Inspection on 20/04/09 for The Manor House

This inspection was carried out on 20th April 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House 02/05/07

The Manor House 29/11/05

The Manor House 08/09/05

The Manor House 15/03/05

The Manor House 20/09/04

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 20/07/2009.

Key inspection report Care homes for older people Name: Address: The Manor House North Walsham Wood North Walsham Norfolk NR28 0LU     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: Jane Craig     Date: 2 0 0 4 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 Manor House North Walsham Wood North Walsham Norfolk NR28 0LU 01692402252 P/F01692402252 admin@themanorhouse.healthcarehomes.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: The Manor House (North Walsham Wood) Limited care home 52 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home The Manor House is a care home providing personal care for up to 52 older people, 10 of whom may have a dementia type illness. The home is located close to the market town of North Walsham and is set in 18 acres of beautiful gardens and woodland, all of which are accessible to residents. The home provides accommodation in 45 single bedrooms and 3 shared bedrooms including 5 apartment type rooms located within a courtyard to the back of the home. Most of the bedrooms have en-suite facilities and the apartments have en-suites and small kitchen areas. Bedrooms are located on the ground and first floors. There is extensive communal space in the home including a conservatory, dining room, lounge, lounge/diner and library. This home has won awards for its pet-friendly approach and residents are able to bring their own pets into the home. The charges in April 2009 ranged between 400 to 600 pounds per week. Residents paid extra for hairdressing, chiropody, taxis, newspapers, pet food, vet fees, Care Homes for Older People Page 4 of 29 Over 65 10 42 0 0 Brief description of the care home telephone and personal shopping. 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: The last key inspection on this service was completed on 2nd May 2007. This key (main) inspection includes information gathered since the last inspection and an unannounced visit to the home. The visit was carried out on 20th April 2009 and was conducted by one regulatory inspector. At the time of the visit there were forty five residents in the home. We met with some of them and asked about their views of The Manor House. We spent time observing daily routines in the home and how staff interacted with residents. Four residents were case tracked. This meant that we looked at their care plans and other records. We talked to the acting manager, the Quality Director for the company and some of the care team. We looked around the home and viewed a number of documents and records. Care Homes for Older People Page 6 of 29 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: Care plans should have clearer instructions so that staff know exactly what support the Care Homes for Older People Page 8 of 29 resident needs. In addition, to ensure that residents continue to receive the right care, the plans must be kept under review and be amended when the residents needs change. There must be clear assessments to identify risks to residents health and safety. The risk assessments must be kept under review and plans drawn up to minimise risks. There should be care plans to help staff to meet residents individual social and recreational care needs. There were some regular activities but not all the residents we spoke with thought these were sufficient. The complaints procedure should be clearer. It must include the contact details of the Commission to make it easier for anyone wishing to make a complaint to understand the options they have. Each resident must receive a copy of the complaints procedure. 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 9 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 10 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. People thinking of moving into the home received sufficient information to help them to make a decision and staff received sufficient information to understand the persons needs. Evidence: People thinking of moving into the home were given an information pack about the home and the wider organisation. We were told that a revised choice of home document was also to be included. When available, this would further ensure that potential residents received meaningful information about the home and the service they could expect. As recommended following the last inspection, the statement of purpose made it clear that the accommodation provided in the apartments may not be suitable for all residents. It stated that this would be looked at as part of the pre-admission process. Care Homes for Older People Page 11 of 29 Evidence: The manager obtained health or care management assessments for anyone referred to the service from those sources. She also carried out a pre-admission assessment with all prospective residents to ensure that The Manor House was able to provide the right care and environment to meet the persons needs. The manager involved the resident and their family in the assessment process to make sure that they had opportunities to talk about the issues that were important to them. The pre-admission assessments we saw provided a clear picture of the residents needs and abilities, which helped staff to be able to plan care. Staff said they were given enough information about new residents to know how to support them. They received verbal handovers and had access to the written assessments. Standard 6 was not applicable as The Manor House does not provide intermediate care. Care Homes for Older People Page 12 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. The lack of up to date and accurate information in care plans could result in residents not receiving the right care and could compromise their health and safety. Evidence: One of the four people we case tracked had been admitted to the home very recently and did not have a set of care plans. However, the document staff were working from gave them enough direction to provide support. Residents had opportunities to be involved in drawing up and reviewing their care plans if they wished. Some of the care plans to support people with their personal care needs included information about the residents needs, preferences and abilities. This helped to ensure that staff provided consistent care in the way the resident preferred and in a way that helped to maintain their independence. Not