also contained evidence of checks made against the Criminal Records Bureau and the Department of Health Protection of Vulnerable Adults list. This provides the service with all the information available to best determine if the applicant is a suitable to work at the home and supports the protection of people living there from abuse. The services AQAA states that 60 of staff have their NVQ level 2 or above There were also two staff undertaking NVQ level 3 and one staff undertaking NVQ level 4 at the time of the inspection. The staff training programme included items required by health and safety legislation such as moving and handling, food hygiene and Fire safety training. Some elements relating to needs of people living at the home were included such as mental health, falls prevention, the Alzheimers Societys Yesterday, Today and Tomorrow session and Activities with dementia. However these should be further developed to reflect fully the range of needs people at the home experienced and to enhance the staffs skills in supporting people with dementia. The service has applied and been awarded a training grant from Essex County Council. The manager stated that they planned to use this monies to identify how they can enhance staff skills in dementia care. Care Homes for Older People Page 23 of 34 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. People who use the service cannot be assured that they will be listened to and that there is leadership that plans how to improve the way in which it delivers a service. Evidence: Mrs Sahadew a director of the company, St Marks Care Ltd who own the home, has been operating as the manager. She is a registered nurse and has worked in the residential care sector for 8 years. There has not been an application made for registration of a manager with the Commission. Mrs Sahadew demonstrates a willingness to learn and improve the quality of the service at St Marks. However the progress in meeting the requirements made at previous inspections has been slow, and Mrs Sahadew stated that it is not always easy to understand where to get the right help and advice from to understand how to do the right things. Care Homes for Older People Page 24 of 34 Evidence: Although the service returned the AQAA when asked to do so there was limited information about how the home was listening to the people who lived there and was moving towards a greater compliance with the Care Homes Regulations 2001. The primary purpose of the AQAA is to inform the Commission about how the Registered Person understood the strengths and weaknesses of the service in meeting its regulatory obligations and how they were seeking to address these. The quality of the information in St Marks AQAA evidenced a lack of clearly defined planned progress towards a quality service provision. It is important that the organisation and manager identify ways in which they can access information and support in respect of good practice in their care sector and consider how they will incorporate this learning into the service development plans. The manager is liked and respected by the staff and people living at the home. They said she was approachable and always responded to what they told her. The service only holds money for one person living at the home. The accounts for this person were looked at during the inspection. They demonstrated a robust auditing system that included details of all income and expenditure from the account with associated receipts. The balance of money held by the service matched the accounts totals. The manager stated that the service had conducted a quality assurance survey since the last inspection, but that the documentation was not available at the home on the day of inspection. At a meeting following the inspection the manager provided a summary of the survey results and the services responses. These documents did not set out how many responses had been received in each category but gave an overall summation of their content. The outcomes centered on central issues such as quality of care, meals and administration. The manager had not produced a published report at the time of the discussion. The stakeholders surveys are an important element of the services quality assurance system. It is important that people who use the service, their supporters and others are asked how their experience of the service meets their expectations. The information gathered from this should be used to inform the services annual development plans and their completion of the AQAA returned to the Commission. The quality of the current format and information gathered by the St Marks surveys and their responses should be considered by the organisation to understand how this affects their overall quality assurance programme and their progress in meeting the National Minimum Standards for Older People 2001. Staff records demonstrated some staff supervision was taking place but that this was Care Homes for Older People Page 25 of 34 Evidence: not consistently carried out for some staff. The opportunity to give feedback to staff in relation to their performance is an important element of staff development and quality assurance. The records relating to the maintenance of health and safety systems and equipment within the home were reviewed at this visit. The certificates for the maintenance of gas and electricity systems, the passenger lift and hoists and fire safety equipment were all within date. The service has a current liability insurance. These records demonstrated a robust approach to the health and safety of people living at the service. Care Homes for Older People Page 26 of 34 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 3 14(1) The pre-admission 04/09/2007 assessments must be expanded to provide more information on prospective residents mental health status and to cover their abilities, interests and preferences in order that their expectations and needs can be fully explored prior to admission. 