Inspection on 09/01/09 for The Manor House (Residential)

This inspection was carried out on 9th January 2009.

CSCI found this care home to be providing an Poor 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House (Residential) 14/02/07

The Manor House (Residential) 20/03/06

The Manor House (Residential) 20/12/05

The Manor House (Residential) 07/03/05

The Manor House (Residential) 01/09/04

The Manor House (Residential) 25/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Manor House (Residential) 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH     The quality rating for this care home is:   zero star poor 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: Paula McCloy     Date: 0 9 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: The Manor House (Residential) 127 Wakefield Road Lightcliffe Halifax West Yorkshire HX3 8TH 01422202603 01422204113 oliverjamesthomas@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Jean Thomas Name of registered manager (if applicable) Mrs Jean Thomas Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home The Manor House Residential Home is a family run home providing care and accommodation for up to thirty older people. The home is set in its own extensive grounds within walking distance of a bus route. There is plenty of car parking available. There are two lounges and a comfortable dining room. The majority of the bedrooms are single rooms and some have en suite toilet facilities. There is a pleasant outdoor seating area overlooking adjacent fields. 0 Over 65 30 care home 30 Care Homes for Older People Page 4 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor 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: We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This inspection was carried out to assess the quality of care provided to people living in the home. The inspection process included looking at the information we have received about the Care Homes for Older People Page 5 of 30 home since our last key inspection as well as a visit to the home. Two inspectors carried out the visit over one day and it lasted for approximately 6 hours. During the visit we spoke to 6 people living in the home, 3 members of staff, 4 relatives and the manager. We observed care staff delivering care, looked at various records and looked around the home. Comment cards were sent to 10 people living in the home, 10 staff and 5 health care professionals; these cards provide people with the opportunity to share their views of the service with us. Information received in this way is shared with the home without identifying who has provided it. We received comments from six people living at the home, 3 health care professionals and 4 members of staff. Their comments have been used in this report. What the care home does well: What has improved since the last inspection? What they could do better: Make sure that they talk to people about their health and social care needs and check these against the assessment information they have been given. This will make sure staff know what peoples needs are before they move into the home. Make sure that peoples care plans tell staff everything they need to do to support that person. This will make sure people get consistent care. Make sure detailed risk assessments are in place that show clearly how decisions have been made and how people have been involved in these decisions. This will make sure that peoples rights are not undermined or their liberty restricted. Make sure that they know about peoples preferences and their life history. This will help staff to support people in an appropriate way. Make sure that medication is stored safely at all times. Make sure that any concerns or complaints are written down. This will show that people are being listened to. Care Homes for Older People Page 7 of 30 Make sure that staff receive adult protection training. This will make sure they understand the different types of abuse and know how to keep people in their care safe. Make sure that all staff receive up to date training in moving and handling, infection control, health and safety and first aid. This will make sure that staff are working safely. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are not checking the assessment information they receive or using the assessments to plan for peoples care. This means there is no guarantee the home will be able to meet peoples needs. Evidence: There is a Service User Guide that gives people information about the home and the service it provides. The manager told us that if if someone is interested in moving into the home that she gets the assessment information from the social worker. People are invited to visit for lunch and spend some time in the home to see if they think they would like to move in. Staff in the home do not do their own assessment or make any notes about the visit. The manager stated on the AQAA that she felt information they get from the hospital is often inaccurate and that peoples needs may be different to those identified Care Homes for Older People Page 10 of 30 Evidence: on their assessment. It is therefore important that staff complete their own assessment in order to be sure they can meet peoples needs. The manager took an emergency admission to the home in October 2008. We asked to see the assessment information for this person. It was not available in the home, the manager seemed to think that the specialist nurse that is offering support may have taken it. A copy of the assessment was requested and faxed to the home. It was completed in April 2008 and did not reflect the reasons for the admission. The home had not completed their own assessment or put a plan in place about how this persons needs would be met. A copy of the terms and conditions of residence document is included in the Service User Guide. We didnt find any signed copies of this document on peoples files to acknowledge that they had received and accepted the terms and conditions stated. It is important that the terms and conditions documents are signed by the person accepting them and the manager. This will make sure that people are clear about their rights and responsibilities. Care Homes for Older People Page 11 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are not planning peoples care properly. The lack of written care plans means that there is a danger that peoples needs will not be met as most of the information about people is passed between staff verbally. Evidence: We looked at records relating to four people but we could not find any individualised care plans in any of them. Care plans are important because they set out the needs of each individual and tell staff what action they must take to make sure they are met. We found some brief information about whether people wore glasses, dentures, used walking aids and had continence problems. There was very little information about peoples preferences and preferred routines. When we asked