Care Home: Drayton House

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What the care home does well People we spoke to on the site visit told us they enjoyed living at the home. One person said the home was like a "family" and another said they "all get on well here". The home offers an extended period environment, with the majority of the rooms having some en suite facility and several having attractive period features. There is a choice of communal areas. Considerable investment is now being made to training staff to ensure they have the skills and confidence to care for people; Many people at the home were from the local area and could discuss places and people they knew in common; People living at the home have been drawing together memories and experiences to reflect their lives with a staff member. This could be developed further to be in a more multi media format; The home has a shaft and passenger lift available to access the first floor so that people can have a choice of which to use; All areas of the home seen were clean, warm and comfortable; People we spoke to without exception spoke highly of the meals served. What has improved since the last inspection? The staff and management were welcoming and keen to show the developments they have made. Since the last inspection the home has: Improved the care plans to include much more information on how care is to be delivered in accordance with the person`s wishes wherever possible; Medication management has improved; Activities are now being very regularly provided and evidence of this could be seen on the walls of the lounge; Risk assessments have been implemented to ensure that as far as possible any risks have been reduced; Staffing levels have been increased; The laundry floor has been replaced and other repairs made to the building. What the care home could do better: The home`s management should make sure any best interest decisions are recorded; Activities should also be provided that cater for people with memory loss at a level they can feel comfortable with; Period windows should be risk assessed and any actions required taken to ensure the glass does not present additional risks; Risk assessments for the environment should be regularly reviewed; The manager should check whether the induction programme is compliant with skills council standards; Risk assessments should be provided for all areas of staff health and welfare; Data sheets should be provided for all chemicals in use; And a full quality assurance and quality management system must be implemented to ensure that the home are clear about what is working well and what could be improved. Key inspection report Care homes for older people Name: Address: Drayton House 50 West Allington Bridport Dorset DT6 5BH     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: Michelle Finniear     Date: 3 0 0 3 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 29 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 29 Information about the care home Name of care home: Address: Drayton House 50 West Allington Bridport Dorset DT6 5BH 01308422835 01308422835 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Mary Josephine Pitcher,Mr John Stanley Pitcher,Mrs Isabella Fitzgerald,Miss Andrea Helen Quirk Name of registered manager (if applicable) Mrs Jeanette Rodway Type of registration: Number of places registered: care home 19 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 19. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender 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 of 19 places Dementia aged 65 years or over on admission (Code DE(E)) - maximum of 4 places Date of last inspection Brief description of the care home Drayton House is registered to provide personal care for a maximum of 19 older people including up to four with dementia. The accommodation is on the ground and first Care Homes for Older People Page 4 of 29 0 2 0 2 2 0 1 0 0 0 Over 65 4 19 Brief description of the care home floors with a small passenger lift serving both floors. Seven of the thirteen single bedrooms have en-suite hygiene facilities and there are 3 larger rooms that may be used to accommodate 2 residents who have made a positive choice to share with each other. None of the shared use rooms have en suite facilities; all bedrooms have a wash hand basin. Communal facilities include two lounges, a small dining room and 3 bathrooms including two for assisted use. Drayton House is within walking distance of Bridport town centre with its shops and services. There is space at the front of the house to park two cars; parking is not permitted in the road in front of Drayton House. Behind the house is a steep raised garden accessible only by steps and therefore rarely used by residents of the home. There is a small patio at the side of the house accessible via patio doors from the rear lounge. Laundering of clothing and household linen is carried out at the home and arrangements can be made for chiropodists, opticians and other health and social care professionals to visit individual residents. At the time of this inspection fees ranged between GBP 473 and GBP 500 each week. Care Homes for Older People Page 5 of 29 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: To carry out this inspection we looked at the annual quality assurance assessment completed by the home for a previous inspection. This gave us information about how the home was being run, what changes they have made since their previous visit and what they intended to do in the coming year; We looked at the last key inspection report, and the reports of the random inspection and specialist pharmacy inspection which have been completed since then; We visited the service without telling them when we were coming. We visited at 8am on a weekday morning and spent most of the day at the home; We spoke to the management and an owner of the home; We looked at the records the home keeps about the way the home is run and on the Care Homes for Older People Page 6 of 29 care delivered to people; We looked round the premises, looking at the decor, cleanliness and equipment available to support people; We spoke to the people living at the home, and took part in an activity session with them; and we spoke to the staff on duty, and observed them doing their job. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: The homes management should make sure any best interest decisions are recorded; Activities should also be provided that cater for people with memory loss at a level they can feel comfortable with; Care Homes for Older People Page 8 of 29 Period windows should be risk assessed and any actions required taken to ensure the glass does not present additional risks; Risk assessments for the environment should be regularly reviewed; The manager should check whether the induction programme is compliant with skills council standards; Risk assessments should be provided for all areas of staff health and welfare; Data sheets should be provided for all chemicals in use; And a full quality assurance and quality management system must be implemented to ensure that the home are clear about what is working well and what could be improved. 