Care Home: Ashlea Park Residential Home

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Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ashlea Park Residential Home Archer Road Farringdon Sunderland SR3 3DJ     The quality rating for this care home is:   two star good 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: Clifford Renwick     Date: 2 1 0 4 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 32 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 32 Information about the care home Name of care home: Address: Ashlea Park Residential Home Archer Road Farringdon Sunderland SR3 3DJ 01915225977 01915282044 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Winnie Care Limited care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability sensory impairment Additional conditions: 2 MD(E) category refers to two current service users only The SI(E) service user category relates to current service users only. Date of last inspection Brief description of the care home Ashlea Park is care home, providing personal care for up to 40 older people, some of whom may have dementia related needs. Nursing care is not provided, but Community Care Homes for Older People Page 4 of 32 Over 65 22 2 28 8 5 0 0 0 0 0 Brief description of the care home Nursing services can be arranged where necessary. It is a purpose built care home with accommodation provided over two floors, with level access throughout. A lift provides access between the two floors of the home. There is a garden area in front of the home, which includes a paved seating area. The home is situated on the outskirts of Sunderland near to local public transport links. It is also situated near to a range of local facilities, including a doctors surgery, shops, pubs and places of worship. The fees for the home range from #407.00 to #429.00. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. What is included within the fee is outlined within the `statement of terms and conditions available from the home. Care Homes for Older People Page 5 of 32 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: two star good 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 inspections may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services 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. The quality rating for this service is 2 stars. This means that the people who use this service experience Good quality outcomes. The last inspection of this service was carried out in April 2007. Care Homes for Older People Page 6 of 32 Before the Visit. We looked at. Information we have received since registration. How the service has dealt with any complaints or concerns. Any changes to how the service is run. The providers view of how well they care for people from information they provided in the annual quality assurance document (AQQA) that they sent to us. The Visit. An unannounced visit was made on the 21st April 2009. During the visits we. Met with the people who live in the home. Spoke with the staff who were on duty. Held discussion with the manager who was present during our visits. Spoke with relatives who were present during our visit. Observed staff working practices. Looked at information about the people who are receiving support and how well their needs are met. Looked at other records which must be kept in relation to health and safety and staffing. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the home to make sure it was accessible, well maintained, safe and free of any hazards. We also gathered information from looking at, care records to assess how staff supports people with their assessed needs. We also focused upon looking at the records for the 4 people who are currently receiving a service we refer to this as case tracking. And this involves looking at all of the records for a named individual. We told the manager what we had found. What the care home does well: What has improved since the last inspection? What they could do better: The manager must ensure that the written care plans contain more detail about the support that is being offered to the residents. Care Homes for Older People Page 8 of 32 Assessment documents should always be dated and signed by the person who completes them. Staff must not use terminology such as pleasantly confused when completing assessment documents. Information should be recorded in a way that offers a full description of what level of confusion someone may have. The manager must ensure that planned and structured activities take place for all residents. Steps should be taken to amending the complaints procedure so that it includes information about other organisations that can be contacted in the event of making a complaint. And consideration should be given to amending the homes complaints monitoring form so that it offers clear instructions as to what actions will be taken in the event of a complaint being made. And also who will deal with this and within what timescales. The shower rooms must be repaired and all broken tiles replaced. Steps must be taken to improve the external amenity areas and the grass should be cut. The registered provider must take the necessary steps to rectify the issues relating to the block paving pathways in order that they are safe to use by residents and others. On completion of the works to the external areas, steps should be taken to provide comfortable seating so that if residents wish to access the garden area they have somewhere to sit. 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 9 of 32 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 32 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. No one is offered a place in the home without a full assessment of need being carried out by staff and this ensures that only persons whose needs can be met are admitted. Evidence: Discussion with the manager confirmed that before anyone is admitted to the home a detailed assessment is carried out. We looked at three care files for people and this confirmed that in addition to the assessment carried out by the home, assessments are also obtained from the Local Authority if they are responsible for the placement. The assessment documents used by the home varied in the level of information that had been collated by staff. With some areas being detailed and other areas not so detailed. Care Homes for Older People Page 11 of 32 Evidence: This was discussed with the manager who was advised to ensure that the assessment documents are always dated when completed and also to record who completed the assessment. Overall the information