all plans were as clear or individualised. For example, the plan to support one resident with an ongoing health care need only instructed staff to ensure medication was given. However, on talking with the resident it was clear that staff provided him Care Homes for Older People Page 13 of 29 Evidence: with the support he needed, despite shortfalls in the plan. There were no specific plans to support people who had mental health care needs. The care files we saw included a monthly dependency assessment. This helped to indicate if there were any changes and the resident needed more, or less, help with their activities of living. The assessment for one person showed that their care needs had increased in a number of areas but there were no care plans in place to reflect this. Not all of the dependency assessments were up to date. Some of the care plans had not been reviewed for a number of months, which meant that staff could not be sure that the information was accurate and up to date. Care plans were not always amended when the residents needs changed. For example, the assessment for one resident indicated that they needed a hoist for all transfers but all their care plans still directed staff to use the standaid. This could result in staff providing the wrong care. A member of staff told us that they did not always receive a verbal handover as soon as they arrived on duty, which increases the risk. The difficulties with the handover was discussed with the manager who said she would look into this. The manager told us that a new set of care documents were to be introduced later in the year. These would assist staff to write plans with the residents and ensure that the residents perspective and preferences were always taken into account. There were assessments on files to show that potential hazards to residents health and safety were looked at. Several of the risk assessments, and plans to control identified risks, had not been reviewed for a number of months. This meant it was not clear whether these were still relevant. Care records showed that people had routine health checks and were referred to health professionals whenever necessary. Residents we spoke to said they were satisfied with the care. One said, they do everything they can. Another commented, Its the way they look after me that I am so pleased about. One resident told us that staff knew they had painful knees and always asked whether they needed a painkiller. There was a full set of policies for the management of medication in the home and staff had good practice guidance to refer to. Staff who handled medication had received training. One member of staff who was undergoing the course said it was excellent. There was a care plan in place for one resident who administered some of their own Care Homes for Older People Page 14 of 29 Evidence: medicines. Although the plan highlighted that the resident may sometimes need reminding to take their medicine, there was no risk assessment or review notes to show whether the resident was still safe to continue, or whether they needed help. Records of medicines received, and disposed of were complete, which provided an audit trail and reduced the risk of mishandling. All medication administration record (MAR) charts were handwritten. The staff had recently introduced the good practice procedure of checking and double signing entries. There were gaps on one MAR chart without explanation as to why the medication had not been given. This was an isolated incident and all other MAR charts were complete. The deputy manager carried out an audit of all medication at least once a month, which helped to make sure residents received their medicines correctly and identify if any staff might need further training. We looked at a small sample of medication during the visit and found the stock matched the records. Medicines were stored securely. Controlled drugs were stored, administered and recorded according to the policy. We observed part of a medicine round and found staff followed safe and hygienic procedures. Staff received training on core values in their induction and NVQ training. During the course of the inspection we observed staff speaking to residents politely and with respect. The staff we spoke to described how they promoted residents privacy during their day to day work. One member of staff told us it was important to help people to maintain their independence and not to take over things they can do themselves. Residents said that staff were polite and respectful to them and one told us they had, no problems with privacy. Care Homes for Older People Page 15 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. The majority of residents received the support they needed to lead their chosen lifestyle. Evidence: Residents interests and participation in social activities were explored during their initial assessment but none showed any evidence of review. None of the residents we case tracked had an individual plan to support them to meet their social and recreational needs. The manager said that this would improve when the new care records were brought in as this was an area where residents would regularly be consulted as part of their care plan review. The residents we spoke to had mixed views about the level of activities on offer. For example, one person told us, There are only a few activities, it is very poor, whereas another resident said, There is always something on, the activity person does a marvellous job. Another person said the activities on offer did not appeal to them. The activity records were not up to date, therefore it was not clear exactly what was on offer to support people. Information about special events, such as the Easter service and a clothing party were displayed on the notice board and sent to residents. Staff told us they thought the level of activities was, getting better. Care Homes for Older People Page 16 of 29 Evidence: Subject to a risk assessment residents were able to bring their pets into the home with them. The service had won an award in 2007 for being a pet friendly home. Staff told us that they gave residents choices in all aspects of their daily lives. One member of staff said that if they had to make choices for residents who were not able to do so, then they asked family members. Others said they would look in care plans to find out what people liked. Several care plans included information about residents choices and preferences about food, clothing and routines. Residents we spoke with were happy with their lifestyles in the home. One said, this is as good a place as youll