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 29 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 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is available to help people make a decision about whether the home is the right place for them. A full assessment is undertaken by senior staff before a decision is made about whether the home can meet the persons needs. Evidence: Drayton House has a statement of purpose and service user guide available to support people to make the decision about whether the home is the right place for them or their relatives. It also contains information about the terms and conditions of living at the home, their rights, as well as information about policies such as how to make a complaint. On the site visit we discussed the most recent admission to the home and looked at the records the home had completed. This included an assessment carried out by the manager of the individuals needs, and whether any specialist support or equipment would be required . This was completed before a decision was made as to whether the Care Homes for Older People Page 11 of 29 Evidence: home could offer them a place. The manager also said that it was important the person would be able to be compatible with other people already living at the home. Relatives had visited a number of homes before making a decision that this was the right placement, although the person had not been able to visit themselves. The home manager said that a review following the admission had shown that the person was improving their quality of life and had put on weight which the family were very pleased with. The home does not provide intermediate care. This means they do not aim to provide a specialist programme of rehabilitation with the aim of returning the person to their own home. Care Homes for Older People Page 12 of 29 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. Plans have been developed to ensure peoples care is assessed, reviewed and planned, as far as possible in the way they wish. Medication is being managed appropriately. Evidence: For this inspection we looked at three care plans for people who live at the home; we spoke to the management about the ways in which care needs are identified and reviewed and we spoke to staff about how they deliver the care people need. We also spoke to the people who live at the home about how they were being supported. Since the last Key Inspection in September 2009, the home has been visited by a Care Quality Commission specialist pharmacy inspector and has also had a random inspection carried out, looking at the ways in which the staff were interacting with the people who live there. This was carried out using an observational tool, which gives us information about how well support needs are being met. Information about these inspections are contained in separate reports, available from the home or the Care Quality Commission. Both demonstrated that the home had developed and improved their practice since the last key inspection, and no additional requirements or Care Homes for Older People Page 13 of 29 Evidence: recommendations were made as a result. The care plans we looked at on this inspection showed that the home have developed clear plans of how peoples needs are to be met, based on a full assessment. Where concerns were identified in the assessment, plans had been completed to manage any risks. As an example one plan identified that the person was at risk of tissue breakdown and pressure areas forming. A plan had been developed that identified the interventions and management the home was carrying out to ensure this did not happen. Assessments cover areas of need such as communication, nutrition, mobility and health care along with identified social profiles and some information on peoples past life history (where people are willing to share this). People we spoke to on the visit told us they were happy at the home, and felt their care needs were met. One person said We love it here, we are like a family. Plans were being reviewed monthly and all care staff are involved in their compilation and review. This helps to ensure that all staff are aware of peoples needs and are working with greater consistency to support people in the way that they want. Peoples views and wishes on their own care are included in the plan wherever possible. Plans include individual risk assessments on areas such as falls, moving and handling, Infection control, nutrition and more general assessments in relation to peoples care. Risk assessments are a way of identifying and minimising risks to people wherever possible. These were also being updated regularly to ensure they remain an accurate reflection of fluctuating risks. On this visit we also looked at the medication system in use and observed medication being administered to people. We discussed the system with the senior on duty who dealt with the medication on the day of the visit, and saw the ways in which medication is received, administered and destroyed or returned to the pharmacy. The homes care staff do not deal with any invasive procedures or dressings people may need, as these are carried out by district nurses. The home is situated across the road from the local medical centre so medical or community nursing support is close at hand. Medication is supplied in a series of blister packs by the pharmacist. This system helps to reduce risks of errors and makes it easier to check that medication has been given. Staff who administer medication receive training to do so, and when we watched medication being given to people they were encouraged to take it at their own pace Care Homes for Older People Page 14 of 29 Evidence: and respectfully. Some staff have recently attended training in managing palliative and end of life care. Care Homes for Older People Page 15 of 29 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 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 developing further opportunities for people to enjoy more options for a lifestyle that meets their preferences. More activities are being provided. The home must consider restrictions placed on people. Evidence: During the site visit we spent time with the people who live at the home, looking at how they spend their time and what activities are available to them. We participated in an organised activities session, and looked at how the home supports them to follow their chosen lifestyles. We arrived at 8am to enable