Inspection on 29/05/09 for The Lawns, Brixton

This inspection was carried out on 29th May 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Lawns, Brixton 21/05/08

The Lawns, Brixton 21/03/07

The Lawns, Brixton 15/02/06

The Lawns, Brixton 04/08/05

The Lawns, Brixton 28/02/05

The Lawns, Brixton 09/09/04

Similar services:

The Vicarage

Fairfields Country Rest Home

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Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for older people Name: Address: The Lawns, Brixton The Lawns, Brixton Brixton Plymouth Devon PL8 2AX     The quality rating for this care home is:   one star adequate 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 review of the service. We call this full review a ‘key’ inspection. Lead inspector: Graham Thomas     Date: 2 9 0 5 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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 29 Information about the care home Name of care home: Address: The Lawns, Brixton The Lawns, Brixton Brixton Plymouth Devon PL8 2AX 01752880465 01752880465 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Wells House Limited, Name of registered manager (if applicable) Mrs Janet Trinick Type of registration: Number of places registered: care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The Home is registered as a Care Home with Nursing for a maximum of 22 Service Users in the categories of PD(E) 18, OP 8, TI(E) 4 Date of last inspection Brief description of the care home The Lawns care home is situated in the village of Brixton, in the South Hams area of Devon. The home is a detached country house, set in its own grounds. Accommodation is provided on two floors with a mezzanine floor between. The home provides 16 single and 3 double bedrooms. Communal facilities comprise: a lounge, conservatory and dining room. Most parts of the home are wheelchair accessible. There is a shaft lift to all floors and a stair lift on the main staircase. The home is registered to accept a maximum of 22 persons, aged over 65 years of either Care Homes for Older People Page 4 of 29 Over 65 8 18 0 0 Brief description of the care home gender whom suffer from physical frailty, illness or disability. The Lawns provides a comfortable friendly atmosphere. People living at the home are encouraged to furnish their rooms as they choose, and each room is individual in its character. The last inspection report is displayed in the entrance foyer at all times for people to read. Fees vary depending on the degree to which nursing care is required. The contracts examined clearly breakdown the fees charged and what is included in the fee. Contracts are issued to every person whether they are publicly or privately funded. Care Homes for Older People Page 5 of 29 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: Before the inspection we reviewed our records about the home. We looked at the Annual Quality Assurance Assessment (AQAA) that the General Manager had completed and returned to us. We visited the home and spent one and a half days there. During our visit we spoke with people living in the home individually and in a group. We looked at how three peoples needs were being planned and catered for. This included looking at care plans, meeting the people, looking at their medication, talking with two relatives and staff. An hour was spent observing people during the midday meal. We toured the home and looked at records about maintenance, health and safety. We looked at how staff were recruited, trained and supported. This and other matters Care Homes for Older People Page 6 of 29 were discussed with the Registered Manager and the General Manger. Care Homes for Older People Page 7 of 29 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 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 8 of 29 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 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 1, 3 and 6 Enough information is provided to people who are considering moving into The Lawns. People can feel confident the home will check that it can meet their needs before they move in. Evidence: While at the home we saw a a comprehensive Statement of Purpose and Service Users Guide. There was also a brochure providing information about the home including the type of accommodation and services provided, the aims and objectives of the home and the philosophy of care. Information was also provided about staffing. Information about independent advocacy services was on display in the homes foyer. The Registered Provider told us that this information can be provided in large print. We looked at the files of a person recently admitted to the home. This contained professional information obtained before admission to The Lawns as well as the Care Homes for Older People Page 10 of 29 Evidence: homes own assessments. These included physical, social and psychological needs as well as a questionnaire about the persons life and experiences. An interim care plan had been produced shortly after the persons admission and prior to writing a full and comprehensive care plan. We talked with the manager about the homes admission procedure. People considering a move to the home or their representatives are offered the opportunity of visiting the home. The Manager told us that people thinking about moving to The Lawns are fully assessed before they are offered a place. Where the person is self funded, the General Manager visits them in hospital or their place of residence to assess their needs and to find out whether the home can meet their needs. Care Homes for Older People Page 11 of 29 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. Standards 7, 8, 9, 10 and 11 Recent inprovements mean that peoples care needs are generally well met. However, measures to preserve individual privacy and dignity are insufficient. Evidence: We looked at peoples individual plans to see how the home was planning to meet their needs. The plans were kept on open shelving in the homes office. The office door remained open and unlocked during most of our visit. This is not good practice as it leaves private and personal information unprotected. We examined three plans and checked to see if these were being carried out and reviewed regularly. Since our last key inspection the content of the plans had been improved. They now include information about the persons history