Care Home: Fairmount Nursing Home

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What the care home does well When we spoke with staff they showed a good knowledge of people`s diagnosis and could verbally describe the health and personal care needs of the people they cared for. People looked well cared for and told us that they are. The overall feedback from people and relatives was that the care delivered by staff at Fairmount was very good. Individually: People`s comments included: "The staff are lovely ", "I`m really happy here at Fairmount ", "Everything about this place is excellent ". People`s representatives said: "The staff are first class"," Staff don`t just look after the residents they care for us relatives too, we are one big family"," The care my relative receives is wonderful". There is a "warm and homely" feel to Fairmount. The aroma of home cooked food and baking that greets you when you enter the home and the calm atmosphere helps to create this feeling. People spoke highly of the staff team and said staff always listened and acted on what they said. Staff said "We get lots of training; the company are very good for providing training ". There is evidence that the ethos of the home is open and transparent. The views of both people who use the service and staff are being listened to, and valued. What has improved since the last inspection? This is the first inspection since the new company of Czajka Properties Limited registered with us. What the care home could do better: People`s care plans need further attention and more detail so that the staff know, and can evidence, what support each person needs. People should be involved in drawing up and reviewing their care plans so that they can have more of a say in how they receive care or support. Some medication practices and storage procedures need to improve so that people`s health and welfare are protected. Key inspection report Care homes for older people Name: Address: Fairmount Nursing Home 10 Nab Wood Drive Shipley W Yorkshire BD18 4EJ     The quality rating for this care home is:   three star excellent 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: Mike ONeil     Date: 1 4 1 2 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 27 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 27 Information about the care home Name of care home: Address: Fairmount Nursing Home 10 Nab Wood Drive Shipley W Yorkshire BD18 4EJ 01274592922 01274585749 enq@fairmountltd.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Czajka Properties Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 40. The registered person may provide the following category of service user 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 Service users with a Physical Disability - Code PD Date of last inspection Brief description of the care home Fairmount is a converted, extended property situated in a residential area of Shipley, close to local bus routes and within easy reach of the main road to Bradford and Bingley. The home was first registered in 1989 as part of the Czajka Care Group, and provides nursing care for up to forty people. Care Homes for Older People Page 4 of 27 Over 65 40 0 0 40 Brief description of the care home Accommodation is provided in a combination of twenty-four single and eight double bedrooms, eleven of the single rooms having en-suite facilities. People living at the home have a choice of two lounges and a dining room,one lounge leads out to a patio area . The home is situated in extensive and well-kept gardens and patio areas, to which there is level access from the home. People living at the home also have access to the grounds of the adjacent care home, and putting and bowling greens. There is a car park to the front of the building. In June 2009 the home registered with the CQC under a new company although the overall management of the company remained unchanged.The responsible individual is still Konrad Joseph Czajka. The current fees range from 535.00-730.00 pounds per week with additional charges payable for services like hairdressing, chiropody and newspapers. This information was provided at the December 2009 inspection. The home should be contacted directly for up to date information about charges. Care Homes for Older People Page 5 of 27 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: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The inspection process included looking at the information we have received about the home since the new company of Czajka Properties Limited registered with us in June 2009. Because the overall management of the company has remained unchanged we have considered information we received before June 2009. Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the service was doing well, what had improved in the last year and any plans for improving the service in the next twelve months. The AQAA also included data as to when utilities and equipment at the home were serviced. Information from the AQAA is included in the main body of the report. Before the visit we sent surveys to the home to distribute to people using the service, visiting health care professionals and staff. Five surveys were returned to us two from people and three from peoples representatives. The information from the surveys is included within this report Care Homes for Older People Page 6 of 27 We made an unannounced visit to the home. This was carried out by one regulation inspector on 14th December 2009 over six and a half hours. We talked to 7 staff about their work and the training they have completed. We checked some of the records, policies and procedures the home has to keep. We also looked at some parts of the home and observed staff as they carried out their duties. We spoke with 8 people who use the service and 2 peoples relatives during our visit, their views are included within this report. The homes acting manager was in charge of the home at the time of our visit. At the end of our visit we also provided feedback to the area manager. Following the key inspection we met with the provider of Fairmount.He provided us with additional information about the service some of which we have included in this report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Older People Page 8 of 27 order line 0870 240 7535. Care Homes for Older People Page 9 of 27 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 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the information they need about the service to help them make an informed choice about where they live. Assessments were carried out to ensure that the home could meet peoples