Care Home: Elm House

Similar services:

• Byars Care Home
• St Marys Nursing Home
• Bramble Lodge
• Parkmanor Residential Home
• Thornham Grove
• Hunter`s Lodge
• London Road Neurological and Specialist Care Unit
• Carlton Care Home

What the care home does well Potential new people benefit from a pre- admission assessment that allows for only those who needs can be met, being admitted to the home. The health needs of people living at the service are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to individuals in such a way that promotes and protects, their privacy and dignity. People using the service benefit from an activities calendar that is arranged according to their choice. They experience mealtimes that are unhurried, whilst all meals are home cooked with an alternative option being available for each mealtime. People living at the service can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect individuals in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to the people using the service. People using the service experience the benefits of a staff team that have the necessary skills and experience to the meet their needs. Staff training is on going and is appropriate to the level of needs of people accommodated. The management and administration of the home is good, with evidence of consideration being given to people who live at the service and/or their relatives opinion at all times. What has improved since the last inspection? Plans of care have continued to be developed to ensure that they are person centred and reflect the needs of people using the service receiving care in the way they prefer. Risk assessments have also been further developed for all identified risks to ensure that people using the service remain safe at all times. The management of the home have consulted with the Fire authority regarding keeping doors open, whilst complying with Fire safety regulations to keep people living at the service safe. Practices recommended by the Fire authority have been implemented. Staffing levels are constantly reviewed to ensure that the number of staff on duty is sufficient to meet the care needs of people accommodated. Further activities and stimulation have been offered to people using the service to ensure that their social and recreational needs are fully met. These have subsequently been ceased due to poor attendance. A new programme of activities is currently being devised with residents input. Menus have been reviewed in order to ensure that people using the service receive adequate choices and a wholesome meal at teatime.The Registered Manager analyses accidents to establish whether there are time patterns, which enables additional support to be provided to residents if time trends are apparent. What the care home could do better: In order to ensure that people livign at the service receive care that meets their specific needs, all elements of individual care plans must be completed consistently. To ensure that the home is run in the best interests of the peole using the service, the results of Quality Assurance Audits should be published and made available to stakeholders and any other interested party. Recommendations for good practice were made in that: where pre assessment recordings are brief in content, it is clearly recorded why the content is basic. Consideration should be given to the comments made, by the people using the service, in the surveys conducted by CQC, in relation to activities held in the home. Staff files are to be updated to include a recent photograph of each individual staff member. A record should be maintained of all daily informal discussions held between the people using the service and the Registered Manager and that any issues raised are addressed. Key inspection report Care homes for older people Name: Address: Elm House 22 Elm Avenue Beeston Nottingham NG9 1BU     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rebecca Shewan     Date: 0 9 0 6 2 0 0 9 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 26 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 26 Information about the care home Name of care home: Address: Elm House 22 Elm Avenue Beeston Nottingham NG9 1BU 01159225573 01159436147 selectelm@ntlworld.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Union Healthcare (Nottingham) Ltd care home 25 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: 1. 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 Older persons Code OP. 2 The maximum number of service users who can be accommodated is 25 Date of last inspection Brief description of the care home Elm House is situated within a quiet residential area of Beeston and provides residential care for older people. Accommodation is on two floors and a passenger lift is provided. There are four single rooms and ten double rooms. There are several seating areas that service users may access and there is a large well established garden for service users to enjoy. The home is convenient for local amenities and has good car parking facilities. Both the building and grounds are accessible for use by wheelchair users. The current weekly fees range from: 300 GBP - 600 GBP depending upon individual needs. The fee scale and all necessary information to make an 0 Over 65 25 Care Homes for Older People Page 4 of 26 Brief description of the care home informed choice to enter the home is available upon enquiry. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection took place during the morning and afternoon of the 9th June 2009. The homes Annual Quality Assurance Assessment (AQAA), incident reports and previous inspection reports, held by the Care Quality Commission, were read before the inspection. The inspection of the home took six and a half hours. Records such as care plans, staff files and medication records were also viewed. Seventeen people (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Registered Manager, a cook, two relatives, three people living at the service and one staff member were spoken with. The Care Quality Commission also conducted surveys of both people using the service and staff, the responses to which were generally positive in all aspects of care, provisions and staff training. Care Homes for Older People Page 6 of 26 Care Homes for Older People Page 7 of 26 What the care home does well: What has improved since the last inspection? Plans of care have continued to be developed to ensure that they are person centred and reflect the needs of people using the service receiving care in the way they prefer. Risk assessments have also been further developed for all identified risks to ensure that people using the service remain safe at all times. The management of the home have consulted with the Fire authority regarding keeping doors open, whilst complying with Fire safety regulations to keep people living at the service safe. Practices recommended by the Fire authority have been implemented. Staffing levels are constantly reviewed to ensure that the number of staff on duty is sufficient to meet the care needs of people accommodated. Further activities and stimulation have been offered to people using the service to ensure that their social and recreational needs are fully met. These have subsequently been ceased due to poor attendance. A new programme of activities is currently being devised with residents input. Menus have been reviewed in order to ensure that people using the service receive adequate choices and a wholesome meal at teatime. Care Homes for Older People Page 8 of 26 The Registered Manager analyses accidents to establish whether there are time patterns, which enables additional support to be provided to residents if time trends are apparent. 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. 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 26 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 26 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. There are good processes in place for assessing potential new people prior to admission with services being offered to only those individuals whose needs can be met. Evidence: The homes Registered Manager carries out pre- admission assessments. Copies of care management assessments from the placing authority are obtained, where these exist. The Registered Manager addresses any issues, which are highlighted within this assessment. Documented records are maintained of all correspondence with the placing authority. Records inspected showed that pre- admission assessments are carried out on all new and potential persons to be accomodated. Documentation relating to the most recent admissions to home were viewed and found to have been conducted with the involvement of the individual and/or their representatives (where applicable). Care Homes for Older People Page 11 of 26 Evidence: Some entries observed were basic in content for example sections marked eyesight and hearing had entries of poor, oral health - dentures and personal care - needs assistance. This was discussed with the Registered Manager who reported that basic entries were made, where only this amount of information exists. Therefore a Recommendation has been made. Interim care is provided for those whose needs can be met. The Registered Manager reported that if a potential new person is able to be rehabilitated to return to their home environment, then the home would be able to provide the apropriate support to enable this. Care Homes for Older People Page 12 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are offered a good provision of health care and personal support by the home. All care is administered in way that protects the individuals privacy and dignity. Medication procedures ensure that medication are stored and administered safely. Evidence: During the fieldwork visit we observed that the previous inspection Requirements that plans of care must continue to develop to ensure that these are person centred and reflect the needs of people using the service to ensure that their needs are fully met in the way they prefer and that risk assessments must be developed for all identified risks to ensure that people using the service remain safe at all times, have been met. The Registered Manager reported that the care plan format is currently under review and a new pro forma for care planning will be implemented in the near future. Care Homes for Older People Page 13 of 26 Evidence: Care plans and risk assessments were sampled and it was evidenced that these covered all aspects of the individuals needs/risk. Care plans are written to allow the assessor to gain an overview of individuals medical health, social and personal care needs. We observed that a care plan relating to diabetes was dated but was unsigned and did not have objectives included. Whilst another care plan had an incomplete continence assesment. Therefore a requirement has been made in relation to the consistency in the way that care plans are recorded. From records viewed we observed that individuals are involved in the care plan review process, that such reviews occur on a monthly basis and are updated to accurately reflect any change in needs. People using the service are registered with one GP from one of five local surgeries. District Nurses, attend the home as needed and are accessed directly by the staff of the home. Dentist and Opticians appointments are arranged privately, with individuals being supported to attend local practices. Access to audiology is acheived via the Rope Walk Clinic. Physiotherapy, Occupational Therapy, Speech and Language Therapy and the Dietician are sourced via the GP. The home has a Chiropodist who attends the home every six weeks and as required. We observed records and medication procedures and it was noted that the home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Staff were observed providing personal support to residents in such a way that promoted and protected their privacy and dignity. It was observed that peoples bedroom doors were knocked before staff entered them and that individuals were called by their preferred choice of address. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a range of social, cultural and recreational facilities, including specialist diets to people using the service. Evidence: Discussions and observations made at the ispection provided evidence that the previous inspection Requirement that further activities and stimulation must be offered to people using the service to ensure that their social and recreational needs are fully met has been addressed. People using the service have been consulted regarding their social and leisure interests. The Registered Manager reported that a daily programme of activities maintained by an Activities Coordinator had been put in place, though this has now ceased. It was reported that attendences to activities were low and that the people using the service had declined involvement in one to one sessions. The Activities Coordinator has subsequently left the home and activities are now being developed to meet the wishes of people using the service. Activity records and discussions with people using the service provided evidence that individuals accommodated, where able, are encouraged to attend the local shops and Care Homes for Older People Page 15 of 26 Evidence: town. Staff, people using the services and relatives reported that contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the individual accommodated wishes. Comments received in the Service user Surveys conducted by the CQC included: More outings. There seems to be no move towards these events and Have more outings, country rides, boat trips on the river, visits to garden cntres, BBQs, theatre visits. I would not mind paying towards some of the trips, it would be a chance for more outings apart from always going in to Beeston. Therefore a Recommendation has been made. The Registered Manager reported that the people using the service have currently declined the offer of Holy Communion, however this can be arranged if their wishes change. Discussions with the Cook confirmed that menus are planned with input from the people using the service. Menus viewed detailed that they are devised on a four weekly basis. All meals are home cooked with an alternative option available for each mealtime. Observations made at the inspection confirmed that meals can be taken in the persons bedroom or in the communal dining room. Medical, therapeutic or religious diets are provided as needed. People using the service and staff reported that drinks and snacks are available at all times. We observed that the meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried. Menus were observed and were found to offer a good variety. Menus viewed and discussion swith the Cook highlighted that the tea time meal has been reviewed and there is now a selection of sandwiches available, along with soup and or a hot snack. Therefore the previous inspection Requirement that the current menu must be reconsidered to ensure that people using the service receive adequate choices and a wholesome meal at teatime has been met in full. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect individuals in the event of an allegation of abuse. Evidence: We observed that the home has an established complaints procedure in place. Records viewed provided evidence that t he home has received no complaints in the past twelve months. Comments made by people using the service and CQC survey responses highlighted that they would know how and who to complain to. Staff records viewed provided evidence that both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new and existing staff. Staff have not attended training in the Safeguarding of Vulnerable Adults within the last twelve months. Further information received from the Registered Manager has confirmed that such training will be taking place, in the next month. Discussions with the Registered Manager confirmed that there have been no Safeguarding Alerts raised by the home in the last twelve months. We also observed that staff have ready access to the Multi Agency Procedures for Safeguarding Vulnerable Adults. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides accommodation for people using the service that is safe, and well maintained, whilst infection control procedures are adhered to at all times. Evidence: From the tour of the premises it was observed that the location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to the people using the service. Discussions with the Registered Manager and records observed detailed that the home has an ongoing plan of refurbishment in place. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. A daily cleaning schedule was observed to be in place. The Registred Manager has consulted with the Fire authority regarding keeping doors open, whilst complying with Fire safety regulations to keep people living at the service safe. Recommended practices by the Fire authority have been implemented and the practice of propping open doors will cease, once appropriate dorguards have been installed. The Registered Manager reported that such products are currently on order and will be installed in the next few months and that until such time they are fitted, appropriate risk assessments are in place. Care Homes for Older People Page 18 of 26 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 home has a staff team that have the necessary skills and experience to the meet the needs of the people living at the service. Evidence: There is a staff rota in place, which details staff hours of working and job designations. The duty rota provided evidence that a competent staff team, sufficient in number, meets the needs of people living at the service. Therefore the previous inspection Requirement that the staffing levels are reviewed to ensure that the number of staff on duty is sufficient to meet