Inspection on 21/01/10 for West Abbey House

This inspection was carried out on 21st January 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Abbey House 01/04/10

West Abbey House 19/11/09

West Abbey House 05/08/09

West Abbey House 30/01/08

West Abbey House 04/07/07

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Key inspection report Care homes for older people Name: Address: West Abbey House Stourton Way Yeovil Somerset BA21 3UA     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: kathy McCluskey     Date: 2 1 0 1 2 0 1 0 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: West Abbey House Stourton Way Yeovil Somerset BA21 3UA 01935411136 01935420829 westabbey@barchester.net www.barchester.com Barchester Healthcare Homes Ltd care home 97 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 97. The registered person may provide the following category of service: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) maximum of 32 places Physical disability (Code PD) maximum of 10 places Old age, not falling within any other category ( Code OP ) maximum of 55 places Date of last inspection Brief description of the care home West Abbey is located in a residential area on the outskirts of Yeovil. It was purpose built as a nursing home in 1994. In the main building is a 66-bedded unit for service users requiring general nursing care and this is located on two floors. There is one 13-person lift to the first floor. The Care Homes for Older People Page 4 of 29 Over 65 0 55 0 32 0 10 0 6 0 8 2 0 0 9 Brief description of the care home corridors are wide and can accommodate people who mobilise using a wheelchair. The home has accessible and pleasant garden areas. The majority of the service users in the main wing are older people. The home is also registered to take up to 10 younger people (18-65). In a separate wing there is a single storey 28 bedded unit (Lyde) for older people with mental health needs. The Lyde unit has its own central courtyard garden. The homes current fees are £550 per week plus free nursing care,and for younger people fees are in line with their individual care needs assessment. 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: This unannounced key inspection was conducted over one day (7 hours) by regulation inspectors Kathy McCluskey and Justine Button. Following the homes last key inspection conducted in August 2009, we monitored the home through an additional random inspection in December 2009. The home were also required to complete an improvement plan which identified how the home would address the concerns raised and improve the quality of the service provided. The home submitted its Annual Quality Assurance Assessment (AQAA) to the Commission within an extended timescale. The AQAA is a self assessment which focuses on how well outcomes are being met for people using the service. It also provides us with some numerical information. During this inspection we were able to meet with one of the companys operations Care Homes for Older People Page 6 of 29 managers who has been drafted in to provide interim management cover in the absence of the registered manager. Three further members of the companys senior management team were available during this inspection. We were given unrestricted access to all parts of the home and all records required for this inspection were made available to us. We were able to meet with staff and people using the service. We would like to thank all those involved for their time and cooperation with the inspection process. The term we used throughout this report refers to we the Commission. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? At the last inspection concerns were raised regarding the homes care planning procedures. We also found that insufficient procedures were in place to reduce the risk of pressure sores. During this inspection, some improvements were noted though further improvements are required. At this inspection we found that the majority of people in their bedrooms had access to fluids and a call bell. We found that the home were now recording more detailed information on peoples diet and fluid intake charts. This enables staff to monitor the amount an individual is actually consuming. The home are now following safer procedures for the management and administration of peoples medication. Previous concerns related to the use of as required medication, the storage of controlled drugs and the storage of prescribed creams. We found all outstanding requirements to be met. The homes procedures for staff recruitment have improved and now provide better protection for people using the service. Recruitment files examined at this inspection and the random inspection contained all required information. No malodours were noted at this inspection or the random inspection. We were able to see that the home had taken steps to ensure peoples privacy and dignity was respected. Screening was in place in shared rooms and viewing windows in bedroom doors on the dementia unit had been covered. As raised at the last inspection, we were able to see that the home had introduced signage to assist people on the dementia unit with orientation. The meal time experience for people on this unit was also noted to have improved. People are now able to make choices about their meal preference at the time the meal is served. As recommended at the last inspection, the home have reviewed the previous practice of Care Homes for Older People Page 8 of 29 laying tables on the unit more than an hour before the meal is served, and now people are encouraged to assist in laying tables just before the meal is served. This is positive as it not only reduces any confusion, but helps promote a level of independence. The home have ensured that people have access to a range of activities appropriate to their needs and abilities. 