Care Home: Aylesham Court Nursing & Residential Home

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What the care home does well The staff are well trained to care for the residents. ` They give good care, the staff are excellent but there could be more` ` Staff are very good, I am looked after well` The residents live in a clean, pleasant and well - maintained home with bedrooms that are personalised and suit their needs. The home gives the residents a good and nutritious diet and they have choices in what they have to eat. `I enjoy the food` ` Good choice of menu and can choose whatever I would like` What has improved since the last inspection? There has been some improvement in the time that the residents receive their breakfast. The incidence of pressure sores has reduced and monitoring has improved. Staffing levels have improved but there are still difficulties with some residents not receiving care in a timely manner. Staff supervision has been put in place to give the opportunity for staff to have time with their `line manager` to discuss work and training issues. What the care home could do better: They should make sure that the care records are regularly reviewed and updated to make sure that the residents have the right up to date care. Night staff could record the nights events at a time that reflects the whole night. A new system of administering the medicines should be put in place to help with the administration and the time spent. The activities programme could be reviewed to make sure that the residents are having the type of activities that they need and want. That enough staff are available to give individualised attention at meal times. A new call bell system should be installed to make sure that residents are attended to in a timely manner. Each resident who needs to be helped with the hoist to move should have their own sling in the right size. There should always be sufficient staff on duty to make sure that the residents` needs can be met in a timely manner. Where the residents need to use a hoist to be moved they should have an individual sling of the correct size, which will also reduce the risk of cross infection. All the required documentation should be available in the staff files before a member of staff is employed. Arrangements should be made to make personal money available during out of office hours. Key inspection report Care homes for older people Name: Address: Aylesham Court Nursing & Residential Home 195 Hinckley Road Leicester Forest East LE3 3PH     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: Anthea Richards     Date: 1 3 0 4 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: Aylesham Court Nursing & Residential Home 195 Hinckley Road Leicester Forest East LE3 3PH 01162395599 01162395982 dudda@bupa.com www.bupa.com BUPA Care Homes (BNH) Ltd Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Hazel Smith Type of registration: Number of places registered: care home 60 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: No person under 55 years falling within category PD may be admitted to the home. No person who falls within category PD may be admitted to the home when 14 persons of category PD are already accommodated within the home. To be able to continue to accommodate the named person in category PD who is under 55 years of age, subject of variation application V10139, who is currently residing in the home as agreed with the previous registration authority. Date of last inspection Brief description of the care home Aylesham Court is a 60-bedded a purpose built care home providing personal and nursing care for older persons. It is located on a main road on the outskirts of Enderby and Kirby Muxloe in Leicestershire and is easily accessed by public transport from the City of Leicester and the County. Care Homes for Older People Page 4 of 29 Over 65 60 60 0 14 1 1 0 1 2 0 1 0 Brief description of the care home The home provides residential and nursing care for sixty service users whose care needs fall within the categories of Older Persons and or Physical Disability over 65 years of age or Terminally Ill. The home is arranged over two floors with good access for residents with a physical disability. The first floor is accessed by, either the stairs or a passenger lift. There are bedrooms, lounges and a dining room on both floors. The two spacious lounge areas on the ground floor have an outlook onto the well-landscaped gardens, which are mainly laid to lawn with surrounding shrubbery and have a patio area where the residents can walk and sit. The home has two large dining rooms, which are well decorated, and have a private area where the residents can have a meal with relatives or friends if they wish. The home has fifty-four single bedrooms and two double bedrooms; all have en-suite facilities of a W.C. and wash-hand basin. Many of the ground floor bedrooms overlook the patio area. The latest copy of the Inspection report from the Care Quality Commission Inspection is available at the reception desk. The current fee level ranges are agreed dependent on the residents needs. There are additional costs for individual expenses such as personal toiletries, optician, hairdressing and some recreational activities. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we [throughout the report the use of we indicates the Care Quality Commission], spent five hours reviewing information received by the Care Quality Commission [CQC] since the last Key Inspection on the 15th August 2009 and the Random Inspection on the 11th January 2010. The visit took place on the 13th April 2010 and lasted nine hours. During the visit we checked all the key standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means that we looked at the care provided to three of the residents. To achieve this we spoke with the staff supporting their care and looked at the records relating to their health and welfare. We spoke with the residents and their families. With their permission the residents bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff Care Homes for Older People Page 6 of 29 records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them was checked. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. We checked the Annual Quality Assurance Assessment [AQAA] that the home had sent to us. This describes the services provided at the home for the residents, how the home is hoping to improve services and statistics about the residents and the staff. The comment cards that we sent out were seen and comments made were noted. We did not receive any comment cards from the residents or their families. During the visit we spoke with the homes manager, the area manager, the staff, the residents and visitors to the home. 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: They should make sure that the care records are regularly reviewed and updated to make sure that the residents have the right up to date care. Night staff could record the nights events at a time that reflects the whole night. A new system of administering the medicines should be put in place to help with the administration and the time spent. The activities programme could be reviewed to make sure that the residents are having the type of activities that they need and want. That enough staff are available to give individualised attention at meal times. A new call bell system should be installed to make sure that residents are attended to in a timely manner. Each resident who needs to be helped with the hoist to move should have their own sling in the right size. Care Homes for Older People Page 8 of 29 There should always be sufficient staff on duty to make sure that the residents needs can be met in a timely manner. Where the residents need to use a hoist to be moved they should have an individual sling of the correct size, which will also reduce the risk of cross infection. All the required documentation should be available in the staff files before a member of staff is employed. Arrangements should be made to make personal money available during out of office hours. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents needs are assessed by a senior member of staff before moving in and they have information to help them choose a home. Evidence: The residents or their families who were case tracked and others who we spoke with told us that they had seen the Statement of Purpose and Service user Guide. The Statement of Purpose contained thorough information that described the services that the home provided. These documents could be made available available in other formats including large print and other languages to give as many people as possible the opportunity to read them. The manager or the deputy visits all prospective residents to complete a pre assessment of the residents needs, to make sure that the home can meet them and gives them a full picture of the resident before they are admitted. It also gives the resident the opportunity to meet someone from the home who they can recognise Care Homes for Older People Page 11 of 29 Evidence: when they are admitted. Prospective residents are given the opportunity to visit the home. Assessments by the home and social services were seen in the residents care plans and the residents and the families spoken with said that they had seen the manager or the deputy before they came in. A visitor spoken with told us that they had a visit from somebody in the home before they came in and that they had seen the Statement of Purpose. The current registration certificate from the Care Quality Commission (CQC) with the latest report and an up to date public liability insurance certificate were available in the main entrance. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff mostly meet the care needs of the residents, with privacy, dignity and respect. Evidence: The records for the residents who were case tracked were mainly found to contain good individual evidence of the care being given to them and reflected the care that they needed. There was evidence that some of the care plans had not been regularly reviewed and gaps of between two and four months were found in the records looked at. The residents and the families spoken with confirmed that they could be involved and were aware of the care to be given and that they were happy with it. There are records of the residents weight and a nutritional assessment in the care plans to make sure that they are eating properly and not losing weight. The home were working hard to make sure that the care plans did reflect the needs of the resident and that they were person centred making sure that the residents have their care as they would like it and that they continue their interests. Care Homes for Older People Page 13 of 29 Evidence: There are records of the involvement of G.P.s, district nurses, chiropodist and optician, where needed in the care plans, showing that thorough health care is being provided for the residents. We spoke with a visiting Doctor who told us that he was happy with the care that was being given but felt that the staffing was not always as organised as it could be as he often had to wait for somebody to accompany him to a resident. Comments received on the day included: They give good care, the staff are excellent but there could be more Staff are very good, I am looked after well The daily record of care was up to date and there was a full record of the resident day. The night time entries appeared to have been written at 02:00 and 03:00 which would not reflect the residents whole night. We saw residents being treated with dignity and respect when staff spoke with them and undertook their care, particularly when moving them. On one level of the home we saw that the staff did not have the time to spend with the residents with them being left in wheelchairs all morning and coffee being served ten minutes before they were taken into the dining room for lunch. There were risk assessments in place to cover all the identified risks for the residents and how the staff should manage those risks. This makes sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. Medication records for the case tracked residents were in order. Medicines are given by the registered nurses who have regular updating in medicines. We saw that the medicines were administered individually and the residents were seen to be taking them. Medicines are supplied in a Nomad system where all the tablets for each medicine round is in one box. This could lead to difficulties if tablets need to be missed as they cannot be identified. They also have separate, individual boxes of medicines which are time consuming to administer. Care Homes for Older People Page 14 of 29 Evidence: We have previously recommended that the home look at putting a Monitored Dosage system in place where each tablet is in a separate pop out card, which is a safe method of administration, helping to make sure that the resident is always given the right medicines at the right times. The manager told us that this is in the process of being put in place. The medicine administration records were looked at and found to be in order. