Care Home: Avery House

What the care home does well The decor was homely and there were no unpleasant odours anywhere (including the sluice rooms). Staff were keen and had completed a wide range of courses, with many of them saying they wanted to undertake further studies. A range of activities take place and people are encouraged to participate but know they do not have to. What has improved since the last inspection? This was the first inspection of the service. What the care home could do better: Accurate information about the services to be provided needs to be available. Comprehensive care plans must be completed with the person to whom the care is being provided as soon as possible after admission. Assessments of risks to a person`s health and safety must be undertaken. There must be enough staff available on each floor to meet the needs of people living in the home. Robust recruitment policies and procedures must be in place and carried out. Where there are specific requirements for the administration of a medication there must be written instructions to ensure the health of the person being given the medication. Key inspection report Care homes for older people Name: Address: Avery House Avery House Eagle Way Hampton Vale Peterborough PE7 8EA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Alison Hilton     Date: 2 9 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Avery House Avery House Eagle Way Hampton Vale Peterborough PE7 8EA 0 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): averycare@btinternet.com Avery Homes Peterborough Ltd Name of registered manager (if applicable) Mrs Rebecca Temperton Type of registration: Number of places registered: care home 86 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care home with nursing Code N 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 Dementia - Code DE The Maximum number of service users who can be accommodated is: 86 Date of last inspection Brief description of the care home Avery House is a brand new home situated in Hampton Vale near Yaxley and approximately three miles from the centre of the city of Peterborough. The home can accommodate up to 86 older people some of whom can have a diagnosis of dementia. Although the home is registered to take people who have Care Homes for Older People Page 4 of 29 Over 65 0 86 86 0 Brief description of the care home nursing needs the manager stated this element of care is not currently being provided. The home is built on four levels. The ground floor can accommodate 20 people, the first floor 27, the second floor 24 and the third floor 15. All bedrooms have en suite wet rooms with a toilet, but there are specialist baths located on each floor if people prefer them. There are dining rooms, sitting rooms and other spaces available for people to sit and relax. The weekly cost of the home is between £365 and £700. This does not include chiropody, hairdressing, private telephone or newspapers. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We, the Care Quality Commission (CQC) carried out a key unannounced inspection of Avery House on Monday 29th March 2010 between the hours of 08:20 and 18:00, using the Commissions methodology described below. This report makes judgements about the service based on the evidence we have gathered. Staff, people who live in the home, visitors and the manager were spoken to. An Annual Quality Assurance Assessment (AQAA) was completed and returned to the Commission prior to this inspection. This provides us with some numerical data together with evidence of the outcomes for people living in the home. Surveys were sent to people in the home and staff. We received 2 surveys from people living in the home and 6 from staff. Information they provided will be in the body of the report. A number of records were seen together with three staff files and nine files of people who were living or had lived at the home. Care Homes for Older People Page 6 of 29 There were 37 people living in the home at the time of the inspection and 9 care/senior staff, deputy manager and manager plus a number of ancillary workers. Care Homes for Older People Page 7 of 29 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information provided does not reflect the care available at Avery House, which means people cannot make an informed choice. Evidence: Information in the Statement of Purpose and Service User Guide was misleading as although Avery House is registered to accommodate people with nursing needs the manager stated that the home does not provide this level of care at the moment. This was because the recruitment of nurses has been more difficult than anticipated. This means people are under the misapprehension, when reading the literature, that the home provides something it does not. One person who lives in the home informed us that they were unaware of the restrictions about smoking in the home, however management of the service have informed us that there is a smoking shelter adjacent to the main care home building and this has been made available to residents, visitors and staff. Information Care Homes for Older People Page 10 of 29 Evidence: regarding this is included in the homes brochure. People spoken to said they had had the opportunity to visit the home or one of their relatives had done this on their behalf. There were pre-admission assessments completed by appropriate staff on the files seen during the inspection but they need to be more detailed to ensure there is sufficient information to show what assistance is required and that the staff can meet those needs. There was no evidence of how certain diseases such as Parkinsons or Dementia affected the person or how this impacted on their care needs. Intermediate care is not offered in the home and therefore Standard 6 does not apply. Care Homes for Older People Page 11 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was evidence of good input from a variety of health professionals to meet peoples needs, but with few risk assessments being completed the overall wellbeing of people in the home could not be guaranteed. Evidence: We looked at the files of nine people who reside or did reside in Avery House. There was good evidence that doctors from the local GP surgery attended the home regularly