Care Home: China Cottage Nursing Home

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What the care home does well People who used the service and their relatives said that they were satisfied with the care that was provided at the home. They stated that staff were ‘hard working and very caring’. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 There is a good, competent and committed staff team, which works well together to ensure the health and wellbeing of people who live at the home. The service provides good training opportunities to its staff to make sure they continue to have the relevant knowledge and skills to provide care and support to people live at the home. The home is well organised and well run and managers use good quality monitoring methods to continually improve the service. What has improved since the last inspection? Since our last inspection (July 2007), a new registered manager has been appointed. An activities co-ordinator has also been appointed and this has led to an improvement in the organisation and provision of social and recreational activities for people who live at the home. The home has been refurbished and some parts upgraded. A new shower facility has been provided and this has improved bathing options for people who live at the home. Both the communal areas and residents’ bedrooms have been decorated and new flooring has been provided in many areas of the home. Infection control measures have been strengthened to ensure the safety and wellbeing of people who live at the home. Quality assurance methods have been improved and this has led to continual improvement in the service. What the care home could do better: Although there was a sufficiently good care planning system in place, staff should make sure that the records of care provided are able to reflect the interventions agreed in care plans and also the actual care given. The documents used to record the daily care provided should be kept together with individual care plans. This will enable care workers to refer to the care plans for guidance when providing care and when recording care that they have provided. This should help improve the quality of care recording. There is a need to make sure that complaints records show clearly the outcomes achieved following complaint investigations and also the actions taken to put things right, as necessary.China Cottage Nursing HomeDS0000053683.V378891.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE China Cottage Nursing Home 154 Owston Rd Carcroft Doncaster South Yorkshire DN6 8EA Lead Inspector Ramchand Samachetty Key Unannounced Inspection 9th July 2009 09:45 DS0000053683.V378891.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 2 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 China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service China Cottage Nursing Home Address 154 Owston Rd Carcroft Doncaster South Yorkshire DN6 8EA 01302 724815 01302 728312 manager@ccchd.eclipse.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Doncaster Property Investment Fund Ltd Mary Machina Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N 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 places 33 The maximum number of service users who can be accommodated is: 33 10th July 2007 2. Date of last inspection Brief Description of the Service: China Cottage is a care Home registered to provide personal care and nursing care for up to 33 persons in the category of older adults. The home is situated in the village of Carcroft, which is about six miles from the town of Doncaster. It is a two-storey building with 29 single and 2 double bedrooms. There is a passenger lift to both floors. Accommodation is provided on both floors. The lounges, dining areas, kitchen and laundry facilities are all located on the ground floor, there is also a hair dressing facility. There are patio and lawn areas at the rear of the home and car parking spaces to the front. The fees are from £398.72 to £550.00 per week. This information was provided on the 9th July 2009. The home charges extra for chiropody, telephone, holidays and hairdressing. Further information about the home can be obtained from the manager. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use the 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 significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This key unannounced inspection was carried out on 9 July 2009, starting at 09.45 and finished at 18.00 hours. The registered manager, Mrs Mary Machina was present throughout the inspection and was later joined by the regional manager, Ms Diane Daniels. The service is registered to provide accommodation and personal and nursing care for up to 33 older people. There were 30 people in residence at the time of our visit. All the key national minimum standards for ‘Care Homes for Older People’ were assessed. The inspection included a visual check of the premises, examination of care documents and other records, including those pertaining to complaints, staff employment, staff duty rota, medicines management, maintenance of equipment and quality assurance methods. We also looked at the information contained in the ‘Annual Quality Assurance Assessment’ document, which was submitted to us before this inspection. We spoke to people who lived at the home and to relatives and to staff. Their views and comments have been included in this report. We gave feedback about our initial findings to both the manager and the regional manager. We would like to thank all the people living at the home, their relatives and staff who helped with this inspection. What the service does well: People who used the service and their relatives said that they were satisfied with the care that was provided at the home. They stated that staff were ‘hard working and very caring’. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 6 There is a good, competent and committed staff team, which works well together to ensure the health and wellbeing of people who live at the home. The service provides good training opportunities to its staff to make sure they continue to have the relevant knowledge and skills to provide care and support to people live at the home. The home is well organised and well run and managers use good quality monitoring methods to continually improve the service. What has improved since the last inspection? What they could do better: Although there was a sufficiently good care planning system in place, staff should make sure that the records of care provided are able to reflect the interventions agreed in care plans and also the actual care given. The documents used to record the daily care provided should be kept together with individual care plans. This will enable care workers to refer to the care plans for guidance when providing care and when recording care that they have provided. This should help improve the quality of care recording. There is a need to make sure that complaints records show clearly the outcomes achieved following complaint investigations and also the actions taken to put things right, as necessary. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 7 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. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 sought to use the service had their needs appropriately assessed to ensure that their identified care needs could be met once they were admitted. EVIDENCE: We checked the care files of three people who had recently been admitted to the home. They included appropriate care needs assessments, which identified their diverse personal, physical and social needs. The assessments were carried out by both the placing social workers and staff, before people were admitted to the home. The home’s assessment was carried out in a very comprehensive manner. This ensured that a service was only offered to people whose needs could be met at the home. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care services. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 used the service and their relatives were satisfied with the care being provided. The health and personal care of people living at the home was appropriately planned and provided. This helped to maintain and promote their welfare. EVIDENCE: People who lived at the home and their relatives told us that they were satisfied with the care and support that was provided. They described care staff as ‘hard-working and very caring’, and that they were ‘good at their work’. People who lived at the home and who were able to express their views told us that their personal care was always provided to them in a diligent and private manner. This helped to maintain and promote their dignity and privacy. We also observed some good interactions between staff and the people who lived China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 12 at the home. There was a relaxed and friendly atmosphere in the home and people said they were ‘well cared for.’ We looked at the care plans of three people who lived at the home. They were based on the assessment and review of their care needs, risks and preferences. They outlined the actions that were required to make sure that the identified care needs were properly met. Risks faced by individuals, were appropriately assessed and managed. The care plans were reviewed on a monthly basis and outcomes of such reviews were acted upon. We noted that some of the daily records of care provided consisted of generalised comments and did not therefore reflect the actual care provided. This could affect the evaluation of care. We also noted that daily records of care were kept separate from the care plans. We advised that this practice may lead to staff having fewer opportunities to refer to the actual care plans and therefore potentially missing out on relevant guidance. The care plans that we checked indicated that people using the service were well supported in accessing appropriate community health care services. Visits and any involvement by health care professionals were properly recorded, with their outcomes and follow-up actions. We looked at the way medicines were managed at the home. The storage, receipt and handling of medicines were satisfactory. Medicines received at the home were appropriately recorded and any unused medicines were returned to the dispensing chemist for disposal. We checked a sample of medicines administration record (MAR) sheets. They were satisfactorily maintained. Medicines administered were appropriately signed for. None of the people living at the home were administering their own medicines. The manager showed us the outcomes of her regular medicines audits and they indicated prompt remedial actions when issues were identified. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 living at the home were able to benefit from a range of recreational and social activities that were offered to them. This helped in maintaining and improving their quality of life. EVIDENCE: During our visit, we observed people who lived at the home, spending time in the lounges and in their own rooms, watching television and listening to music. A few people were playing a game of skittles, with the assistance of the activities co-ordinator. Some people were playing other board games, which they said, were ‘quite enjoying’. The activities co-ordinator explained that she regularly consulted with people in relation to what recreational and social activities they wanted. She also supplied them with information about local events so that they may choose whether to attend or not. Staff confirmed that the local vicar and church choir members attend on a monthly basis to support faith activities. People who lived at the home said that they enjoyed activities that staff had put on, and in China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 14 particular, outings to sea-side resorts and attending the theatre. Some people said they also enjoyed going for short shopping trips in the locality. We observed that staff were able to spend some time with people in order to give