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The manager carries out a monthly written audit of the medicines and the medicine sheets to make sure that they are correct. The controlled (dangerous) drugs were checked and found to be correct with two signatures for every entry. Staff spoken with were aware of the regulations for administration and storage of controlled drugs. There was a self-medicating policy in place but there were no residents looking after their own medicines at that time. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents enjoy some activities and have their spiritual and nutritional needs met. Evidence: There is a full time activities organiser employed in the home, who told us that she is well supported. We were told that activities provided include quizzes, reminiscence groups, crafts. There was little evidence of activities happening on the day of the visit. We did see residents being taken out into the grounds The activities organiser told us that she managed to spend time every month with those in bed, talking with them, giving them a hand massage. Comments received on the day of the visit included: There is not a lot to do The residents, families and the staff told us that there were some activities but they didnt see a lot of the activities organiser. The activities organiser was seen to be talking with a resident and later on in the day taking a resident into the garden. Care Homes for Older People Page 16 of 29 Evidence: There is a regular religious service held in the home and clergy of all denominations may visit whenever the residents would like. The hairdresser visits weekly and has a room that has been fitted as a hair salon. Residents were visiting on the day of the visit and told us that they appreciated having it. There was a social atmosphere in the salon with the ladies having a chat whilst they were having their hair done. The families spoken with said that they were made very welcome in the home, which we saw whilst we were there. The residents spoken with said that the food was good and that they had a choice of what they had. The menus were varied and were changed regularly. Comments made by the residents included: I enjoy the food Good choice of menu and can choose whatever I would like The residents choose from the choices on the menu, if there is nothing that they like they may choose something else. We spoke with the residents during their lunch, which was served attractively and they told us that they were enjoying. The cook is happy with the quality and amount of food supplied. She is aware of different diets such as vegetarian and diabetic. The staff were seen to be sitting with individual residents helping them with their meals. One carer was sitting and feeding two residents at the same time. This is not dignified for the residents who should be assisted individually. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to support and protect residents and staff are aware of the processes. Evidence: There was a complaints policy in place which gives the details of how to complain and who to complain to in the home if they needed to. This can be made available in a large print and other languages. The home has received 23 complaints in the 12 months before this inspection, 19 of which were found to be upheld with one still being investigated. There is a good audit form containing all the information and dates required. The residents and the families spoken with were aware of the policy, of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. There have been no safeguarding referrals in this time. The staff spoken with were able to describe how they would deal with an allegation of abuse, knew the areas where abuse could happen and could describe the process that they would go through if they suspected any abuse. Care Homes for Older People Page 18 of 29 Evidence: They confirmed that they had had training in safeguarding adults and whistle blowing and the manager and the records seen supported this. The staff are aware of the Mental Capacity and Deprivation of Liberty acts. They were confident that the management would handle any issues correctly. We looked at the accident book, which had been completed correctly. Care Homes for Older People Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are mostly protected by the policies and procedures in the home to provide a safe and pleasant environment. Evidence: Aylesham Court is a purpose built building in Leicester Forest East The home was warm, clean, homely and welcoming. There was an unpleasant odour on arrival on but this cleared. There are bedrooms, lounges and a dining room on both floors. The first floor can be reached by the stairs or by the passenger lift in the home. The lounges and dining room were clean, bright and well decorated, with suitable seating for the residents. All of the bedrooms seen had been personalised and were found to be clean and there is a redecoration programme in progress. The residents and the families told us that they could bring their own belongings in with them to make their rooms their own. There was evidence of equipment in the home to help the residents, such as wheelchairs and special mattresses. The residents who needed to move with the help of a hoist did not have individual slings, which could result in the wrong size sling being used and a risk of cross infection. Care Homes for Older People Page 20 of 29 Evidence: There was a good provision of bathrooms in the home and these were were found to be clean and clear of any items that could cause a hazard for the residents. We did receive comments from the residents and the visitors that sometimes call bells took a long time to answer. We did notice this on the day of the visit and the manager told us that she had