Care Home: Ivy Leaf Care Home

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What the care home does well Visitors to the home are welcome and one resident told us, “My brother comes twice a week and I have a mobile phone I can use” There is a varied diet provided and a resident told us, “I like the liver and steak and kidney pies. We have a hot meal every day. Sometimes I don’t feel like a hot meal at night so they do me sandwiches.” There are measures in place to prevent the spread of infection and a resident told us, “They always wear protective clothing when seeing to my care”. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.2 Adults check. A resident told us, “I was worried if they would turn me properly, which was my main priority, but they do it right” What has improved since the last inspection? Staff ensure residents receive the healthcare they need and routine health checks are arranged. Regular training is provided to ensure staff are able to meet people’s needs. What the care home could do better: When anyone new wants to come to live at the home they should have an assessment to ensure their needs can be met in the home and any equipment needed can be put into place before the person moves in. One resident told us, “I didn’t have the right bed, I had to use a divan, and it was horrible. As time went on things got sorted.’” Each person living at the home must have a care plan that clearly describes how their needs are to be met and where a need is identified a care plan must be written for this so that staff know how to meet people’s needs. A resident told us, “If they have got one (care plan) I have not seen it, if there is one I would like to see it out of curiosity.” Medication must be kept secure at all times so someone cannot take it by mistake and ways of promoting people’s privacy and dignity need to be identified. There needs to be more effort put into providing meaningful activities for people to take part in Details about any complaints must be available in the home and staff must know the procedures to follow to ensure residents are safeguarded. There are some days when a cleaner is not working in the home and as a result the home is not kept as clean on those days. A resident told us, “I like my room now I have got my own things in. I wouldn’t be able to go up and down the ramp in the corridor on my own.” There are not always sufficient staff on duty as the carers are having to work in the kitchen as there is not a cook and clean the building when the cleaner is off. One resident told us, “There are always 2 care staff on duty. If I buzz them they let me know how long it will be before they can come to me”. The home must be managed by someone who has been through the registration process to become a registered manager.Ivy Leaf Care HomeDS0000070390.V378066.R01.S.doc Version 5.2 All financial transactions made on behalf of residents must be signed and witnessed Key inspection report CARE HOMES FOR OLDER PEOPLE Ivy Leaf Care Home 29 Gedling Road Carlton Nottingham NG4 3EX Lead Inspector Stephen Benson Key Unannounced Inspection 9th October 2009 09:00 DS0000070390.V378066.R01.S.do c Version 5.3 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. Ivy Leaf Care Home DS0000070390.V378066.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 Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy Leaf Care Home Address 29 Gedling Road Carlton Nottingham NG4 3EX 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) 0115 961 6785 Mauricare Ltd Manager post vacant Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 named service users may be accommodated within category DE/E as detailed in application dated 13/06/06 15th November 2008 Date of last inspection Brief Description of the Service: Ivy Leaf is an adapted property situated in the heart of Carlton, a busy area on the outskirts of Nottingham. The home is situated less than a five-minute walk away from shops, cafes, public houses and places of worship. There are very good public transport links to the home and a small car park to the rear of the building. The service is registered to accept up to 14 people within the category of old age only. Nursing care is not provided at the home. The accommodation comprises two lounges, a dining room with a conservatory and 14 single occupancy bedrooms, three of which have full en suite facilities with 11 having a sink in the room. There are sufficient toilet and bathing facilities available. There is a small garden to the rear. The current fees range from £290 to £350 per week. This fee does not include hairdressing or chiropody services. A copy of out latest inspection report was in the entrance hall. Ivy Leaf Care Home DS0000070390.V378066.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people accommodated and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This was our first visit to the home since 1st April 2009. This inspection involved one inspector; it was unannounced and took place in the daytime, including lunchtime. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. We sent survey forms entitled Have your say about... to a sample of 6 service users and 2 of these were returned. The main method of inspection used is called case tracking which involves looking at the quality of the care received by a number of people living at the home. We also use evidence from our observations; we speak with them about their experience of living at the home; we look at records and talk with staff about their understanding of the peoples needs who they support. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: Visitors to the home are welcome and one resident told us, “My brother comes twice a week and I have a mobile phone I can use” There is a varied diet provided and a resident told us, “I like the liver and steak and kidney pies. We have a hot meal every day. Sometimes I don’t feel like a hot meal at night so they do me sandwiches.” There are measures in place to prevent the spread of infection and a resident told us, “They always wear protective clothing when seeing to my care”. