Inspecting for better lives Key inspection report
Care homes for older people
Name: Address: Windsor House Kirkley Cliff Road Lowestoft Suffolk NR33 0DB The quality rating for this care home is:
one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Diane Roberts
Date: 2 6 0 3 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 28 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 28 Information about the care home
Name of care home: Address: Windsor House Kirkley Cliff Road Lowestoft Suffolk NR33 0DB 01502566664 01502516943 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Saivan Care Services Ltd care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 17 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Windsor House is a large bay fronted property set on the sea front at Lowestoft. It benefits from having the lounge and dining areas at the front of the house. It is close to the local shops and transport links. The home provides accomodation over three floors and primarily has single rooms with no en suite facilities. The home does have a small number of double rooms and singles with en suite facilities. 0 Over 65 17 Care Homes for Older People Page 4 of 28 Brief description of the care home The current scale of charges is from £355.00 to £380.00 per week. Additional charges are made for items such as chiropody and newspapers etc. Care Homes for Older People Page 5 of 28 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: We visited the home for a whole day and met with the manager and her team. We reviewed all the information that we already had on the home and this included the managers Annual Quality Assurance Assessment. The manager was asked to complete this and this tells us how well they think are doing, what they do well and what they would like to improve upon. We refer to this throughout the report as the AQAA. Some of the evidence was within the AQAA was limited and the manager needs to ensure that she is giving a full picture of the home in the future. On the day of the inspection we spoke to residents and staff at the home and prior to that we sent out surveys to residents, asking for feedback on the home. The response was quite good and these comments are referred to in the report. Whilst at the home we also reviewed records and undertook a tour of the home. Care Homes for Older People Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 7 of 28 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 8 of 28 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. Prospective residents would be properly assessed prior to coming into the home, to ensure that their needs would be met living in Windsor House. Evidence: The manager has a statement of purpose/service users guide in place. This had been reviewed in September 2008. The format is not user friendly for the resident group and this was discussed with the manager, who plans to review it further. Whilst the present guide contains helpful information, it also requires reviewing to ensure that it meets Standard 1 of the National Minimum Standards, as some information is missing, for example the complaints procedure. There have been no recent admissions to the home and therefore no new residents to speak to regarding the admission process. However, residents who commented in our surveys all said that they had received enough information about the home at the time of admission.
Care Homes for Older People Page 9 of 28 Evidence: The manager undertakes all pre-admission assessments and completes documentation that she has in place. This documentation was reviewed and found to be generally sound, covering nearly all the required subject areas that one would need to make a comprehensive assessment. A review is recommended to ensure that all areas are adequately covered and this primarily relates to mental health, medication and past medical history. The manager in her AQAA said that visits are made to prospective client in their own environment and an assessment is carried out, families are included in the admission procedure. Care Homes for Older People Page 10 of 28 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. Residents have their basic care needs met but outcomes would be further improved by a more individualised approach to care planning. Evidence: The manager has a care planning system in place. Two care plans were reviewed in full with two further care plans being used to cross reference. The manager told us that the proprietors plan to introduce a new care planing system, that they use in their other registered homes. The care plans consisted of an assessment for good care planning book care plans and additional risk assessments. The assessments books seen were not always up to date, some having been completed in 2007, giving one impression of a residents needs and the care plans, which were slightly more up to date, August 2008, giving another. For example, in the daily notes one resident was noted to get up own their own and manage their personal care, but the care plan for this person says that they need the input of 2 staff. This was further confused on discussion with staff who took a different approach to the care of this resident. It is a concern that there is not a thought out, person lead approach to care and that the care provided is intuitive rather than knowledge based. Whilst, from discussion with
