Care Home: Cambridge Park Care Home

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What the care home does well People are given up to date information about the facilities and services available within the home, and the manager, deputy or care managers will also talk through the information with those people who may have difficulty with reading. People living in the home have good access to professional medical staff and are able to access external services such as dentists and opticians. There is a good choice of planned activities that offer people living in the home stimulating and enjoyable entertainment, which families and friends are encourage to join in with. People living in the home are provided witha warm, safe and comfortable environment that is both homely and welcoming. The home is clean and staff work hard to make sure that the building is odour free. People said that they liked their rooms and were happy to have some of their own possessions around them, which they are able to bring into the home. There is a good management structure within the home giving staff clear direction and support to maintain a good standard of care. The atmosphere in the home is calm, homely and welcoming. Relatives said that the staff are friendly and polite, while people living in the home said that they were wonderful and couldn`t do enough for them. The home has an enthusiastic staff team who like doing their jobs. The staff show respect to people living in the home and were observed being kind and courteous throughout the day. People feel that they can choose how they spend their time, this helps them to have control over their lives and people enjoyed the freedom of their own preferred routines. People said that they had a choice of food and the quality of it was good. The home arranges and enables people to attend regular religious services, if they choose. What has improved since the last inspection? This was the first inspection of the newly registered service. What the care home could do better: The home continues to provide a good standard of care and no requirements were made at the site visit. Recommendations were made that all food available is included in the menu as well as the daily choices. An extensive variety of food is provided within the home, but is not recorded on the menu. One of the care plans examined had not been evaluated during the last month, but each of the others examined were complete. There were a couple of gaps in the recording of the administration of creams, although from speaking to staff and people living in the home, these medications had been administered as prescribed. This needs to be looked at and action taken to prevent further occurances. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Cambridge Park Care Home Peterhouse Road Grimsby North East Lincs DN34 5UX     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Wilma Crawford     Date: 1 8 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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: Cambridge Park Care Home Peterhouse Road Grimsby North East Lincs DN34 5UX 01472276716 01472276675 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) : Leyton Healthcare (No 1) Limited care home 60 Number of places (if applicable): Under 65 Over 65 0 60 dementia old age, not falling within any other category Additional conditions: 60 0 The maximum number of users who can be accommodated is 60 The registered person mayprovide the following category of service only Care home only - Code PC To service users of the following gender - Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of plaes, 60 Dementia Code DE, maximum number of places, 60 Date of last inspection Brief description of the care home The home has recently changed ownership and has been re registered by Leyton healthcare No1 Ltd following a period of administration of the previous provider. Cambridge Park Care Home is located in a quiet residential area on the outskirts of Grimsby town;there is a regular bus service to the town centre, however the home is close to a number of local amenities. The home provides care for up to 60 people who require residential care support, including people with Dementia. Accomodation is provided over two storeys with both stairs and lift access to the upper Care Homes for Older People Page 4 of 27 Brief description of the care home floor. The downstairs accomodation is known as The Courtyard Suite and provides accomodation for people with dementia. The upstairs accomodation is known as The Evergreen suite. Each unit is fully ciontained with bedrooms, lounges, sitting ares, dining areas, bathrooms and toilets and an office. The upstairs accomodation also has a large activity room. 48 of the bedrooms are en suite. The gardens are well maintained with seating areas for peoples use.There is also ample car parking to the front and side of the building. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. Information from the home manager on 18/03/09 at the site visit indicates that the home charges are from 398.84 pounds to 443.78 pounds. There is an additional top up of ten pounds if there is a willing third party. This is not applicable to privately funded individuals. People living in the home wiill pay additional costs for optional extras such as hairdressing, chiropody and dental treatment. 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: The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. we have reviewed our practice when making requirements, to improve national consistency. some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at considerable risk of harm. In future, if a requirement is repeated it is likely that enforcement action will be taken. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the registration of the home on 05/08/09, including information gathered during a site visit to the home. The site visit was unannounced and took place over eight hours including preparation time. Four service users, and seven staff were spoken with during the inspection. The Care Homes for Older People Page 6 of 27 deputy manager was available throughout and the registered manager for part of the visit. The main method of inspection used was called case tracking which involved selecting eight service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of eight people living in the home and four staff were inspected. An Annual Quality Assurance Assessment document was provided by the home before this visit and information from this was included as part of the inspection process of this service. Comments from replies to surveys, to people living in the home, staff ,relatives and professionals are also included in the report. The range of fees charged is 334 pounds to 399 pounds each week. Items not included in the fee are toiletries, chiropody, hairdressing, newspapers and magazines.The inspector also checked with people living in the home to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 27 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 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 10 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. People who use this service experience good quality outcomes in this area. People are provided with information and their individual needs are assessed before admission to ensure they can be met. The judgement has been made using available evidence including a visit to this service Evidence: Evidence seen at this inspection in service users files and care plans showed that the home does not admit people without a care assessment being undertaken. Prospective service users are assessed very carefully due to the layout of the building and the vulnerability of the people living there. Prospective service users are also written to by the home confirming that they can meet their care needs or not. People are also encouraged to visit the home before they make a decision as to whether they wish to live there. Feedback from surveys demonstrated that people had been offered this facility before moving in. Care Homes for Older People Page 11 of 27 Evidence: Discussion with people living in the home and relatives also confirmed that this happened. Comments about the home included;I have never had any grumbles about the staff or the care. This home is lovely, very homely and the staff are very good to my mum, I cant speak highly enough about the staff. We are involved in all aspects of our relatives care and we are very happy with the care provided. The home does not provide intermediate care. Care Homes for Older People Page 12 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. People who use this service experience good quality outcomes in this area. People receive a high standard of care and health and personal care needs are routinely met. The judgement has been made using available evidence including a visit to this service. Evidence: The care plans seen showed that they are developed from the initial needs assessment carried out by the home. Reviews of the plans are monthly to ensure that they are still current and any new issues have been addressed. One care plan seen did not have an up to date evaluation, but the remainder were all complete. Risk assessments are available, including a falls risk assessment. These show how each person has had risks assessed that are relevant to them. There is evidence that all residents have access to relevant health care professionals. Care plans evidence that health care professionals visit the home and that residents when required visit the hospital. A visitor commented that they are happy with the care provided and confirmed that Care Homes for Older People Page 13 of 27 Evidence: their relatives see the GP, district nurses, and the chiropodist as they would were they living in their own home. People living in the home said that they were consulted about their care and were aware of their care plans. The home is currently involved in a pilot projects, a working group on tackling healthcare associated infections outside hospital. This is in collaboration with North East Lincolnshire Care Plus and the improvement Foundation. The care plans and risk assessments in the home were considered and detailed. Service care plans also showed that personal care required is documented and mention is made of maintaining the residents dignity and privacy at all times. Daily entries had been made in care plans by care staff, which identified the care given. Care staff were seen to treat residents with respect and dignity during this inspection. The homes accident book was examined and it was found that accidents occurring to residents have been recorded appropriately in their individual file and appropriate remedial action to prevent further problems arising. This information is also made available to the Commission by the home. The home uses an approved Monitored Dosage System for the administration of drugs. Medication records showed that all drugs administered were recorded on the residents individual records sheet. There were no gaps in recording seen. Any drugs that are refused are disposed of safely and returned to the chemist for disposal. All staff that are involved in the administration of medicines have received relevant training. Medication audits are undertaken on a regular basis, both in house and by an independent pharmacist. Care Homes for Older People Page 14 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. People who use this service experience good quality outcomes in this area. People are offered a range of activities and relatives and friends are encouraged to be involved in the service. Food and drink provided are of a good standard. The judgement has been made using available evidence including a visit to this service. Evidence: People said that the food at this home is varied and well prepared. Menus were inspected and found to offer choices for all mealtimes. Additional choices are also available, this was confirmed by both staff and people living in the home, but this is not recorded on the menu, a recommendation was made that this was done.The menu is planned in consultation with people living in the home and there is always a minimum of two hot choices at mealtimes and special diets are catered for. The Aqaa document stated that individuals dietary needs, their likes and dislikesare completed as part of the assessment process and this was confirmed in individual care plans seen. Staff spoken with, were aware of individuals personal likes and dislikes. People are able to take their meals in the dining rooms or as a tray service in the lounges or their rooms. The tables in the dining rooms were set with cloths, glasses and flowers Care Homes for Older People Page 15 of 27 Evidence: and very well presented. Observations made by the inspector were that adequate numbers of staff are available at mealtimes