Care Home: Asmall Hall Nursing Home

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What the care home does well The owner/ manager and the management team demonstrate that they are prepared to listen to any suggestions or advice. This was clearly shown in the improvements that had occurred between the first inspection visit and the second one a week later. There is evidence to show that good relationships exist with health professionals. The provision of activities is of a good standard, helping to give assurance that people are receiving appropriate motivation and stimulation. The provision of meals continues to be varied, nutritional and wholesome. Mealtimes also continue to be flexible and relaxed, enabling people to have choices and helps maintain independence. The provision of training is satisfactorily provided and it is evident that training is kept up to date and appropriate. It is evident that good and trusting relationships exist between service users and members of staff. There was a calm and relaxed atmosphere in the home, with a number of people commenting about the homely and big family atmosphere.There is a well established staff team, which helps to give the assurance that people are familiar, comfortable and trusting of the people who support and care for them. What has improved since the last inspection? A CCTV system has been installed at all exits to the home. This shows that the safety of the people living and working at Asmall Hall is taken seriously. Extensive restructuring /refurbishment has taken place in the Mulberry unit. This unit is specifically for people who have dementia and Asmall Hall consulted with the Alzheimer`s society about, what would be appropriate regarding decoration, carpeting and visual aids to promote stimulation. A `Closimatic Toilet` has been purchased, which is a `valuable asset for anybody with mobility problems`. What the care home could do better: There is a need to ensure that any complaints are dealt with, within the required maximum twenty eight day timescale. This would give the assurance that any concerns or complaints are appropriately and satisfactorily dealt with. Continue with the structured Supervision programme, that has recently been implemented. It is a requirement that formal supervisions take place six times annually. Supervisions should cover, all aspects of work practice, the philosophy of the home and also to discuss individual staff development needs. This will also help to give the assurance that staff feel supported and valued. Ensure that care plans are written in a way that they are specific to the person. At the time of the inspection they were too generic and not individualised enough. Continue with the work already started, regarding the auditing and reorganising of staff files. This will help with the management of files and reduce the possibility of information going missing or being misplaced. Key inspection report Care homes for older people Name: Address: Asmall Hall Nursing Home Asmall Hall Asmall Lane Ormskirk Lancashire L40 8JL     The quality rating for this care home is:   two star good 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: Phil McConnell     Date: 2 4 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 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 28 Information about the care home Name of care home: Address: Asmall Hall Nursing Home Asmall Hall Asmall Lane Ormskirk Lancashire L40 8JL 01695579548 01695579978 asmallmatron@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: JenCare Homes Limited care home 56 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 registered person may provide the following category of service only: Care home with nursing - Code N To people 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 (maximum number of places: 56) Dementia - Code DE (maximum number of places: 19) Physical disability - Code PD (maximum number of places: 5) The maximum number of people who can be accommodated is: 56 Date of last inspection Brief description of the care home Asmall Hall has fifty-six beds, the majority of which accommodate elderly service users who require personal or nursing care. Included within the total of fifty six, twelve beds are available, in a separate unit, for Care Homes for Older People Page 4 of 28 Over 65 0 56 0 19 0 5 Brief description of the care home elderly service users with dementia care needs. Included in the registration are three beds that accommodate service users with a physical disability under the age of sixty-five years. A qualified nurse is on duty in the main part of the home and in the specialist unit at all times. Asmall Hall is owned by JenCare Homes Ltd, with the registered manager being Mrs Jennifer Chapman. The service users guide and the statement of purpose are readily available for all concerned. The service users guide gives detailed up to date information about Asmall Hall including, what to expect from the service, how to make a complaint if needed and specific information about the qualifications and experience of the manager and the staff employed. The home is set in extensive well maintained grounds in a quiet residential area of Ormskirk. The grounds are accessible to wheelchair users and the less mobile and outdoor seating is provided to enable service users to enjoy the gardens. A number of aids are provided to assist service users with their activities of daily living and to promote and maintain their independence. The present rate of fees is between £451.50 and £677.50, depending on individual assessed needs. 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: 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: Various information was gathered in order to be able to assess the National Minimum Standards for Care Homes for Older People, including: The Annual Quality Assurance Assessment, this is a document which the registered manager completes every year and it contains information about the service being provided. We use this information, in part to focus on our inspection activity. An unannounced Key Inspection, which was carried out on the 17th of September 2009 by the Care Quality Commission (CQC) and a following visit on the 24th of September 2009. The registered manager ( Jennifer Chapman) was present throughout the inspection visits. There was also the opportunity to speak to some of the people who use the service in private, speak to some visitors and discussions also took place with some of the staff team. Peoples files were examined, with all relevant documentation being in place including, initial assessment documentation and care plans. Care Homes for Older People Page 6 of 28 A number of the staff files were examined and they also contained all of the necessary documentation needed for inspection purposes including, recruitment information and evidence of training that has been provided. The files were disorganised, however on the second visit, considerable work had been carried out to remedy this. Throughout the site visit there was the chance to observe the support and care that was being provided to individuals, which was done in a caring, appropriate and professional manner. The organisations policies, procedures and the health and safety documentation were examined and they were found to be up to date and satisfactory. A tour of the premises was carried out and it was evident that a number of improvements have taken place since the last inspection visit that was carried out by the Commission for Social Care Inspection (CSCI). Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: There is a need to ensure that any complaints are dealt with, within the required maximum twenty eight day timescale. This would give the assurance that any concerns or complaints are appropriately and satisfactorily dealt with. Continue with the structured Supervision programme, that has recently been implemented. It is a requirement that formal supervisions take place six times annually. Supervisions should cover, all aspects of work practice, the philosophy of the home and also to discuss individual staff development needs. This will also help to give the assurance that staff feel supported and valued. Ensure that care plans are written in a way that they are specific to the person. At the time of the inspection they were too generic and not individualised enough. Continue with the work already started, regarding the auditing and reorganising of staff Care Homes for Older People Page 8 of 28 files. This will help with the management of files and reduce the possibility of information going missing or being misplaced. 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 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 10 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. There is a satisfactory admission process in place, helping to give the assurance that peoples nursing and care needs will be appropriately assessed and determined if the they can be provided for at the home. Evidence: Four service users files were examined, including the last person to go and live at Asmall Hall. The files contained relevant information regarding pre admission assessment documentation including, copies of pre admission assessments, either the homes own assessment or an assessment that had been completed by the Social Services Department. An initial enquiry sheet is completed , which were observed to contain significant, detailed and appropriate information, giving the care and nursing staff relevant information, which would help them to support and care for the new / prospective service user. Care Homes for Older People Page 11 of 28 Evidence: Peoples files also contained signed contracts between them and the provider. The contracts clearly demonstrated what the person could expect from the home and people are also given a copy of the service users guide and a statement of purpose, which helps to show that people are given as much information as possible to enable them to make the decision about whether to go and live at Asmall Hall. Although the files did contain significant and appropriate information, they were in need of being brought up to date. The manager commented that she was aware that some of the files needed to have some work done on them, in order to bring them up to date. Care Homes for Older People Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning documentation was observed to be too generic. The plans are in need of being personalised for each person, helping to provide and promote a person centered service to all. Evidence: Peoples care plans were observed and it was apparent that care plans are devised from the initial admission assessments. The Care Plans examined did give detailed information, which would give the carers and nurses some important and helpful information. For example plans contained individuals past employment history and some of the things that are important to them. However, the care plan format is out of date, especially with some of the terms used, for example they refer to a persons problem /need. In discussion with the manager there was an agreement that the care plans are not as person centered or individualised as they could be and at the present time they are too generic. The manager commented that an organisation who provide up to date care planning documentation were visiting the home in the near future to show what other more Care Homes for Older People Page 13 of 28 Evidence: appropriate alternatives are available. The manager confirmed that she was aware that the care planning documentation does need updating and gave an assurance that this shortfall will be addressed. Files contained evidence that peoples health care needs are being provided,with records of GP visits, hospital appointments and all other appointments and consultations with health professionals. Some of the comments from service users relatives regarding, the health provision was very positive for example, My father had a sore eye this morning, it was mentioned to the nurse and it was dealt with immediately. This is typical. They are absolutely fantastic and I am always informed of appointments or if the GP is visiting. There was a medication policy in place, clearly informing the staff the correct procedures to follow in the administration of medication. The medicine administration records (MAR) were examined in the Mulberry unit and in the general unit. The MAR information, the storage and the administration of all medication were observed to be carried out satisfactorily. Each persons MAR chart had a photograph attached. This helps to avoid confusion and any potential medication error. Blister packs are being used and there was up to date information available regarding, what medication had been prescribed for, with detailed information available about any possible side affects. Unused medicines are being returned to the pharmacist, with appropriate records being maintained. The medicines are stored in secure locked cabinets, which were very well organised,clean and tidy. The members of staff on duty during the inspection visit were observed demonstrating a caring and respectful approach to service users. Care Homes for Older