Care Home: Castlegate House

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What the care home does well The people live in comfortable and homely accommodation. They are also offered choices about what they wish to do and to make decisions about how they spend their lives. Staff communicate well with them and respect their choices and decisions. They are cared for and supported by a caring, educated and committed team of staff who are aware of their needs and preferences. We saw throughout our inspection visit this taking place. People who live in this home told us they were happy with the facilities provided and the way the staff care and support them. They told us, "the staff are very kind" and "I am very happy here". People are offered a varied menu that takes into consideration their likes and dislikes. There is a very enthusiastic manager who leads the team. There is a programme of education and training provided for staff, which ensures that staff know how to care and support the people who live at the home. What has improved since the last inspection? They have appointed a new manager and she has improved the organisation and direction of the home. They have introduced new care records to make care more individual. They have increased the amount and variety of staff training to enable the staff to have the skills and understanding to care and support the people living in the home They have redecorated 4 bedrooms, and one of the bathrooms was in the process of being redecorated during our inspection visit. They have made the home more welcoming and made it tidier. They have introduced regular and minuted resident/relative meetings every 2 months and staff meetings every month. They have introduced a welcome pack in each persons bedroom which gives details about the home and the services provided by the home. They have reviewed all policies and procedures to make sure that staff are working correctly. What the care home could do better: All but 2 of the requirements from the last key had been addressed in their entirety. They need to ensure that when monthly monitoring visits are made by the person on behalf of the company that reports of each visit are produced and made available so that they can be seen by us when visits are made to the home. They also need to further develop their quality assurance system to evaluate the quality of services provided throughout the home. Key inspection report Care homes for older people Name: Address: Castlegate House 49 Castlegate Grantham Lincs NG31 6SN     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: Tobias Payne     Date: 2 0 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 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 28 Information about the care home Name of care home: Address: Castlegate House 49 Castlegate Grantham Lincs NG31 6SN 01476560800 01476565672 alison.watson@mpscare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Castlegate House Rest Home Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 20 The registered person may provide the following categories 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 faling into any other category - code OP Dementia - Code DE Date of last inspection Brief description of the care home Castlegate House is an adapted, partially listed building situated a short walking distance from the town of Grantham. The home provides personal care for up to 20 older people. The bedrooms are mainly situated on the ground and first floors although two bedrooms are located between floors and are accessed by several steps. Access to the upper floors is by way of a shaft lift. There are two lounges and a separate dining Care Homes for Older People Page 4 of 28 Over 65 0 20 20 0 1 4 1 0 2 0 0 9 Brief description of the care home room. Further seating is provided in two hallway areas. There is car parking for four vehicles at the side of the home and a small fenced terraced area with seats and plants providing an outside area for people to sit. Fees charged by the home on the day of our inspection visit on the 20/4/2010 for care ranged from £380 to £480 each week. Extra charges were for hairdressing which ranged from £6 to £15, chiropody £6, personal newspapers and magazines. A copy of the service users guide, statement of purpose and copy of the last inspection report can be obtained from the manager or staff. Copies of the last inspection reports and complaints procedure is also displayed on the notice board at the entrance to the home. Information about the home can be provided in large print on request. Care Homes for Older People Page 5 of 28 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 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit which formed part of a key inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of the people who use the service. The visit lasted approximately 6 hours and we took into account previous information held by us including the previous inspection reports, their service history and records of any incidents that we had been notified of since the last inspection. The manager was present for the inspection as was the operations director and senior manager for the company who were present for part of the inspection visit. The manager and senior manager were given feedback at the end of the inspection. The main method of inspection used was called case tracking which involved selecting 2 people and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of Care Homes for Older People Page 6 of 28 interaction between staff and the people living in the home and related care practises. We looked at a sample of care records and walked around the home to see the quality of accommodation and visited some of the bedrooms with the permission of the people living in the home. We spoke with 9 people living in the home, as well as 3 members of staff. Everyone we spoke with was very positive and spoke about the improvements in the home since the last key inspection. Where the use of we or us is used it refers to the Care Quality Commission. The previous key inspection took place on the 13th October 2009 and a follow up random inspection visit was made on the 28th January 2010. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: All but 2 of the requirements from the last key had been addressed in their entirety. They need to ensure that when monthly monitoring visits are made by the person on behalf of the company that reports of each visit are produced and made available so that they can be seen by us when visits are made to the home. They also need to further develop their quality assurance system to evaluate the quality of services provided throughout the home. Care Homes for Older People Page 8 of 28 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 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 28 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 coming in to the home receive information and support to help them make an informed choice of where to live. There are assessment processes in place, which ensure that individual needs can be met within the home. Evidence: There was an up to date statement of purpose and service users guide together with copies of our last inspection reports were on a notice board at the entrance to the home. Each person also receives a welcome pack in their bedrooms which gives further information about the home. The manager told us that where a referral was made to stay in the home she would visit each person and make a thorough assessment of their needs involving the person and any other person involved in their care and support. We saw in the records that assessments take place before admission to the home. We did notice however that no written confirmation is sent to the person to confirm the service can meet their needs. The manager agreed to ensure this was done for all future admissions to the home. Care Homes for Older People Page 11 of 28 Evidence: The care home does not offer a dedicated intermediate care service. Care Homes for Older People Page 12 of 28 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. Each person has a detailed care plan giving details about their care and support. Medication was given safely by staff who knew what they were doing Evidence: The manager told us that she had reviewed the way care was recorded and introduced a new person focused system. We saw records for 3 people. Each person had a separate file with clear up to date information about the persons care and support. Records were signed and dated and showed evidence of review. The records included a photograph, time and dates of entries, brief life history, body map, local doctor visits, professional visits, assessment of daily living covering all aspects of daily living with assessment dates, completed and review dates. Each person had a care plan with agreed aim, action to be carried out. This covered falls risk, infection control, continence, hygiene, social life, nutritional screening, infection risk assessment, moving and handling, quality time activities and daily record. We also saw that a record summary was made for each person covering their personal care morning and afternoon, what the person ate at breakfast, coffee, lunch, tea and supper, daily activities, bed time and night checks. Care Homes for Older People Page 13 of 28 Evidence: Records were signed and dated. We could see that they also included a mental capacity assessment for each person. We saw instructions were personal and included choices, likes and dislikes. We saw the care records for one person with complex needs who was confined to bed. There were very clear records showing how often they were attended to by staff and there was also a chart showing the times her position was altered even though she was cared for on an alternating pressure mattress. The home has established contacts with local doctors, community nurses, community psychiatric nurses, opticians and dentists. Each person has a key worker. There were also clear instructions about how staff should meet the particular needs of people who had a dementia. Throughout our visit we saw staff respecting the peoples wishes and choices in the way they made contact with the people living in the home and their response. We also saw staff showing good knowledge of the particular needs of the people living in the home. Comments left at the entrance to the home included, staff are superb and friendly. Most importantly show a carers spirit towards each person. People we spoke with told us the staff are very kind and nothing is too much for them. Care staff administered medication. There was a policy and procedure for this and the manager assessed each person before they were considered safe to administer medication. Records we saw were clear and well maintained with a good audit trail. The manager told us that the people were encouraged by the staff team to self medicate but all the people needed a degree of assistance in order to ensure they took their medication safely. The service received a pharmacy inspection on the 4/2/2010. The report comments included, some concerns about recording of medication and temperature monitoring of the drugs fridge. As a result of the report all issues had been addressed, a new drugs fridge purchased and improved recording has taken place. An audit had also been carried out to monitor the quality of records and the manager agreed to carry out regular internal audits. We found no concerns during our inspection. People we spoke with were satisfied with the way staff cared for them and had confidence in the staff. We saw throughout our inspection staff attended to the people in a warm, friendly and kind manner, knocking on doors before entering their bedrooms and asking whether they needed any help. Care Homes for Older People Page 14 of 28 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 are encouraged to maintain and develop social interests and relationships of their choice. People receive a nutritious, varied diet, which meets their individual preferences and health requirements. Visitors are made to feel welcome and supported. Evidence: When admitted to the home details were obtained of each persons interests. This was contained in their care records. The manager told us that there was not a written activities programme and no particular member of staff responsible for activities. We however saw clear records about activities offered to the people with a weeks summary Monday to Sunday with names of people who had been