Care Homes for Older People Page 11 of 28 Evidence: staff, they know the residents and their basic needs well, new staff would be confused as to the care needed, from the records and the approach to follow. The manager needs to ensure that the assessment, from which the care plans are developed, are reviewed on a set basis or sooner when there are significant changes. The care plans, whilst generally in place were basic and lack detail in order to sufficiently guide staff. A more person centered approach is also needed to help ensure that residents are treated as individuals and that their preferences are recorded and taken into account. Care plans showed little of no input from residents. From the records it was clear that residents have needs around such issues as mental wellbeing, speech and diet but care plans were not in place for these needs. It was also noted that aids for promoting speech and communication, from the speech therapist, were kept unused in the care plan, rather than with the resident. Residents with difficulties swallowing and who required specialist dietary input had no care plan in place. This needs to be addressed. There was some evidence that the actual care plans were reviewed, for example in January 2009, but this was not consistent across all the plans seen. Risk assessments were in place for a variety of issues, such as moving and handling, nutrition, the risk of falls etc. However these were seen to be out of date as some of them were dated 2007 and from other records within the care plan, did not always reflect the residents current needs. Some residents, for example with bed rails in place, did not have risk assessments and those at risk of pressure sores were not adequately assessed and care plans were also not in place. Residents were seen to have pressure relieving equipment in use in their rooms. Records showed that residents are receiving the medical input they require and that they see their GP in a timely manner. Records show that they are also visited by other health care professionals such as chiropodists. Records show that residents are being weighed, but nutritional risk assessments were not always up to date. Records are maintained of what residents have eaten but this could be developed further to record the amount. This was discussed with the manager. Residents who commented in surveys said that they always got the care and support they needed and that the staff did listen to them and act upon what they said. Relatives said that the staff at the home communicated with them well about any issues that arose. The manager in her AQAA says we plan to involve families more in the care planning process. The manager uses a blister pack system for the administration of medication in the home. This system was reviewed and was generally found to be in good order. Care Homes for Older People Page 12 of 28 Evidence: Medication record sheets were clear and well maintained, however photos are needed for each sheet. There was evidence of GP review and staff were using the appropriate codes for omissions etc. Quite a large stock of medication is held and this should be reviewed as a matter of good practice. The use of laxatives is quite high in the home and should be reviewed to ensure best practice and proper use and where residents are self administering a risk assessment should be completed and kept under review. No controlled medications are currently in use. The manager has the correct recording books should the need arise although work is needed on the controlled medications cupboard to ensure that items are stored securely and this was discussed with the manager. The use of topical creams in the home should be reviewed to ensure that the residents are receiving the care that they need. Some creams were noted to be used without prescription to potentially susceptible areas - such as pressure areas. The use of topical creams should be reflected in the care plan. On touring the home it was noted that out of date prescribed creams were being stored in bathroom cupboards. This practice needs to stop to avoid inappropriate use and items should be returned to pharmacies where appropriate. Interaction between the staff and residents was seen and heard to be respectful and caring. The manager in her AQAA said that staff understand the need to treat all residents with dignity. Care Homes for Older People Page 13 of 28 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. Residents experience good outcomes in relation to the food provided but their social care needs may not always be met. Evidence: From discussion with the staff, residents and review of the records it shows that staff at the home do have quite a person centered approach to the provision of care and understand residents choices etc. However, the staffing of the home impinges on this due to the current levels and lack of domestic staff, making care staff more task led in some aspects of care than they should be. Residents spoken to said that they had choice about how they spent their day and when they got up. It was noted that the staff team use a high number of pressure mats by residents beds to monitor any movement during the night. This is high compared to standard use in comparable homes and should be reviewed and independently assessed for each resident to ensure that they are used in their best interests and that it is not a deprivation of their liberty. Care plans were seen to have good personal profiles in place that would give staff a picture of the resident and their past life, that would help them appreciate the person as an individual. On speaking to staff, they do know the residents well in relation to
