Care Home: Fosse Court

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What the care home does well All the residents we spoke to were happy about the care given by staff. They felt they got good support. They felt the home was comfortable and they have what they need. People who sent us surveys also told us they were happy living in the home and felt they received good care. There is an assessment process before people come into the home, to make sure the home is right for them. Assessments include information about religious or cultural needs, and staff have training to help them to be able toFosse CourtDS0000053757.V374983.R01.S.docVersion 5.2meet a range of needs. People told us they had choice about moving into the home and were given information. There are written care plans, which give information about people`s needs and choices. These have good detail, and people told us that they are able to make choices in their daily lives. Staff show good understanding of people`s needs. The manager and staff pay good attention to people`s healthcare needs. Medication is looked after safely and given out carefully, with good recording. There is a range of activities for residents in the home, including celebration of religious and cultural events. Some residents enjoy activities outside the home, such as going to day centres, or going to shops and the library. Main meals are brought to the home from another home, and served hot. Fresh foods, such as chapattis, are made in the home. People we spoke to told us they enjoy the food, and they are able to have choice. The food is culturally appropriate, mainly Asian, with vegetarian and meat dishes served separately. People who live in the home told us they felt able to raise any problems with the staff and manager, and that they felt listened to. Staff make sure they report any incidents of concern to us, as they are required to. Staff understand about the need to keep vulnerable residents safe from harm. All areas of the home seen were clean and tidy. Safety checks are carried out in the home, to make sure equipment is safe. We found that staff have had relevant checks carried out about them, such as Criminal Record Bureau checks, to ensure that they are safe to work with vulnerable adults. Training is given to staff on a regular basis, to help them to do their job well. Staff have had training in areas such as protecting people from harm, first aid, moving and handling, and National Vocational Qualifications in care. Staff told us they feel well supported in their work. The registered manager continues to manage the home and to make improvements. Residents meetings are held and there are other processes in place for the home to check the service it gives to residents, such as occasional questionnaires for people to fill in. What has improved since the last inspection? There have been improvements in care records, with care plans having more detail and information about people`s choices and wishes as well as their care needs. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 The home has been re-decorated throughout and looks brighter and fresher, creating a more homely environment for people who live there. There is a new laundry with commercial washing machines, which meet the laundry needs of the home. An in-house library has been provided, to give people opportunities to read or listen to books, CDs etc. What the care home could do better: Key inspection report CARE HOMES FOR OLDER PEOPLE Fosse Court 207-211 Fosse Road North Leicester LE3 5EZ Lead Inspector Chris Wroe Key Unannounced Inspection 18th March 2009 10:00 DS0000053757.V374983.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fosse Court Address 207-211 Fosse Road North Leicester LE3 5EZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 2518822 F/P 0116 2518822 Eastern Care Ltd Ms Sadhna Patel Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (11), Old age, not falling within any other category (22), Physical disability (11), Physical disability over 65 years of age (11) Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No person under 55 years of age who falls within categories MD or PD may be admitted to the Home No person who falls when 11 persons of accomodated. No person who falls when 11 persons of accomodated. within categories MD or MD(E) may be admitted these categories/combined categories are already within categories PD or PD(E) may be admitted these categories/combined categories are already 12th July 2006 Date of last inspection Brief Description of the Service: Fosse Court is part of Eastern Care Ltd group of care homes. Fosse Court is a large care home made up of three terraced houses, which is situated in the West End of Leicester. The home is on a main road, close to shops, parks, local amenities and places of worship. The home is on a bus route and ten minute bus journey to the city centre. Fosse Court provides accommodation and care for older people. In addition, staff at the home may care for up to eleven residents who are physically disabled, or who experience mental ill health. The home promotes itself as offering a service for people who wish to live an ‘Asian lifestyle’. There are three separate lounges in the home, and to the rear of the home, a large dining room, which overlooks the small flat garden. Bedrooms are mainly located on the upper floors, which can be accessed via stairs or the passenger lift located at the centre of the home. The home provides Asian meals, which are prepared at another home close by. The fees charged at the time of this inspection range from £341 to £401 per week. Additional charges are made for personal costs, such as newspapers and toiletries. In addition there may be further charges where extra one to one care is required (generally agreed in placement agreement with funding authorities). Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection included a visit to the service. We visited the home on 18th March 2009. The visit started at 10am and lasted for six and a half hours. The registered manager, Ms Sadhna Patel, assisted the inspector during the visit. Most residents were at home during the inspection. Four residents spoke to us about living in the home, with the help of an interpreter. The main method of inspection used was ‘case tracking’. This means looking at the care given to residents in different ways. The ways this was done are: • talking to the residents • talking to staff and the manager • watching how residents are given support • looking at written records. We also sent out surveys to people who live in the home, and three people filled them in and returned them to us to tell us what they thought about the home. The provider (owner of the home) also sent us information in their Annual Quality Assurance Assessment to tell us about what improvements and developments have been made. All the key standards were checked during this inspection. The information below is based only on those aspects checked in this inspection. Individual detail has been kept out of the report, to make sure it is kept confidential. What the service does well: All the residents we spoke to were happy about the care given by staff. They felt they got good support. They felt the home was comfortable and they have what they need. People who sent us surveys also told us they were happy living in the home and felt they received good care. There is an assessment process before people come into the home, to make sure the home is right for them. Assessments include information about religious or cultural needs, and staff have training to help them to be able to Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 6 meet a range of needs. People told us they had choice about moving into the home and were given information. There are written care plans, which give information about people’s needs and choices. These have good detail, and people told us that they are able to make choices in their daily lives. Staff show good understanding of people’s needs. The manager and staff pay good attention to people’s healthcare needs. Medication is looked after safely and given out carefully, with good recording. There is a range of activities for residents in the home, including celebration of religious and cultural events. Some residents enjoy activities outside the home, such as going to day centres, or going to shops and the library. Main meals are brought to the home from another home, and served hot. Fresh foods, such as chapattis, are made in the home. People we spoke to told us they enjoy the food, and they are able to have choice. The food is culturally appropriate, mainly Asian, with vegetarian and meat dishes served separately. People who live in the home told us they felt able to raise any problems with the staff and manager, and that they felt listened to. Staff make sure they report any incidents of concern to us, as they are required to. Staff understand about the need to keep vulnerable residents safe from harm. All areas of the home seen were clean and tidy. Safety checks are carried out in the home, to make sure equipment is safe. We found that staff have had relevant checks carried out about them, such as Criminal Record Bureau checks, to ensure that they are safe to work with vulnerable adults. Training is given to staff on a regular basis, to help them to do their job well. Staff have had training in areas such as protecting people from harm, first aid, moving and handling, and National Vocational Qualifications in care. Staff told us they feel well supported in their work. The registered manager continues to manage the home and to make improvements. Residents meetings are held and there are other processes in place for the home to check the service it gives to residents, such as occasional questionnaires for people to fill in. What has improved since the last inspection? There have been improvements in care records, with care plans having more detail and information about people’s choices and wishes as well as their care needs. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 7 The home has been re-decorated throughout and looks brighter and fresher, creating a more homely environment for people who live there. There is a new laundry with commercial washing machines, which meet the laundry needs of the home. An in-house library has been provided, to give people opportunities to read or listen to books, CDs etc. 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 Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 8 order line – 0870 240 7535. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable at this time) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in this home benefit from a good assessment and admission process. EVIDENCE: We saw that there were written assessments in place for people, which were prepared when they came to live in the home. These gave information about what care and support people needed. One person we talked to told us that their social workers had helped to find a place in the home for them; another that their family had come to look around before they moved in. Three people told us in our surveys that they had choice about moving in and were given good information about the home. We saw information about fees and contracts in people’s files. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 11 We found that there was information in assessments about individual religious and cultural needs. People who live in the home told us said they had choices about religious practice, and were able to pray in the home. People who have different religious and cultural backgrounds are able to live together in the home, and have their needs met. We found that staff have training in different aspects related to their role, such as moving and handling and health and safety. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and personal needs are well met in this home. EVIDENCE: People who live in the home told us that they feel well cared for by staff. They told us that they are given choice, and that staff treat them with respect. We saw that staff understand the different needs of individual residents and respond to them with sensitivity. One person who lives in the home told us: “Here it’s like a family – everyone is very nice. Staff are really good – hearts of gold”. Another person said “I like it here, it’s a nice place. The staff are fine, I feel they know what they are doing.” Each person has a care plan, which gives details about what kind of care they need. These include information about people’s choices in how they like to live Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 13 their daily lives. The care plans have been improved since we last inspected, and contain good detail about people’s needs and wishes. Some risk assessments have been prepared, which give information about how to keep residents safe. We found that there were some areas of risk to residents, for which a risk assessment had not been carried out – for example in relation to mobility and moving and handling, and relating to risks of smoking in the building. These must be done so the manager can ensure everyone is looked after in the safest possible way. We discussed with the manager that the moving and handling policy could be improved to include rules about training and clearer guidance about risk assessments. We found from records and from talking with people, that everyone has access to a GP, and that staff are good at following up any health concerns of people who live in the home. Care plans contain good information about people’s health and medical care needs. One person told service user that staff help them look after their personal needs well – washing their hair and helping them to dress. People also have access to regular health checks, such as from the dentist and optician. We checked a sample of medication stocks and recording and observed medication being administered. This was done with great care, and records are maintained well. We found that there are safe processes for the handling and storage of medication. Staff who give out medication have completed training. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in this home are supported to have a generally good lifestyle. EVIDENCE: Different activities are provided for residents in the home, including celebration of religious and cultural events. One member of staff told us that at Christmas and Diwali, everyone is taken out to a hotel for a party. During the inspection we saw residents taking part in a music session, shaking percussion instruments to music. We saw that staff and the manager spend time talking to people who live in the home. There is an in-house library service, providing books, audio cassettes and CDs for people. People we spoke with involved themselves in different activities. This varies according to people’s wishes. One person told us they go to a day centre during the week; another said they go out to the local shops and to the library. More attention has been paid to providing some activities for people who live Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 15 in the home. People told us they have contact with their families and sometimes go out to visit them at their homes. Two people told us they would like to go out more – this was passed on to the manager to look at further. Staff confirmed that people do not go out very much – more during the summer months. It would be good if the home continued to look at how to provide opportunities for people to go out if they would like to. We saw people who live in the home gathering to have meals in the dining room. The meals are brought in from another home in heated storage containers. Temperatures are tested before the food is served to make sure it is hot enough and safe. Chapattis are freshly made in the home. Any food left is stored and heated for tea if people would like it – or other foods can be prepared in the home, depending on people’s choice. One person told us they like having eggs and toast for breakfast. Everyone we spoke to told us that they like the food and were happy with it. The food is culturally appropriate, mainly Asian foods, with vegetarian and meat dishes served separately. The manager said that staff have been booked on a healthy eating and nutrition distance-learning course, because they have recognised that it would be helpful to learn more about nutrition and supporting people to have a healthy diet. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The safety and wellbeing of people who live in this home is generally well protected. EVIDENCE: People we spoke to told us they felt able to raise any problems with the staff and manager, and that they felt listened to. This was confirmed by people who responded to our surveys also. We saw that there is a written complaints procedure in the home, but the information about our service and the process of making a complaint was not up to date. This needs to be corrected to make sure people have proper access to raise any concerns they have. There is a suggestions and comments box in the home for people to put any comments in they wish. Staff make sure they report any incidents of concern to us, as required. Almost all staff have had training about keeping people safe from harm. We spoke with one member of staff who had not received the training – but they too understood about how to keep people safe and what procedures should be followed where there was any suspicion of harm. The home co-operated with Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 17 a safeguarding investigations, which has been held since the last inspection, following an incident, which happened at the home. People who live in the home are supported by families and by local authorities in managing their money. Everyone has lockable facilities for safe storage. Records are kept of any transactions that the manager is involved with or supports people with. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in this home benefit from living in a generally well maintained environment. EVIDENCE: We looked around parts of the home, including shared areas and some bedrooms. We found that the home has been re-decorated, and it looks much fresher and brighter. There are pictures and decoration throughout, and this makes for a more homely environment. There are also photos of people who live in the home, which creates a sense of belonging. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 19 We saw that people are able to have their own possessions in their bedrooms. People who live in the home told us they have what they need in their bedrooms and that they are pleased with them. They also told us that the home is always fresh and clean – and we found this during our visit. We did note that while there are some signs in the home to help to orientate people, these are written in English, and it may be of benefit to some people living in the home, whose first language is not English, to have signs in languages relevant to them – particularly as some people within the home are developing conditions where they may become more confused. There are still some improvements that could be made to the outside of the building and to the garden area at the back, to make it more attractive and more accessible for people who live in the home. The manager is aware of this and said that there are plans to make improvements over the next year. We saw from written records and documentation that checks are carried out of equipment, and that the manager ensures requirements relating to safe premises are met. The Environmental Health Department recently inspected the food service aspects of the home and found that a very good service is provided. The home has a fire risk assessment in place. There is a new laundry in the home with commercial machines, which are suitable for their purpose in the home. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in this home benefit from a well trained and supported staff team. EVIDENCE: We looked at a sample of staff records and found that staff have had the proper checks carried out on them to make sure they are safe to work with people, such as Criminal Record Bureau (CRB) and collection of references People who live in the home told us that they feel staff look after them well. One member of staff told us “I like working here… I care for [residents] like I would at home”. There is a mixed staff group in the home, and most staff can communicate with residents in one of the Asian languages. Training is given to staff on a regular basis, to help them to do their job well. Staff have had training in areas such as protection from abuse, health and safety, first aid, moving and handling, and National Vocational Qualifications in Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 21 care. Staff told us that they receive support and supervision from the manager to help them to develop in their work. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Fosse Court benefit from living in a well managed home. EVIDENCE: The registered manager remains in place in the home and continues to work to make improvements. One member of staff told us “The manager is good at following up on things, good at looking after staff and residents – that’s why I’ve stayed [for] years – happiness at work matters.” Another member of staff also describe the manager as helpful, “and all-rounder”. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 23 There are processes in place for the home to check the service it gives to residents. One person who lives in the home told us “Every few weeks we have resident meetings. We can talk to the management if we have any problems.” Questionnaires are given to people who live in the home and visitors from time to time, asking for views about the home. The manager makes sure that policies are reviewed on a regular basis. Safety checks continue to be carried out within the home, and staff have training in safety aspects. We saw that a range of checks are regularly carried out, including fire safety checks, temperature testing, and checks of hoist and lift equipment. Staff have training in infection control, first aid and other aspects to make sure they carry out their work safely. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 Requirement The provider must ensure that risk assessments are put in place where a risk to someone’s health or wellbeing is identified – including in relation to moving and handling, mobility, use of bed sides and smoking in the home. Timescale for action 15/05/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that improvements are made to the Moving and Handling Policy in the home, to ensure that training is included and that risk assessments are properly put in place. It is recommended that the manager and staff look at how to provide more opportunities for people (in particular those who are more dependent on staff) to have trips out of the home if they would like to. It is recommended that the complaints procedure is DS0000053757.V374983.R01.S.doc Version 5.2 Page 26 2. OP12 3. OP16 Fosse Court revised so that it show up to date information about the process and contact organisations, to enable people to have proper access to opportunity to raise any concerns 4. OP12 It is recommended that signs in the home to help people to orientate are put up in languages other than English, which would be relevant to people who live in the home. Fosse Court DS0000053757.V374983.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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