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 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with information about the home and services offered. Procedures are in place to ensure that people are assessed before they are offered a placement at the home. The home needs to make some improvements before people can be confident of the homes ability to meet their needs fully. Evidence: The home have produced a Statement of Purpose and Service User Guide which provides people with information about the home and services offered. These documents were seen to be displayed in the reception area of the home. We did not examine contracts at this inspection but the homes completed AQAA told us; All residents are given contracts with clear information and costs. It also told us Care Homes for Older People Page 11 of 29 Evidence: that the contracts now far more detailed and clearly state the terms and conditions of occupancy. On examinination of care plans we were able to see that the home has procedures in place which ensure that people are appropriately assessed before a placement is offered. The AQAA told us that people are encouraged to visit the home before making a decision to move there. It told us that people can stay for lunch so that they have the opportunity to chat with other residents and staff. The home also offers a respite facility. Although there have been some improvements since the last inspection, some concerns were identified where the home are not fully able to demonstrate that they are meeting the needs of persons using the service. Deficits in the homes care planning procedures and related documentation were identified at this inspection and are detailed under the outcome group, Health and Personal Care. We were also unable to confirm that all staff have received up to date training. Senior managers who were present for this inspection confirmed that had already acknowledged this deficit and were taking measures to ensure that all staff were up to date with training requirements. It is strongly recommended that the home consider dependency levels before accepting new admissions to ensure that staff are fully able to meet peoples assessed needs. 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 homes care planning procedures require further improvements so that peoples. assessed needs are clearly identified and can be met by staff in a consistent and person centred way. Further improvements are needed for the management of wounds. People are treated with respect and their right to privacy is upheld. Evidence: During this inspection we tracked the care and examined care plans for a number of people receiving care on the general nursing unit and dementia unit. We were also able to spend time observing staff interactions with people using the service and to speak with a number of people using the service. Although some improvements were noted in the homes care planning procedures, further improvements are required to ensure that people receive care in line with their assessed needs and that people receive a consistent and person centred approach to Care Homes for Older People Page 13 of 29 Evidence: care. We were able to see that the home were now recording more information on peoples diet and fluid intake charts thus enabling staff to better monitor peoples intake. We also found that the home had taken steps to ensure that people with an assessed need, were turned at frequencies according to their assessed need rather than every 4 hours for everybody as identified at the last inspection. On the dementia unit we examined a care plan for an individual who was receiving one to one supervision for part of each day. We found that a plan of care had not been raised to reflect this and there was no care plan to address the periods of aggression which had regularly been recorded in the care records. The home must ensure that care plans are raised to address an assessed/identified need so that staff are fully aware of how these needs should be met. We found that a nutritional care plan for another individual had not been updated to reflect the fact that they were no longer receiving nutritional supplements or having their intake monitored as their weight had increased and was now stable. In the general nursing unit we looked at the care plan for an individual who was seen to be in their bedroom without access to a nurse call bell. On discussion with the individual it was apparent that, due to confusion, they did not know how to summon help. We looked at the individuals care records which confirmed their level of confusion though there was no plan of care in place to address the fact that the individual was unable to summon help if needed. An observational chart was in place for another individual who was unable to summon assistance with a call bell. We looked at records for an individual who was being nursed in bed and had two pressure sores. We found that a wound care plan had not been raised to address this. For another individual we found a cup of unthickened squash in their room although the care plan identified the individual as being at high risk of aspiration and therefore requiring all fluids to be thickened. Staff spoken with informed us that they leave a drink in the room and add the thickener just before assisting them. This practice may put the individual at risk and should be reviewed. The care plan did not contain any preferences regarding the individuals preferences with regard to food and drink. We looked at a care plan for an individual who had been prescribed nutritional supplements and who was assessed as being at high risk of developing pressure sores. We looked at associated records and were unable to see documented evidence that the individual was receiving the supplements as prescribed. A care plan had not been raised to address the high risk of developing pressure sores. As identified at the last inspection, we again noted that people who were being nursed in bed and required staff assistance with fluids, were not always being provided with a hot drink. We discussed this with the management team and recommended that Care Homes for Older People Page 14 of 29 Evidence: communications between the hospitality staff (who serve the drinks) and nursing/care staff are reviewed so that all people using the service are offered and assisted with hot drinks. We examined the homes procedures for the management and administration of peoples medication and some improvements were noted. As required at the last inspection we were able to see evidence that medicines were being administered as prescribed and that medication administration records (MAR) accurately reflected the medicines currently in use. We found medicines to be securely stored and we were able to see that the home had taken appropriate action to address the requirement of the last inspection relating to the appropriate storage for controlled drugs. We were informed that the home experienced some difficulties in getting the prescriber to supply more information on the instructions for some as required medication. The home are currently exploring this further. During this inspection we observed people being treated with respect and were able to see that staff respected peoples right to 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 provision of activities has improved and