involved. Activities included music, dominoes, fashion show, cards, residents meeting 12/3/2010, chiropody, artwork, mosaic work, baking, music and dance, music and dance. On the day of our visit a volunteer who visits the home regularly to carry out activities was involved in art work with 2 people and we could see that there was collage of artwork in the dining room. The people were enjoying the activity and the volunteer spoke of the improvements in the home. We saw 2 people sitting in a small lounge with drinks and personal items with quiet music playing. Other people were either in the main lounge reading, watching the television, talking to one another or members of staff Care Homes for Older People Page 15 of 28 Evidence: who were seen regularly to go into the lounges to see how the people were. The manager told us they had arranged from students from a local college to visit the home and with support spend time with the people, carry out activities and they were in the process of revamping the small garden area at the back of the home. Comments in the comments book since March 2010 included, what a change, the place now looks as if someone loves and cares for those who are hear. A person in the home told us I like to do what I want with my life to remain independent and the staff fully respect my wishes to do so. The people living in the home were offered 3 main meals a day plus snacks. The menu for the day was displayed on white boards outside the kitchen and on the wall leading to the dining room. There was a set menu with 2 choices but an alternative could be arranged to suit the needs of the person. South Kesteven District Council awarded the home 4 stars (good) following an inspection on the 20/10/2009, in recognition of the catering service provided. We looked at the records for food temperatures, menus and cleaning rotas and found them well maintained and up to date. People we spoke with told us I have had a good lunch, If I do not like something they will always find my something else to suit me and the food is just how I like it to be cooked. We also saw that the dining room tables had vases with fresh flowers and there was a bowl with fresh fruit. Care Homes for Older People Page 16 of 28 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 know how to make a complaint and feel that staff will listen to their views. They are protected from abuse by correct, robust and safe recruitment procedures. Evidence: Each person received a copy of the complaints procedure in the service users guide. The information was also in the statement of purpose and displayed on the wall at the entrance to the home. It was up to date and contained our National Contact Centre telephone number and address. We have received no complaints or safeguarding adults issues since the last key inspection visit . The home had received one complaint and we saw that the complaint was taken seriously, addressed with very clear records showing action by the manager when it was received to when it was concluded. The home had a copy of Lincolnshire County Councils adult protection procedures and each member of staff was given a pocket workers guide about safeguarding vulnerable adults produced by Lincolnshire County Council. All staff were correctly recruited including a check by the Criminal Records Bureau (CRB). During their induction each member of staff received information about abuse. Two staff were asked what abuse was and knew their role and what to do if abuse was suspected. Staff also received regular refresher training to ensure their knowledge was up to date. None of the people living in the home, or the staff had any complaints about the home Care Homes for Older People Page 17 of 28 Evidence: and felt they could discuss any concerns with staff or the manager. Staff also knew what to do if they received a complaint from a person living in the home. As the inspection visit took place close to a general election we asked about how the manager was dealing with this issue. She told us that all had been registered to vote and that assistance would be given as necessary. Care Homes for Older People Page 18 of 28 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 live in clean, comfortable, safe and well maintained accommodation. Evidence: Since the last inspection a great deal has been done the improve the environment in the home. During our visit we saw that the corridors were free from clutter and hazards. New pictures had been put up and the entrance made more welcoming with new colours and the staff desk had been moved near the kitchen. The menu was displayed on notice boards as was an up to date complaints procedure at the entrance to the home. There were signs with pictures indicating toilets and bathrooms. The manager told us that some of the bedrooms had been redecorated and that new bedding and curtains had been provided in all bedrooms. We were also shown a newly redecorated show bedroom which had been re carpeted with a new profiling bed and new bedding. The operations director who was visiting the home during part of the inspection told us that they were to replace the domestic laundry machines in the very near future with a commercial washing machine and commercial tumble dryer to improve the service to the people living in the home. During our visit we walked around the home and found all areas of the home were clean, tidy and odour free. People we spoke with told us they were satisfied with the decoration and cleanliness of the home. They also spoke of how they liked their bedrooms. They were encouraged to bring into the home small items of furniture, Care Homes for Older People Page 19 of 28 Evidence: television, pictures and personal items. A comments in the comment book included, my mothers room is really lovely. There were signs showing people where their room , toilets and bathrooms were. There was an infection control policy. In addition staff had gloves and aprons when attending to people and there was an alcohol hand wash at the entrance to the home to further assist infection control. There were a variety of pressure relieving mattresses and a number of mobile hoists with a variety of slings and other moving and handling equipment. In shared rooms there were privacy screens. Care Homes