to help people, and supported them in a patient and dignified manner. Four service users seen during this inspection commented that their visitors are always made welcome in the home and refreshments are made available. One also confirmed that she could take her visitors to her bedroom. The homes signing in book was seen and showed that visitors attend this home in numbers at various times of the day. Residents and relatives meetings are held in the home and the outcome of these is used within the homes Quality Assurance Reviews. People living in the home and relatives are also consulted through the homes Quality Assurance process. Results from surveys and any relevant action plans are displayed on the homes notice board. One person said I feel fully consulted about all aspects of my care and the day to day running of the home. The home undertakes a variety of activities for the stimulation of residents and a record of these is maintained. Two activities coordinators are employed for a total of 45 hours each week. This enables a variety of stimulating activities being offerd to all people living in the home. During the morning of the inspection a trip had been organised for lunch out at the bradley Inn, this was a regular event enjoyed by people living in the home. Other 1:1 activities were also taking place as well as a craft session. There is a varied activity programme available within the home and two activity coordinators available to support staff to facilitate this. The activity programme has been developed by asking people what they would like to do. There is a varied activity programme available within the home, which has been developed by asking the peopel what they would like to do, this includes; outings, arts and crafts, entertainers, pampering sessions, reminiscence, one to one sessions. There is also considerable equipment for peoples use including books, films and a sensory trolley, which is also used for people nearing the end of life. Memory boxes were in place outside of bedrooms in the Courtyard suite asssiting the people ther to find their bedrooms. There are also church services of all denominations held regularly in the home or people are assisted to go to church if they wish. People confirmed that a planned activities programme is in place within the home, but that they also have the opportunity to go out into the town and local community on day trips, attend church and coffee mornings. A number of fundraising events are also held in the home the proceeds of which are used for further activities. People said that the food at this home is varied and well prepared. Menus were inspected and found to offer choices for all mealtimes. The menu is planned in consultation with people living in the home and there is always a minimum of two hot choices at mealtimes and special diets are catered for. The homes pre-assessment forms were seen and included individuals dietary needs and listed their likes and dislikes. Staff spoken with, were aware of individuals personal likes and dislikes. People are able to take their meals in the dining rooms or as a tray service in the lounges or their rooms. The tables in the dining room were set with cloths, glasses and Care Homes for Older People Page 16 of 27 Evidence: flowers and very well presented. Observations made by the inspector were that adequate numbers of staff are available at mealtimes to help people, and supported them in a patient and dignified manner. Care Homes for Older People Page 17 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. People who use this service experience good quality outcomes in this area. Complaints are listened to and acted upon, and people feel safe and protected. The judgement has been made using available evidence including a visit to this service. Evidence: The home takes all complaints seriously. There had been seven complaints in the last year and each had been dealt with appropriately and within the agreed timescale. There has also been two safeguarding referrals made, these were investigated, one was partially upheld and apprpriate action taken by the home in respect of this and the second considered to have been unfounded on investigation,by the Social services Department. A copy of the homes complaint procedure is displayed in the home. Service users and their relatives are made aware of the complaints procedure on admission and this was confirmed during discussion. Staff members were aware of the procedure and the documentation used to record complaints. Two people using the service spoken with confirmed that they felt safe in the home. One stated, I have never had any cause to make a complaint, but if I did Im sure that the staff would take action. They would definitely sort it out. They also said that they would feel confident about approaching staff with a complaint. There is a Whistle blowing policy in place and a clear adult abuse policy. The home has Care Homes for Older People Page 18 of 27 Evidence: a copy of local authority guidelines for reference and staff have received Adult Protection training and spoke knowledgeably about abusive practices and what action they would take if this came to their attention. People living in the home are registered on the electoral role. Details of external advocacy agencies are displayed within the home. Care Homes for Older People Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service experience good quality outcomes in this area. The clean and well-maintained environment has a positive impact on the quality of life for people.The judgement has been made using available evidence including a visit to this service. Evidence: Accomodation is provided on two seperate levels, accessible by lift or stairs, in the form of two self contained units. These are known as The Courtyard Suite on the ground flor and The Evergreen Suite on the first floor. All areas are equipped with handrails; grab rails and adapted equipment to promote service users independence. Each call bell is situated within easy reach for speoples use. All bedrooms had lockable facilities and privacy locks to the doors. The laundry was well organised and equipped with industrial type washing machines and driers. The home was clean and free from odour throughout. Care Homes for Older People Page 20 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service experience good quality outcomes in this area. People using the service have their