how they get to know what care people need they just know. They said they get some information from the initial assessments and any other information they discover is passed on verbally to members of the care team. This means that the care people receive may not be consistent because it is not prescribed in a written care Care Homes for Older People Page 12 of 30 Evidence: plan, instead it depends on what staff remember to pass on. In the report from the last inspection we made the following requirement in relation to care planning: The service user plan must set out in detail the action which needs to be taken by care staff to ensure that all aspects of health and personal care are met. In the AQAA (the Annual Quality Assurance Assessment, this is information provided before the inspection) the manager told us that a comprehensive plan of care is commenced upon admission to the home. On this visit we there was no evidence of this. None of the plans we looked at contained detailed risk assessments about nutrition, pressure sores or falls. It is important that these are completed and reviewed monthly so that action can be taken to minimise risks. We saw some brief risk assessments that contained very little information. The assessments are divided into different, numbered sections. We looked at a continence assessment which was numbered 3. The assessment read risk of constipation. There was no instruction to staff telling them what action they must take to provide this person with the care they need. In the daily records staff simply recorded 3 giving no indication of the care they had delivered. We saw the same type of recordings against mobility and diet. This is poor practice, it means that there is no guarantee that care is delivered with any consistency and the lack of detailed records makes it is impossible to carry out an evaluation to see if it meets peoples needs. We could see from the files that people have been seen by doctors, chiropodists and opticians but we were unable to track the outcomes of these contacts because separate records of professional visits are not kept. It is not easy to get an overview of health care in these areas because any advice arising from these consultations is recorded in the daily records which are regularly archived. One person has been seen by a specialist nurse about Parkinsons disease, we were concerned to find nothing recorded in the care plan about the advice given by the nurse. It is important that this is recorded and made available to all staff to make sure that can provide consistent care. It is important that proper risk assessments are in place to show how how decisions are being made. This is to make sure that peoples rights are not undermined. For example, we found very little information in one of the files we looked at about the needs of this person. We learned from staff that this individual had been very unsettled at night and had tried to get into someone elses bed. This person was then moved to a another bedroom. There was no risk assessment in place, no information to show that any monitoring had taken place and no information about how the decision had been made to move bedrooms. We could not tell whether there were any adult protection issues in relation to this person entering someone another persons bedroom. We discovered that bedrooms on the ground floor are being locked during Care Homes for Older People Page 13 of 30 Evidence: the day to make sure that peoples possessions are safe, this means that if someone wants to go to their room they have to find a member of staff to let them in. This restricts the choices of people living at the home. We could not find any evidence in the records to show that people are consulted about the care they receive. There was nothing to indicate that people had been asked whether it suits them or could be improved upon. In the AQAA the manager told us for the most part service users are unable to contribute in this regard and many of their needs have to be anticipated. When people are unable to comment on their care needs it is good practice to consult with and record the views of relatives. We spoke to people living in the home and to some visiting relatives. People told us they ike the home and said that their needs are being met. Relatives said they were satisfied with the service and they told us they were kept informed about care issues. We received surveys from 2 GPs and one district nurse. They told us that staff call them out appropriately and follow any instructions that they give. They made the following comments: Good team of carers who know the residents well and cater for all their needs. They always seek advice with regard to service users. In the care plans we looked at we could not find any evidence of what advice had been given by health care professionals or details of what action staff had taken. We observed a medication round. The trolley that is being used is not large enough to hold the racks of medication. The member of staff had to use an additional table and put some of the racks on the floor whilst she was giving out the medication. This practice is not hygienic or safe. If the member of staff had to attend to an emergency she would not be able to secure the medication safely. The medication administration records are being typed and printed by the home. This is not safe practice because there is a risk of the wrong information being transferred. The supplying pharmacist should be asked if they will supply medication administration records, as they are supplying the medication in line with the doctors prescription. The member of staff giving out the medication stayed with each person until they had taken their medication and then signed the administration record. We found that the medication administration records were being properly completed, which means that people get their medication at the right times. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some activities on offer to keep people stimulated and meals at the home are good. There is a lack of consultation with people and decisions are made on their behalf. This means that their rights are being undermined. Evidence: We looked at four peoples care files; only one had a very brief life history and none of them contained any information about peoples preferred routines or interests. It is important that this information is recorded so that staff know about the people they are caring for, how they like to spend their time and what their interests are. There were no care plans in place to show how peoples social care needs are planned for and met. We spent time sitting in the lounges. During the morning people upstairs turned the TV off and were reading or talking to each other. Staff brought round mid morning drinks, post and medication, apart from this there was little staff presence. In the downstairs lounge music was playing, staff gave out the medication, brought round the mid morning