Care Home: Beechwood Hall

What the care home does well This is a pleasant small residential care home for people with Dementia. It has good links with its local community. It has a very caring and committed staff group, who know their residents well and have established good relationships with them and their families. People living in the home seemed very happy to be there, and spoke highly of the manager and staff, as did relatives in a recent survey. Comments included, "More than happy with the care"; "Delighted to say that we are always made welcome, and we feel your staff are of the highest calibre"; and, "I feel the care my father receives is excellent by caring and loving staff". Residents said that they are very happy with the food in the home. People were seen to well groomed. Their religious and spiritual needs are noted and met, with regular visits from clergy. What has improved since the last inspection? The quality of the information used to decide whether or not the home can meet the needs of a potential new admission to the home is much improved, both in the information supplied by the person`s social worker and in the home`s own assessment of needs. There has been a significant improvement in the quality of the care plans drawn up to guide staff to meet those assessed needs. People`s healthcare needs and treatment is being better recorded. New mental health assessments have been introduced and staff are being given better training to meet the needs of people with Dementia. Medication administration and recording have improved, with better training and new systems of recording, including individual medication care plans. People`s privacy and dignity are being given more attention, and the manager has signed up to become the home`s `dignity champion`, as part of the local authority`s `Dignity Challenge` project with residential care homes. There has been some improvement in the range of social activities, and the introduction of illustrated books and magazines is welcomed, as they were obviously being enjoyed by residents. Catering and care staff are being given training in the nutritional needs of the client group, with individual care plans drawn up, where necessary. More choice is now being offered at meal times. A simpler, more `user-friendly` complaints procedure has been introduced, as have a comments book and a suggestions box. Staff have been given training in how to recognise forms of abuse, and how to correctly respond to it. The building has benefitted from a thorough redecoration and refurbishment programme over the past nine months, and this is ongoing. Hygiene and control of infection have been given a much higher profile, with a lead person allocated, and more training given. Staff recruitment practices have been made more robust. There has been a substantial investment in staff training in the past quarter, and staff are now much better able to deliver safe and professional care to the people living in the home. Proper staff supervision has been introduced. The management of the home has improved significantly, with a new manager in post, with the support of an experienced registered manager of another care home. Necessary improvements are being addressed in an energetic and organised way, and staff morale has improved. Money held on behalf of people in the home is now properly accounted for and securely held, with clear records and receipts. The home has recently re-assessed its fire safety, and is making improvements to the building and to systems where necessary. What the care home could do better: The specific and individual needs of people with Dementia need to be better understood and met, in terms of assessment, care planning and service delivery. Current staff training needs to be translated into appropriate actions. Staffing levels need to be reviewed to make sure that people`s needs are being properly met at all times of the day and night. The recent improvements to the service need to be supported and sustained, and regular re-assessments of progress carried out by the owner and manager. Key inspection report Care homes for older people Name: Address: Beechwood Hall 34 Beechwood Gardens Lobley Hill Gateshead Tyne and Wear NE11 0BY     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: Alan Baxter     Date: 1 9 0 5 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 30 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 30 Information about the care home Name of care home: Address: Beechwood Hall 34 Beechwood Gardens Lobley Hill Gateshead Tyne and Wear NE11 0BY 01914605899 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Humayun Saleem Name of registered manager (if applicable) Type of registration: Number of places registered: care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The registered person may provide the following category of service only: Care Home Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category(ies): Dementia, not falling within any other category - Code DE, maximum number of places: 17 The maximum number of service users who can be accommodated is: 17 Date of last inspection Brief description of the care home Beechwood Hall is a care home for older people who suffer from Dementia. It is situated in a residential area in Lobley Hill, Gateshead. It is reasonably close to local shops and transport. There are 17 single bedrooms, two assisted bathrooms, a large lounge and a dining area. The weekly fees range from £424 to £430. Care Homes for Older People Page 4 of 30 Over 65 17 0 1 1 0 1 2 0 1 0 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 is an overview of what the inspector found during the inspection. The