gathered by staff during the assessment process was sufficient enough for staff to develop a care plan and this is discussed more fully in sections 7 10 of this report. Intermediate care is not provided so this standard was not assessed. Care Homes for Older People Page 12 of 32 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Though individual plans of care require further development staff takes appropriate action to ensure that each residents receives the care they need. And good records are in place to ensure that all health needs are being met. Evidence: During our visit we looked at care records for four people and we call this process case tracking. And this involves looking at all records related to care for a named individual. Each person has an individual plan of care that sets out what support is needed and how staff are to provide this. The layout and format of the care plan in use is well set out and easy to follow though the level of detail contained in the care plans varies. For some people particularly where care and support was needed with physical tasks Care Homes for Older People Page 13 of 32 Evidence: the information recorded was good. However for some areas of care that were needed particularly in supporting people with their social needs the information was not as detailed as it could be. Discussion held with the manager and the staff confirmed some of the positive actions that were being carried out by staff when they support people particularly those who have behaviors that challenge. Staff were also observed working with people and good practices were in place. However this positive work was not always recorded in detail in the care plan. In addition to the care plans the staff also complete a range of assessment documents to assist with the care process. And this includes manual handling assessments, risk assessments and nutritional assessments. It was good to see that for one person who had been prone to falls advice had been sought from a specialist adviser and steps had been taken that had resulted in reduced falls. Throughout our visit staff were observed carrying out their work in a manner that was respectful and sensitive toward individual residents needs and personal care tasks were carried out in the privacy of residents own rooms. Good records are in place that confirm that residents are able to access all health services as and when required. And it was good to see that families of residents are kept fully informed if there are any changes with peoples needs. Staff who have received appropriate training are responsible for administering prescribed medicines. And observations made during our visit confirmed that good practices are in place. In addition to this a good standard of record keeping is in place that records, receipt, administration and disposal of medicines. For those residents who are able or who express a wish to manage their own medicines then this is supported by staff and an appropriate risk assessment is completed. A good rapport existed between staff and residents and also their relatives. Care Homes for Older People Page 14 of 32 Evidence: Staff refer to people by their chosen form of address and this is noted in their care files in order that staff are familiar with this. In discussion with residents they confirmed that staff offer support to them when dressing and help them to choose their clothes whilst at the same time encouraging them to be as independent as possible. Care Homes for Older People Page 15 of 32 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 residents are supported to exercise choice and control over the lives and maintain contact with relatives and friends. A well balanced and wholesome diet ensures that the residents receive food that is both nutritious and which they enjoy. However there is lack of opportunity to receive stimulation as there no planned leisure and recreational activities. Evidence: The routines within the home around are flexible and residents are encouraged to follow their own routines. There are some residents who prefer to spend time in their bedrooms and choose to socialise with others at mealtimes only or unless there is a special event occurring. Some residents have chosen to have a later breakfast and arrangements have been made for this to happen. In addition to this some residents have also chosen to take their meal in their room while sitting with a relative who is also able to have a meal with them. Care Homes for Older People Page 16 of 32 Evidence: Good contact arrangements are in place that enable the residents to keep in touch with friends and relatives. And there are no restrictions on visiting the home. A number of relatives were visiting the home at the time of our visit and everyone spoken to confirmed that they are very satisfied with the services in the home. At least three families that we spoke with confirmed that they had looked at other homes before choosing this one for their relative. And they stated that they had found this home to be more welcoming and friendly when they were making their decision. They went on to say that staff always made them feel welcome and encouraged them to be involved in making refreshments and if required to have a meal when visiting. Residents are also offered a choice as to whether they wish to retain a key for their bedroom door and record of this is kept on their personal file. A number of people have brought a range of personal possessions into the home and this has helped them in personalising their bedrooms. One person has a small fridge in their room to keep their drinks cool and it was good to see they made use of this. At the time of our visit the activities coordinator was on long term sick leave and as such there was no person specifically responsible for organising activities for the residents. Though a list was available in the entrance lobby confirming that some games and activities would be taking place on the day. The only activity that took place was an impromptu floor skittles game. The dependency levels of the residents and the current staffing levels ensure care needs are being met but there is a shortfall with meeting many of the social needs. And on current staffing numbers there would be insufficient staff to meet social needs also. And the lack of planned leisure and recreational activities means there are limited opportunities for stimulation for the residents. In discussion with the relatives who were visiting they to confirmed that the lack of activities was an area in which they hoped to see some