Care Home: Blenheim Care Centre

What the care home does well Prospective residents are assessed prior to admission to ensure the home is able to meet their needs. Overall the service user plans viewed were up to date and evidenced that there had been input from the residents or their representatives. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The activity provision in the home is varied and there is a range of individual and group activities. The home has an open visiting policy and visiting is encouraged. Contact information regarding advocacy services is available in the home.The food provision at the home is good, offering variety and choice. The home has clear procedures for the management of complaints and safeguarding adults issues, and these are adhered to. Procedures are in place and being followed for infection control. The home is now being appropriately staffed to meet the needs of the residents and this is kept under review. Systems are in place for vetting and staff recruitment.There is a training programme in place, which includes induction training and training relevant to the needs of the residents.The home has a comprehensive quality assurance system in place. Monies held on behalf of residents are well managed. Overall health and safety is being well managed. Overall the comments received via the CQC comment cards were positive. Examples of these are: `very kind and friendly` `welcoming, kind and caring staff. good food, try to meet individual needs` `Overall I am satisfied with the care my relative receives and I would not want them moved to another home. Very caring staff who appear to want to help and look after the residents properly as opposed to simply doing a job.` `Always in touch with me over any problems and prepared to discuss any issues.` What has improved since the last inspection? There is a full list of specimen staff signatures in relation to medication administration. Work has taken place to maintain the cleanliness in the kitchen and this is ongoing. What the care home could do better: There still needs to be further improvement with the recording on the medication administration record to ensure all information is recorded. The clinical rooms were dirty and action must be taken to ensure these rooms are kept clean at all times. The work on the heating system must be concluded and thereafter the redecoration and refurbishment programme recommenced without delay. The staff rosters must be kept up to date to provide an accurate record of the shifts each person has actually worked. There must be an improvement in the checking and auditing of staff employment records to ensure the information is being obtained from the required sources, for example, references from the last employer. It is clear that there had been a gap in staff undertaking training in health & safety topics, which the Acting Manager had identified and is taking steps to remedy. The fire risk assessment was due for review and updating, and this must be done annually.Comments had been received in May 2009 on the CQC comment cards regarding staffing levels, especially on the residential dementia care unit. This information was relayed to the Acting Manager at that time and she had also identified this issue, which has since been addressed. Key inspection report Care homes for older people Name: Address: Blenheim Care Centre Ickenham Road West Ruislip Middlesex HA4 7DW     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Clare Henderson-Roe     Date: 0 8 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Blenheim Care Centre Ickenham Road West Ruislip Middlesex HA4 7DW 01895622167 01895622240 blenheim@lifestyle.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd care home 64 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: 10 Beds for service users with dementia requiring nursing care. Of these 10 beds, 5 may be used to accommodate service users with dementia requiring personal care or nursing care. 12 Beds for service users in the category of old age requiring nursing care 12 Beds for service users with Dementia requiring personal care. 22 Beds for service users falling within the category of old age requiring personal care. 8 beds for service users with a physical disability requiring nursing care. Date of last inspection Brief description of the care home Blenheim Care Centre is a purpose built Care Home providing care for 64 residents. There are 5 separate units and these are designed to provide a homely environment, consisting of single accommodation with en-suite toilet and hand washbasin facilities Care Homes for Older People Page 4 of 27 Over 65 0 64 0 64 0 64 0 7 1 0 2 0 0 8 Brief description of the care home and fitted telephone sockets and residents can have a land line or mobile phone as they so wish. Each unit has a spacious lounge and dining area and there is an enclosed garden, with some residents bedrooms and a communal lounge opening out onto it. The home is located on the Ickenham Road next to West Ruislip underground station and visitors car parking is available. The fees range from £650 to £1,200 per week. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection carried out as part of the regulatory process. A total of 24 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 15 residents, 12 staff and 4 visitors were spoken with as part of the inspection process. The CQC Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives, staff and health and social care professionals have also been used to inform this report. Comments and suggestions received via the surveys were fed back to the Acting Manager in general terms and some general comments are included below. It must be noted that it is sometimes difficult to ascertain the views of residents with dementia care needs. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: There still needs to be further improvement with the recording on the medication administration record to ensure all information is recorded. The clinical rooms were dirty and action must be taken to ensure these rooms are kept clean at all times. The work on the heating system must be concluded and thereafter the redecoration and refurbishment programme recommenced without delay. The staff rosters must be kept up to date to provide an accurate record of the shifts each person has actually worked. There must be an improvement in the checking and auditing of staff employment records to ensure the information is being obtained from the required sources, for example, references from the last employer. It is clear that there had been a gap in staff undertaking training in health & safety topics, which the Acting Manager had identified and is taking steps to remedy. The fire risk assessment was due for review and updating, and this must be done annually. Care Homes for Older People Page 7 of 27 Comments had been received in May 2009 on the CQC comment cards regarding staffing levels, especially on the residential dementia care unit. This information was relayed to the Acting Manager at that time and she had also identified this issue, which has since been addressed. 