People Page 14 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A varied activities programme is being provided, helping to give the assurance that people are being stimulated and motivated. Evidence: The activities programme was examined and it was found to contain information with regards to what activities had been provided and who had attended. It was evident that there is a variety of stimulating and interesting activities for people to get involved in. An activities coordinator is employed at the home and in the feedback received from service users and family members, it was apparent that the activities provided are really good. Some of the comments were, The activities person is fantastic, she does everything with the residents My Mum is doing things we never thought she would do and they try to involve everybody in the activities. There was a prominently displayed notice board, with information about the weeks activities and the weather forecast for the day. This helps to promote interest and stimulation in day to day events. An open house policy is evident within the home and family and friends of people using the service are encouraged to visit at times acceptable to the service users. Care Homes for Older People Page 15 of 28 Evidence: Some comments from visitors were, I think its the most amazing place, you can visit anytime its absolutely fantastic, I havent got a bad word to say, they keep you informed about everything and I can talk to anybody at anytime. The menus for meals were examined and they were found to varied and nutritional. There was the opportunity to have a meal at the home and it was very nice. People gave positive comments about the meals including, the meals are really good and I am really picky, but I cant find fault with the meals. The kitchen staff maintain good records of individuals specific dietary needs and it was evident that the cook endeavors to consistently provide nutritional wholesome meals and is fully aware of peoples dietary requirements. Care Homes for Older People Page 16 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. There is a policy and procedure in place for the protection of vulnerable adults, however it is necessary to ensure that the required timescales for dealing with complaints are appropriately managed. Evidence: There was a complaints policy and procedure in place. The AQAA stated that there had been seven complaints made to the home since the previous inspection visit, which had been carried out by the Commission for Social Care Inspection (CSCI). Although the complaints have all been addressed and dealt with, the AQAA also stated, Our time frame for dealing with complaints has not always been met. This has sometimes been due to circumstances beyond our control, ie, staff holidays or unable to contact relevant people for a full investigation and in the next twelve months, we aim to meet the time frame for dealing with complaints. This was discussed during the inspection visit with the registered manager and an assurance was given, that any future complaints would be appropriately dealt with in the required timescale. A copy of the complaints procedure is made available in the Service Users Guide and within the Statement of Purpose. There was a policy and procedure in place, giving guidance and advice in how to deal with a suspicion or allegation of abuse being made. In discussion with staff it was apparent that staff members are familiar with the different areas of abuse and would know what to do if a safeguarding issue was raised. It was also evident that all Care Homes for Older People Page 17 of 28 Evidence: members of staff have received satisfactory safeguarding adults training. This helps to give an assurance that the protection of vulnerable people is actively promoted. Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally the home is reasonably decorated, however some refurbishment is required in various areas, in order to improve the environmental standards. Evidence: A full tour of the premises was carried out and it was evident that a number of improvements have been made since the last inspection visit, which was carried out by the Commission for Social Care Inspection (CSCI). The Mulberry unit is where dementia care is provided. The unit has had a number of specific adaptations made, which promote and enhance the practical care and support for people with dementia. The Alzheimers Society was consulted regarding, advice and guidance, in order to help ensure that everything possible is done to assist and enable people, with dementia to live as normal a life as possible. For example, there are plain carpets, to avoid confusion, red and gold carpets in the dining room, which are considered to provide a calming atmosphere, the paintings/pictures are of food or of people eating food to provide stimulation, different coloured door handles to identify different rooms and the door frames have finger protectors, which prevent people from getting their fingers trapped in the doors. Overall the dementia care provision was observed to be very good. Some other areas of the home are in need of some redecoration and re carpeting. This Care Homes for Older People Page 19 of 28 Evidence: was discussed with the registered manager and there was an agreement that there is a need to refurbish in some parts of the home, she commented, We know the home is looking tired in some areas and we are planning to address this. The first visit to the home identified that the kitchen was in need of some updating and on the second visit, it was observed that improvements had taken place. This helps to show that the provider takes into account any suggestions, recommendations and advice and acts appropriately. The homes laundry was observed to be well equipped and well organised. Throughout the home, hand washing facilities and anti- bacterial gels are made available to all. This demonstrates that the provider is doing all they can to promote the management of cross infection. There is a small chapel/quiet room, which was described to be a peaceful place to go. The outside grounds are very well maintained, with sufficient walking areas and seating readily available. The home was assessed to be clean and safe, fresh smelling and it was also apparent that a welcoming and friendly atmosphere was present during both visits. Care Homes for Older People Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an established, committed and well trained staff team, giving the assurance that service users receive a good quality service. Evidence: Asmall Hall was observed to be