improvement. Though they confirmed that in respect of health and care needs they were very satisfied. Care Homes for Older People Page 17 of 32 Evidence: Lunch was taken with the residents in the ground floor dining room and the tables were set out nicely with tablecloths, serviettes and assorted condiments. There were two choices for the main meal and also the dessert and it was good to see the steps in place that staff followed to assist people with making their choices. Each resident was shown the two meals available on a tray and asked which meal they would like. The residents stated that this helped them in deciding on what to eat especially as they could see the meals in front of them. The meal was well presented, hot and tasty and of a good size. And in discussion with residents they confirmed that the food is always very nice. For those residents who have been assessed as being at nutritional risk appropriate assessments have been carried out. The cook is then given a list of people where additional measures have to be put in place. Care Homes for Older People Page 18 of 32 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. Robust policies and procedures are in place that ensure residents are protected from abuse and an effective complaints procedure ensures that their legal rights are protected. Evidence: Policies and procedures are in place that deal with complaints and a copy of the complaints procedure is contained within the service user guide. Each resident has been issued with a copy of the service user guide and a copy is also on display on the main lobby noticeboard. Discussions with residents families confirmed that the home has an open policy in dealing with complaints. And at any stage if they had any concerns they would raise them with the manager, knowing that they would be dealt with promptly and satisfactorily. Some minor revision is required to the complaints procedure in order that it includes the correct address and the name of the commission due to recent changes. In discussing complaints with the manager and also looking at the records the home keep when dealing with complaints. It was confirmed that the home have their own internal complaints logging and monitoring form. Care Homes for Older People Page 19 of 32 Evidence: These are used to record the complaint and who will investigate though it does not include information about the actions that are to be taken. This was discussed with the manager who was advised of how the form could be amended to include more detail of the planned actions. Policies and procedures are in place that deal with safeguarding adults and the manager confirmed that staff have received appropriate training. The home have demonstrated in the past that any safeguarding alerts that have been made have been dealt with promptly and have involved other agencies. The manager arranges for staff to receive updated training in safeguarding adults and this ensures that staff are aware of how to protect residents from the potential of abuse. Care Homes for Older People Page 20 of 32 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 residents live in a safe and homely environment that has been improved as part of ongoing refurbishment, however some further works are required. And furthermore work needs to be carried out to the external amenity space in order that it is safe and accessible to the residents. Evidence: During our visit we looked at all communal areas, sampled a number of the residents bedrooms on both ground and first floor and also looked at the external amenity space. The home was clean and tidy and free from any unpleasant odours. And the residents and their relatives commented positively upon the cleanliness of the home, stating that there was never any unpleasant odours. Some refurbishment has taken place in parts of the home and magnetic catches have been fitted to all bedroom doors. This has enabled residents to keep the bedroom doors open without compromising fire safety. In addition to this the ongoing refurbishment has assisted in making the home comfortable. Care Homes for Older People Page 21 of 32 Evidence: New bed bases and mattresses and furniture have also been provided to all rooms. As previously stated in this report most of the residents have personalised their bedrooms and it was good to see that residents had been encouraged to bring a range of personal possessions into the home. A number of the residents on the first floor have photographs on their door and this assists them with locating their bedroom. Areas that we looked at on the ground floor were in good decorative order though some defects were noted to the shower room where a number of tiles are missing. A temporary repair has been made by covering the exposed wall with perspex though this is not a satisfactory long term solution and needs to be addressed. The assisted bath was out of order and awaiting a new replacement bath that has been ordered. The first floor is in need of some further refurbishment particularly within the communal areas, corridor and dining rooms. The carpet in the main lounge was sticky and your shoes stuck to this when standing in this area. It requires professional cleaning or replacement. And general wear and tear to the decor and other carpets was noticeable throughout the 1st floor area. The first floor shower room has cracked tiles in the bathing area and the tiles need removing and replaced with new tiles. The external garden areas to the home were unusable on the day of our visit. The grass was overgrown and strewn with weeds and the lack of any appropriate permanent seating meant that these areas could not be used by residents. The manager did state that there were plastic patio chairs and tables that could be used however due to the length of the grass these would not be appropriate for use. The block paving pathways to the front of the home are sinking in places causing the surface to be uneven and could potentially be a tripping hazard for an older person if they used them. Care Homes for Older People Page 22 of 32 Evidence: In addition to this the edging stones have lost most of their retaining mortar and these too are overgrown with weeds. On the day of our visit the weather was extremely warm but due to the height of the grass and the lack of appropriate permanent seating the residents were unable to access any of the external amenity space. Similarly the grass to the rear of the home where there is one bench seat was also overgrown and not being used. Overall the outside areas, approaching pathways and garden areas are