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 27 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 27 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. Information about the home is kept up to date so that prospective residents and people living at the home are kept informed about the facilities and services available. Residents are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Evidence: The Statement of Purpose and Service User Guide documents have been updated to reflect changes in staffing. Copies of both these documents were available in the main reception area. The home has a pre-admission assessment that is carried out for all routine admissions to the home. These were seen in some of the service user plan documentation viewed and were comprehensive, giving a clear picture of the resident and their needs. Copies of Social Services and Primary Care Trust assessments are also obtained. Care Homes for Older People Page 10 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service user plan documentation is completed to provide staff with the information to meet each residents needs. Overall medications are being managed at the home, however more attention is required in relation to the MAR completion to fully protect residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. Evidence: Service user plans were sampled on each unit. The care plans that we viewed overall were detailed and up to date, giving a clear picture of the residents needs and how these are to be met. There was evidence of monthly updates. We were informed that further work is being planned in this area to individualise the care plans. Risk assessments for falls had been completed and a falls monitoring document is in place and updated following any falls. There was evidence of input from residents and/or their representatives into the service user plans. Care Homes for Older People Page 11 of 27 Evidence: Assessments for continence, nutrition and moving & handling were complete, and care plans had been formulated where needs were identified. Moving and handling assessments and mobility care plans identified all equipment to be used in respect of moving and handling. Residents are weighed monthly and more often if a problem is identified. Wound care documentation was viewed. Pressure relieving equipment was in use and had been identified in the service user plan. Wound care dressing regimes with details of the product to be used and frequency had been clearly recorded and a record had been made each time a dressing had been changed. Pain assessments were in place. Where residents have several wounds a separate care plan is written for each wound. We were informed that two of the registered nurses are to undertake the tissue viability training, and one will become the Tissue Viability Link Nurse for the home. Risk assessments for the use of bedrails were in place and signed consents were available. There was evidence of input from healthcare professionals to include GP, tissue viability nurse, podiatrist, speech and language therapist, dentist and optician. One healthcare professional that we spoke with at the inspection commented that the staff were positive, helpful and professional in their manner. We viewed medication management for each unit. The home uses the Monitored Dosage System for medication management. A list of staff signatures and initials was available on each unit. Approved lancing devices for blood glucose monitoring were in use. Liquid medications and boxed medication had been dated when opened. On the personal care units blood glucose monitoring is carried out by the District Nurse. We viewed the MARs (medication administration records) on the personal care unit and found that there were several gaps on the MAR viewed. When we checked the blister packs the medication was not in the pack and appeared to have been given but not signed for. We found for one resident on the ground floor nursing unit receipts had not been recorded. All other receipts had been recorded on the ground floor. Records of disposals were available. Receipts had been recorded on both the dementia nursing and personal care units. Fridge and room temperatures were being undertaken and were within the required range. The Controlled Drugs register was viewed and the stock balance of medication in use was correct. We noted that all the drug trolleys and clinic rooms were dirty and required cleaning. This was discussed with the Acting Manager at the time of the inspection. We were shown the competency assessments being undertaken by all staff who administer medication. Staff were seen caring for residents in a professional and gentle manner, respecting Care Homes for Older People Page 12 of 27 Evidence: their privacy and dignity. Several of the bedrooms viewed were very personalised and there was a homely atmosphere throughout. Residents can have their own telephones, either mobile or land line, and they receive their post unopened. Where residents have cognitive impairment then staff will help them with post to ensure any appointments that may be received can be recorded and planned for. Information regarding the resuscitation status of each resident had been recorded in the service user plans viewed. Care plans for death and dying were also in place, and there was evidence that discussions had taken place in the event of the health deterioration of residents, to ensure wishes were known and could be respected. Care Homes for Older People Page 13 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The activity provision for the home is good, with activities and outings to meet the individual needs, abilities and wishes of the residents. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the residents rights, choices and opinions are heard and respected. The food provision in the home is of a good standard, offering variety and choice, to meet individual needs and preferences. Evidence: The home has two activities co-ordinators in post. On the first day of inspection the activities co-ordinators were on leave and no-one had been rostered to undertake activities within the home. This had been addressed by the second day of inspection and it is acknowledged that the evening activity on the first day was carried out. There was evidence of activities usually taking place throughout the week and several outings had been arranged to Whipsnade Zoo. The Acting Manager said that she does discuss the budget for activities with the co-ordinators so that they are clear that there are funds for additional entertainments etc to be organised. Several of the residents on the Young Physically Disabled unit do attend local day centres, which they enjoy. The activities programme was available throughout the home. Care Homes for Older People Page 14 of 27 Evidence: The home has an open visiting policy and visiting is encouraged. Visitors spoken with commented that they are made welcome at the home and kept up to date with any issues. Information regarding advocacy services to include Alzheimers Concern, Age Concern and financial advocacy services was on display in the home. We viewed the kitchen and on the first day of inspection there was debris on the floor in several areas. This had been addressed by the second day of inspection, when the kitchen was clean and tidy. The Acting Manager confirmed that a deep clean is carried out every week and that the importance of ongoing cleaning had been discussed with the kitchen staff. Menus were available and the meal choices tallied with those being offered to the residents. We observed staff following the menu choice lists when serving meals, and for residents who were unable to make choices in advance, alternatives were offered at the time of the meal. We sampled the lunchtime meal on both days and these were satisfactory. As part of the quality assurance feedback there had been a survey about the food provision, and changes had been made, for example, the removal of unpopular pasta dishes. The Acting Manager was clear that further improvements are required with the food provision and work is ongoing to address this. Most residents spoken with expressed satisfaction with the food provision and confirmed that choices are offered. Care Homes for Older People Page 15 of 27 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. The home has a clear complaints procedure which is followed, thus ensuring any issues are being fully addressed. There are clear systems in place for safeguarding adults, thus keeping them protected. Evidence: Copies of the complaints procedure to include contact details for making a complaint were on display throughout the home. The home has a complaints file and for each complaint a front sheet is completed to show that each complaint has been recorded, investigated and responded to. Residents and representatives spoken with during the inspection confirmed that they were aware of the complaints procedure and knew the process to follow should they need to make a complaint. Southern Cross have policies and procedures in place for Safeguarding Adults and staff had received training in this area. Staff spoken with were clear to report any concerns and knew about Whistle Blowing procedures. The Acting Manager said that more training is being planned around Whistle Blowing procedures to ensure all staff clearly understand the processes and the significance of Whistle Blowing. Southern Cross are working with Action For Elder Abuse and a dedicated line is available for anyone to contact them to report any concerns. Posters providing this information were on display in the home, plus contact details for the Hillingdon Safeguarding Adults Team. Care Homes for Older People Page 16 of 27 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 home is clean and there is a homely atmosphere, however repeated shortfalls in redecoration and refurbishment indicate that the environment is not being maintained for the comfort of the residents. Infection control procedures are in place and are followed, thus protecting residents, staff and visitors. Evidence: We carried out a tour of each of the floors. The Acting Manager had drawn up a redecoration and refurbishment plan in May 2009 and some redecoration has taken place on the ground and second floors. There has been an historical problem with the heating system in the home, and previous work had not fully addressed the problem. The Acting Manager confirmed that the majority of the correctional work had been carried out, however they were still awaiting stage 3 to be actioned. The Responsible Person has since confirmed that this work will commence on 16/09/09. Thereafter the redecoration and refurbishment programme must be implemented without delay as there are areas of the home that are looking shabby, to include the decoration on the first floor corridors, some communal areas and bedroom and en suite areas, plus many carpets that are old and marked and in need of replacement. We viewed the laundry and the area was clean and tidy. We noted some malodours in specific areas of the home, and the need to replace some carpets had already been identified by the Acting Manager. Protective clothing to include aprons and gloves Care Homes for Older People Page 17 of 27 Evidence: were available in the home and infection control procedures are in place and adhered to. Care Homes for Older People Page 18 of 27 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 is appropriately staffed to ensure that the needs of the service users are met. Although systems for vetting and recruitment practices are in place, more attention to detail is required to fully protect residents. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. Evidence: CQC surveys had been sent out in May 2009 and we noted that several comments had been made regarding the staffing, especially on the residential dementia care unit. We communicated this concern to the Acting Manager in June 2009 and she had also identified this issue. At the time of inspection the home was being appropriately staffed to meet the needs of the residents. The staffing roster had not always been updated to reflect the actual shifts worked by each person, and the importance of maintaining an accurate roster for each unit at all times was discussed. On the first day of inspection the activities co-ordinators were on leave and no-one had been rostered to undertake activities within the home. This is commented on further under Standard 12. The AQAA identifies that over 50 of the permanent care staff have attained NVQ in care to level 2 or 3. In addition there is evidence of staff receiving training in topics relevant to the diagnoses and needs of the residents. The shortfalls in mandatory Care Homes for Older People Page 19 of 27 Evidence: training is commented on under Standard 38. We viewed 4 sets of staff employment records. We requested to see the records for the most recent 3 employees, however were presented with one set of records that were for a member of staff who we were later informed no longer works at the home. There was a shortfall identified in these records with regard obtaining references from the previous employer. In the 3 other sets of records viewed the