Care Home: Masson House

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What the care home does well Masson House is over two hundred years old, and has superb views over the local countryside. As a result it has a `homely` atmosphere, and the building has character, rather than being a functional modern building. When asked., the people who live at the care home spoke positively about their experiences, and said that they liked living there, comments about the food were particularly positive. A visiting relative, also spoke positively about the home, and said that their relative was happy living there. What has improved since the last inspection? The dining room, lounge and kitchen have been decorated. Bedrooms 2 & 3 have been decorated, and the sash window in room 7 is being repaired. The hall has been replastered and decorated. Carpets in three rooms have been refitted, as has the top landing. What the care home could do better: As a result of this key inspection visit five statutory requirements havce been made. These relate to: Assessments of need must be dated and signed, and in sufficient detail to allow staff to be able to understand what needs people have. Assessments must be kept under review, and updated when necessary. Care plans must contain enough detail so that staff know how to meet people`s needs. The contact details for the Care Quality Commision must be correct and up-to-date. A functional quality assurance system must be in place to monitor the quality of the home, and identify areas for improvement. In addition ten good practice recommendations have been made. Key inspection report Care homes for older people Name: Address: Masson House 86 Derby Rd Matlock Bath Matlock Derbyshire DE4 3PY     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rob Cooper     Date: 2 8 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Masson House 86 Derby Rd Matlock Bath Matlock Derbyshire DE4 3PY (01629)55740 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Brian Richard Boam,Mrs Hazel Teresa Boam Name of registered manager (if applicable) Mrs Hazel Teresa Boam Type of registration: Number of places registered: care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Masson House is a grade II listed building and is approximately two hundred and fifty years old. The care home is situated opposite Masson Mill on the outskirts of Matlock Bath. Set within woodland grounds, only the frontage of the building is accessed by residents and visitors. There are a limited number of car parking spaces to the front of the property. The care home provides residential care for up to seventeen older people with a wide range of personal care needs. Accommodation is provided on three floors, with access to all floors by shaft lift or staircase. Care Homes for Older People Page 4 of 27 Over 65 17 0 1 1 0 3 2 0 0 9 Brief description of the care home At the last key inspection, which took place in June 2010 the manager/ owner said that the weekly fees ranged between: £364 and £375. 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit as part of the key inspection process, so that no one at Masson House knew that the inspection visit was going to take place. The visit took approximately seven hours through the middle of the day, with two inspectors present. In preparing for this inspection, the information that the Commission holds about this care home was reviewed, this included looking at the last inspection report, the inspection record, considering any complaints or concerns that have been made about the service, and reviewing any notifications made relating to incidents that affect the well being of people living at Masson House. The methods used during this key inspection and visit were to visit the care home, Care Homes for Older People Page 6 of 27 where a method called case tracking was used; this involved identifying four people and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour, looking at the activities on offer, and talking to three people who live there, one relative and three members of staff about the quality of the service, and their experiences of living and working at Masson House. We also sent out an Annual Quality Assurance Assessment (known as an AQAA), which allowed the home to carry out a self-assessment; and provide a range of information relating to their service. Information provided by them helped to form the judgements in this report. We also sent out ten surveys asking for views and information to people who live at the home and five to relatives. Of these we received three surveys from people living at the home and three surveys from relatives, which also helped with the judgements that we made. The registered manager/ owner Hazel Boam provided much of the information during this key inspection visit. On the day of this inspection there were nine people living at Masson House. People who might want to live at Masson House can obtain information about the home direct from them, and this would include seeing previous inspection reports prepared by the Care Quality Commission. Alternatively previous inspection reports are available on the Care Quality Commissions web site at: www.cqc.org.uk 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 order line 0870 240 7535. Care Homes for Older People Page 8 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 9 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments of need are in place, however they are limited, and do not identify all of the individuals needs. Evidence: The care files for four people who live at Masson House were seen. These all had an assessment of need in place, which had been completed in-house. The detail within the assessments was brief, and did not cover the full range of needs that each individual might have, with in most cases just a few words to describe an area of need. None of the assessments that were seen provided a good basis for the care planning process. A number of the assessments were not signed or dated, and therefore it was not possible to assess whether the assessments had been reviewed, no other evidence to support the view that the assessments had been reviewed was seen. Care Homes for Older People Page 