them personal attention, on a one to one basis. Relatives said that this practice was ‘very much appreciated’ as it showed that people were valued. We noted that people’s preferences relating to recreational and social activities were recorded in care plans and that the activities co-ordinator was referring to them in planning the programme of activities. Relatives told us that they were always welcomed at the home. They felt that staff communicated well with them. They also commented that they felt routines at the home were flexible, for the benefit of their loved ones. People who lived at the home could choose, for example, how to spend their daytime and where they could not fully make decisions on their own, staff would assist them. This helped to ensure they could benefit from social stimulation that was available. People who lived at the home and their relatives stated that meals served at the home were ‘good and nourishing’. People were offered good menu choices for breakfast, lunch and dinner each day. We observed lunch being served on the day of our visit. This was the main meal of the day. It consisted of braising steak, fish, mash potatoes, Yorkshire pudding, seasonal vegetables and deserts. People were also offered water, tea and coffee to accompany their meals. We observed staff helping a few people who required assistance with eating their meals. They offered help in an unhurried and dignified manner. The care plans that we checked included nutritional assessments and records of the person’s food preferences. Staff explained that this helped them to cater appropriately for the nutritional needs of people in their care. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 views and concerns of people who used the service and those of their relatives were listened to and complaints were appropriately investigated. However, records relating to complaint management were not consistently robust enough and they could hinder opportunities to improve the service. People living at the home were appropriately protected from harm and abuse. This helped to maintain and improve their wellbeing. EVIDENCE: The complaints procedure for the home was displayed and copies had been provided to people who used the service and their relatives. People said that they were aware of the procedure and would sue it if they had to do so. Relatives told us that they would approach the manager, if they had any concern. They were confident that she would address their concerns in a prompt manner. They commented that staff were good at ‘listening’ to people and ‘putting people at ease’. The manager confirmed that she had received seven complaints in the previous twelve months. We looked at the complaints records. The complaints had been investigated and concluded, in line with the stated procedure. However, in some instances, it was not clear from the records, whether the China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 16 complaints had been upheld or not and what actions were subsequently taken, if any. However, the manager explained that she had communicated the issues around these complaints to all her staff to make sure that the overall service was improved. The home had an adult safeguarding policy in place to promote the safety and wellbeing of people who used its services. Staff had received appropriate training to ensure they could effectively implement the safeguarding procedures. Staff training records confirmed that staff were receiving on-going training on this subject. The manager confirmed that she had made only one referral to the local safeguarding team, since the last inspection. The matter had been investigated and appropriately concluded. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 lived at the home and their relatives were satisfied with the standard of accommodation and the facilities, which they found to be pleasant, comfortable and safe. This helped to maintain the health and wellbeing of people who lived at the home. EVIDENCE: We checked the premises in the company of the manager. The building comprised of two floors and there was a set of stairs and a passenger lift to facilitate access between them. Private accommodation was provided on both floors and communal areas, kitchen and laundry facilities, were located on the ground floor. There were two lounges, a hairdressing room and four conservatories, including a large television lounge. The building was in good state of repair. The furniture and soft furnishing were in good condition. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 18 The manager stated that there was an on-going refurbishment programme at the home. She confirmed that a number of bedrooms had been decorated and provided with new flooring, since our last visit. A new walk-in shower has been installed and this has helped for more comfortable bathing for a number of people, in particular those with limited mobility. The sluice room has been relocated from the laundry and hand sanitizers have been provided throughout the home, in order to prevent any cross infection. We viewed a few bedrooms with the permission of people who occupied them. The rooms were clean, tidy and well decorated. A few people had brought in some memorabilia and this helped them to personalise their bedrooms. People who lived at the home told us that the home was ‘pleasant, comfortable and safe’ and that that they were ‘happy with it’. The surrounding grounds were well maintained for the time of the year. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate and appropriately trained and competent staff were employed to provide care and support to people who lived at the home. This helped to protect and promote the health and wellbeing of people who used the service. EVIDENCE: At the time of this inspection, there were 30 people in residence. Besides the registered manager, there were one first level general nurse and six care workers. One first level nurse and two care workers were scheduled to work at night. Other support staff included an administration officer, an activities coordinator, domestics and kitchen and laundry staff. The manager stated that the care staffing level took account of the dependency needs of people who lived at the home. We looked at the duty rota and it showed that appropriate levels of care and nursing staff were consistently deployed on duty. People who lived at the home and their relatives told us that there were always staff around to give personal attention to those who needed it. They commented that request for assistance was promptly met. People who lived at the home also told us that the staff were ‘good at what they do’ and that they were ‘kind and caring’. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 20 We looked at the files of three members of staff who had been most recently recruited to work at the home. The records showed that the recruitment and selection procedures were appropriately followed. All pre-employment checks, including the appropriate disclosures (CRBs) and references were sought and obtained before staff started working at the home. Records also showed that the staff concerned had received induction and initial training to make sure that they had the necessary skills to start working at the home. The manager stated that staff had been offered training on a number of topics in the last twelve months. Records showed that staff had been provided with training on food hygiene, first aid, moving and handling, health and safety, fire safety, dementia care and adult safeguarding. A few senior members of staff had received training on the mental capacity act and on the deprivation of liberty safeguards. The manager explained that there was a rolling programme for all staff to receive training on the latter subjects. We noted that 15 out of 18 permanent care workers at the home had achieved their ‘National Vocational Qualifications’ (NVQ) level 2 in care. The other three care workers had started the course. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 used the service and their relatives were satisfied with the quality of the service they were receiving. Appropriate management arrangements were in place to ensure the proper day-to-day running of the home. This helped to maintain and promote the health, safety and welfare of people who lived at the home. EVIDENCE: There was a new registered manager in post. She is a first level registered general nurse with wide experience in care. She had worked as the deputy manager for two years before taking on the role of manager. She has started her training for the ‘Registered Manager’s Award. In discussion, people who China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 22 lived at the home, relatives and staff told us that she was ‘very approachable’ and that the home was well organised and well run. We noted that the manager was well supported by the regional manager of the company, which owns the service. We noted that reports relating to the owner’s monthly unannounced visits to the home were compiled and kept. These reports were comprehensive and served as an excellent tool to monitor the management of the home and its overall quality of service. Staff stated that they felt well supported in their work and that they were receiving regular supervision from the manager and her deputy. They also said that they were satisfied with the training and development opportunities that they were offered. Staff records confirmed that regular supervision was being provided. The manager told us that staff were given clear information about their work and of what was expected of them, and the need to abide by the relevant codes of conduct. She commented on instances where staff had been dismissed from employment due to lack of professionalism. The manager explained that she had use of some quality monitoring tools to help improve the service. These included monthly audits of care plans, pressure ulcers, medicines records, health and safety measures and ‘residents and relatives’ satisfaction surveys. The manager explained that these checks formed part of the home’s quality assurance and auditing system, which was carried out on a monthly basis. We noted that regular staff, residents and relatives’ meetings were held and we saw minutes of such meetings. Relatives and staff also confirmed that they were regularly invited to take part in these meetings. Arrangements were in place to support people living at the home with the management of their personal allowances. The financial transactions undertaken on behalf of people concerned, and that we checked, were appropriately recorded, witnessed and signed for and receipts were kept. The accounts we looked at, were in balance. These accounts were regularly audited by the regional manager and were found to be satisfactory. The manager had submitted the home’s ‘Annual Quality Assurance Assessment’ document to us prior to this inspection. It showed that all appliances and equipment used at the home had been appropriately serviced and maintained. Appropriate risk assessments and health and safety measures, including fire precautions and infection control were in place and these helped to maintain and promote the health and safety of people who lived and worked at the home. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP7 Good Practice Recommendations The record of care should be improved in order to reflect the actual and agreed plan of care for each person who uses the service. Efforts should be made to keep the daily records of care together with the relevant care plans. This should help staff to refer to care plans when making daily entries and therefore improve the relevance and quality of such records. The records relating to the management of complaints should be improved to show clear outcomes following investigations and also the actions taken to put things right, as necessary. 3 OP16 China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. China Cottage Nursing Home DS0000053683.V378891.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!