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.2 Page 6 Adults check. A resident told us, “I was worried if they would turn me properly, which was my main priority, but they do it right” What has improved since the last inspection? What they could do better: When anyone new wants to come to live at the home they should have an assessment to ensure their needs can be met in the home and any equipment needed can be put into place before the person moves in. One resident told us, “I didn’t have the right bed, I had to use a divan, and it was horrible. As time went on things got sorted.’” Each person living at the home must have a care plan that clearly describes how their needs are to be met and where a need is identified a care plan must be written for this so that staff know how to meet people’s needs. A resident told us, “If they have got one (care plan) I have not seen it, if there is one I would like to see it out of curiosity.” Medication must be kept secure at all times so someone cannot take it by mistake and ways of promoting people’s privacy and dignity need to be identified. There needs to be more effort put into providing meaningful activities for people to take part in Details about any complaints must be available in the home and staff must know the procedures to follow to ensure residents are safeguarded. There are some days when a cleaner is not working in the home and as a result the home is not kept as clean on those days. A resident told us, “I like my room now I have got my own things in. I wouldn’t be able to go up and down the ramp in the corridor on my own.” There are not always sufficient staff on duty as the carers are having to work in the kitchen as there is not a cook and clean the building when the cleaner is off. One resident told us, “There are always 2 care staff on duty. If I buzz them they let me know how long it will be before they can come to me”. The home must be managed by someone who has been through the registration process to become a registered manager. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.2 Page 7 All financial transactions made on behalf of residents must be signed and witnessed 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. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are not being properly assessed to ensure their needs can be met when they move in to the home. EVIDENCE: We were told in the assessment they completed that, ‘We carry out need assessment of the service users prior to admission and if similar information exist from other professional source we will use it to that end. This makes sure that the home has the right information before the resident is admitted, so that the resident gets the best care. It also makes sure the home can meet the resident’s needs’. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 10 The files for four residents were seen and only one of these had a pre admission assessment in. The information contained in the assessment was limited and did not provide information about all the resident’s needs. The acting manager showed a template or a more detailed assessment that she will be using in the future. One file had an assessment completed by the Local Authority and the manager said she had requested a copy of the assessment from the Local Authority as the one sent had been mislaid. There was a note in one resident’s file stating a District Nurse was unhappy the correct equipment needed by a resident was not in situ before he was admitted. A resident told us, “No one came to see me from the home. I didn’t have the right bed, I had to use a divan, and it was horrible. As time went on things got sorted.’ The acting manager said they had not been given sufficient notice to go out to assess the resident. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents cannot rely on their care needs being fully recorded and up to date within their care plans. Residents have the healthcare support they require but can be placed at risk through medication not being properly stored. EVIDENCE: We were told in the assessment they completed that, ‘The care plans have been done again from all relevant information available. Families have been shown where feasible and agreed. We keep up todate record of care to make sure that residents receive the right care and the staff know what has happened during the day or night’. A sample of three care files were seen which were all different. One contained a detailed description of a resident’s daily routine, but there was key Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 12 information and changes missing in each plan. There was no reference seen to known medical conditions, including dementia, and one file, which was evaluated monthly, did not show any changes that had occurred. Each resident also had a daily log book where daily notes were recorded. There was information contained in these that was not in the care plans and in some instances it was not possible to follow what had been done, for example when a red mark was noticed on a resident, there was no record of the district nurse being informed. A resident told us, “If they have got one (care plan) I have not seen it, if there is one I would like to see it out of curiosity.” The acting manager said she will be redoing all the care plans to make sure all the required information is clearly recorded and kept up to date. Staff said they request visitors not to come into the home if they are unwell and arrange for routine health checks to take place. In our survey forms both residents said they always get the healthcare support that they need. One resident said his leg had swelled up and the