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some individuals are potentially at risk from having care plans and risk assessments in place which lack crucial information, to direct staff in the best practice to keep people safe, and meet their needs. Evidence: Of the four care files seen, all of them contained a set of care plans. One person who had moved from another care home, still had the documentation from that home, and this was found to contain some inappropriate words and phrases, such as Do not contact the priest for silly reasons, and he is allowed two cigarettes a day. All of the care plans, in all four care files were brief, and lacking in detail. The care plans did not have clear instructions to the staff on how to meet peoples needs. Currently all recorded information relating to a persons care is entered into the daily notes which means finding specific information is both time consuming and complicated. Evidence was seen that care plans were being reviewed on a monthly basis, however use of the phrase: No change shows a routine approach rather than a considered review of the care plan. In addition risk assessments were seen in files, these however were again very brief, with little detail, and no obvious evidence that the risk assessments had Care Homes for Older People Page 11 of 27 Evidence: been reviewed. Information relating to health care professionals such as visits to the doctor, or by the nurse, and any hospital visits were recorded in the files, and general information about opticians was also recorded, however there were few specific care plans relating to health in place, with most information being recorded in the daily notes. Dicussions with two people who live at the care home showed that the staff would get them a doctor if they were unwell, and if they needed one. During the inspection visit the vitising District Nurse was spoken with, and she directed the inspector to her line manager for further comment. Concerns have been raised in the past about physical care. Boots the chemist provides Masson House with their medication. An inspection of the care homes medication systems showed that medication is handled safely. Administration records were seen and found to be complete, with no obvious errors or omissions. The records relating to an individual who self-medicates were seen, together with the storage facilities, and found to be correct. All aspects of the medication procedures for checking medication in and out of the building showed a clear audit trail for medication, and indicated that medication procedures were safe. Evidence of Boots having provided training to staff around medication procedures was seen in the staff files. Discussions with people who live at Masson House, and observation of the staff working with people, showed that the staff treated people in a respectful and dignified manner. This included observing staff knocking on peoples doors before entering, and speaking in a respectful manner. In their AQAA they said: We offer flexible arrangements for getting up and retiring to bed. We offer flexible meal times. we encourage residents to choose how they spend their day and respect and support these choices. Discussions with people who live at Masson House produced the following: The staff are very kind. I decide what time I get up and go to bed. I like living here. Comments received in the questionnaires sent to the home by the Commission included: We are happy with the care that is given to everyone. Masson House is a homely place in lovely surroundings. All of the staff and carers are friendly and helpful. I consider myself lucky to get a place in this home from home. They keep me comfortable and secure. I am pleased with the staff and management who are always helpful to me. Care Homes for Older People Page 12 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 lifestyle that reflects their cultural and social interests, and needs. Evidence: The day of the inspection visit was very warm, and many of the people who live at the care home, were outside enjoying the sunshine. No organised activities were observed on the day of the visit. One person went out with a neighbour to walk their dog in the hills above Matlock Bath, and documentation in files recorded activities such as: reading newspapers and watching TV. Notes in another persons file said that they: wrote letters, makes modles and walks the next door neighbours dog. In the dining room there were a number of ceramic pots which had been made by people at the care home, these however had been mentioned in previous inspection reports, and there was no evidence seen to suggest this was a current activity. In addition there were collages made by the people at the home, on the dining room wall, but again no indication that this was a current activity. A relative who was spoken with said: There are things to do and she (their relative at the home) enjoys these. The home have just made a big thing of the World Cup. Among the activities that the relative identified as taking place were: Bead making, flower making, nail painting, reading and making hats at Easter. Masson House produces a newsletter, and the June 2010 copy says: We are hoping to make one outing per month, starting from the end of Care Homes for Older People Page 13 of 27 Evidence: June through to September. Also The next planned musical visit will be in early July. There will be a Reminiscence talk with memory box, by a visitor on 15th June at 2:30pm. In their AQAA the home said: Last year the home was invited to take part in a promotional DVD, for positive adult learning and interaction. The home was filmed during a music and exercise session with our local activities provider (First taste.) The DVD will be used only by the sector to promote continuing activities and intreraction with the older age groups. One relative was spoken with during the inspection visit, they had been visiting regularly for a few months, and spoke positively about the home, and the staff. Their relative appeared settled and happy living at Masson House, which the visitor found to be clean and tidy. The relative said that: The staff are nice and caring towards my relative, who says that she likes the staff. Staff were observed to see