and interests as well as their psychological and social needs. We saw in one plan how a person was losing weight on admission. Their weight had been monitored regularly and their diet had been adjusted to help them regain weight. Care Homes for Older People Page 12 of 29 Evidence: Fluid intake was also being monitored and there were instructions in the plan as to what drinks the person needed throughout the day. When we visited the person in their room, we saw that drinks had been supplied as indicated in the plan. Another plan stated that the person was at risk of developing pressure sores. We saw that a pressure relieving mattress had been provided in this persons room. Annual eye tests mentioned in this persons plan had also been followed up. One person told us about how their continence needs were being met by the home. What we were told by this person matched what was written in their plan. The plans we saw contained records of visits from medical specialist and specialist appointments. However, one relative told us that they had complained that recommendations of a physiotherapist about seating were not being followed through until they complained to the home. An incident had also occurred during hoisting this person that had placed the person at risk. This had been reported to the family. Staff had received further advice and a new strap had been obtained to meet the particular needs of this person. Risk assessments about falls and moving and handling were seen in peoples plans. One plan showed that the person was at risk of falling out of bed. Rails had been provided and consent obtained for their use. We looked at how medication was managed in the home. The medicines were securely stored in a dedicated room. A secure trolley was in use. For medication requiring cool storage, a separate refrigerator was available. We looked at three peoples medicines. Except for a minor error, these records were up to date and in good order. Controlled drugs were recorded in a separate register with double signatures when they were administered. Where the life of medicines was limited, as with some eye drops, a record had been made of when the bottle had been opened. On this occasion, we found that medicines not required were being disposed of promptly. We looked at how peoples privacy and dignity was respected and promoted. As previously mentioned, we found that care plans were not securely stored , thus placing their privacy at risk Staff generally addressed people in a kindly and respectful manner. However, terms of endearment such as darling were used on occasion rather than the persons preferred form of address. We saw staff knocking on doors before entering rooms. People we spoke with felt that they were treated with respect by staff. None of the individual rooms had locks on the doors and some bathrooms and toilets Care Homes for Older People Page 13 of 29 Evidence: were without locks. Some people told us that other, more confused people had wandered unexpectedly into their room and expressed concern about their privacy, dignity and the security of their possessions. We also noted in one bathroom a list attached to the wall with individual names and their bathing routines. This does not preserve peoples individual dignity. We looked at how the home manages end of life care. In each persons plan there was a record of their wishes concerning end of life care and arrangements following their death. The home uses the Liverpool Care Pathway and records concerning this were seen in the plans. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 12, 13, 14 and 15 Peoples social and cultural needs are generally well met. However the programme of activities could be improved by being more closely linked to individual preferences and abilities. Evidence: We saw that individual plans had been improved to include information about peoples social needs and an individual profile. We looked at how people were supported to exercise choice. When we arrived at the home, we found that peoples breakfasts were being prepared according to their individual requests and preferences. This meal was served in accordance with peoples individual morning routines. Throughout the day we saw people moving around the home as they wished. People living in the home with whom we spoke told us about their routines including walks in the grounds, receiving visitors and going out with them. One relative told us that they had expressed concern to the home that their relative was being put to bed very early but that this had changed after their complaint. Care Homes for Older People Page 15 of 29 Evidence: In the hall we saw an activities programme displayed. This included board games, hoopla, manicures and exercise afternoon, videos and music. On the day of our visit the exercise session was due. This did not take place and the Registered Manager told us that this was being reorganised. Two people living in the home told us that they would like more exercise. It was not clear how organised activities related to peoples individual needs or how people less able might be offered activities appropriate to their needs. In the kitchen there were records of peoples individual dietary needs and preferences. This was followed by rice pudding or fruit. The people cooking during our visit told us that the menu would be discussed with individuals who would make their choice for the next day. The menu was also posted on a notice board. This was based on a four week cycle which included an alternative main meal and vegetarian options.The main meal being prepared during our visit included fish and chips or baked potato with a variety of alternative fillings. During our observation at lunchtime we saw people eating and enjoying their meals. One person asked for more jam with their rice pudding and this request was attended to. The meal was generally unhurried and staff offered support where this was required. One person required a low sugar diet and others required pureed food. Low sugar products were used where appropriate and the components of pureed meals were presented in separate portions to preserve individual flavours. People living in the home told us that their visitors were generally made welcome. We saw that there were flexible visiting arrangements . One couple living in the home went out with visitors during our visit. Another visitor stayed over the lunch person