needs. This home does not provide intermediate care. Evidence: When we looked at peoples surveys it told us people had received enough information about the home before they moved in so they could decide if the place was right for them. When we spoke to the representative of someone who had moved in they said, We chose Fairmount because it had a nice atmosphere and felt homely . The AQAA completed by the home stated that before people choose to stay at Fairmount There is the opportunity for people to look around the home, meet staff and other residents, have a drink or a meal, and ask any questions that might occur to them. Care Homes for Older People Page 11 of 27 Evidence: The provider told us that people intending to stay at Fairmount on a long term basis are offered one weeks free accommodation and care to see if the home is the right place for them to to live. The company has its own website and has registered this on various well known search engines.The provider told us that the company are also currently developing a website film. We looked at three peoples files. Pre admission assessments had been undertaken. This told us that prior to the admission taking place, staff from the home carried out an assessment of peoples needs. This confirmed that the service was appropriate for the person and provided staff with information to formulate an individual plan of care. We also saw in all peoples files we checked that the home was consulting with, and requesting reviews from health care professionals when the persons needs were changing. Care Homes for Older People Page 12 of 27 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 were treated with respect and said they were very happy with the care they received. Peoples health and personal care needs were met and in the main medication procedures ensured that people were protected. Care plans generally reflected peoples care needs. This will mean that staff know what care each person needs. Evidence: We checked three peoples care plans. The care plans contained details about the persons biography, personality and their preferences and choices. Overall we felt that the plans were good and they did try to focus on the individual person. The care plans were concise and clear. Risk assessments were included within the documentation and included moving and handling, skin integrity, nutrition and other risk factors. The care plans identified that a range of health care professionals visited the home to assist in maintaining peoples health care needs. People said they had regular contact with their GP and other health care professionals such as district nurses. The provider told us that the service also employs their own physiotherapist to provide ongoing support and treatment for people. Care Homes for Older People Page 13 of 27 Evidence: We did find an inadequacy in one persons care plan we checked: The persons risk assessment identified that they were at risk of developing pressure sores. However despite this assessment staff failed to formulate a detailed care plan which would offer guidance and instructions to staff of how to minimise the risk and monitor the skin condition of the person. We found evidence that staff, in the care they were providing, were taking action to minimise the risk of the person developing pressure sores. The person had a specialised mattress in place on their bed and they said that the care staff help them to move their position in bed very frequently. However none of these care interventions were recorded in the persons care plan. Staff must provide written evidence of the care each person needs. In all care plans checked we found that pressure sore risk assessment tools were completed. However there was no supporting guidance for staff to follow as to what is deemed a high risk score or the action to take should the risk be medium or high. This guidance should be kept in peoples care plans. Some people and /or their representative said they were aware of care plans and that they were involved in discussions about their care. This means that most people can have a say in how they receive care or support. However there was no evidence recorded in one care plan to show that the person was involved in drawing up and reviewing their plan. This may mean that this person cannot have a say in how they receive care or support. When we spoke with staff they showed a good knowledge of peoples diagnosis and could verbally describe the health and personal care needs of the people they cared for. People looked well cared for and told us that they are. The overall feedback from people and relatives was that the care delivered by staff at Fairmount was very good. Individually: Peoples comments included: The staff are lovely , Im really happy here at Fairmount , Everything about this place is excellent . Peoples representatives said: The staff are first class, Staff dont just look after the residents they care for us relatives too, we are one big family,The care my relative receives is wonderful. Medication was securely stored in locked cupboards in a locked room. Medication Administration Records (MAR) were up to date with no gaps. The Controlled Drugs Care Homes for Older People Page 14 of 27 Evidence: Register was checked and this had been completed correctly with two signatures and a diminishing total. Qualified nursing staff dispense all medication. Guidance from the Nursing and Midwifery Council on the administration of medication is available to staff at the home. However people were not fully protected because not all Medicine Administration Records (MAR) were adequate. We found one handwritten MAR sheet checked did not contain General Practitioners or two members of staffs signatures alongside any directions regarding the dosage of the medication or the time the medication was to be given. Controlled drugs under the Misuse of Drugs Act were securely stored.However; there was no evidence to show that there had been a recent audit of all medicines stored in the cabinet. We would recommend that audits of all controlled drugs held be carried out on a frequent basis. Controlled drugs of people no longer at the home should be returned as soon as possible to pharmacy or destroyed. We saw staff valued and respected the privacy of people. There was clear and respectful communication between people and staff and staff treated people in a kind manner. Despite the inadequacies in the care plan documentation evidence shows that people at Fairmount experience good outcomes relating to health and personal care. This judgement is based on the evidence that the service has far more