quality rating for this home is one star. This means that the people using this service experience adequate quality outcomes. Before the visit we looked at information received about the home since the last key inspection in January 2010. We looked at how the home has handled any complaints or concerns since the last visit, and whether there had been any changes to the way the home was being run. We looked at the providers view of how well they care for people, and also the views of people who live in the home, their families and the staff. An unannounced visit was made to the home on 18th May 2009, with a follow up visit on the following day. This inspection took fourteen hours in total. Care Homes for Older People Page 5 of 30 During the visit we talked with people who live in the home, their families, the staff and the manager. We looked at information about the people who live there and how well their needs are met. We looked at other information that must be kept. We checked that the staff have the knowledge, skills and training to meet the needs of the people they care for. We looked around parts of the building to make sure it was safe, clean and comfortable. We checked what improvements have been made since the last inspection. We told the homes manager what we found at the end of the inspection. Care Homes for Older People Page 6 of 30 What the care home does well: What has improved since the last inspection? The quality of the information used to decide whether or not the home can meet the needs of a potential new admission to the home is much improved, both in the information supplied by the persons social worker and in the homes own assessment of needs. There has been a significant improvement in the quality of the care plans drawn up to guide staff to meet those assessed needs. Peoples healthcare needs and treatment is being better recorded. New mental health assessments have been introduced and staff are being given better training to meet the needs of people with Dementia. Medication administration and recording have improved, with better training and new systems of recording, including individual medication care plans. Peoples privacy and dignity are being given more attention, and the manager has signed up to become the homes dignity champion, as part of the local authoritys Dignity Challenge project with residential care homes. There has been some improvement in the range of social activities, and the introduction of illustrated books and magazines is welcomed, as they were obviously being enjoyed by residents. Catering and care staff are being given training in the nutritional needs of the client group, with individual care plans drawn up, where necessary. More choice is now being Care Homes for Older People Page 7 of 30 offered at meal times. A simpler, more user-friendly complaints procedure has been introduced, as have a comments book and a suggestions box. Staff have been given training in how to recognise forms of abuse, and how to correctly respond to it. The building has benefitted from a thorough redecoration and refurbishment programme over the past nine months, and this is ongoing. Hygiene and control of infection have been given a much higher profile, with a lead person allocated, and more training given. Staff recruitment practices have been made more robust. There has been a substantial investment in staff training in the past quarter, and staff are now much better able to deliver safe and professional care to the people living in the home. Proper staff supervision has been introduced. The management of the home has improved significantly, with a new manager in post, with the support of an experienced registered manager of another care home. Necessary improvements are being addressed in an energetic and organised way, and staff morale has improved. Money held on behalf of people in the home is now properly accounted for and securely held, with clear records and receipts. The home has recently re-assessed its fire safety, and is making improvements to the building and to systems where necessary. 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. Care Homes for Older People Page 8 of 30 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 30 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 30 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 available to people about the home has improved, as has the quality of the assessments of need carried out before someone is admitted to the home. This means that people can be confident that the home can meet all their needs. Evidence: The homes statement of purpose and its service user guide have been updated since the last inspection. The date of the most recent revision is being added to the document. Recently admitted residents had had either a comprehensive assessment or a detailed care plan drawn up by their social workers before coming into the home. The manager was thus given appropriate information upon which to make a decision as to whether the home could meet those persons needs. The manager has adopted the appropriate policy of not considering future referrals for admission unless a full assessment has been supplied by the referring social worker. Care Homes for Older People Page 11 of 30 Evidence: The manager also conducts her own assessment of needs before admission, using an activities of daily living-type assessment format. This is reasonably holistic in scope, but does not give much space for responses to questions. Usefully, the format also identifies whether or not there is the need for a care plan under each heading of the assessment. Care Homes for Older People Page 12 of 30 