and told us that she visited daily. Care Homes for Older People Page 16 of 29 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. Standards 16 and 18 When people express concerns they can be confident that these will be addressed. However peoples concerns are not well enough recorded to ensure that any patterns are identified and addressed. Work on safeguarding training needs to be completed so that people can feel confident that all staff know what to do about abuse. Evidence: The Lawns has a complaints procedure specifying how to make a complaint, who will deal with it and in what time scale. It also includes the procedure to follow if not satisfied. We saw this in the Service Users Guide and on display in the entrance hall. In the homes own questionnaires, two relatives had expressed dissatisfaction at the way complaints had been dealt with. However, most people with whom we spoke felt confident that their concerns would be listened to and acted upon. One relative told us about complaints they had made. These were not recorded in the homes complaints record though they had been acted upon. It is important that all complaints are accurately recorded so that these can be audited and any patterns addressed. Since the last inspection, a training programme had been commenced for all staff in safeguarding vulnerable adults from abuse. At the time of our visit, about half the Care Homes for Older People Page 17 of 29 Evidence: staff had received this training and more was planned. Staff with whom we spoke were clear about types of abuse and internal reported procedures. However, not all were clear as to outside agencies they might approach if required. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 19, 24 and 26 The Lawns is generally clean and homely. However the absence of door locks in the home compromises peoples privacy and dignity. Safety is also unacceptably compromised by free access to hazardous areas. Evidence: We looked around the home to check whether the environment was safe, wellmaintained and hygienic. The Lawns is set in its own grounds with a terrace, garden and car parking outside. Inside, accommodation is arranged on two floors with a mezzanine level in between. A shaft lift provides transport to all floors and three stair lifts are also provided. Most parts of the home are accessible by wheelchair. The home is decorated in a traditional comfortable and homely style. We saw that rooms had been individualised with peoples own furniture, possessions, pictures and photographs. We visited on a warm day. However one relative told us that during colder weather, the home had not been warm enough. The Manager told us that this was a temporary problem which had now been resolved. During our tour we noted that individual rooms did not have locks. Some people living in the home told us that others who were confused had wandered into their room unexpectedly. They also expressed concern about the security of their possessions. There were also bathrooms and toilets without locks. This compromises peoples Care Homes for Older People Page 19 of 29 Evidence: privacy and dignity. Some safety measures had been put in place. For example, radiators had been covered and main doorways fitted with fire-safe hold open devices. There was no lock on the door to the laundry. Hazardous substances and laundry machinery and equipment posed a potential risk to a confused person who might wander into this area. We also found the sluice room open where there were hazardous cleaning agents. On an upstairs landing, a cupboard containing a hot water tank with exposed hot pipes was open. Staff told us that this was not usually kept locked. The bedroom overlooking the terrace had a large bay with glazed doors leading onto the terrace. A person occupying this room was at risk of falls. The General Manager told us that the glazing on these doors was reinforced. The terrace had a low balcony. Though most of the length of this was screened with plant pots, there were unprotected parts. In the lounge / conservatory area some floorboards were uneven and loose. This poses a potential trip hazard. During our tour we noted that the home was clean and there were no unpleasant odours. A recent Environmental Health Report regarding food standards commented upon very good standards of cleanliness and organisation. We saw that staff used appropriate gloves, aprons and so on when providing personal care and dealing with infectious materials. Although communal bathrooms and toilets were supplied with liquid soap and paper towels, there was also bar soap. This poses a risk of cross infection and is not now considered good practice. In one bathroom we found skin cream belonging to a person now deceased. This was removed immediately. Care Homes for Older People Page 20 of 29 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. Standards 27, 28, 29 and 30 People living at The Lawns can feel confident that they will be supported by appropriately trained staff. Some risk is posed to people by shortfalls in recruitment. Evidence: The Lawns provides nursing care. In accordince with regulations regarding this type of service, a Registered Nurse is on duty at all times. This was confirmed by staff and the rotas that we examined during our visit. Our examination of the staff rotas and observations during our visit suggested that there were sufficient staff on duty during the day and night to meet the needs of people living in the home. We looked at the file of a recently recruited staff member. The file was not well organised but did show that, in accordance with a previous requirement, POVA First as well as criminal records checks had been completed prior to the person commencing duties in the home. These checks help to keep people safe from potentially unsuitable staff. However, there was not a complete employment history in the persons application. This is an important requirement as it also helps to keep people safe. Care Homes for Older People Page 21 of 29 Evidence: Staff had individual training records and there was a training matrix which showed overall training needs. Induction training for all staff includes induction to the home and the homes philosophy of care. In addition, this training includes the principles of care, manual handling, health and safety and safe working practices. Training arrangements are in place for Registered Nurses who