the care needs of people accommodated has been met in full. The homes AQAA and duty rota confirmed that the home has a permanent staff team of the Registered Manager, six Senior Carers, one Registered Nurse, seven Carers, a Cook and two Domestics, two Kitchen Assistants and a Handyman. The staff training matrix was viewed and it was noted that six care staff are NVQ, level 2 or above, trained in care and a further ten care staff are currently completing the NVQ level 2 or 3, in care training. Staff recruitment files were viewed and it was evidenced that these files contain the majority of items required under the Care Homes Regulations 2001. It was observed Care Homes for Older People Page 19 of 26 Evidence: that staff photgraphs are currently those on their passports, therefore a Recommendation has been made. It was observed that the home has an Equal Opportunities policy in place and is an equal opportunities employer. Training records were observed and it was evidenced that the staff induction training is conducted in line with Care Skills Sector guidance. Mandatory training consists of Skills for Care Induction, Moving and Handling, First Aid, Safeguarding Vulnerable Adults, Infection Control, Fire Safety, Health and Safety, Tissue Viabilty and Medication. Additional training is also provided in other subjects that arise from changes in residents needs. Training has also been conducted in the subjects of the Mental Capacity Act and Deprivation of Liberties. Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service experience the benefits of a home that is appropriately managed and administrated. The health, safety and welfare of the staff team and the people living at the service are protected at all times. Evidence: Discussions with the Registered Manager highlighted that she has been the Registered Manager of the home for four years and has been employed by the home for ten. The Registered Manager is a Registered General Nurse and has achieved the Leadership and Management Certificate. CQC survey responses, people living at the service and their relatives spoken with, said that the Registered Manager is friendly, approachable and always takes concerns or comments about residents, the home and services offered seriously. Care Homes for Older People Page 21 of 26 Evidence: From records viewed it was observed that a formal quality monitoring system is in place. Records provided evidence that annual residents questionnaires are conducted, other stakeholder and relative questionnaires are also conducted on an annual basis. The results of which are not currently correlated and published, therefore a Requirement has been made. Regulation 26 visits are conducted on a monthly basis and a report is generated from each visit. Regulation 37 incident reports are sent to commission. All such reports were observed to be in place. Staff meetings are held every three months. Minutes are maintained of all meetings held, these were viewed as part of the inspection process. Residents meetings are no longer held, the Registered Manager reported that she has daily informal meetings with Residents. There are no records maintained of comments made during these discussions, therefore a Recommendation has been made. The Registered Manager reported that the home does not take any responsibility for any of the individuals accommodated finances and that most individuals have family, friends or representatives who protect their financial affairs. Discussions with the Registered Manager highlighted that two individuals are supported to maintain their own finances. Records maintained for all personal allowance accounts and money storage systems were observed and it was noted that two staff sign for all transactions, all monies are kept locked in the homes safe and in secure individual money bags. The homes AQAA, observations made on the tour of the premises and records viewed provided evidence that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. Accident reports were viewed and it was evidenced that these are audited monthly, in order to establish whether there are trends in the accidnets that occur. Therefore the previous inspection Requirement that accidents must be montired to establish time patterns, to ensure that additional attention to the needs of people accommodated can be paid during these times to ensure that they are protected has been met in full. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 27 18(1,a) Review the staffing levels to ensure that the number of staff on duty is sufficient to meet the care needs of people accommodated. 29/07/2008 Care Homes for Older People Page 23 of 26 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 7 15 That all elements of individual care plans are completed consistently. In that a care plan relating to diabetes was dated but was unsigned and did not have objectives included. Whilst another care plan had an incomplete continence assesment. 09/08/2009 2 33 24 That the results of Quality Assurance Audits are published and made available to stakeholders and any other interested party. In that the results of Quality Assurance Audits are not currently published. 09/09/2009 Care Homes for Older People Page 24 of 26 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 12 That where pre assessment recordings are brief in content, it is clearly recorded why the content is basic. That consideration is given to the comments, made by people living at the service, in the surveys conducted by CQC. That staff files are updated to include a recent photograph of each individual staff member. That a record is maintained of all daily informal discussions held between the people living at the service and the Registered Manager and that any issues raised are addressed. 3 4 29 33 Care Homes for Older People Page 25 of 26 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. Care Homes for Older People Page 26 of 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!