needs fully met by a competent and trained staff group, who are recruited appropriately. The judgement has been made using available evidence including a visit to this service. Evidence: Staff are encouraged to reach their potential and gain qualifications above their job requirements. All staff are subject to an induction and statutory training, which includes, fire safety, food handling, health & safety, manual handling and first aid. The organisation has a training plan, which corresponds to the information contained in staff files and in discussion with them. Training is provided through a mix of in-house, external facilitators, distance learning, local colleges and visiting professionals. Regular staff meetings are held and staff receive regular supervision and appraisals, which are recorded. Staff spoken with said that they felt well supported in their roles. Appropriate checks for all new workers are completed before they commence work at this home. Four staff files were examined and each had application forms, two references, POVA first checks and Criminal Record Bureau Checks prior to the start of their employment. 71 of the staff team have achieved a National Vocational Qualification at level two or three in care. The remaining staff are either progressing or awaiting to enrol. the ancillary staff are also working towards a relevant NVQ.The Care Homes for Older People Page 21 of 27 Evidence: Deputy manager has completed the Registered Managers Award and the acting Deputy is currently undertaking NVQ Level 4 in Health and Social Care. The duty rota showed that the Manager , Deputy, two senior careres, six carers , an activity coordinator, handyman, administrator,chef , kitchen assistant, two domestic staff and laundry staff are available during the day and two seniors and four care staff during the night. the numbers on duty on the day corresponded to the duty rota for that day.Staff said that the numbers of staff on duty even at the busiest times are able to accommodate the numbers of people living in the home. The staffing levels are reviewed regularly and altered when the need arises. The staff have attended significant training including both mandatory and more specialised training. this includes Dementia training, equality and diversity, Improvement foundation, Infection control,nutrition,activities,prevention of pressure damage, care planning. The home has its own back care trainers. Mandatory training included Coshh, Moving and handling, Fire first aid, Safeguarding of Vulnerable Adults, Health and safety, Food Hygeine, Emergency First Aid and Infection Control. All staff records showed that they had received up to date mandatory training. Staff spoken with said that thetraining had been very good and they were given opportiunities to pursue training if they had a particular interest or had identified it as a development need, over and above that arranged by the home. There was clear evidence to show that the manager is committed to ensuring the staff are skilled and knowledgeable in their roles. Care Homes for Older People Page 22 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. People who use this service experience good quality outcomes in this area. People using the service benefit from a safe and well managed home. The judgement has been made using available evidence including a visit to this service. Evidence: The Home Manager is competent through her experience and has extensive experience of working with older people. She is a Registered Nurse, holds a post graduate certificate in managing health and social care, experience of working in care management, safeguarding and palliative care. TheManager is well supported by a deputy manager and two care mangers.Staff said they are well supported and they are confident to approach the manager with concerns or ideas. Staff, relatives and people living in the home commented; The Manager is excellent, she is always there and available to talk Care Homes for Older People Page 23 of 27 Evidence: The minutes from the recent residents meeting show that residents contribute and raise issues, and that action is taken to address these. There is consistent audit systems within the home including a a robust quality assurance system in place that is based on seeking information from the staff, residents, relatives and other visitors to the home. It is obtained through discussion, interviews and comment cards, depending on the individual needs of the person. A detailed report is completed from the information collated and areas, in which the home excels or identified areas that need to be improved, are included. The home is further audited throuh the regulation 26 visits made by the area manager, from which action plans are developed if needed.Staff are regularly supervised both formally and during every day observation. Annual appraisals also take place. Assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are also kept and support regular checks of equipment. Safe working practices are maintained by risk assessment and the provision of training for staff in the form of moving and handling, food hygiene, first aid, medication, infection control, and fire safety. generic risk assessments are also in place to support staff in their roles and in maintaining a safe environment. Accident records are completed and records show that all individual incidents are followed up by the manager and audited on a monthly basis to identify any trends that may be apparent and taking the necessary action to maintain peoples health and welfare. Records within the home are stored securely and service users said they were aware that they can see them if they wish. Policies and procedures were found to correspond to the information made available by the home in the Annual Quality Assurance Assessment document. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks have been undertaken. Certificates were available showing that equipment is serviced six monthly. Electrical equipment had also been serviced. Care Homes for Older People Page 24 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 25 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 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 All care plans should be evaluated on a monthly basis. All medicines administered in the home should be signed for. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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