Care Homes for Older People Page 14 of 28 Evidence: their past history. Hobbies and interests were also listed in this section of the plan. No actual social care plans were seen to be in place, that outlined how a residents social care needs would be met and how staff could promote independence, self worth and the retention of skills via such activities. This needs to be addressed to improve outcomes for residents in this area, especially in relation to their mental health. On a day to day basis, care staff undertake activities. This is a group rather than individual approach and no records are maintained to evidence what has taken place and who took part. This approach does not meet all the social needs of residents in the home and a review is needed to see how this can be achieved in both a group and individual way. A rolling activities programme is displayed which offers light exercises, boxed games, knitting, art, bingo, sing a long, watching DVDS etc. Residents who commented said that there was either always or usually something for them to do. Comments included I enjoy taking part in activities, I do take part in the activities and there are no real activities, just a singer occasionally and at Christmas. Relatives who commented in the managers own survey said maybe they could plan some one to one time with residents, the exercise and craft days you use to have were good and some music. The manager in her AQAA said we need to improve the range of activities and methods of recording. From relatives comments, they are made welcome at the home and feel free to visit at any time. Lunch was seen to look very appitising and residents were observed to enjoy their lunch. Tables were nicely laid and residents were able to eat with their visiting family members. On discussion with the cook, an alternative was available. Residents were noted to be using plastic beakers at mealtimes and this should be reviewed in relation to residents age and dignity. This was discussed with the manager. From nutrition records and the menu, residents are offered a good range of age appropriate meals and from comments made, the food at the home is very popular. Comments included the food is good, all my meals I enjoy, very nice meals , too much food sometimes, I would like more vegetarian choices of food and the prepacked fish is not very nice. Home made cakes were observed in the kitchen and they also have a good supply of fresh vegetables. There was evidence of good consultation with residents about the menus at a residents meeting in October 2008. Care Homes for Older People Page 15 of 28 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. Residents can be assured that as far as possible they will be protected and listened to in the home. Evidence: The manager reported that there have been no complaints received since the new proprietors took over. A complaints procedure is in place but it was seen to be very wordy and not user friendly for the resident group. A review is recommend. A logging system is also recommended to record any complaints to help ensure that the procedure is followed. This was discussed with the manager. All the residents who responded to our surveys said that they knew about the complaints procedure and who to speak to if they were unhappy about anything. The manager has a policy/procedure on adult protection for staff. On inspection, this needs review to ensure that it is in line with local council practice/policy. Some parts of the managers policy were also contradictory with regard to who investigates concerns. This was discussed with the manager. Staff spoken to showed an understanding of adult protection matters and training records showed that there was a good level of compliance with training on this subject, with the majority of staff being trained in January 2008. Care Homes for Older People Page 16 of 28 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. Variable standards in the home and a inconsistent approach to safety and maintenance means that the home is not always safe and would not meet everyones needs. Evidence: A partial tour of the home was undertaken with the manager. All communal areas and bathrooms were seen along with a number of the bedrooms, on all floors. The lounges and the dining room have been recently decorated and face the sea front, making both rooms a popular and pleasant place to spend time. The quality of the bedrooms ranged from very good and well decorated to those that require decoration and possibly new furniture. Rooms were seen to be personalised and overall clean and tidy. Some rooms need more cleaning and this needs to be negotiated with individual residents. Odours were noted in some bedrooms but this was contained within those room. Three bedrooms in the home have en suite facilities. One, with a shower, was not working and also the toilet needed attention. It was positive to see that some residents have keys to their rooms and are able to have choice regarding privacy. Bathrooms in the home were satisfactory but some are in need of redecoration or refurbishment. One bathroom on the first floor is not in use and consideration is being given to changing this to a shower room. Care Homes for Older People Page 17 of 28 Evidence: Thermostatic valves have been fitted to the hot water system and temperatures were seen to be satisfactory from records seen of the regular checks. The supply of hot water to some rooms in the home is an issue and the manager informed us that the proprietors were looking to upgrade the system to ensure a constant supply. One resident spoken to said that there was a lack of heat and hot water in their room. The manager told us that the outside of the home was due to be painted this year and that there are also plans in place to improve the access outside for residents, to the only garden at the front of the home, as at the current time hard standing is limited and there are small tripping hazards. This would improve outcomes for residents. Relatives who commented to the home via their own quality assurance system, do highlight the steps and the access to the home as an issue. Residents and relatives who commented were happy with the standards of decor etc. in the home and felt that it was always fresh and clean. The manager in her AQAA says that we provide a relaxed and homely environment. A maintenance man is employed, who works 4 -5 hours a day. No domestic staff are employed and this person also completes cleaning work in this time along with care staff. Therefore most of the maintenance time is taken up with cleaning and this is reflected in the amount of work that is needed around the home to improve standards overall. One fire exit in a downstairs bedroom was noted to be obstructed by equipment and this needs to be addressed. The manager was informed on the day of the inspection. On inspection of the records relating to fire safety, it was noted that staff at the home had not undergone a fire drill since May 2008. Alarm systems and emergency lighting in the home had not been tested consistently and the fire safety risk assessment needed review as it was dated 2006. Care Homes for Older People Page 18 of 28 Staffing