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. Although there have been improvements in the way that care is planned, this tends to be generalised rather than person-centred, and doesnt always fully reflect the individual care that different people need. Evidence: A new care plan format has been introduced since the last inspection. This covers assessed need, aim of care and support worker instructions. The first is spelled out in reasonable detail; the latter two tend to merge, and need to clarified. Overall, the care plans are detailed, but some plans are rather general, and not personalised to the needs of the individual, with examples seen such as Assist to dress/undress when rising/retiring, and Toilet on a regular basis. Also, there is a tendency to try and cram too much information under certain assessment headings. The heading personal hygiene/dressing, for example, could usefully be broken down into its component parts, with a detailed care plan for each element (dressing/washing/bathing etc). Nevertheless, there has obviously been a great deal of work put into upgrading the care plans and, overall, there has been a significant improvement in their quality. Care Homes for Older People Page 13 of 30 Evidence: It was a requirement of the last inspection that a thorough assessment of the needs of people with Dementia must be carried out and a detailed care plan drawn up with the advice of appropriate professionals. To meet this requirement, the manager has arranged for all carers, including night staff, to undertake a Dementia Awareness course (total course time 36 hours); and is undertaking a Dementia Mapping course herself. Two carers have also completed the more advanced Certificate in Dementia Awareness. The manager is undertaking a Dementia Mapping course. A new Mental Health Assessment tool has been introduced, and the importance and impact of peoples mental health needs is now reflected more clearly in their individual care plans. The assessment identifies areas of need or concern, but further work is needed on meeting those identified needs (for example, where the assessment identified random episodes of violence an appropriate care plan should be drawn up to minimise the risks identified). The manager is currently negotiating with the homes attached Community Psychiatric Nurses for input and advice regarding the meeting of such needs. The input from health professionals, previously only sporadically recorded, is now routinely entered in the care records. These showed visits to and from the expected range of GP and ancillary professionals, optical prescriptions, annual health checks, podiatry appointments etc. The input of dietitians was noted, and a falls risk assessment was seen to lead to an occupational therapist appointment. Care plans were in place for specific high risk health conditions such as osteoporosis. The homes medication policy is held in the front of the Medication Administration Record (MAR). This policy is cross-referenced to the Care Quality Commission medication guidance documents. The MAR includes a service user medications profile for each person receiving medicines and has the persons name, photograph, list of allergies etc. Previous requirements to physically count the numbers of Controlled Drugs held each day, and to use the appropriate codes on the MAR to account for any episodes of nonadministration of any prescribed drug, have been carried out. No unexplained gaps were seen in the MAR. Individual medication care plans have been introduced for each resident receiving medicines. Only those staff who have had the appropriate training administer medications. All Care Homes for Older People Page 14 of 30 Evidence: other care staff are currently undergoing this necessary training. Dignity Challenge information is publicly displayed in the home, and the manager is training to become the homes Dignity Champion, in conjunction with the local authority dignity co-ordinator. The manager said that the training is already having a positive impact in that both the people living in the home and the staff are being treated with more respect, and that residents now have more say in the home. It was noted that each persons care record now includes documentation recording the Residents right to access their personal records. Care Homes for Older People Page 15 of 30 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. A more individualised approach is being adopted to meeting the social care needs of people living in the home, and the range of activities is improving. Meals are enjoyable, and more choice is being offered regarding meals. Evidence: The home takes note of peoples religious, cultural and end of life care needs in its assessments and care planning. Each person also has a life history book, although this is currently rather brief, and has yet to be fully developed. The environment is reasonably stimulating, with large bright wall pictures, a big fish aquarium, vases of flowers and a large wall-mounted plasma screen television. The manager has introduced illustrated books and reading materials specifically aimed at people with short attention spans, and at least four residents were reading books. There is an activities programme, and the activities diary included references to singalongs, reminiscence, skittles, musical bingo, knitting, sewing, crafts, cards, musical instruments and lots of one-to-one sessions. Visitors are welcomed at any reasonable time. Residents may choose which visitors Care Homes for Older People Page 16 of 30 Evidence: they see, and may see their visitors in private. The local Catholic priest visits every Sunday, and contacts are being developed