us to see the staff handover, and found that some people who live at the home were up and eating their breakfast while others stayed in bed until much later. Those people who were up had opportunities to decide where they wanted to eat and spend their time during the day. Since the last key inspection the home have spent time developing activities for people who live there. People we spoke to were keen to tell us about the activities they had recently been taking part in, pictures of which were on the walls of the lounge. On the day of the visit people were engaged in making cards for Easter, followed by a word game. The home has also obtained a number of crafts and games suitable for people who may have a need for extra support, such as large sized Care Homes for Older People Page 16 of 29 Evidence: dominos for people with impaired vision. People have also been working on recording some of their social history and recollections with staff. We discussed ideas the people living at the home plan to develop, including the gardens, along with adopting a whole home approach to activities rather than relying on them being something a specialist staff member does. In addition the home may wish to ensure that activities are arranged that meet the differing and individual needs of the people accommodated. This would include people with some degree of memory loss or frailty, to ensure that people are not excluded by their level of disability. The manager told us that people are supported to follow their chosen faith, (or none) as they wish and that visitors are welcomed at any time. We were told that the manager informs relatives when people are going out. The home said they have an open communication line with relatives and residents and always keep them informed of outings. Advice should be sought on the Mental Capacity Act if people are considered to lack capacity to make decisions. No evidence was available in peoples files to detail any best interest decisions made on behalf of people who may lack or have variable capacity. Without exception the people we spoke to told us the meals were very good. The meal on the day we visited was shepherds pie and cabbage with swiss roll and custard for dessert. The home has a three week rota for meal choices and a free choice for the evening meal. Although there is not a choice for the main meal at lunchtime the cook sad that they would always do something else if someone didnt like the main choice or wasnt feeling well. Care Homes for Older People Page 17 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People should be protected by the homes policies on complaints management and safeguarding. Evidence: We spoke to several people on the visit who told us they knew how to make a complaint if they wished, and were confident that they would be listened to. The manager told us that no complaints have been received since the last key inspection in September 2009, and that previous safeguarding issues have been resolved. The manager told us that all staff have now received training in risk assessments, and the manager and deputy have also undertaken some training in the Mental Capacity Act. However the majority of the staff still need to do so. This legislation helps to protect peoples rights, particularly where there is variable or limited capacity. We discussed one person who has a fluctuating capacity and sometimes refuses to take her medication. The manager could demonstrate that if this happens then they try again later but then record she has not taken it and notify the GP. This showed the home respected her decision making. Staff have received training in safeguarding and the protection of potentially vulnerable adults, and we saw the homes whistleblowing policy, which is available in the office. This helps to ensure staff should have a clear idea of what to do if they suspect abuse or abusive practices. Care Homes for Older People Page 18 of 29 Evidence: Care Homes for Older People Page 19 of 29 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. Drayton House provides a comfortable environment in which to live and work. Evidence: On the site visit we toured all areas of the home, looking at the environment, cleanliness and the progress that has been made since the last inspection. The home is substantially a period building with a large extension to the rear. Many of the rooms are en-suite and some could be used for shared occupancy if needed. People have a choice of communal areas in which to spend time and there is some limited garden space accessible to the rear of the property. People were able to tell us of the plans they and the homes management have for gardening in this area. The front of the home and gardens are also being improved. We looked at peoples rooms, some of which were individual, with items of personal belongings. We discussed the environmental adaptations made for people with individual difficulties, such as visual impairments, and although the home have not made any specific adaptations they said they would undertaken reasonable work where indicted. Communal bathrooms have moving and handling equipment and there is a mobile hoist for use around the home. Since the last Inspection a chairlift has been fitted to the staircase so the home now Care Homes for Older People Page 20 of 29 Evidence: provides both shaft and stair lifts to access the first floor rooms. The laundry floor that required attention has now been replaced and the manager told us that all the radiators have now been covered. This is to prevent people being accidentally scalded by coming into contact with a hot surface. All the areas that we saw were clean, warm and comfortable. There had been some areas of water intrusion to the first floor, but the owner told us that this had now been remedied. Risk assessments have been undertaken for the environment, to help ensure that people are safe while living and working there. Some original windows are still fitted with period glazing which could present a hazard if people were to fall against it. These should also be risk assessed and any action taken as necessary. Care Homes for Older People Page 21 of 29 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 recruitment and training processes support staff to care for people appropriately. Evidence: On the site visit we looked at the ways in which staff are recruited, trained, supported and the way in which they work with people. On the day we visited the service, unannounced, there were ten people living at the home, and three staff came on duty at 8am. There had been two staff on duty overnight. The manager came on duty at 9am and there was also a cook. The owner attended for the inspection, and an activities organiser came on duty after lunch to support people with organised activities. These staffing levels have