acting manager had called the district nurse. The doctor also visited but did not detect the leg was fractured and this was only discovered when he was taken for an x ray when at hospital. A resident told us, “The chiropodist comes regularly, I haven’t had an eye test for a long time, I wouldn’t mind one being done and I think I might need a filling”. Staff said there is an eye test booked for November. The medicine administration records were fully completed showing residents have their medication as required. There was a bag of medication on the office floor, which was waiting to be collected by the pharmacist. Staff moved it when it was bought to their attention. The acting manager said she had not yet decided who was going to act in the role of dignity champion but intended to identify someone soon. One resident was seen being given an injection by a healthcare professional in the dining room just before lunch, which staff did not comment upon, but when asked afterwards said they did not think it was appropriate and the treatment should have been given in private. A resident told us, “I am able to wash some of me, when they have to help they cover me up, its dignified”. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not receive sufficient stimulation, but are able to maintain contact with families and friends and enjoy a varied diet. EVIDENCE: We were told in the assessment they completed that, ‘Activities are provided on a daily basis. This is recorded. A planned programme of activity has been designed with the residents and next of kin and staff involved’. However the acting manager said there is little interest shown in activities and there is not a programme of activities being followed. The acting manager said people enjoy listening to music and enjoy the entertainers. The acting manager said she is planning to have an entertainer every month and have just ordered a game to play on the television. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 14 Staff said there had been someone coming to do armchair exercises but they had not been for a while. The acting manager said this was due to a lack of interest. During the visit residents were watching television, reading a newspaper and listening to music. There was no evidence seen of residents being offered or encouraged to take part in any activity, and staff did not have the time to do so. No records were seen of activities they have taken part in. In our survey forms one resident said there are always activities they can take part in and another said there sometimes are. A relative rote, ‘I would like to see more exercises and sing a longs although most of the residents are immobile and have dementia so it may be difficult’. One resident told us, “I like to watch football, the boss had Sky put in for me. Staff will talk with me when they come to do something.” Residents were heard discussing relatives that visit the home, one resident is visited by her husband almost daily. Another resident said, “My brother comes twice a week and I have a mobile phone I can use”. The menu for the week was displayed in the dining room and this showed there were choices provided some days. Lunch today was fish and chips with mushy peas, which residents said they enjoyed when asked. In our survey forms both residents said they always like the meals in the home. A resident told us, “I like the liver and steak and kidney pies. We have a hot meal every day. Sometimes I don’t feel like a hot meal at night so they do me sandwiches. One resident said he sometimes ordered himself a take away and “I would really like to have a fried chicken take away as a treat”. The acting manager said she would arrange this. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents cannot be confident that the systems intended to allow them to raise any concerns and to ensure they are protected are working properly. EVIDENCE: We were told in the assessment they completed that, ‘A complaint policy is in place . This is widely displayed all over the home. It gives details who to complain and how to complain if service users need to. A complaint book is in place and we are glad to say no complaint has been received at time of filling this form. Staff are aware how to deal with complaint if ever they come across a situation where there was one.’ We have been notified of a complaint since the last inspection concerning the care of a resident, but there was not a record of this in the home, and the acting manager said she was not aware of this. The acting manager showed a complaints register, but not a book to record the actual complaint in and what the outcome was. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 16 After the insepction one of the providers said over the phone that he had dealt with the complaint, had the notes about this, and that he had discussed it with the acting manager. In our survey forms both residents said they know how to make a complaint. A resident told us, “If anything is not right, I have told them, and they have sorted it out”. Staff were aware of different forms of abuse but did not konw the safegaurding procedures they should follow in the event of any allegation of abuse. Part of the procedures were displayed on a noticeboard in the office. A resident told us, “Staff have been really understanding, I haven’t been in any rows with them or anything, they let me get it out of my ststem when I am frustrated, they always come back when I have calmed down. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not live in a home that is kept to a high standard of cleanliness at all times. EVIDENCE: We were told in the assessment they completed that, ‘The home is well maintained, clean and free from odours. It gives our residents a pleasant and homely place to live in’. Areas of the home seen were clean and tidy, and a domestic was working in the home, however she dos not work everyday and we were told the cleanliness of the home suffers as a result of this. During a telephone Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 18 conversation with the provider after the inspection he said he was making arrangements to have a cleaner in the home every day. In our survey forms one resident said the home is always fresh and clean and another said it usually is. There is some work due to start in the next few days to comply with requirements set by the fire brigade over fire safety. The acting manager said that once this is completed there will be a programme of decoration carried out. A resident told us, “I like my room now I have got my own things in. I wouldn’t be able to go up and down the ramp in the corridor on my own.” There are measures in place to prevent the spread of infection, including a system for disposing of soiled waste and having protective clothing available. A resident told us, “They always wear protective clothing when seeing to my care”. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not sufficient staff to meet resident’s needs, but they are suitably trained. EVIDENCE: We were told in the assessment they completed that, ‘We ensure we have staff with good skill mix to provide the right care to our residents’. There were two care staff on duty who also had to prepare lunch as there is no cook at present, and no cover arrangements have been made. Two of the residents who were case tracked require two staff to support them at various times throughout the day. One resident told us, “There are always 2 care staff on duty. If I buzz them they let me know how long it will be before they can come to me”. All care staff have either achieved a professional qualification or are in the process of working towards one. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 20 It was stated on the assessment form that the required recruitment checks are carried out on new staff. A sample of staff files were seen and these showed the correct recruitment practices had been followed. A member of staff said she had undergone the recruitment checks and had an induction when she started work. There is a training programme which provides the training staff require. One staff member said she had missed the food hygiene and dementia awareness courses but had arranged to do these with staff from another home owned by the provider. A resident told us, “I was worried if they would turn me properly, which was my main priority, but they do it right”. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The absence of a registered manager prevents the service being developed in the best interest of residents. EVIDENCE: The acting manager has been in post for over a year but has not submitted an application to us to become registered. Surveys were distributed in June 2009 seeking views on the home. The questions asked did not look at services provided in any depth. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 22 We asked the provider to complete an assessment and return this to us. The information contained in this was brief, there were some differences to what we saw during our visit and did not give sufficient detail about the service and the views of the people living there. There is a wallet system to help residents manage their personal allowances. One wallet did not have any record of when money was given in or paid out, and another had some entries written on an envelope which was not clear and did not have two signatures for each transaction. A third seen was correctly recorded. It was stated on the assessment they completed that equipment is tested or serviced as recommended by the manufacturers or other regulatory body Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The home must have a system for assessing the needs of any prospective new resident. This will ensure that the home can make sure they are able to meet the person’s needs. Care plans must clearly describe how resident needs are to be met and kept updated when there is any change. This will ensure that staff know how to meet residents’ needs. Medication must be stored safely at all times so residents are not placed at risk More frequent and varied activities must be provided. This will ensure that residents have opportunities to spend time doing things they find enjoyable and stimulating. A record must be made of any complaints, which include any investigation and outcome of the complaint. This will ensure that any complaint made is fully investigated All staff must be familiar with the DS0000070390.V378066.R01.S.doc Timescale for action 01/12/09 2 OP7 15 01/01/10 3 4 OP9 OP12 13 16 07/11/09 01/01/10 5 OP16 17 (2) 01/12/09 6 OP18 12 01/01/10 Page 25 Ivy Leaf Care Home Version 5.3 7 8 OP26 OP27 13 18 9 10 OP31 OP35 18 17 procedures to follow to safeguard residents if there is any suspicion of abuse. This will ensure that staff know how to protect them. Ensure the home is kept to a good standard of cleanliness at all times. There must be sufficient staff on duty at all times. This will ensure that staff are available to meet residents’ needs. The home must be managed by a registered manager All financial transactions made on behalf of residents must be signed for and witnessed. This will ensure that their financial interests are safeguarded 01/12/09 01/12/09 01/02/10 01/12/09 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 2 Refer to Standard OP19 OP33 Good Practice Recommendations Notify us when the fire officer has approved the work they have required to be carried out. Develop the quality assurance questionnaires to ask questions in more depth. Ivy Leaf Care Home DS0000070390.V378066.R01.S.doc Version 5.3 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@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). 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