receive a contribution towards their training. Care staff are supported to follow NVQ courses in care. This was confirmed in the records and in discussion with staff. Our discussion also confirmed in house courses in such topics as incontinence, dementia, moving and handling and infection control. Some gaps in training were identified including, for example, food hygiene. However plans were in place for training in Safer Food Better Business as well as palliative care, dementia awareness, safe handling of medicines and nutrition. Care Homes for Older People Page 22 of 29 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. Standards 31,33,35 and 38 A new registered manager is beginning to introduce improvements to the service. However some safety hazards seen during this inspection pose a risk to people living in the home Evidence: Since our last inspection a new Registered Manager, Janet Trinnick, has been appointed who is also described as the Head of Care. Ms. Trinnick is a Registered Nurse with many years experience experience in the care of older people. She is currently awating the start of a management course. She is supported in this role by the Resposible Individual who is the General Manager of Wells House Ltd. (Care Homes). Each has a clear job description. However, in discussion, Ms Trinnick was less clear about the roles and responsibilities of a Registered Manager. Nonetheless, a number of improvements have been noted at this inspection in accordance with previous Care Homes for Older People Page 23 of 29 Evidence: requirements and recommendations. This indicates effective management. We looked at how the quality of the service is monitored and improved. Plans were in place to review and address staff training needs and the maintenance of the environment. We saw completed questionnaires giving feedback about the service. A monitoring tool is in place to collate the results of the surveys and feedback is provided to people using the service and in the Service Users Guide. The policy of the home is to encourage relatives to take responsibility of peoples monies where they lack capacity to manage it themselves. For those whose money was manged by the home, records of transactions were in place. Each person has a lockable facility in their room for monies and valuables which can also be stored in the homes safe if necessary. Since her appointment as Registered Manager, Jant Trinnick had met with the day trained nurses but not the whole staff group. Individual supervision had fallen behind. This is important in supporting staff to develop their practice and identify any needs and problems. Staff training arrangements included training in health and safety topics such as moving and handling, infection control and fire safety. A training plan is in place which identifies shortfalls and current needs. Evidence was seen in the homes maintenance records of safety checks and maintenance such as a gas safety in April 2009, repairs to the passenger lift in January 2009, asbestos removal and fire equipment maintenance in March 2009. Some hazards were noted in the environment and are also mentioned in the Environment section of this report. Infection control procedures were generally sound though the provision of bar soap in communal bathrooms / toilets falls short of current good practice. People living in the home were found to have free access to hazardous substances and equipment in the laundry and sluice rooms. As previously a risk assessment is needed in relation to the terraced area outside. The Annual Quality Assurance Assessment completed by the General Manager stated that hot water temperatures are regulated at all hand basins. Our inspection found that this was not the case. However, risk assessments had been conducted for these outlets. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 29 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 17 The Registered Person must ensure that individual care plans are securely stored This is to preserve and protect peoples privacy 16/08/2009 2 8 12 The registered person must 16/08/2009 ensure that all advice received from visiting health professionals is carried out This is to make sure that peoples care accords with their assessed need 3 16 17 The Registered Person must 17/08/2009 ensure that all complaints made by people using the service or their representative are recorded, together with any action taken and the outcome. This is to ensure that complaints can be audited to identify any patterns Care Homes for Older People Page 26 of 29 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 4 19 13 The Registered Person must ensure that flooring in the lounge / conservatory area is made secure and even This is to reduce the risk of accident and injury to people living in the home 30/09/2009 5 19 13 The Registered Person must 17/08/2009 produce a risk assessment for the external terrace and balcony and take steps to minimise any identified risks This is to reduce the risk of accident and injury to people living in the home 6 19 13 Access to the sluice and laundry areas must be restricted. This is to reduce the risk of accident and injury to people living in the home 17/08/2009 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 2 3 9 12 18 Staff should use peoples preferred form of address in order to demonstrate their respect for individuals. The homes activity programme should be more closely linked to peoples individual needs and abilities. The programme of staff training in safeguarding vulnerable adults from abuse should be completed for all the current staff group Page 27 of 29 Care Homes for Older People 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 4 5 19 24 Locks should be fitted to all communal toilet and bathroom facilities to maintain peoples privacy and dignity. People living in the home should be offered the facility of a door lock to their room. Such locks should conform to the requirements of the Fire Authority and be lockable from the inside but accessible by staff in the event of an emergency. The registered person should ensure that any staff applications include a full employment history and that any gaps are accounted for. 6 29 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 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. Copyright © (2009) Care Quality Commission (CQC). 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