These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Shortfalls in staff training and staffing levels mean that outcomes for residents are variable and some of their needs may not be met in full. Evidence: The current staffing levels for the 15 residents currently in the home is three care staff on duty in the morning, dropping to two in the afternoon then three in the evening and two awake at night. This includes the manager, who is not supernumerary. In addition to this are a cook and some maintenance/cleaning hours. The rotas seen show that these levels are maintained. Care staff are also expected to undertake cleaning and laundry duties, taking them away from the care of residents. From discussion with the manager and the care staff there have been some shortages recently through natural staff turnover. The manager reported that two interviews were pending and that they have covered shifts with their own staff rather than use agency. A review of the staffing is needed to ensure that the manager has the time to undertake her management responsibilities and also to ensure that the home has sufficient ancillary staff to enable care staff to focus on the individual needs of residents. Staff, in their supervision records comment that am spending too much time cooking and cleaning and not spending quality time with residents. Residents who commented said that there are enough staff around but some have to do the cooking and thats not right.Relatives who commented said they have been
Care Homes for Older People Page 19 of 28 Evidence: short of staff and I am concerned that my relative is not also getting the care they need. Relatives who commented in the managers own surveys said the staff are very good and they listen to us, friendly, caring staff, good attitude of staff towards residents and the staff are wonderful with the residents. Staff files were reviewed in order to check the recruitment of staff at the home. Files were found to contain all the required checks and documentation, including appropriately timed POVA first and CRB checks. A checklist may help with the organisation of these files, saving management time. The manager has undertaken exit interviews on any staff that have left and all have a reasonable account of why they left. Records show that staff have done and are currently undertaking NVQ qualifications. Out of 16 care staff, 50 have an NVQ qualification and two further staff are currently attending the course. Training records show that the staff are up to date with the majority of their training at the current time. This includes manual handling, food hygiene and adult protection. Unfortunately only two of the staff have up to date training in fire safety and the manager has arranged to address this matter through a training company. Some staff who dispense medication have not had training since 2004/5 and an update is recommend. It was also noted that only one person has attended training in health and safety and this needs to be addressed. More additional training should be provided in conditions associated with old age to improve the knowledge base of staff looking after residents with specific care needs, for example, diabetes, Parkinsons disease, strokes. Records of induction show that previously the manager was using an induction not linked to Skills for Care. On discussion the manager says that there are plans in place to change over to this system. Care Homes for Older People Page 20 of 28 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. Restrictions on the management of the home are potentially affecting outcomes for residents, as development of services is limited. Evidence: The manager has worked at the home for several years and was deputy at the home before coming into post. She has an NVQ level 2,3 and 4. The manager has no supernumerary management time and this is reflected in the amount of work that is needed in relation to care planning and general development of systems and standards in the home. This needs to be reviewed with the proprietor to ensure that the manager has time to manage the home. Residents and staff spoken to speak positively about the manager, say that she is approachable and flexible. One resident said the manager is good, she chases things up for you and lets you know what is happening. The manager last held a staff meeting in December 2008, with staff raising any concerns they had and these were openly minuted. The manager started a staff supervision system in January 2009 and records show
