Care Home: Chestnut Grove Rest Home

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What the care home does well People who want to move into Chestnut Grove visited by the Registered Owner/Manager prior to admission to ensure that their health and social care needs are understood. The social, dietary and spiritual needs of people are respected, and the social activities that are available to people are well managed, giving people the opportunity to enjoy events but inside and outside of the home. There are appropriate policies and procedures in place that help to safeguard the welfare of the people living at the home. These polices and procedures are understood by the staff team, and the people living there. The home is clean and well furnished, providing a safe and attractive place for the people who live there. The policies for the recruitment of staff to work in the home are robust and help to safeguard the welfare of people. Staff are encouraged to and take part in undertake regular training based on the needs of the people living at the home. Work needs to be carried out to ensure that appropriate management systems are in place that promote the health and safety of people living at the home, doing this will enhance the this already well managed service. What has improved since the last inspection? In many key areas, standards have been maintained. What the care home could do better: Despite some excellent work taking place in caring for people, insufficient details in care plans and risk assessments, and the operation of a medication system that is seen to be unsafe, poses risks to people`s health and well being. The registered person must make appropriate arrangements for the safe administration of medications held at the home. People care plans should set out in detail the action that needs to be taken by care staff to ensure that all aspects of the person`s health, personal and social care needs are met. The detail in people`s risk assessments relating to their health and personal care needs, and the way these risks are to be either eliminated or reduced should be more specific and individualized. With reference to the propping open of designated fire doors: this practice must cease, and action must be taken to ensure that the building fully complies with the requirements of the local fire service. The Registered Owner/Manager should ensure that appropriate management systems are put in place so far as is to reasonably practicable to promote the health, safety and welfare of people living at the home. Key inspection report Care homes for older people Name: Address: Chestnut Grove Rest Home St Catherines Way Todd Lane South Lostock Hall, Preston Lancashire PR5 5XE     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Tony Brindle-Wills     Date: 2 9 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 30 Information about the care home Name of care home: Address: Chestnut Grove Rest Home St Catherines Way Todd Lane South Lostock Hall, Preston Lancashire PR5 5XE 01772337061 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: kneen3@aol.com Ms Doris Mary Kneen care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide 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 The maximum number of Service Users who can be accommodated is: 11 Date of last inspection Brief description of the care home Chestnut Grove is a care home that has eleven places for older people of either sex. The home is set in its own grounds in a quiet residential area in Lostock Hall, Preston. Chestnut Grove is close to motorway links and main bus routes. Accommodation is provided on two floors. The first floor is accessed by stair lifts at each end of the home. In one part of the home there are three steps from the stair lift to the bedrooms, in the other part the stair lift provides direct access to bedrooms. People living at the home with mobility problems can be accommodated on the ground floor. The home has a large lounge and separate dining area. There is ramped access to the grounds Care Homes for Older People Page 4 of 30 Over 65 11 0 1 2 0 1 2 0 0 9 Brief description of the care home which are safe and well maintained, outdoor seating is provided so people living at the home are able to enjoy the garden. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited the service and looked at the following records; care assessments and care plan files, care reviews, personnel and training records, medication records, health and safety records. We talked to two members of staff who work at the home along with the Registered Owner/Manager who oversees the operation of Chestnut Grove. We sent surveys to people who use the service, their relatives, and professionals with an interest in the people living at the home. The comments we received were positive, with relatives stating that they believed the care and support being given by the home was very good. Below is a summary of the comments we received: I am satisfied with what the staff the home are doing. I am very happy with the service that my relative is receiving. I am quite happy with the staff. Chestnut Grove is fine, no problems as far as I can see. We made a request for an Annual Quality Assurance Assessment (AQAA) prior to our Care Homes for Older People Page 6 of 30 visit, which the Registered Owner/Manager completed and sent back to us in time for our visit. We used this document to to cross reference a variety in information and evidence we had gathered while visiting the home. 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 significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 30 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. Care Homes for Older People Page 8 of 30 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who want to move into Chestnut Grove visited by the Registered Owner/Manager prior to admission to ensure that their health and social care needs are understood. Evidence: A discussion took place with the Registered Owner/Manager about what would happen if people wanted to move into the home. She explained that if someone wanted to move into the home, then she would visit the person, and their family or representative, and undertake an assessment of their needs. Following the assessment, if the staff at Chestnut Grove could meet the persons needs, then arrangements would be made for the person to visit the home and spend time there getting to know other people. Information contained within the records of one person living at the home confirmed what the Registered Owner/Manager had said. Appropriate assessments about the Care Homes for Older People Page 11 of 30 Evidence: persons needs and desires, their health and personal care needs, and information about their life history were found. There were written details of how these needs should be met. On discussing the admissions procedure with a person living at the home we found that information had been gathered by the Registered Owner/Manager through meeting the person, talking to them, their family and the health and social care professionals involved in their life. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Despite some excellent work taking place in caring for people, insufficient details in care plans and risk assessments, and the operation of a medication system that is seen to be unsafe, poses risks to peoples health and well being. Evidence: We looked at the care plans of all the people living in the home, and at two of them in some detail. We found that assessments covering areas such as mobility and nutrition have been undertaken, and if people were at risk of falls or malnutrition, then staff members reading the assessments would be alerted to this. We found that peoples health and social care needs, desires and wants are listed in a straightforward manner. The care plans are written from the persons perspective and give people reading the plans the information they need to meet these needs. As previously mentioned, we found information relating to risks posed to individuals such as mobility issues and the actions needed to be taken by the staff to minimize or eliminate these risks. Care Homes for Older People Page 13 of 30 Evidence: However, in one care plan file we found information that showed that one person was prone to depression, hypertension, oedema (a condition that causes too much fluid (mainly water) to accumulate in the body and dizzy spells. We did not find any care plans that specifically dealt with these issues, and thus showed the staff team how to support this person with their specific health issues. The risk assessments did not state whether these health issues were potentially problematic or not. It was explained to the Registered Owner/Manager that if assessments highlight a specific health issue for an individual then reference should be made to it in the persons care plan and risk assessment even if the risk is low. The daily records were looked at the in the main they gave a good account of each persons daily activities and the care they had received. However, we did note that several entries stated care given as care plan. It was pointed out that when the daily records are completed, the staff team need to clearly state what care has been given, so that assurances can be made that each individual has received the right level of care and support. Information contained within peoples care plans showed that they regularly visit local healthcare facilities. One person who we spoke to had just come back from a visit to a health professional, and arrangements had been made from them to visit a local healthcare clinic for on going screening and treatment. Another person explained that the district nursing team are frequent visitors to the home, and that if a GP visit is required, then the Registered Owner/Manager and staff organize this promptly. Records relating to healthcare professionals visits were found in peoples care plan files. The Registered Owner/Manager explained the systems relating to medication. Either she and her deputy take responsibility for ordering and booking in medication for people. Information held within peoples care plans show that medication issues are discussed with people, and people are given the option of either looking after their own medication, or having the Registered Owner/Manager and staff look after it. The Registered Owner/Manager explained that the medication people need in the morning at breakfast is routinely dispensed into individual pots the night before, by either herself or the deputy manager. She explained that as there are only two staff members available in the morning, preparing the medication in this way enables the staff to stay in the dining room and kitchen area of the home. They can then assist people with breakfast and give them their medication as required, instead of one staff member having to leave the dining room or kitchen, go to where the medication is Care Homes for Older People Page 14 of 30 Evidence: stored, collect it and return to the dining room in order to give people their medication. It was explained to the Registered Owner/Manager that the system she operates relating to preparing medications the night before, is known as secondary dispensing, or potting up, and that it is seen to be an unsafe system by not only the Commission but the Nursing and Midwifery Council and the Royal Pharmaceutical Society. Following a Random Inspection that took place at Chestnut Grove in 2009, the Registered Owner/Manager was given a recommendation to have robust policies relating to secondary dispensing that reflect best practice. Current best practice indicates the following: that medicines should be taken from their original containers immediately before giving them to a person; that the care worker should make an accurate record, immediately after observing a person taking or refusing their medicines; that the services medication policy and procedure should reflect best practice; and that there are robust procedures to cover any secondary dispensing, that has been agreed as exceptional. It is the view of the Commission that the current practice relating to medication at Chestnut Grove does not reflect best practice, and as such an unsafe system is being used. Therefore, a requirement has been made that the Registered Owner/Manager have in place a safe system relating to the administration and dispensing of medication. On checking the medication administration records we found that a running total of the medications held in the home was not available as the quantities received into the home, and the quantities of medication carried forwarded had not been recorded. We also found that handwritten entries on the MAR charts had not been doubled signed (a best practice point). We found that the service does not have a sample signature chart for people administering medication. We explained to the Registered Owner/Manager that we would expect to find within peoples care plans, information relating to the exact circumstances when medication that should be taken only as needed (PRN medication), so that there is a clear audit trail that can be followed to show that the right medication has been given at the right time, for the right reasons, and in the right dosage. We discussed issues relating to privacy and dignity with people living at the home, and a visiting relative. Each person that we spoke with explained that they believed the information the service holds about them, is carefully looked after and not used for any other purpose but for providing them with a high level of care and support. When discussing dignity, everyone