people have the opportunity to take part in a range of activities. The meal time experience for people on the Lyde (dementia unit) has improved. The home need to ensure that documentation held in some peoples care files does not impinge on their right to make choices. Evidence: Since the last inspection, the provision of social activities has improved. We were informed that a new head of activities has been employed and that the activity programme has been redesigned. The homes completed AQAA stated; We have increased our activities programme and provide good and comprehensive activities with input from our residents and We try very hard to ensure all residents can enjoy something from our programme even if this means organising something on an individual basis. On the day of this inspection there were four activities staff on duty, including one volunteer. Throughout the day and on each unit, we observed staff engaging people in Care Homes for Older People Page 16 of 29 Evidence: a range of activities including singing. Staff were also observed spending one to one time with those people who were unable to leave their bedrooms. People were seen to respond positively to staff interaction. Each person is provided with a weekly activity programme. The current programme appeared interesting and varied and included a visiting hairdresser, music therapy, crafts, reminiscence, pat dog, massage, films, food tasting and one to one time. The homes completed AQAA told us that visitors are welcome at any time and that people can choose to see their visitors in the privacy of their own rooms if they wish. To ensure the safety of persons living at the home and in line with current fire regulations, all visitors are required to sign the visitors book when they arrive and leave the home. At the last key inspection concerns were raised regarding peoples opportunities to exercise choice about their lives on the Lyde (dementia) unit. At that inspection we observed an individual become confused and distressed when they were changed into their nightclothes after an afternoon bath. We did not observe this practice during the follow up random inspection though we were concerned to find letters in peoples care files which had been sent to relatives asking them to indicate what time they would like their relative to get up, go to bed, preference for bathing and requesting permission to change into nightclothes following a bath. We discussed our concerns at that inspection and recommended that these letters were removed and that staff supported people to make choices about their lives. This recommendation remains in place as we found that the letters were still in peoples care files. We have again recommended that the home completes deprivation of liberties and best interest assessments for the individual who is being nursed in bed due to a very long delay in obtaining an appropriate specialist chair. At the random inspection we noted improvements in the meal time experience for people on the Lyde (dementia) unit. At this inspection further improvements were noted and it was apparent that the home had acted on the findings of the last inspection. As recommended at the last inspection we observed staff encouraging people to help lay the tables just prior to lunch being served. We also observed staff offering meal choices to people. People were able to choose from three plated meal options. The lunch time experience was very relaxed and unhurried. There was a good staff presence and staff were observed assisting people in a dignified manner. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home have a satisfactory procedure in place which allows people to raise concerns. Procedures are in place which ensure that people are protected from the risk of harm or abuse. Evidence: The home has a satisfactory complaints procedure in place. Records indicated that the home have received one complaint since the last inspection. we were able to see that this had been investigated and responded to in line with the homes complaints procedures. No concerns were raised with us during this inspection. We were able to see evidence that the management team have taken steps to ensure that all staff receive training in the protection of vulnerable adults. The home have a whistle blowing policy in place. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable and well maintained home. The standard of cleanliness has improved and procedures are in place to reduce the risk of the spread of infection. The home have taken steps to assist people with dementia to orientate themselves around their home. Evidence: The home is purpose built and is equipped with a range of aids and adaptations to assist people with mobility difficulties. Accommodation is provided over two floors and the home is divided into three units. Some shared bedrooms are in use and all bedrooms are fitted with en-suite toilet facilities. During this inspection we looked at all communal areas and sampled some bedrooms. Areas were comfortably furnished, clean and free from malodours. People appeared comfortable in their surroundings and we were able to see that people were able to personalise their bedrooms. Staff hand washing facilities and sanitising gels were seen to be appropriately sited and staff had access to a good supply of protective equipment. We were informed by Care Homes for Older People Page 19 of 29 Evidence: the senior management team that training has been booked for those staff identified as requiring training in infection control. At the random inspection, we were able to see evidence that the home had taken steps to address the requirement raised at the last key inspection. These related to malodours, storage, screening in shared rooms and appropriate orientation aids on the Lyde (dementia unit). Although no concerns were noted at this inspection, the home should continue to monitor dependency levels on the upstairs general nursing unit so that the communal lounge can comfortably accommodate people along with any specialised equipment they may require. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are met by appropriate numbers of staff. The homes staff recruitment procedures ensure that people are protected from the risk of harm or abuse. The senior management team are currently reviewing staff training to ensure that all staff have the skills needed to meet the needs of people using the service. Evidence: Duty rotas demonstrated that an adequate number of staff and qualified nurses were on duty over a twenty four hour period. No concerns about staffing levels were raised with us during this inspection. Staff indicated that they did not experience any difficulties in meeting the assessed needs of people using the service. The home remains responsible for ensuring that staffing levels remain appropriate to the dependency levels of people using the service. A four week duty rota was made available to us and on examination we noted that some staff were, on occasions working in excess of 50 hours a week. This could have an impact on the quality of the care delivered. We discussed this with the senior management team at the time of the inspection who agreed to review this practice. Care Homes for Older People Page 21 of 29 Evidence: The homes completed AQAA did not provide us with information as to the number of permanent care staff who have achieved a minimum of an NVQ Level 2 in care. We examined the homes procedures for staff recruitment. We examined the recruitment files for four recently employed staff. These contained all required information including checks against the criminal records bureau and vulnerable adults lists. Newly appointed staff undergo a period of induction. We identified one staff member who had not yet completed their induction programme and there were some gaps in mandatory training for staff. We were informed by the senior management team that, following a review of staff induction and training, they had raised some shortfalls which they were in the process of addressing. We were provided with documented evidence of staff training which had already been planned and booked. 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. Interim management arrangements have been introduced in the absence of the registered manager. Systems are in place to seek the views of people on the quality of the service provided. The home need to ensure that all staff are appropriately supervised. Procedures are in place to ensure the health and safety of persons at the home. Evidence: In the absence of the registered manager, the management of the home is being overseen by one of the companys operations managers. Since the last inspection a deputy manager has been appointed. Management support is also provided by other senior members of the companys management team. Although further improvements are required, we were able to see that the management team have taken steps to Care Homes for Older People Page 23 of 29 Evidence: address many of the concerns raised at the last inspection in line with their completed improvement plan. The home have procedures in place to monitor the quality of the service delivered. Monthly visits are conducted by a company representative with reports maintained at the home. Minutes were seen for regular meetings held for staff, relatives and people using the service. The recommendation of the last inspection relating to staff supervision has not yet been addressed though we were able to see that the current management team had started to take steps to address this. This will be followed up at the next inspection. We toured the premises and examined records which confirmed that up to date procedures were in place relating to health and safety. We were able to see evidence that steps are being taken to ensure that staff have received up to date mandatory training. Care Homes for Older People Page 24 of 29 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 8 12 (1) The registered person 11/12/2009 must ensure that a recorded system of appropriate supervision is implemented to support people to summon assistance when needed. This is to ensure the health, safety and well-being of people who are unable to use a nurse call bell 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 15 (1) The registered person 01/03/2010 must ensure that a plan of care is raised to address peoples assessed needs and that care is delivered in line with the plan of care This is so that people receive care in line with their assessed needs. 2 7 15 The registered person must ensure that care plans are regularly reviewed and remain fully reflective of peoples current assessed needs This is to ensure peoples assessed needs are met by staff. 08/03/2010 3 8 12 (1) The registered person must ensure that appropriate care plans are raised for the management of peoples pressure sores. 01/03/2010 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 This is to ensure that people receive the necessary treatment required. 4 8 12 (1) The registered person 26/02/2010 must ensure that a recorded system of appropriate supervision is in place for those people who are unable to summon help using the nurse call system. Previous timescales of 21/04/2008 & 11/12/2009 were not met. This is to ensure the health and welfare of people using the service 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 4 It is strongly recommended that the home fully consider dependency levels of people living at the home or referrals to the home, before accepting admissions. The home should ensure that care plans contain sufficient information about peoples preferences so that staff can deliver a more person centred approach to care. Where people have been assessed as being at risk of aspiration, the home should review its current arrangemnts of leaving unthickened fluids in those peoples bedrooms. The home should ensure that where people are prescribed nutritional supplements, that these are recorded on individuals diet/fluid intake charts when they are administered. 2 7 3 7 4 8 Care Homes for Older People Page 27 of 29 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 5 8 The home should review its current arrangements on the upstairs general nursing unit so that each person is offered and, where appropriate, assisted with a hot drink. The home should liaise with the prescriber and request more detailed information for the use of as required medication so that this will be shown on the medication administration records. The home should ensure deprivation of liberties and best interests assessments are completed where required. This relates to the individual who is being nursed in bed as the specialised equipment there require was not available. This was also raised at the last inspection. The home should ensure that the identified documentation found in care records on the Lyde unit is removed so that this does not impinge on peoples right to make choices about their lives. The home should ensure that staff receive formal supervision at least six times a year. This was also recommended at the last inspection. 6 9 7 14 8 14 9 36 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. 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