drinks, asked people what they wanted for tea and brought the telephone to one person so they could talk to their relative. Just before lunch 2 people, who have Care Homes for Older People Page 15 of 30 Evidence: moved from another home on a temporary basis, were both given a glass of sherry. This was the routine they were used to at their previous home and staff from there had asked for it to be continued. No one else was asked if they would also like a glass of sherry. During the morning the manager entered the lounge and opened a window without asking anyone. She said she would be back later to close it. This caused an immediate drop in the room temperature and awoke two people sitting near the window. People immediately commented to each other saying it was draughty and cold. There were no staff in the room. We asked the manager to close the window, she said they need some fresh air, its too warm in here. In the afternoon staff arranged a beetle drive and spelling game in the downstairs lounge. People enjoyed these activities and everyone joined in the spelling game. Staff need to use this to develop the activities programme further. We talked to one person who is living at the home temporarily and hoping to go home soon. This person wants to maintain his independence and go out of the home more often on his own but he did not feel he was supported to do this. The manager told us that when he had been out previously he had not come back at the agreed time or telephoned to let them know he would be late, this concerned the staff. There was no evidence of discussion with this individual about their concerns, no risk assessment about going out and no evidence of any agreement about contacting the home to let them know he was safe. It is important that discussions and agreements are documented so that peoples rights are not undermined or their liberty restricted. Relatives told us that they are made to feel welcome when they visit. Meals at the home are good and provide choice and variety. Everyone we spoke to said that they enjoyed the food. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have not received adult protection training. This means that they are not aware of abuse in its different forms and what they need to do to make sure people in their care are safe. Evidence: The homes complaints procedure is on display, two of the people we spoke to said if they were unhappy they would tell a relative. We did not see a record of complaints received by the home. Although in the AQAA we were told Whilst we have had two or three complaints in the past years, upon investigation they have not been upheld and In the rare event of anyone raising concerns about any part of our service, we deal with the situation swiftly and effectively. However, there is no record of any complaints being received by the home or details of what action was taken to resolve them or the outcome. We feel that although there is a complaints procedure, complaints are not seen by the manager as a way of improving the service. For example, any concerns that are raised by people living in the home or their relatives should be logged. This will make sure that any common themes can be spotted and also make sure that issues are dealt with properly. Concerns and complaints need to be seen as a positive way for people to influence the service so that they live the life they want. Care Homes for Older People Page 17 of 30 Evidence: We asked the three care staff on duty if they had received adult protection training. Two of them had completed some training as part of their National Vocation Training (NVQ) in care, but had not done any other training. We looked at the staff files for the remaining staff and there was no evidence of any of them completing adult protection training. In the AQAA the manager told us the following; Service users are safeguarded from abuse in its many forms and we have whistle-blowing policies in place. We are very concerned about the lack of staff training. In order to make sure that people are safe and protected staff need to understand the different types of abuse and how these might present in a residential setting. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and tidy. Rooms are comfortable but some are in need of redecoration. Evidence: The home is located in Lightcliffe, Halifax in its own extensive and well maintained grounds. There is plenty of car parking space and outside seating for people to use in fine weather. The home is clean and tidy. People living there told us this is always the case. Some areas of the home are are in need of redecoration, where wall paper has become discoloured and worn. In the AQAA the manager has told us that in the next 12 months they will be redecorating some areas and installing some new en-suite facilities. The bedroom doors can be locked by using a coin. When one person wanted to show us her room a member of staff had to let us in. We are also concerned about the suitability of these locks if there was a fire in the home and will be speaking to the local fire officer about this. People living in the home told us that the laundry service was good and that their Care Homes for Older People Page 19 of 30 Evidence: clothing is well looked after. When we looked at the staff records we could find no evidence that staff have completed any infection control training. It is important that staff have this training to make sure that they know about infection control issues. (See section on Management and Administration.) Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment procedure is good and staff are suitable and safe to work with older people. People living in the home like the staff that care for them. Evidence: There are three care staff on duty in the mornings and then 2 care staff for the rest of the day. At night there are 2 waking members of care staff. The care staff are supported by catering, laundry and domestic staff. Two people living in the home told us that they didnt think there were enough staff. They would like to go out, but there arent enough staff to take them. The manager needs to keep the duty rotas under review to make sure there are enough staff on duty as more people move in to the home or as peoples needs change. Having an effective care planning system will help to identify if peoples needs are being met on a consistent basis or if additional staff need to be available at certain times. People we spoke to and relatives said that the staff were good and that they liked them. One person said: The staff are extremely pleasant and courteous. I like them and get on well with them. In the AQAA the manager told us that there are 12 care staff and 6 of these have achieved their National Vocational Award (NVQ) in care. This means that people are Care Homes for Older People Page 21 of 30 Evidence: cared for by competent staff. However, there are some staff who still need to complete mandatory training (see section on Management and Administration). The homes recruitment procedures are good. We looked at two staff files and found that all of the necessary checks had taken place before staff had started working in the home. This means that staff are suitable and safe to work with older people. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not being run in the best interests of the people living there. Evidence: The owner of the home is also the registered manager. She has been operating the home for 17 years. The AQAA was completed and returned to us. It gave us some information about the service but did not identify anything they thought the home could do better and there were very few areas identified for improvement over the next 12 months. The manager has the view that the home provides a good service. We feel that the home has not moved forward and there is a lack of understanding about the importance of care planning, risk management, adult protection, staff training and involvement of people in how the home is run. The manager told us that recently she has given out quality assurance questionnaires Care Homes for Older People Page 23 of 30 Evidence: to people living in the home. She told us that comments have been generally favourable. The manager told us about one person who completed a questionnaire and gave the food a B grade. No attempt was made to discuss this in detail to see if any improvements could be made, instead the manager instructed staff to give this person more food. When this individual asked why he was being given so much food the manager related it back to the rating on the questionnaire. This action could be seen as a punishment and shows a lack of understanding about the quality assurance process. Peoples answers on the questionnaires should be used to develop the service not to single people out. The point of the surveys is to find out what people living in the home think and what they think could be better. The manager does not hold money on behalf of anyone living in the home. People are invoiced separately for extra services such as hairdressing and chiropody. We looked at staff training in safe working practices. There was only one member of staff who had up to date moving and handling training. Other staff had not had any training and other were over 4 years out of date. Staff told us that they had regular fire safety training and we found that 3 members of staff had up to date basic first aid training. None of the staff have completed infection control or health and safety training. The manager must make sure that all staff complete the mandatory training courses, to make sure they are working safely. We looked at the accident records. We noted that over a four week period there were 12 reports of people being found on the floor of these 10 had happened in the early hours of the morning. There is no system in place in the home for monitoring accidents or risk assessments completed to look at how a similar accident could be prevented in the future. For example change in times of night staff checks or the use of pressure pads linked to the call system so staff are alerted if someone gets out of bed. Care Homes for Older People Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 The service user plan must set out in detail the action which needs to be taken by care staff to ensure that all aspects of health and personal care are met. 30/04/2007 Care Homes for Older People Page 25 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Staff must make sure that 27/03/2009 they use the assessment information to check with the person concerned the care and support they will require if they move into the home. This will make sure that peoples needs will be met. 2 7 15 People and/or their relatives 27/03/2009 or representative must be involved in the care planning process and monthly reviews. This will make sure that people are consulted about their care. 3 7 12 A care plan must be written 27/03/2009 for each person living at the home. The care plan must details what peoples needs are including their health care needs and what action staff have to take in order to meet those needs. Care Homes for Older People Page 26 of 30 This will make sure peoples needs are met in a consistent way. 4 8 14 Detailed risk assessments 27/02/2009 must be in place for each person living in the home. These must clearly identify what the risk is and what action staff have to take in order to eliminate or reduce that risk. These assessments must be reviewed on a monthly basis or sooner if the need arises. This will make sure that people arekept as safe as possible. 5 9 13 The home must ensure that safe and effective arrangements are in place for handling and recording the use of all medicines in the home. All medication must be stored securely at temperatures recommended by the manufacturer, and records must demonstrate that medicines can be accounted for and that they have been administered in accordance with the prescribers directions. 27/03/2009 This will make sure that peoples medication is stored and accounted for properly. 6 12 16 Social care plans must be in place for people living in the home. 27/03/2009 Care Homes for Older People Page 27 of 30 This will make sure peoples social care needs are met. 7 14 12 People living in the home must be encouraged to make their own choices. Peoples preferences must be documented in their care plan. This will make sure peoples social care needs are met. 8 18 13 All staff must receive adult protection training. This will make sure staff are aware of all of the different types of abuse and how to report any concerns. 9 33 24 Feedback from people living in the home about the service must be actively sought. This will make sure people can influence the way the home is managed. 10 38 18 All staff must receive training in the following; Health and Safety Moving and Handling First Aid Infection Control This will make sure that staff are working safely 27/03/2009 27/03/2009 27/03/2009 27/02/2009 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 Care Homes for Older People Page 28 of 30 1 2 People moving into the home or their representative and the manage of the home should sign the terms and conditions of residence document. This will make sure that people are fully aware of their rights and responsibilities . The manager needs to make sure that when people visit the home that staff are checking that their needs assessment accurately reflects the care and support that person requires. This will make sure that the staff are fully aware of their needs before they move in Details of all visits by health care professionals should be maintained in a designated section of the care plan. This will make it easy to get up to date information quickly. The manager needs to make sure that the staffing levels are kept under review and are increased as peoples needs change or as more people move into the home. 2 3 3 8 4 27 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!