and on an emergency basis. People were referred appropriately to other services such as opticians, continence advisors, physiotherapists, District Nurses and dieticians. There did however appear to be less input from specialists in areas such as Parkinsons Disease, which affected a number of people living in the home. We spoke to some of those who had a diagnosis of Parkinsons and they said their symptoms changed day by day and staff did not always acknowledge that. Some people had been admitted to the home with pressure ulcers and these were treated by the District Nurse. There were turn charts in place for some people and Care Homes for Older People Page 12 of 29 Evidence: these had been completed well and included the actual time of turning and which side the person had been moved to. There were details in the diary for one person to be turned regularly and kept off their back dated 27 March. On talking to staff and looking at records there was no turn chart. When staff realised this they immediately put one in place. The manager was informed of this and said it would be dealt with. The care plans seen varied considerably in content. Good information in the first person detailing specific likes and dislikes was seen in some files with further information provided in a life history. In other files however there was no life history, which meant there was less sense of the whole person and therefore less ability to understand certain behaviours (which is especially important in care of people with dementia). For one person with dementia there was no mental health care plan completed at all. It was evident from some of the daily entries and in talking to staff that although staff on the unit understood one persons needs and how to meet them, when they went onto other units for activities there was less understanding and no risk assessment to ensure that persons wellbeing. One relative asked to speak to us and complained about aspects of her relatives personal care, which was resulting in an increase in problems that needed to be dealt with by the District Nurses. As a result of the concerns we asked the deputy manager to accompany us to the room and check the details of the issue. The complaint was found to be correct and the deputy immediately made arrangements for the person to be assisted. The person had further comments about other aspects of the home and had arranged to see the manager during the day. We suggested that this meeting went ahead so that issues could be resolved. (See also Complaints and Protection). Part of each area of the care plan called my typical day had not been completed in many of the files seen (and especially those in the dementia unit). This meant staff had no overview of the care required for that person in each specific area of care. The manager stated that some training had recently been given to staff on the completion of files but was aware that there needed to be an audit of files to ensure the training was being put into practise. There were very few risk assessments seen in any of the files, which meant people with specialist needs in dementia or with other physical issues were at greater risk from poor practice. Some people who had fallen on many occasions had falls risk assessments completed and been referred to the falls assessor, GP and other appropriate professionals. One person has his own medication administered by a relative but there was no risk assessment on file. There was a note written by the relative that they took full responsibility for the medication. In later discussion with the manager she stated there had been a risk assessment available in the files of both Care Homes for Older People Page 13 of 29 Evidence: residents and was unable to say why it was not found during the inspection. Medication Administration Records (MAR) were seen for six people. Medication is stored in trolleys, locked in designated rooms on each floor. There were some discrepancies between dates when medication had been refused and where they were in the blister packs, as well as numbers of tablets left not corresponding with entries on the MAR sheets. This meant we were unable to maintain an audit trail of medication. Examples were Omeprozole and Ropihirole where the MAR showed the medications as given on all 22 days of this 4 week period but 23 tablets gone from the blister pack, with no explanation on the back of the MAR sheet. The manager was made aware and said it would be looked into immediately. She stated that medication audits were completed and would ensure this issue was raised with staff. There was no guidance on the administration of Alendronic Acid, (which has specific requirements), for three people to whom it was prescribed. This means people may be at risk of harm. Staff said this medication was usually given by the night staff but agreed that there may be times (such as if the person wanted to stay in bed a little while longer) that they may need to administer it. The manager was informed and stated this would be rectified immediately. The fridge temperatures in the medication room on one unit showed a range between minus 1 degree C and plus 29 degrees C. The manager said the recording of the range of daily temperatures would be addressed and she would ensure that this was done immediately. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a varied selection of food available to suit individual tastes and choices. Activities provided were seasonal and people were able to exercise a choice to join in or not. Evidence: The manager stated that the home should have two full time activities co-ordinators but currently only has one. Adverts have been placed in the local press and interviews will take place as soon as possible. A comment from one member of staff was more entertainment in the evenings and possibly weekends was needed. One person we spoke to enjoys flower arranging and admits she often takes over. Staff were aware that this person is involved in the church and the activities co-ordinator has been in contact with the local clergy to visit. A list on the noticeboard showed the activities for the week which included tipple trolley (trolley containing sweets, soap, soft drinks etc), musical bingo, craft afternoon, competitive games, film (Sherlock Holmes this week), 1-1s, Easter raffle, Easter service and board games. On the day of inspection we observed the tipple trolley making the rounds and saw the Easter bonnet competition. The lunch on the day of inspection was fish in sauce or lamb stew with potatoes and Care Homes for Older People Page 15 of 29 Evidence: vegetables and dessert was almond tart. People we spoke to said the food was not fancy but what I like, the pastry isnt cooked right. Its soggy on the bottom and too hard on the edges. We tasted the food and the comments about the pastry were correct and the manager said she would speak to the chef. Staff said that alternatives are available if people dont like the choice of menu but people in the home seemed less aware of this. It may be that staff need to remind people they can opt for a different meal at each mealtime. Mealtimes are reasonably flexible with breakfast from 8am to 11am, however this may mean someone who breakfasts at 11am will have lunch between 12:30 and 13:30. One person we spoke to said they had not had breakfast as it would be too near lunch and spoil my appetite. It was not clear what facilities were available for anyone who came to live in the home who smoked. The expectation was that people did not smoke in their rooms, but if assistance was required to leave the building then this could pose a problem if staff were not available at the time the person wanted to smoke. The manager was not aware there was an issue but agreed to look into a concern raised to us by someone living in the home. People were dressed appropriately and in clothing that was clean. Their hair had been combed and people looked neat and tidy. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Formal processes are in place but have not been tested, although people felt safe but some did not feel listened to. Evidence: The complaints log for the home was seen and no complaints had been received by the manager or staff. This means we were unable to see if complaints are dealt with according to the policies and procedures held by the home. The commission had received one complaint, which was discussed with the manager and relevant paperwork was seen. The issues raised by the relative were looked into and we found the manager and staff had dealt with them appropriately. One person commented that they knew how to complain but it doesnt do any good. One survey returned showed the person knew how and to whom a complaint should be made. During the inspection we asked people who live in the home and any relatives if they were aware of who to talk to if they were unhappy with any aspect of their care. They indicated they knew and would talk to the carers and other staff if necessary. One person was in the process of making a complaint and had an appointment with the manager that day. Information provided by the manager showed that 74 of staff have received training in Safeguarding Vulnerable Adults and this was confirmed by staff spoken to during the inspection. Care Homes for Older People Page 17 of 29 Evidence: The manager said that training in the Mental Capacity Act and Deprivation of Liberty was being rolled out to staff over the next few weeks. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the decor is excellent throughout the home making it a homely and comfortable environment in which to live. Evidence: Avery House is a newly built home on the edge of Hampton Vale near the town of Yaxley and approximately 3 miles from the city of Peterborough. There is a shopping centre within walking distance as well as a hotel/restaurant. The home is built on four floors and all bedrooms are singles and have en suite wet rooms and toilets. There are specialist bathrooms on each floor should anyone want a bath and not a shower. Each room is decorated to a high standard and furnishings are tasteful and different in each room. People have brought small items of furniture with them and those spoken to were very happy with this. People had lots of pictures and other items of a personal nature in their rooms. The maintenance person said he and another full time person were available when needed to put up pictures, clocks etc. The ground floor has 20 bedrooms, the first floor 27, the second floor (for people with dementia) 24 and the third floor 15. On the day of inspection there were 18 people accommodated on the ground floor, 6 on the first, 4 on the second and 9 on the third. There are kitchenettes, dining rooms,lounges and medication storage rooms on each Care Homes for Older People Page 19 of 29 Evidence: floor. All rooms are well furnished to a high standard and are homely. There is a separate hairdressers and a therapy room. People we spoke to said they had moved furniture around in the room to suit themselves and had been encouraged to do this by staff. They said they had chosen the room they occupied and all were very happy with them. There were no malodours anywhere in the building (including the sluice room). The grounds are accessible from the ground floor. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an enthusiastic staff group that works with people living in the home to improve their lives, but needs the skills and numbers to ensure this happens in a positive and professional way. Evidence: The three staff files seen contained most of the necessary paperwork to ensure people in the home are cared for by staff who have been recruited according to the procedures laid down by the company. One person had completed training or been paid to remain at home until the appropriate police checks had been returned. One file showed that only one reference had been obtained, although there was a testimonial from a previous employer but this was from 2007. Another file showed two references but one gave no information about the person that would enable an employer to deem them suitable to work with vulnerable people. One file showed only the years for previous employment dates. We discussed these issues with the manager who stated they would be corrected. Comments made during the inspection about staff were staff are very nice; sometimes have to wait a bit (in relation to staff answering the emergency call bell); very good, very helpful. It felt like coming home; there are not enough