we spoke to praised the Registered Care Homes for Older People Page 15 of 30 Evidence: Owner/Manager and staff team for the way they care for them, saying that promoting and protecting their dignity was always the first consideration. This was supported by way of observations made on the day with staff working responsively, sensitively and responsibly with people. The Registered Owner/Manager explained that when people are approaching the end of their life, every effort would be ma ensure that the person was looked after at Chestnut Grove if they so wished. This was demonstrated by the way the staff were caring for one person who was very poorly. Their relative had been invited to stay with them in the home, and they had nothing but praise for the way the Registered Owner/Manager and staff had cared not only for their relative, but they themselves. Appropriate records relating to the way this person should be cared for by the staff team were found within their care plans. Care Homes for Older People Page 16 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The social, dietary and spiritual needs of people are respected, and the social activities that are available to people are well managed, giving people the opportunity to enjoy events but inside and outside of the home. Evidence: People at the home told us how the Registered Owner/Manager and staff meet their social needs through the organizing of trips, social events, religious and recreational activities. One person said that they look forward to the visit of the local priest as they perform a Holy Communion service and another person said that they enjoyed the singalongs they have with the staff. The Registered Owner/Manager explained that later on that afternoon a group of singers were visiting the home, and a buffet tea was being prepared to celebrate the birthday of a person at the home. One person explained that events such as this take place throughout the year, and that many relatives and friends visit and theres always a real party atmosphere. People who we spoke with told us that they can exercise control and choice over their lives in different ways. This is demonstrated by individuals keeping control of their Care Homes for Older People Page 17 of 30 Evidence: bank accounts and paying their bills; people having telephones in their rooms and making personal calls; people telling the staff what they do and do not like; influencing decisions about the care they receive, the food they eat and the activities they take part in. One person said despite being a grand old age, no one is going to tell me what to do. The staff know that and respond accordingly. People who responded to our survey said that they receive a good diet and that the meals in the home are always excellent. A look at the menu showed that their is a variety of meals on offer, and a discussion with the catering staff indicated that there is flexibility built into the system so that if people require different meals or show a preference for something, then that need can be met. People living at the home confirmed this. Care Homes for Older People Page 18 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate policies and procedures in place that help to safeguard the welfare of the people living at the home. These polices and procedures are understood by the staff team, and the people living there. Evidence: The Registered Owner/Manager explained that the home has a complaints procedure, which is available for all to see as it is posted in the home. The procedure was seen to be satisfactory. When asked if the service had received any complaints, the Registered Owner/Manager said we dont do complaints. The records show that no complaints have been received by the home or the Commission in the last 12 months. People who were spoken with indicated that they knew who to speak to if they had a concern or complaint, and that they felt confident that their concern or complaint would be dealt with quickly and appropriately. One person living at the home said that they would speak to a staff member if they were worried about anything, and that they felt sure the staff would support them and deal with their worries properly. The Registered Owner/Manager explained that staff have had adult safeguarding training, and added that the service has an adult safeguarding policy and procedure, which is displayed within the home, given to staff, and used as a basis for staff training. She added that the organization also has a whistle blowing procedure. One member of staff who was spoken with was able to talk about what they would do if they suspected or witness abuse, and their explanation was found to be in line with Care Homes for Older People Page 19 of 30 Evidence: the policies and procedures operated by the service. The Registered Owner/Manager has not had to make any adult safeguarding referrals in the last 3 years. The personnel records held at the home show that the Protection of Vulnerable Adults register is checked before staff are appointed to work in the home. Care Homes for Older People Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience 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 well furnished, providing a safe and attractive place for the people who live there, however, work needs to take place to ensure that the building fully complies with the requirements of the local fire service. Evidence: The Registered Owner/Manager explained that the comments she regularly gets back from people living at the home, their relatives and visitors state that people see the home as being comfortable, roomy, bright, cheerful and clean. Surveys undertaken by the Commission supported this view with people saying that the home was always very clean and tidy. Hand washing facilities were found to be located appropriately throughout the building, and the Registered Owner/Manager explained that laundry facilities are sited so that soiled articles and clothing are not carried through areas where food is stored and prepared. This was confirmed on having a look around the building. The Registered Owner/Manager explained that she has a programme for renewal and refurbishment of the building, and that she will be working through this over the course of the next 12 months. People were seen to live in a very comfortable home with plenty of space, and activity areas that cater for peoples needs, and encourage independence and participation in social activities. On looking around the home we found a number of bedroom doors and the kitchen door being propped open. We advised the Registered Owner/Manager that this was a Care Homes for Older People Page 21 of 30 Evidence: potential risk to peoples health and welfare, as in the event of a fire, the propped open doors would not contain the fire and smoke. We