strengths than areas for improvement. The manager and area manager have also given assurances that the areas in need of improvement will be addressed and managed promptly. Care Homes for Older People Page 15 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a choice of lifestyle within the home and are able to maintain contact with family and friends ensuring that they continue to be involved in community life. People are able to make choices about daily living and be involved in some social activities. Meals served at the home are of a good quality and offer choice to ensure people receive a balanced diet. Evidence: People said they are able to get up and go to bed when they chose and generally how they spend their day and evenings. They said they often went out with their families. Relatives said they were able to visit at any time and were made to feel very welcome. People and their representatives said that the home is a friendly and welcoming place this was very evident on the day of our visit. There is a warm and homely feel to Fairmount. The aroma of home cooked food and baking that greets you when you enter the home and the calm atmosphere helps to create this feeling. Some people said they enjoyed the activities available at the home, whilst other people said that they chose not to join in with the activities arranged. We found people have been consulted about their interests and what activities and trips they Care Homes for Older People Page 16 of 27 Evidence: would like to take part in. There is also some information recorded in peoples care plans about how people like to spend their day. We found that during the week various activities are arranged on a daily basis and during the next few weeks there are various trips out and parties being organised. Community groups and entertainers are planning to visit the home in the lead up to Christmas. Some people were enjoying games and physical exercises when we arrived at the home. We spoke with the activities coordinator employed at Fairmount. The coordinator showed enthusiasm about her role and was keen to include as many people as possible in different types of activities. She was able to tell us about recent trips out and forthcoming events which will be held in the home. She was also very conscious that some people did not participate in larger group activities. She said she tried to spend time with people who wish to stay in their rooms reading with them or chatting. People said the activities coordinator and staff had helped them wrap their Christmas gifts for their family and also write their Christmas cards. People said they had enjoyed the time spent with staff doing this. We observed the meal service at lunch time. The tables were nicely set, the meal service was well organised and people were given plenty of time to enjoy their food. People told us they had enjoyed their lunch. Staff were supporting people, who needed help with their meal, in a sensitive and discreet way. People also said they always enjoy the food and were offered a choice of meal. People living in the home have been consulted about the meals and mealtimes, through meetings with the manager and meetings with the catering staff. The meetings with the catering staff are continuing on a regular basis. We saw from the minutes of these meetings that people living in the home have brought up various issues directly with the catering manager, who has listened and acted on what had been said. Care Homes for Older People Page 17 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate systems in place to make sure that peoples concerns/complaints are taken seriously and acted on and to make sure that people are protected from abuse. Evidence: Information about the complaints procedure is available in the home. People told us they know how to make a complaint if they need to and know who to speak to if they are unhappy. Several people said Id soon say if I was unhappy, but Im not. The homes complaints procedure is contained in the service user guide which was available in all peoples rooms. The home told us they had not received any complaints in the last year, no complaints have been referred directly to us. Records are kept of any previous complaints made and action taken to resolve concerns. There are procedures in place to make sure that people are protected from abuse. Staff said they are aware of protection polices and procedures. The homes area manager is a member of the local safeguarding board.She has a very good knowledge of safeguarding issues.She provides training for all staff at Fairmount.Records were seen of recent adult safeguarding training staff had undertaken. This ensures people who use the service are safe and protected. Care Homes for Older People Page 18 of 27 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 a comfortable, pleasant and safe place for people to live. Evidence: The home was clean and free of unpleasant odours when we visited. People and their representatives told us the home is always clean and fresh. The communal rooms in the home are comfortably furnished and the standard of decor is very good. The home has a number of shared rooms, but the majority are single with ensuite facilities. The home has lovely gardens and a bowling green where people can play or just sit when the weather permits. In the grounds of the home people and visitors have access to a clubhouse with restaurant and a swimming pool. A passenger lift provides access to the first floor. Care Homes for Older People Page 19 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to meet peoples needs. Staff get the training they need to help them understand and meet the needs of people living in the home. People are protected because all the required checks are done before new staff start work. Evidence: People spoke highly of the staff team and said staff always listened and acted on what they said. People said that staff were always available when needed. Staff and the manager confirmed that staffing levels were good. There were appropriate numbers and grades of staff on duty, to provide effective support to residents living at the home.We saw that staff were available to attend to peoples needs when needed. This will help to ensure that people receive consistent care from sufficient numbers of well trained staff. For many years Fairmount have been taking student nurses from Bradford University to work alongside permanent staff at Fairmount as part of the students training. It was positive to hear that the home have recently been re-audited by the head of clinical placement at Bradford University and retained