with the local Church of England church, as well as schools. A summer fete is being organised to make links with the community. Monthly trips out are also being organised. The manager is looking at ways of increasing choice for the people living in the home, and has stopped the previous practice of locking residents bedroom doors when they are downstairs in the communal areas. All staff are currently undergoing training regarding the implications of the Mental Capacity Act. The manager is doing the more advanced Future Strategies course. A lack of detail and clarity was noted in the Deprivation of Liberty assessments that have been undertaken, but the manager has already booked further staff training in this area from one of the local authority safeguarding officers in July. The Focus on Food nutritional screening tool has been introduced, so that staff are clear about the individual nutritional needs of the residents. Where necessary, a Dietitian is consulted and their advice is included in the care plan, with food and/or fluid record charts completed, as appropriate. The kitchen is modern, clean and well-equipped. The chef offers two choices for the main (lunch) meal. On the day, the options were savoury mince, mashed potatoes, yorkshire puddings and peas, and, egg mayonnaise salad, with Eve pudding and custard or yoghurt. New menus are currently being drawn up, to better reflect the preferences of the people living in the home. Dining tables were pleasantly set, with cruets and cold drinks. Residents were offered choice, and were discretely helped with their meal, where this was needed. Residents confirmed that they were happy with the catering: one said, The dinners are lovely - all the meals are! Care Homes for Older People Page 17 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are being offered better protection by the introduction of new policies and procedures for dealing with complaints and protection issues, and by the significant improvement in staff training being given in these areas. Evidence: A new, simpler complaints procedure has been introduced. It is a positive document that encourages any one with any concerns at all to share those concerns with the manager. No complaints have been received from either people living in the home or their relatives since the last inspection. The manager is currently updating the homes Safeguarding policy. She is meeting with one of the local authority Safeguarding officers in July, to make sure that the homes policy reflects the expectations of the local safeguarding team. All staff are undergoing a four-module safeguarding training course. Rudimentary capacity assessments, under the Mental Capacity Act, have been drawn up. The manager and her staff are currently undergoing further mental capacity training. Care Homes for Older People Page 18 of 30 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. The home provides a comfortable, clean and warm environment for the people living there. Evidence: In the past year the new owner of the home has substantially improved the physical environment of the home. All bedrooms have been re-decorated, as have all ground floor communal areas. The kitchen has been redecorated and re-fitted with new equipment. New carpets are being laid in the hallway, lounge and dining room by the end of the month. A new floor has been laid in the homes laundry. Wheelchairs are now being stored away from communal areas, as was required in the last inspection report. All areas seen were clean, tidy and no unpleasant odours were experienced. A nominated member of staff acts as the homes link person for hygiene and control of infection. He attends meetings of the Community Infection Prevention and Control team, and reports back to the manager and the staff team. Internal hygiene audits show a significant improvement in the past nine months. Department of Health guidance on control of infection is on file, as is guidance from Care Homes for Older People Page 19 of 30 Evidence: the Health Protection Agency on dealing with C.Difficile. Care Homes for Older People Page 20 of 30 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. Whilst the care team is well trained to care for the needs of older people, and recruitment practices have improved, staffing levels at peak times are not always sufficent to ensure peoples needs can be fully met. Evidence: The home is staffed with two carers and one senior carer between 8 am and 8 pm; and two carers overnight, between 8 pm and 8 am. One carer should be designated as being in charge overnight. The manager works a minimum of 9 am and 4:30 pm, Monday to Friday (often working extra hours). The manager and responsible person must review staffing levels at peak times, to ensure that there are sufficient staff to allow a good level of social activities (including accompanying residents to go out for walks), and to ensure sufficient night staff cover for fire safety and night call outs. All care staff hold National Vocational Qualification (NVQ) level 2 in care. There are sufficient ancillary staff. One new member of staff has been employed by the home since the last inspection. This persons employment file and documentation were fully completed, with evidence of all the expected checks of identity, employment history, and qualifications etc having been carried out. She was working Care Homes for Older People Page 21 of 30 Evidence: supernumerary to the rota, supervised at all times, whilst waiting for a second reference and her CRB check to come through. All existing staff have had new Criminal Record Bureau (CRB) checks carried out in the past month. There has been a substantial investment in staff training since the last inspection. Fire safety in Residential Care training was given to all staff in February. Moving and handling training was given in May. All staff are currently doing health & safety, food hygiene and Mental Capacity Act training courses. Senior staff and night staff are being given first aid training. All but one carer have completed safe handling of medication courses, and are awaiting their certificates. Dementia Awareness training is being arranged for all care staff, and two are currently studying for the Certificate in Dementia. The manager has started doing individual staff training needs analysis, as part of the supervision process. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A change in the management of the service has brought about significant improvements in all aspects of the running of the home. This means that the people living in the home are satisfied with the care that is being provided. Evidence: The current manager, Sharon Chisholm, had been in post for only a few weeks before this inspection, having previously been the homes deputy manager. She has over five years experience with working with people with Dementia. She is in the process of applying to become the Registered Manager of the home. She is being assisted in the management of the home by Leanne Jewitt, who is a Registered Manager for another care home, and who is acting as a part time management consultant. The new management arrangements have led to some significant improvements in Care Homes for Older People Page 23 of 30 Evidence: many areas of the service being provided. There is a need for the Registered Provider to demonstrate that these improvements will be sustained and built upon. The manager demonstrated an awareness of the need to capture and record all feedback about the service, and she has started a feedback book at the front door, and a suggestions box. A survey of the views of the people living in the home had been carried out shortly before this inspection, in April 2010. Residents rated the home as being good in most areas, with some fair and excellent responses. A similar survey given to families was even more positive, with the majority of areas being rated as excellent. Relatives comments included the following: More than happy with the care; Delighted to say that we are always made welcome, and we feel your staff are of the highest calibre; I feel the care my father receives is excellent by caring and loving staff; We have noticed a lot of improvements lately - keep up the good work; and, Love the staff! Money held on behalf of people living in the home was checked, and it accurately reflected the accounts records and receipts for purchases made on behalf of individuals. A weekly internal audit is carried out. Staff supervision has been commenced on a regular eight-weekly basis. An recent inspection by Tyne & Wear Fire and Rescue Service had identified that some emergency exits had been blocked and that work was necessary to ensure that the fire warning system was appropriate for the type and use of the premises. These issues had been immediately addressed. It had also been identified that the homes fire risk assessment was not suitable and sufficient. Since then, a new and more detailed building fire risk assessment has been carried out, and a copy submitted for inspection. In-house fire safety training and drills are taking place at the required intervals, as are the necessary checks and tests of fire detection and fire safety systems. Fire Wardens Care Homes for Older People Page 24 of 30 Evidence: are being trained up, and the homes fire evacuation policy and procedure have been updated in the light of the fire risk assessment. Care Homes for Older People Page 25 of 30 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 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Further develop the assessment and care planning process for people with Dementia. 30/06/2010 This is to ensure that people with Dementia have their needs understood, and met using an individualised approach. 2 27 18 Staffing levels at peak times 30/06/2010 and at night times must be reviewed. This is to ensure that there are sufficient staff to allow a good level of social activities (including accompanying residents to go out for walks), and to ensure sufficient night staff cover for fire safety and night call outs. Care Homes for Older People Page 27 of 30 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 3 31 24 A monthly update must be 30/06/2010 submitted to the Commission on the progress made in achieving the goals set by the Registered Provider in his action plan dated 28/03/2010. This is to ensure that the progress noted to date in achieving compliance with National Minimum Standards for care homes is sustained. 4 38 23 A written plan must be submitted to show how the Registered Provider is to meet the recommendations and timescales of the Fire Risk assessment carried out on 1/06/2010. This is to ensure the safety of people living in the home, staff and visitors. 30/06/2010 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 9 Cease the use of abbreviations such as PRN in the Medication Administration Record, and ensure that all handwritten entries are signed and dated. Further develop the deprivation of liberty safeguard assessments on people living in the home. 2 15 Care Homes for Older People Page 28 of 30 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 3 18 Further develop the mental capacity assessments carried out on people living in the home. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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