been checking the time it took to answer the calls and that whilst there were occasions when it took longer than it should that there was a fault on the system where calls were lost and then reappeared. There are plans to have a new call bell system installed very soon. There was a patio area and garden that were easily reached by the residents and made a pleasant place to sit for them. The residents and the families spoken with were happy with the cleanliness of the home, and told us that the staff worked hard to keep it clean. There are staff employed to complete the cleaning in the home and they have had training in health and safety. The cleaning products are stored in a locked cupboard, which we saw. The records for hot water testing had been completed and all the temperatures were within the recommended levels. The fire records for testing alarms and fire drills and training were looked at and found to be up to date. The staff spoken with told us that they had regular training and fire drills. There was an up to date registration certificate and public liability insurance certificate displayed in the entrance Care Homes for Older People Page 21 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 recruitment policy and the staff training meet the residents needs and protect their safety. Evidence: We looked at three staff files and the required information was complete in two of them. This included evidence of identification, adequately completed application forms, two written references, a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults check. One staff file only contained one reference and the one that had been received had no information on it. The manager normally makes sure that all the required documentation is in place before an employee starts work. This was confirmed by the staff spoken with, who told us that they could not start until they had all the paperwork in place. The staff spoken with confirmed that they had received recent training in moving and handling, dementia awareness, health and safety and safeguarding. The manager has a matrix with all the training courses on it so that she can keep their training up to date. Care Homes for Older People Page 22 of 29 Evidence: The residents and the families spoken with felt that the staff were well trained to do their job but that sometimes there were not enough staff to look after them. We saw evidence that the staff numbers or deployment were not appropriate for the needs of the residents, with residents left in their wheelchairs all morning, coffee being served 10 minutes before lunch and the Nurse still administering the morning medicines at 12:00. The induction programme that all the staff complete contained all the required mandatory training needs. The numbers of staff holding or undertaking a National Vocational Award (NVQ) at least at level 2 or above complies with the required numbers. The home encourages the staff to progress and achieve these awards. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. 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 residents safety is well protected by the practices in a home that is run in their best interests. Evidence: The manager is an experienced manager and has worked at Aylesham Court since April 2009. She is not yet registered with the Care Quality Commission. She has achieved the Registered Managers Award, which is designed to help managers in running a home and managing the staff. There are regular meetings held for the residents and for their families, to discuss activities and menus in addition as to how the home is meeting their needs. The residents and the families spoken with told us that they saw her regularly on their visits. Care Homes for Older People Page 24 of 29 Evidence: There were quality questionnaires regularly sent to residents and their families, the results showed concerns around staffing levels and the call bell system. The families and the residents told us that they had completed the questionnaires. The residents accounts were found to be in order, but the residents were not able to access their accounts out of office hours. Money would be made available if the home was informed that it was needed. There was evidence from the staff spoken and from the records seen with that they are having regular formal supervision with their line manager. There are regular staff meetings held, confirmed by records held and by the staff spoken with. All the areas of health and safety such as hot water temperatures and fire drills and alarm testing were found to be in order. 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 7 14 (2)That the residents assessment of need is kept up to date and regularly reviewed. That the resident receives the current care that they require. 31/05/2010 2 22 23 (2)(c) That the call bell system is upgraded to provide a reliable method of communication for the residents. That the residents can readily gain the attention of the staff. 30/06/2010 3 27 18 (1)(a)That staff numbers are 07/05/2010 appropriate for the needs of the residents. That the needs of the residents are met within an appropriate timescale. 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 4 28 19 (1)(b)That all the documentation required in paragraphs 1 to 7 in schedule 2 To make sure that the member of staff is a fit person to work in a care home. 07/05/2010 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 2 7 9 That the night staff record the nights events at a more appropriate time to reflect the whole night. That a new method of medicine administration is put in place to make sure that the residents have the right medication at the right times. That the activities programme is reviewed to make sure that all of the residents have the activities that they want and need. That residents are given the dignity of one person helping them with their meal. That individual slings are provided for each resident in the correct size. That staff are deployed efficiently to make sure that the residents have care at appropriate times. That the residents personal money can be made available to them out of office hours. 3 12 4 5 6 7 15 22 27 35 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. Copyright © (2009) Care Quality Commission (CQC). 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