not in good order and are not currently used or suitable to use by the residents. The home employ their own maintenance person and a maintenance book is in place for work that needs addressing. However there were no plans to demonstrate what actions were to be taken in respect of the external amenity areas. Care Homes for Older People Page 23 of 32 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. Sufficient trained and experienced staff are available in appropriate numbers to meet the needs of the residents. And furthermore robust recruitment procedures ensure that only people who are suitable to work with vulnerable adults are employed. Evidence: At the time of our visit there were sufficient staff on duty to meet the needs of the residents. Discussion with the manager and examination of the rotas confirmed that at present the home are using 6 agency staff until vacant positions are filled. Agency staff are also being used to cover staff holidays when it is not possible for permanent staff to work extra shifts. The manager confirmed that though new staff have been interviewed and employed they will not be offered a permanent position in the home until all of the satisfactory checks have been carried out. And this includes receiving a satisfactory criminal record check. A training plan was available that confirmed what training have undertaken in the last Care Homes for Older People Page 24 of 32 Evidence: 12 months and discussion with the manager confirmed that training is ongoing. Discussion held with a newly employed member of staff confirmed that good training opportunities are available to the staff. All staff have achieved or are working towards NVQ Level 2 and 3 in health and social care. There is only 1 member of staff who is new that has not yet signed up for NVQ training. Good systems are in place for the recruitment of staff and all of the necessary information is obtained before someone commences employment in the home. There was a good atmosphere in the home at the time of our visit and it was evident that staff had formed good relationships with the residents and their relatives. Care Homes for Older People Page 25 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by an experienced and qualified person who ensures that appropriate systems are in place to ensure the home is run in the best interests of the service users. Evidence: The registered manager is experienced and qualified and has worked in the home for a considerable amount of time. In discussion with the manager it was confirmed that she has continued to attend training courses so that she can continue to develop her skills and keep up to date with her knowledge. The manager confirmed that a range of systems are in place that deal with quality assurance of the service. Some of which include the area manager and owners monthly unannounced visits Care Homes for Older People Page 26 of 32 Evidence: which focuses upon a number of key areas within the service. These visits result in an action plan being produced for the manager that lists any areas of improvement that need to be worked upon. We looked at the last monthly report for February and this contained a good range of information. In addition to the monthly visits quality audits are carried out by the manager on a 3 monthly basis and the cook carries out monthly health and safety audits. The manager also sends surveys to families on a yearly basis and though the results of the surveys are not published. The manager could demonstrate how the home act upon any comments that are made. The home currently hold money/personal allowances on behalf of 4 people and good records are in place to deal with this. In discussion with the manager it was confirmed that good arrangements are in place for staff to receive formal supervision. Staff supervisions are carried out monthly and each staff member receives an annual appraisal. The manager is responsible for carrying out all staff appraisals but for supervision has delegated some responsibilities to the principal senior carer. And also the cook who takes responsibility for supervising catering staff. Good records are kept of any accidents in the home and the manager has made the appropriate notifications to the commission when necessary. Though the fire log book was not looked at the manager confirmed that all staff receive regular fire instruction training and take part in regular fire drills. Discussion with residents and relatives described the manager as being approachable and always making herself available to discuss any matters. One relative stated that if it had not been for the manager and the staff their relative would not have made the positive recovery that she had following a spell in hospital in which she described the care as being poor. Care Homes for Older People Page 27 of 32 Evidence: They went on to say that they could go on holiday and forget about things knowing that their relative was in safe hands at all times. Care Homes for Older People Page 28 of 32 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 29 of 32 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 The written care plans must contain specific detail of the actions that staff are carrying out to help people. This will ensure that staff are following consistent care practices. 31/08/2009 2 19 23 All matters relating to the 31/07/2009 premises as identified in this report as requiring attention must be addressed. This will ensure that service users have a safe environment to live in. 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 12 The manager should ensure that service users are given opportunities for stimulation through planned regular leisure and recreational activities. With particular consideration being given to people with dementia and other cognitive impairments. Page 30 of 32 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 2 3 16 16 The complaints procedure should be amended to include the name and address of the Commission for Quality Care. Consideration should be given to amending the complaints investigation form so that it includes what actions are to be taken, by whom and by what date. In order that it matches with the information that is the complaints procedure. Steps should be taken to make the outside garden areas accessible to the residents. The grass should be cut and the paths made safe and on completion appropriate seating should be provided. 4 19 Care Homes for Older People Page 31 of 32 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. 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