2 7 15(1)(2) Care plans must be drawn up 01/10/2007 in consultation with residents (and relatives where appropriate) and demonstrate their preferences, abilities, interests as well as their physical and mental health and care needs in order to encourage more resident centred care. 3 8 18(1) Staff must receive training in 01/12/2007 the prevention and management of pressure sores in order to improve the care to both residents at risk and those who have developed pressure sores. Care Homes for Older People Page 27 of 34 4 8 14(2) Risk assessments must be 04/09/2007 kept up to date in order to accurately assess the current and ongoing risks to residents. 5 10 12(4) Residents must be 04/09/2007 consistently treated in a way that respects their individuality and protects their dignity. 6 12 16(2)(m) (n)18(1)(c) Residents must receive 01/11/2007 sufficient stimulating activities to enhance their daily lives. Staff must receive training in the provision of activities for older people to ensure they are skilled. This has been a requirement in a previous report - timescale of 01/10/06 not met. 7 14 12(2)(3) Residents must be 04/09/2007 encouraged to retain their independence and supported to make choices in order to improve the quality of their daily lives. 8 16 22 Staff must feed back and document verbal complaints to ensure that residents and relatives concerns are fully addressed. 04/09/2007 9 30 18(1) All staff must receive dementia care training to enable them to care appropriately for residents with dementia. 01/12/2007 Care Homes for Older People Page 28 of 34 10 31 24(2) Full time managerial cover must be provided for the home until the post of registered manager is filled, to enable standards of care and services for residents to be monitored and any deficiencies promptly addressed. 10/09/2007 11 33 24(2) Full time managerial cover must be provided for the home until the post of registered manager is filled, to enable standards of care and services for residents to be monitored and any deficiencies promptly addressed. 10/09/2007 Care Homes for Older People Page 29 of 34 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 2 5 People living at the service must be provided with a copy of the contract or terms and conditions. People living at the home must be able to understand the terms under which their residency is purchased, including their rights, fees payable and any services that are not included in their fees. 26/11/2008 2 3 14 People must only be admitted to the service when their needs have been fully assessed and the service has confirmed in writing that they are able to meet these. The service must ensure that any admission is appropriate and that they have the resources and skills to meet the needs of the person. 26/11/2008 Care Homes for Older People Page 30 of 34 3 7 15 People living at the home must be supported by care plans that ensure that staff are clear about objectives and methods to achieve agreed goals and positive outcome for people. Detailed care plans support the service in providing a consistent level of support that meets peoples expectations and needs in a way that reflects their individuality. 10/12/2008 4 8 15 Peoples health care support must be fully documented and the outcomes of any health appointments recorded in their plan of care. The service must be able to demonstrate that they support peoples health needs. This requires that advice and instructions provided by health professionals is recorded and adhered to. 27/11/2008 5 9 15 People must be supported in 26/11/2008 managing their medication within safe practice and following a full risk assessment. The service retains responsibility for the safe adminsitration of medication, even when a person living at the home administers their own medication. The service Care Homes for Older People Page 31 of 34 must satisfy themselves that the risks present in this activity are managed to reduce the likely hood of harm to the indiviudal 6 12 16 People living at the service must be provided with opportunity for social stimulation and activity that are tailored to meet their needs, abilities and interests. Staff skills in this area need to be developed. daily life of people living at the home would be enhanced by opportunities for stimulation. 7 30 18 People living at the service must be supported by staff who have the knowledge and skills to meet their assessed needs. The staff team must be able to support the diverse needs of people living at the service. In particular staff must have a range of skills and knowledge in specialist care such as dementia. 8 31 4 There must be a person registered with the Commission who is day to day control of the service. A registered manager would provide stability and continuity to the development of the service. 9 33 24 People living at the home 26/11/2008 and other stakeholders must be consulted about how the 26/11/2008 26/11/2008 26/11/2008 Care Homes for Older People Page 32 of 34 service operates. The outcomes of these consultations must be recorded and the services response published. The views of people who live at the home and other stakeholders help the service understand if it is meeting its objectives and statement of purpose for the service. Publication of the outcomes of consultion helps people understand how their views influence the service delivery. 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 statement of purpose should be an accurate representation of the services available and how the aims and objectives of the service will be met. The way in which the views of people with cognitive impairments are consulted should be considered to ensure that staff are able to determine their satisfaction or otherwise with the service. The service should consider how it supports people with dementia to access the building, using the guidance provided by published good practice. The registered manager should be able to demonstrate a clear sense of direction and leadership that incorporates strategies for development of the service. Staff should receive supervision in a consistent manner that ensures their practice is supported and developed. 2 16 3 19 4 32 5 36 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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