explained that the practice must stop until contact has been made with the the Lancashire Fire and Rescue Service in order to seek advice about designated fire doors within Chestnut Grove. We explained that it may be the case that the doors on the kitchen and bedrooms, are not designated fire doors, and therefore propping them open would not be a problem so as to allow easy access to the rooms. However, until consultation with the fire authority had taken place regarding designated fire doors, their propping open must cease. If the doors are fire doors we explained that an alternative safe method of keeping the door open must be found. Since our visit, the local fire service as visited the home, and the Registered Owner/Manager now has a plan to ensure the designated fire doors are no longer propped open. The plan consists of placing some doors on magnetic closures attached to the fire alarm, and others with door guards that are sound activated. The local fire safety officer explained to the Commission that this plan s an appropriate one. Care Homes for Older People Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The policies for the recruitment of staff to work in the home are robust and help to safeguard the welfare of people. Staff are encouraged to and take part in undertake regular training based on the needs of the people living at the home. Evidence: The Registered Owner/Manager explained that the comments she regularly gets back from people living at the home, their relatives and visitors state that people believe the staff team to be approachable, reliable, honest and motivated to make sure people are cared for properly. Surveys undertaken by the Commission supported this view. Observations made on the day of our visit demonstrated that the staff work sensitively with people, communicating with people effectively and showing an interest in individuals. Feedback from people living at the home showed that they too believed the staff to be good at what they do, friendly and enthusiastic about the work they undertake. The personnel and employment records that were looked at contained good levels of information. Information contained within the records show that new starters are only confirmed into post once a satisfactory Criminal records Bureau check has been undertaken, and a check against the Protection of Vulnerable Adults register is made. The staff training records show that staff receive good levels of training in all aspects Care Homes for Older People Page 23 of 30 Evidence: of work within a care setting. Feedback from people who lived at the home indicated that they believed the staff to be well trained. Staff working at the home spoke about the training they had received, giving details of scenarios that come up from time to time, and details of what they would do, how they would deal with issues, and how they could do things differently if needs be. This was all found to be extremely satisfactory and demonstrated that the staff understood their role, which is seen to be one of enabling people to live active and positive lives. All the staff at the home hold a National Vocational Qualification Level II or above. The service has achieved the recognised standard with Investors In People (a business improvement tool designed to help organisations develop performance through their people). The supervision records of the staff working at the home were seen, and demonstrated that the staff received a satisfactory level of 1:1 formal supervision as well as supervision through direct observation and at staff meetings. Care Homes for Older People Page 24 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Work needs to be carried out to ensure that appropriate management systems are in place that promote the health and safety of people living at the home, doing this will enhance the this already well managed service. Evidence: The records held by the Commission show that the manager, who is also the owner of the home, is registered with us. The records relating to the health and welfare of people living and working in the home were seen, and overall were found to be satisfactory. These included records relating to food hygiene control measures, infection control systems, the regulation of water temperatures and the maintenance of equipment. However, it was noted that the registered manager does not test the fire alarm system on a weekly basis, and said that she had never been told to do this. It was explained to her that for quality assurance, insurance and inspection purposes a Care Homes for Older People Page 25 of 30 Evidence: weekly test rather than a monthly test must be made and recorded so that any faults with the system can be quickly rectified. Information relating to fire drills undertaken in the home were found to be satisfactory. As previously mentioned, some care plans and risk assessments were found to be inadequate, the medication system operated at the home is seen to be unsafe and fire doors have been propped open for some time. These issues demonstrate that appropriate management measures have not been put in place to reasonably protect the health, safety and welfare of people living at the home, and efforts must be made to recitify these issues. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 19 23 With reference to the 12/05/2010 propping open of designated fire doors: this practice must cease, and action must be taken to ensure that the building fully complies with the requirements of the local fire service. Doing this will ensure that peoples health and wellbeing is protected and promoted. 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 The registered person must make appropriate arrangements for the safe administration of medications held at the home. Doing this will ensure that the right person, gets the right medication, at the right time, thus promoting their health and well being. 12/03/2010 Care Homes for Older People Page 28 of 30 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 People care plans should set out in detail the action that needs to be taken by care staff to ensure that all aspects of the persons health, personal and social care needs are met. The detail in peoples risk assessments relating to their health and personal care needs, and the way these risks are to be either eliminated or reduced should be more specific and individualized. With particular reference to the medication system, the fire doors and the testing of the fire safety systems, the Registered Owner/Manager should ensure that appropriate management systems are put in place so far as is to reasonably practicable to promote the health, safety and welfare of people living at the home. 2 7 3 38 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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