required information had been obtained, and it was explained that 2 photographs had been requested from 2 staff who were still undergoing their induction at the home. We also viewed some application forms from prospective employees and again identified that the previous employer, which is clearly requested on the form, had not always been given as a referee. The Acting Manager said that she was aware of this and always ensured that this was clarified at interview so references could be requested from the appropriate people. We agreed that an audit of the staff employment records of all those currently working at the home needed to be carried out to ensure all required documentation is in place, to include relevant references. Southern Cross has a comprehensive induction programme and this includes the Skills for Care common induction standards. All new staff undergo a 3 day supernumerary induction and this covers familiarisation with the home, basic training in health and safety topics and completion of personnel matters. Thereafter there are 3 in depth induction programmes, for registered nurses, care staff and ancillary staff. Care Homes for Older People Page 20 of 27 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 Acting Manager has the skills and experience to manage the home effectively. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Residents monies are well managed and securely stored. Overall systems for the management of health and safety throughout the home are good, however shortfalls in staff training and in the reviewing of the fire risk assessment could place people at risk. Evidence: The Registered Manager is on long term leave. The Acting Manager is a first level nurse who has also completed the Registered Managers Award. In addition she has a BSc Hons degree in Nursing and post graduate qualifications in adult education and gerontology. She has 15 years management experience in Care Home settings. Several staff spoken to commented that the Acting Manager is supportive and has provided good leadership for the home, giving it more direction and goals to achieve in order to push up standards within the home. The Acting Deputy Manager has many years of clinical experience and is very caring towards the residents. Care Homes for Older People Page 21 of 27 Evidence: Southern Cross have a system in place for quality assurance. This includes regular care audits of care plans, medications, pressure sores and falls. In addition a monthly home audit is carried out by the Acting Manager, which is comprehensive and covers all areas of the home. A full home audit had been carried out in January 2009 and had identified shortfalls in mandatory training, which the Acting Manager has worked hard to address. Regulation 26 visits are carried out and reports are available in the home. It was clear that by following the auditing processes, shortfalls had been identified and the Acting Manager was working with the staff to address the areas of concern. Resident surveys had been carried out in August 2009 and overall the responses were very positive. The Acting Manager said that the responses will be collated and published. We viewed the management of residents personal monies. All records are now computerised and separate records are maintained for each resident. Clear records of income and expenditure are maintained and receipts are given for all cash and cheques received in. A bulk receipt is done for items such as hairdressing and chiropody and each account is then debited with the relevant amount. We noted that interest had not been allocated to the accounts since February 2009 and this was explained as the current low interest rate and relatively small amounts of monies in the majority of accounts, so no there has been no interest accrued. We sampled maintenance and servicing records and those viewed were up to date. Fire drills are being carried out regularly, to include day and night staff, and records are maintained to include any shortfalls identified and the action taken to address this. The fire risk assessment was last updated in August 2009 and the annual assessment was overdue. Risk assessments for equipment and safe working practices were seen and these had been completed in October 2008. Copies were placed in the kitchen and laundry at the time of inspection. As previously commented, the auditing process had identified significant shortfalls in the completion and updates for health and safety training topics, and it was clear that the Acting Manager has worked hard with the training co-ordinator to improve the percentages of staff who have now completed this training. We discussed this and agreed that health and safety training to include all mandatory topics must be completed by all staff by 01/12/09. Care Homes for Older People Page 22 of 27 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 23 of 27 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 9 13 All medication administration records must be fully and accurately completed. To ensure that there is a clear audit trail for medication management. 30/09/2009 2 9 23 The clinical rooms on each unit must be kept clean at all times. To maintain a good standard of cleanliness. 30/09/2009 3 19 23 That the heating system is fully operational. To ensure that the residents have access to heating which meets their needs. 30/09/2009 4 19 23 That the home is fully redecorated and where required refurbished. To ensure that residents live in a well maintained home. 28/11/2009 Care Homes for Older People Page 24 of 27 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 5 27 17 The duty roster must clearly 16/10/2009 identify the actual shifts worked by each individual and the information must be accurate and kept up to date. To ensure appropriate numbers of staff are on duty at all times. 6 29 19 Employment records must 16/10/2009 be audited and any omissions identified addressed without delay. Thereafter all employment information must be kept up to date and be available for inspection at any time. To protect residents. 7 38 18 The home must ensure that 01/12/2009 all staff have received health and safety training to include any mandatory training within the required timescales in line with current legislation and good practice guidance. To safeguard the residents. 8 38 23 The fire risk assessment must be updated annually and a copy of this be available in the homes fire log. 16/10/2009 Care Homes for Older People Page 25 of 27 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 To ensure the home complies with current fire safety regulations and good practice guidance. 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 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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