get. Another said, It is wonderful here. They said they did not know of any rules about where they had to sit or what they had to do. For example, a number of residents said they preferred to stay in their bedrooms during the day and there was no problem with this. They said there were no particular times for getting up and going to bed and they could come and go as long as they told staff they were going out. One resident said, I dont feel restricted, and another told us, I am at liberty to go where I like. One resident said they were pleased that there were no rules about visitors because their friends had to travel a long way. Residents were positive about the meals. One said, The meals are very good but if you dont like anything you can have something else. Another told us, there are lovely meals with plenty of variety. The records showed that residents were offered choices at every meal and the cook said they could have an alternative if they didnt like anything on the menu. The cook was putting together a picture menu to help residents who may have difficulty understanding verbal choices. Care staff passed on information about special diets and preferences and the cook used this when planning meals. Residents had also attended a recent menu planning meeting and their suggestions were being incorporated. The cook had attended courses about nutrition and tried to ensure that residents were offered a nutritionally balanced diet. The midday meal on the day of the visit looked appetising. Pureed meals were served attractively. There had been some changes in the seating arrangements since the last inspection and residents could sit in either dining room, regardless of whether they needed assistance or not. Two of the staff sitting with residents in the South Wing were particularly skilled at providing help whilst also making the mealtime a social and enjoyable occasion. Care Homes for Older People Page 17 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. The lack of clear procedures could result in complaints and safeguarding incidents not being handled appropriately. Evidence: There was a corporate complaints procedure. Although there was an indication that it could be made available in different formats, the procedure on display was small print. In addition, the content may not be easy for a resident with dementia to follow. The procedure did not include the contact details for the Commission. Residents did not receive information about how to make a complaint in their information pack and there was only one on display in the home. None of the residents we spoke with had made a complaint but said that they would feel able to talk to either a member of staff or the manager if there was anything they were unhappy about. One complaint had been made directly to the home in the past year. The records showed that this had been investigated and responded to within the timescales indicated in the procedure. Staff received safeguarding training during their induction and NVQ training. The staff we spoke with were confident that they would be able to recognise abuse and said they would report it to the manager immediately. There was a safeguarding policy for staff to refer to. Part of the procedure was very informative but the action to be taken by senior staff in response to an incident of abuse was not completely clear. The Care Homes for Older People Page 18 of 29 Evidence: quality director for the company told us that this was being addressed. A procedure will be produced which dovetails with the local authority procedure and includes clear information for senior staff about referring suspected or alleged abuse both internally and to outside agencies. There had been no safeguarding referrals. A number of staff had received, or were waiting for, training about the Mental Capacity Act 2005 to help them to understand any implications this may have for the way they support residents at the home. Care Homes for Older People Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. residents were provided with a clean, comfortable and homely place to live. Evidence: There home was generally well maintained. Most of the communal areas and bedrooms were decorated and furnished to a high standard. However, in order to bring all areas up to a similar standard, there were some of areas that needed attention. For example, some bedrooms and corridors were in urgent need of repainting. The manager was aware of the work that needed to be done and advised us of the programme of redecoration and renewal that was in progress. For example, on the day of the visit the hall was being repainted. The renovation of two bath/shower rooms was almost complete. The assisted bathroom downstairs had been redecorated and staff had added a number of finishing touches to make it look homely. Many people personalised their bedrooms with items of furniture, pictures and ornaments. Those residents who were asked said they were satisfied with their rooms. One person said, I like being in my room, it is a lovely place. Another told us, They have provided me with a very nice room in a beautiful house. At the last inspection it had been noted that some areas of the home were not sufficiently heated. During this visit all areas we looked at were comfortably warm. We Care Homes for Older People Page 20 of 29 Evidence: asked a number of residents, in various parts of the home, and they stated that it was usually warm enough even in the middle of winter. There were no free standing radiators in use. An extra radiator had been fitted in one of the bedrooms identified at the last inspection as being particularly cold. New lights had been fitted in some areas of the home, as had been required previously, and on the day of the visit all internal areas were adequately lit. The external walkway to the courtyard apartments had been re-paved to minimise the risk of trips. However, it was not possible to tell whether this outside area had sufficient lights and the manager agreed to monitor this. The home is set in a large woodland area with landscaped gardens immediately outside the house. The gardens were immaculate and a number of residents made appreciative comments about the setting of the home. One resident told us, Especially with summer coming, this place comes into its own. Another said, I like to sit and watch the wildlife. On the day of the visit all areas were clean and free from unpleasant odours. The company considered regular infection control training to be mandatory to ensure all staff were aware of good hygiene practices. There were adequate hand washing facilities around