Care Homes for Older People Page 21 of 28 Evidence: that three staff have been supervised. The manager said that she is aiming for bimonthly but the reality of getting these done is difficult as she is working as a carer. The manager has a quality assurance system in place and this consists of a visitor questionnaire which was last completed in November 2008. Overall the responses from relatives were very positive and comments included just like home, friendly and homely home, staff are always on hand and the staff know about my relative whoever you speak to. A similar survey should be developed for residents. The manager last held a residents meeting in October 2008. Residents were consulted on menus, activities, having a shop in the home and on redecoration of the lounge and dining room and what colours they would like. Records show that this is a good method of resident consultation in the home and consideration should be given to having more meetings. Wheelchairs were noted to be in use and on checking of care records, residents did not have appropriate risk assessments or agreements in place and this should be addressed. On touring the home it was noted that many of the window restrictors on the upper floors were either missing or inadequate, to protect residents at risk of falling. An immediate requirements notice was issued to address this matter as an item of urgency. The manager subsequently confirmed to us that this shortfall had been attended to in full. It was also noted that health and safety in relation to COSHH needs to improve in the home as chemicals were freely available in bathrooms and cupboards were unlocked. This was highlighted to the manager on the day of the inspection. Certificate for the maintenance of fixtures, fittings and equipment in the home were inspected at random and found to be up to date, including the wiring for the home. Accident records were reviewed and found to be completed fully. On discussion with the manager it became apparent that she did not know about the reporting of accidents under RIDDOR and advice was given. It was also suggested that the manager develop links with the local falls prevention team, if the Primary Care Trust has one. Care Homes for Older People Page 22 of 28 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 23 of 28 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 Based upon an up to date 14/07/2009 assessment, residents must have care plans in place that cover all their needs, with input from them where possible and these must be kept under review. So that residents care needs are fully met and their preferences are, taken into account. 2 8 12 Where residents are assessed as at risk, risk assessments must be completed and kept under review. To ensure that residents are kept safe as far as possible and their liberty respected. 14/07/2009 3 12 16 Provide an activities programme that meets the assessed needs of residents in both a group and individual way. 30/06/2009 Care Homes for Older People Page 24 of 28 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 So that residents have good social stimulation and that their independence and self worth are promoted. 4 19 17 Provide staff with regular fire drills, test fire safety systems regularly, update the fire safety risk assessment and keep fire exit doors free from obstructions. To reduce the risk of fire in the home and to keep residents and staff as safe as possible 5 19 23 An ongoing programme of maintenance/refurbishment needs to be put in place and actioned, including work to the hot water/heating system. To ensure that residents are safe and that they have a pleasant home to live in. 6 27 18 A review of the staffing of the home is required, covering both care and ancillary staff. To ensure that residents are adequately cared for and that staff can carry out their responsibilities fully. 30/06/2009 30/06/2009 05/06/2009 Care Homes for Older People Page 25 of 28 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 7 30 18 Provide training to staff they 14/07/2009 enables them to undertake their responsibilities fully. So that residents are cared for by a competent staff team. 8 31 18 Sufficient management time 14/07/2009 must be in place to allow the manager to manage the home. So that the service continues to develop positively and in the best interests of residents. 9 38 12 The health and safety of 30/06/2009 residents and staff must be promoted in the home in relation to regular checks on fixtures and fittings, completion of risk assessments and correct accident reporting. So that residents and staff are kept safe as far as possible. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 1 A review of the service user guide is needed to ensure that all the information is available as listed under Standard 1 of the National Minimum Standards and to ensure that the Care Homes for Older People Page 26 of 28 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 format is user friendly. 2 3 A review of the assessment documentation is needed to ensure that all areas of the assessment are sufficiently covered. Review the use of aperients in the home to ensure that each resident has a rationale for use. As good practice put photos of each resident in the medication file to reduce the risk of errors. Seek advice to ensure that the controlled medication cupboard is suitable for the secure storage of controlled drugs. Review the routines of the day and staffing to ensure that, as far as possible, these are resident rather than task led. Review the use of pressure monitors/mats in the home to ensure that they are used in the best interests of residents. Review the complaints procedure to make it user friendly and have a logging system for complaints to evidence that the procedure is followed. Review the policy/procedure for adult protection in line with local council guidance. Provide sufficient staff and equipment to ensure that all parts of the home are clean and odour free. Provide staff with training on conditions associated with old age to enable them to provide a more knowledgeable approach to to the care provided. Continue to develop the quality assurance systems in the home to be more resident focused. Continue to develop the staff supervision programme to ensure that staff are adequately supported. 3 4 5 9 9 9 6 7 8 12 12 16 9 10 11 18 26 30 12 13 33 36 Care Homes for Older People Page 27 of 28 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 28 of 28 - 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!