satisfactorily staffed, with most of the staff team having worked there for some time. This gives an assurance of continuity and familiarity for the people using the service. Five staff files were examined and although they contained all of the required information, that is needed for inspection purposes, the files were untidy and disorganised. On the second visit the homes administrator had audited the files and placed documents in more appropriate files. A large number of files had been been reorganised and were of a good standard. It was commented by the homes administrator and confirmed by the manager that the remainder of the files would also be brought up to date. Some of the feedback received regarding the staff from service users and their families were, The staff are fantastic, they really do go the extra mile they are marvelous, cant find any fault and its very nice here, the girls are brilliant. One recently bereaved family wrote, Thank you so much for all your love, care and support to Dad. We have all been so encouraged by all you have been able to do, to make the last year manageable for us and comfortable for Dad. The homes recruitment procedures were observed to be satisfactory, with the relevant Care Homes for Older People Page 21 of 28 Evidence: Criminal Record Bureau (CRB) checks in place, evidence of received references, and application forms. It was apparent that correct procedures are carried out, helping to ensure that only suitable people are employed to support and care for vulnerable people. There was available evidence to show that members of staff have received appropriate, relevant and satisfactory training. Some of the training provided included, Dementia awareness, infection control, safeguarding adults, first aid, moving and handling and it was observed that the majority of staff have obtained the National Vocational Qualification (NVQ) in care and This helps to demonstrate that the provision of training is assessed to be good and people using the service are supported and cared for by a well trained and skilled staff team. Some of the staff commented, I have have done NVQ 3 training its a lovely place to work I am working with a nice group of people we work very well as a team and we give excellent nursing care, meeting all residents needs. Throughout the inspection visit people were observed to be treated in a courteous manner. The staff and the manager were seen to interact with people in a non patronising, very sensitive and patient way. This demonstrates that dignity, respect and equality is positively promoted and practiced. Overall with the feedback received and in observation, it was apparent that the dedication and commitment of the staff team is of a very good standard. Care Homes for Older People Page 22 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 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 well managed, helping to give the assurance that the home is run in the best interests of the people who live at Asmall Hall. Evidence: There is a good established management structure in place, which includes the registered manager and a deputy manager. The registered manager has many years of experience in nursing and social care and she has been the owner/manager at Asmall Hall for over nine years. She has achieved the Registered Managers Award, NVQ level four and she has kept up to date with relevant legislation and training, for example she is about to complete training in The Mental Capacity Act and in The Deprivation of Liberty Safeguards. The manager commented, this training will be passed on to the staff. Some of the comments regarding the management from people using the service, relatives and staff were, the manager is a good hearted person and that filters down to the staff the manager came to assess my father in hospital and she was and is marvelous and The management are very approachable. I know I can go and talk about anything. It was apparent that service users, Care Homes for Older People Page 23 of 28 Evidence: members of staff and relatives feel that the Manager and her team are supportive and approachable. There were satisfactory procedures in place regarding individuals finances, with appropriate safeguards, helping to demonstrate that people are protected from potential financial abuse. During the first site visit it was discovered that no formal staff supervisions have been taking place. This was discussed with the Human Resource coordinator and with the registered manager. An assurance was given that this issue would be immediately addressed. On the second visit a week later, it was found that a lot of work had been completed, with a large number of supervisions having taken place. The supervision records/ minutes were of a good standard and it was stated by the manager that the remainder of staff will be supervised as soon as possible and a procedure has been introduced whereby people will have a formal supervision every eight weeks. The health and safety policy and procedures were examined and they were found to be up to date. All of the homes health and safety inspection certificates were also observed including, electricity, gas, fire extinguishers, portable appliances (PAT), water system, clinical waste, emergency lighting,electronic beds, and the lift inspection certificate. The inspection certificates were all up to date and correct. This helps to demonstrate that the health and safety of people is actively promoted. Care Homes for Older People Page 24 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 25 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 16 22 The registered person should ensure that all complaints are dealt with in the 28 day required period. This will help ensure that complaints are addressed in a timely and appropriate manner. 19/11/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Service users care plans are in need of being updated, in order to ensure that they are, individualised and person centered for each person. It is recommended that the redecoration programme is given more attention, as soon as possible. This would help maintain a satisfactory standard. The refurbishment work in the kitchen, should be completed. This would improve the overall cleanliness, hygiene and maintenance. It is recommended that the improved routine of carrying out formal staff supervisions, must continue with a specific 2 19 3 26 4 36 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 annual programme of structured supervisions. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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