carers and Im very happy here, but some carers can be forgetful (this was when staff were Care Homes for Older People Page 21 of 29 Evidence: asked for drinks and they went and got waylaid by other residents needing assistance). One person said they had been up in the dining room for breakfast but because there were few staff on duty they were unable to return to their room (after making the request to staff) for over an hour. They said there were not many on and they were busy washing and bathing people. We looked at the staff rota, which showed that there were an average of 10 or 11 staff in the morning; 9 to11 in the afternoon/evening and five overnight. However this was to cover all four floors in the building. Where there were significantly less staff shown on the rota the manager said there was another sheet where the shifts that needed extra staff were displayed. This was seen and showed that staff put their names down for the extra shifts they were able to cover. The home has not had to bring in agency staff as shifts had been covered in house. We discussed the levels of staff with the manager who stated that one floor was short (on the day of inspection) as someone had phoned in sick at the last minute. The deputy manager was in the building and was helping where needed. From our observations the staff on duty were just managing to meet the needs of the number of people living in the home at the moment. The manager stated that before any new admissions were made the staffing levels would be monitored. A recent recruitment drive had been successful in finding new staff. Statistics provided by the manager show that 91 of staff have received training in Moving and Handling, 90 in Infection Control, 23 in Care Planning, 69 in Nutrition, 66 in Challenging Behaviour and 77 in Safe Handling of Medication. 17 people have completed NVQ Level II or III in Care. Staff we spoke to said they had had a comprehensive induction and had the information they needed to undertake their role in the home. People who work with people with specialist needs such as Parkinsons or Dementia should have training to ensure they have the necessaary skills. This should include domestics and catering staff and anyone who has any role in their care. Some staff spoken to said they had completed the dementia training Yesterday, Today and Tomorrow but were keen to extend their knowledge. As at 29 March 2010 information provided by the manager showed there are 24 care assistants, 13 senior care assistants and 4 nurses employed in the home. There are 5 kitchen staff, 8 laundry/domestic staff, 2 maintenance personnel and 3 administrators. Staff we spoke to during the inspection confirmed they had received supervision and there was evidence in the files inspected. We saw minutes of meetings that had been held in the home including Residents and Care Homes for Older People Page 22 of 29 Evidence: relatives 4/2/10; carers meeting 17/3/10; Ancillary staff 23/2/10; Care staff 9/2/10, Senior carers 2/12/09 and Heads of Departments November 2009. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is providing clear leadership, with regular audits to ensure the service being provided is meeting the needs of those who live there. Evidence: The manager is registered with the Commission. Details provided in the AQAA showed she is a Registered General Nurse (RGN) and holds NVQ Level IV in Management and the Registered Managers Award, and has 15yrs experience of managing care homes. The AQAA showed that there is a comprehensive audit system in place which requires a self audit of one component each month. Other records showed that there had been audits conducted for Medication (Nov 09); Health and Safety (Dec 09); Key Point audit (Jan 10); Person Centred Planning (Feb 10) and Food Safety (Mar 10). Regulation 26 visits by the provider had been made monthly and evidence provided for November (09) to February (10). Care Homes for Older People Page 24 of 29 Evidence: Other records such as maintenance checks were seen and found to be in order. Fire checks had also been completed. Fire drills had been undertaken with details of who had taken part. There was a scoring system but it was not evident why some drills had been deemed adequate and others poor. The manager stated this was because the time it took for staff to react. It was suggested that this be recorded so that people looking at the information were aware of this. We talked to staff and were impressed with their knowledge of what to do in the event of fire and other specific information the lead person knew about which rooms had to be evacuated and in what zones. Care Homes for Older People Page 25 of 29 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 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 Accurate information about the services to be provided needs to be available. This is to ensure people have the necessary information on which to base their decision as to whether they come to live in the home or not. 30/04/2010 2 7 15 Comprehensive care plans must be completed with the person to whom the care is being provided as soon as possible after admission. This is to ensure the care being provided meets the persons needs in a way that is acceptable to them. 28/05/2010 3 8 13 Assessments of risks to a persons health and safety must be undertaken. 30/04/2010 Care Homes for Older People Page 27 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure that where possible risks are eliminated for people living in the home. 4 9 13 Arrangements for the safe 23/04/2010 administration and recording of medication must be in place. This is to ensure the wellbeing of people who have medication administered. 5 27 18 The numbers and skill mix of 30/04/2010 staff on duty must be sufficient to meet the needs of people living in the home. This is to ensure the health and wellbeing of people living in the home. 6 29 19 Robust recruitment policies and procedures must be in place and carried out. This is to ensure the safety of people living in the home. 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 16/04/2010 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 29 of 29 - 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. 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