for Older People Page 20 of 28 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is enough staff on duty to meet the needs of the people living at the home. Procedures for the recruitment of staff are robust and therefore offer protection for people living at the home. Evidence: People we spoke with felt the home was adequately staffed with people who were experienced and competent to care for older people. People we spoke with did not express any worries about the level or availability of staff. During our inspection visit we saw staff attended to the needs of the people promptly and in a calm and friendly manner. People we spoke with told us, the staff are so kind and patient, I am very happy and I am very satisfied. Staff told us, it is fantastic here, there has been so much training provided which has improved my skills and confidence and I have noticed the residents are much happier and I enjoy coming to work. There were separate staff for care, cleaning, catering and maintenance. We examined the files for 2 new members of staff. Records were clear, detailed and showed that staff were safely recruited in accordance with the regulations including receiving 2 references. This included a check by the Criminal Records Bureau (CRB). Each person received a supported induction programme and a new detailed staff handbook. The manager had introduced for all new members of staff a nationally recognised more comprehensive induction and thereafter staff were encouraged and Care Homes for Older People Page 21 of 28 Evidence: supported to study for a National Vocational Qualification in care. We were told that only 2 of care staff had an NVQ to level 2 but efforts were being made to increase this amount. Some staff were studying for an NVQ level 2 and one person NVQ level 3. There was a years programme of training which showed training over the last year had included, moving and handling, infection control, safeguarding adults, dementia awareness, fire prevention, basic food hygiene, medication, first aid, sensory deprivation awareness and nutrition. In addition all staff had received training about the Mental Capacity Act 2005, Deprivation of Liberty Safeguards which was all about ensuring that peoples rights were being promoted. Observation of care practises at the home showed us that staff were caring for people in an appropriate manner. They were visible in communal areas and responded well to peoples needs. The day seemed unrushed with staff having time to chat and spend time with the people. Care Homes for Older People Page 22 of 28 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 and staff benefit from the positive leadership of the management. There is good management, guidance and direction provided to staff to ensure that care is delivered in a consistent manner. Evidence: Since the last inspection a new manager was registered by us in February 2010. This person had experience in care of older people, education, teaching and management. She had a care qualification and was studying for a management qualification. All the people we spoke with told us they were very satisfied with the management of the home. Comments from the people included, I am very satisfied and this is the home I chose and I continue to like living here. Comments in the comments book since March 2010 confirmed these views. Staff spoken with said they were happy working at the home and felt that it was well managed. They told us that they felt the home provided a safe, caring and homely environment for people to live in. Comments included, the home is a much nicer place to live, Alison listens, supports and Care Homes for Older People Page 23 of 28 Evidence: answers questions and know what is going on in the home and so much has changed over the last year, the home is more organised and the atmosphere has changed for the better. The manager sent out an annual questionnaire in January 2010 but although sent out to each person had received no response. She had also had introduced resident and relative meetings every 2 months. There were monthly unannounced monitoring visits by representatives of the company but we were unable to find records which are required to kept of visits which were made in January and February 2010. There was a system in place for peoples monies to be held in safe keeping by the home. This includes keeping a running total of all transactions and obtaining receipts with two signatures. Records samples showed that these were being maintained. There was a range of policies and procedures including equality and diversity, some of which which had been reviewed and updated since the last inspection. Records and staff comments showed that staff were now receiving regular supervision every 2 months and the manager told us each person would have an annual appraisal. The home had comprehensive health and safety policies, which also included up to date risk assessments. There were regular tests of the fire system as well as regular fire drills. The fire risk assessment was reviewed on the 27/11/2009 and issues arising from this assessment were being addressed. Records were available, up to date and well maintained. Care Homes for Older People Page 24 of 28 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 28 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 33 24 A quality assurance system 22/06/2010 must be established which not only takes into account the views of the people living in the home but evaluates the quality of the services provided throughout the home by constant self monitoring and internal audits of the service. This will ensure that a quality service is provided which meets not only the needs of people living in the home and staff but provides a quality service throughout the home. 2 33 26 Reports of monthly visits 22/05/2010 must be made available in the home for examination by the Care Quality Commission. Care Homes for Older People Page 26 of 28 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will ensure that records show the outcomes of these visits and ensure the quality of the service is maintained. 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 27 of 28 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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