this status to provide a training environment for student nurses. The home told us that all the required checks are carried out before new staff start work. Three staff files were checked. The files contained a range of information Care Homes for Older People Page 20 of 27 Evidence: including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. The homes induction training is the programme set by the Skills for Care Council. Many of the care staff have achieved National Vocational Qualification (NVQ) levels two or three in care. The training is co-ordinated and sourced by the homes own training manager who we spoke with during this visit. Staff told us they received induction training when they started work and this covered most of what they needed to know. Over the past 6 months training has taken place on a variety of subjects including nutrition, palliative care and dementia care .Training has also been provided on safe working practices for example fire safety, moving and handling and infection control. Staff said they get the training they need to keep them up to date and to help them meet peoples needs. Staff said We get lots of training; the company are very good for providing training . Staff said they have regular supervision and feel very well supported by the management team of Fairmount. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. All the staff we spoke with were clear about their roles and responsibilities. Staff were very proud of the home and were very keen to continue to provide a good service for the people of Fairmount. Care Homes for Older People Page 21 of 27 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. Overall the management of the home is good, with policies and procedures in place to protect and safeguard people who use the service. Evidence: The acting manager has been in post at Fairmount for approximately two months. She was previously deputy manager at the home for 4 months. The manager has many years experience in care, management and the nursing profession. Staff, people and relatives spoke very highly of the manager. They said the manager is always about, very supportive and she listens and tries to resolve any problems. Prior to the visit the service had submitted an Annual Quality Assurance Assessment(AQAA). The AQAA was received on time. This shows that the service works in a cooperative manner with us. The management team of Fairmount have ways in which to check out the quality of the service that they are providing. Regular staff meetings are arranged. Minutes of Care Homes for Older People Page 22 of 27 Evidence: these meetings were seen. People and their representatives said they saw and spoke with the manager of the home on a regular basis. A newsletter incorporating all the homes in the company is regularly produced and made available to people and their relatives. This provides information to people about what is happening in the home. The area manager and responsible individual visit the home on a regular basis, a report is written following the visits and any identified actions taken. People know the managers and owners of Fairmount. People said They are always about talking to us. There is evidence of internal auditing of the homes environment, services and records. The home is in the process of sending out the annual satisfaction survey to people and their families. There is evidence that the ethos of the home is open and transparent. The views of both people who use the service and staff are being listened to, and valued. The manager and area manager said they have attended training on the Mental Capacity Act and the deprivation of liberty legislation. Other staff however had little knowledge of the legislation and needed training. Some staff thought that the training would be provided early next year alongside the adult safeguarding training that was planned. The area manager confirmed that all staff would receive training on the Mental Capacity Act and the deprivation of liberty legislation within the next couple of months. The manager said that no one in the home was being deprived of their liberty when we visited. The manager is aware of procedures to follow in relation to this legislation. However the lack of staff training relating to deprivation of peoples liberty may mean that peoples rights are not fully protected and promoted. A sample of monies that was looked after on behalf of people living at the home was checked. Records and receipts are kept and money tallied with the records. The AQAA completed by the home indicated that the required maintenance and servicing of equipment is up to date; a sample of records we looked at confirmed this. Staff said they had received recent fire safety and other health and safety training. Following an environmental health inspection the local council have awarded the home a 5* excellent rating for the level of compliance with food safety legislation . These measures will promote the safety and welfare of the people. Care Homes for Older People Page 23 of 27 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 24 of 27 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 The care plan must set out in detail the action, which staff need to take to minimise the risk of people developing pressure sores. To ensure peoples health care needs are met. 01/03/2010 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 7 Supporting guidance on the pressure sore risk assessment tool used should be kept in peoples care plans. This will help to make sure peoples health care needs are met. Documentation should show that people and/or their representatives have been involved in drawing up and reviewing the care plans. This will mean that people can have a say in how they receive care or support. To protect people we would recommend that audits of all controlled drugs held be carried out on a frequent basis. Controlled drugs of people no longer at the home should be returned as soon as possible to pharmacy or destroyed. Page 25 of 27 2 7 3 9 Care Homes for Older People 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 4 9 To protect people the Medication Administration Records (MAR) should contain General Practitioners, or two members of staffs signatures, alongside any directions regarding the dosage of the medication or the time the medication is to be dispensed. To protect peoples rights and choices staff should receive training on the mental capacity act and deprivation of liberty. 5 33 Care Homes for Older People Page 26 of 27 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. 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