increased since the last inspection. People were given care in an unhurried way and staff had time to spend individually with people. The staffing levels at weekends have also improved, and although there are only two staff on duty in the afternoons at the weekend, the manager feels that is sufficient to provide the support needed. Additional staff can be called in as needed. We looked at the way the home had recruited their most recent members of staff. Their files showed a clear process had been followed with a criminal records bureau check, references and a full interview process undertaken. Following a place being Care Homes for Older People Page 22 of 29 Evidence: offered the staff member commences a full induction programme which was seen. The home manager is advised to complete this as each part is achieved rather than signing off when completed as it does not give a picture of the progress made. It is recommended that advice is sought to ensure that this is compliant with current standards. We looked a number of the homes policies, including the whistle blowing policy and some areas of the staff handbook. Currently no domestic staff are employed, although the home is said to be advertising, but the staffing levels allow for some staff cleaning time to be undertaken and all areas seen on this visit were clean and well maintained. We discussed the training that is available for staff following their induction. Since the last inspection the training available has significantly increased. We were supplied with a copy of their training matrix which demonstrated that since the last inspection staff have received training in adult protection, medication, infection control, food hygiene, dementia care, fire safety, risk assessment, choice, equality and diversity, managing challenging behaviour, health and safety, and care planning. Managers have also attended training on registration requirements, the Mental Capacity act and nutrition. Further training is booked later in the month for Parkinsons disease and dementia awareness. The staff we spoke to on the visit were clear about their role and could discuss the needs of individuals they were supporting. The handover we saw was clear in establishing peoples ongoing needs and showed effective communication between shifts. Discussion was held with management on the skills mix and ensuring the training given is consolidated through modelling good practice, practice monitoring and ongoing support and review. An additional safe working practice risk assessment in relation to a member of staff was discussed and will be implemented. Care Homes for Older People Page 23 of 29 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. The homes management are responding to previous concerns and developing the service well. Some development work would benefit the quality assurance systems. Evidence: The manager of the home has achieved a number of senior and management level qualifications in care including the registered managers award which is a management level award specifically in managing care homes. Members of the ownership team have many years experience of working with people in received care settings. The manager is hands on at the home and is supported by a deputy manager. Staff at the home are supported formally though a programme of supervision. This is a system which combines professional development and performance management and should help ensure staff are working consistently and to their full potential. It is recommended this is undertaken at least six times a year for each staff member and the documents seen at the home showed this was on target. Discussion was held on way the home keep this fresh and interesting for staff. Care Homes for Older People Page 24 of 29 Evidence: We also looked at the ways in which the home keeps people safe. We saw some of the risk assessments for the environment, for safe working practices and for the specific needs of individuals. Some of the Environmental risk assessments needed updating but otherwise those we saw were completed and appropriately reviewed. Discussion was held on one staff based risk assessment needed and some COSHH chemical data sheets which were not available. These are data sheets for the chemicals in use at the home and might be needed for example if they were accientally misused. Drayton House does not deal with any personal money for the people living there, as this is dealt with by relatives or formal advocates if the person cannot do this themselves. We discussed the quality assurance systems in use at the home. At the time of the inspection the home has a system that sends questionnaires to people living there, their supporters or family and various other stakeholders such as visiting community nurses and GPs. They also have family meetings monthly where suggestions are sought for improvement. The home does not currently however have a system for pulling together information from a variety of internal and external assessments to form a full quality assurance system or an annual development plan for the service. A full quality assurance system should help the home map their service against national standards for care homes, and see both what is working well and what could be improved. Care Homes for Older People Page 25 of 29 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 26 of 29 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 full quality assurance system must be implemented. This should enable the home to better see what is working well at the home and what could be improved. 13/07/2010 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 12 Activities should be provided that meet the needs of all levels of ability at the home, including people with memory loss. Any best interest decisions made on behalf of people lacking capacity should be recorded. The home may wish to consider whether some of the period windows present a safety hazard from people falling against them and take remedial action. An additional safe working practice risk assessment for a member of staff was discussed and should be implemented to safeguard their well being while at work. 2 3 12 19 4 27 Care Homes for Older People Page 27 of 29 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 5 30 The home is recommended to ensure the Induction programme is signed off as each area is completed. This programme should be verified against Sector skills council standards to ensure it covers all required areas of practice. Risk assessments should be kept under regular review to ensure they remain an accurate reflection. Chemical data sheets should be obtained for all chemicals in use so that people know what to do in case of accidental misuse. 6 38 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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