the home and staff had access to protective clothing to minimise the risk of spreading infection. The laundry was adequately equipped for the size of the home. On the day of the visit it was tidy and organised. There were no complaints about the laundry and we observed that residents clothing was well cared for. Care Homes for Older People Page 21 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were protected by the recruitment practices. Staff had appropriate training to help them to understand and meet the residents needs. Evidence: The service had target minimum and maximum staffing levels. The manager told us that occupancy levels, the needs of the residents, and the layout of the building were all taken into account when calculating staffing needs. We were also told that the manager had the ability to increase staffing on a temporary basis if necessary. Staff had mixed views about whether the current staffing levels were sufficient. They all agreed that none of the residents ever missed out on basic care but said that they did not always have the time to sit and talk to residents. None of the residents told us that they thought the home was short of staff. The staffing levels at night were under review but had not been increased since the last inspection. At that time we highlighted a potential risk that the main building would be left with just one staff if the other two staff were assisting a resident in the courtyard apartments. The manager advised that residents who required assistance from two staff during the night would not be admitted into the courtyard apartments. Should their needs increase after admission extra staff would be rostered until the resident could be moved to alternative accommodation in the main house. Care Homes for Older People Page 22 of 29 Evidence: A number of residents we spoke with were complementary about the staff team. One told us, The staff have been so kind and helped me enormously. Others described staff as, super, caring and lovely. We looked at the files of two recently appointed staff. The files were complete and contained all the relevant documents and information. All the required preemployment checks were carried out to make sure that staff were suitable to work with residents. New staff went through an induction training programme that covered the common induction standards recommended by the national training organisation. Staff completed workbooks and written assessments for each topic before being assessed by the manager as competent. The training programme was very thorough and a member of staff told us that it covered everything they needed to know to help them in their new role. The company employed a training director and had a team of staff to deliver courses when needed. There was a list of mandatory training courses that covered the safe working practice topics. The central training records showed that most staff were up to date with the training and further courses were available. Staff told us that opportunities for attending other training were good. One said that it was mostly very useful for their day to day work. Half of care staff were qualified to National Vocational Qualification (NVQ) level 2 in health and social care, and others were nearing completion. Care Homes for Older People Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The new manager was working to improve the organisation and management of the home for the benefit of the people living and working there. Evidence: A new manager was appointed in January 2009. The new person has previous experience of managing care services for older people and is nearing completion of the recommended care and management qualifications. She is aware of the need to submit an application for registration with the commission. The managers role is supernumerary and a second deputy manager post had been created to provide hands on support to residents and staff on a daily basis. The manager was aware that the service had been through a period of instability and some of the previous standards had not been maintained. Throughout the visit she demonstrated enthusiasm and commitment to improving standards and developing the service. The company had recently appointed a quality director, who was in the process of implementing a range of new initiatives to monitor and improve the quality of services Care Homes for Older People Page 24 of 29 Evidence: and outcomes for residents. One of the projects she talked about was supporting residents to be more involved in recruitment of staff. The satisfaction surveys were also being revised to give residents more opportunities to suggest improvements. The last satisfaction survey had been carried out in September 2008. There was an action plan in place to address issues which had a low score. The manager had reintroduced residents meetings, the first one concentrating on menu planning. Staff received fire safety training and fire safety equipment was serviced regularly. The fire procedure on display was clear and there was appropriate signage throughout the home. Maintenance and servicing of other installations and equipment was up to date. Care Homes for Older People Page 25 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 26 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 15 Care plans must be kept under review and revised to reflect changes in the residents needs. To ensure that residents receive the appropriate care to meet their needs. 31/07/2009 2 8 13 Risks to residents health and 30/06/2009 safety must be assessed and plans drawn up to control the risks. The assessments and plans must be kept under review. To promote residents health and safety. 3 9 13 There must be risk assessments and care plans to support residents to manage their own medication. These must be kept under review. To protect residents health and safety. 30/06/2009 Care Homes for Older People Page 27 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 16 22 The complaints procedure 30/06/2009 must be made available to all residents in a format that is appropriate to their needs. To enable residents to understand the complaints process. 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 12 27 Residents should have individual plans to support them to meet their social and recreational needs. Staffing levels at night should be kept under close review to ensure there are always sufficient staff to meet the needs of the residents. 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). 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. 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