how well they interacted with the people who live at Masson House, and whether choices were being offered. This was seen to be a positive situation with choice offered particularly around food and drinks. Staff demonstrated how choices were offered at meal times, and the staff talked about how activities were organised, and choice was offered. Discussions with three people indicated that they thought they had control over a lot of things in their lives. Comments received included: They come round and ask us what we want for dinner, there are usually two choices. I decide when I get up, I get up when I want, and I decide what time I go to bed. Im very satisfied with the care I get, the staff are very nice, and they ask me what I want to do. On the day of this inspection visit there was a choice between cheese pie and chicken for the main course. The food was well presented, and the dining room was attractively laid out for people, with individual place settings. All of the people spoken with said good things about the food with comments such as: Very good, I love the fish and chips. The food is very good, theres always a choice. Comments received in questionnaires included: Meals - home cooked and choice. Care Homes for Older People Page 14 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are policies, procedures and systems in place for complaints and safeguarding referrals. Evidence: Masson House has not received any complaints since the last key inspection in March 2009. The homes complaints procedure is on display in the foyer, and also forms part of the service user guide. The complaints procedure does make reference to the National Care Standards Commission, rather than the Care Quality Commission, and this needs to be be changed/ updated. Discussions with three people who live at the home indicated that they would speak to the manager/ owner if they were not happy. Discussions with a relative about the complaints procedure identified that they would also speak to the manager/ owner, but so far, this had not been necessary. In their AQAA Masson House said: We listen to the residents, the staff and relatives so that we can deal with any concerns before they need to become a complaint. We follow the guidelines for recruiting staff that supports the safeguarding of vulnerable adults. The Commission has received one complaint since the last key inspection, which was referred back to the manager/ owner for investigation. A review of the staff training records in relation to safeguarding adults, showed that care staff had undertaken this training in the last twelve months, although the records were not clear or up to date. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering people greater Care Homes for Older People Page 15 of 27 Evidence: protection against abusive practice, while also making sure that the staff understand the correct policy and procedure to follow if abusive practice is found. Three members of staff were asked about safeguarding adults training and they said they were aware of the issues, and had undertaken this training. On the day of this inspection visit a safeguarding referral was made with regard to poor moving and handling techniques, a subsequent safeguarding meeting found that the poor moving and handling techniques had occured. Care Homes for Older People Page 16 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. People live in a comfortable home, with their personal possessions around them, this means that people are living in homely surroundings rather than an institutional setting. Evidence: Masson House is a Grade II listed building being over two hundred and fifty years old. A partial tour showed that it was comfortable and spacious. Discussions with three people who live at the care home showed that they thought the care home was comfortable and meets their needs. Several bedrooms were seen, and these were well personalised, and homely, with some having en suite facilities, although not all. Everyone who was spoken with said they felt they had everything they needed, and that they thought their bedrooms were comfortable and the home was well equipped. Discussions with the manager/ owner about the bathrooms, identified that there were plans to upgrade both bathrooms. The seat on the bath hoist on the first floor was found to be scatched in several places, which could encourage bacteria to grow, and the toilet in the upstairs bathroom smelt strongly, despite having been flushed. Domestic staff were seen cleaning in different parts of Masson House during this inspection visit, and discussions with staff showed that there were systems in place for cleaning, and that the care home had a good supply of cleaning materials. The building was found to be clean, and smelt fresh, with no obvious problem apart from Care Homes for Older People Page 17 of 27 Evidence: the upstairs toilet. In relation to cleaning Masson House said in their AQAA: we provide a homely environment that is versatile and comfortable. We provide a safe and clean environment. Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at Masson House have been through the necessary recruitment checks, and are receiving training to do their jobs. Evidence: The staffing rota was reviewed and this showed that there were enough staff employed to meet peoples needs. Three people living at the care home were asked about staffing levels, and they said that they thought there were enough staff. The relative who was spoken with, did not feel that staffing levels were an issue. Observations on the day of the inspection visit did not raise any concerns over staffing levels. The care industry considers National Vocational Qualifications (NVQ) to level II in care to be the basic qualification for staff working in residential care. A review of the staff training records together with information provided in the AQAA showed that currently there are fourteen care staff at Masson House, of whom six have NVQ level II or above. The National minimum standard is for 50 of the staff to be trained to at least NVQ level II. The files of six members of staff were seen, to check that they contained all of the information that would show that staff at Masson House had been recruited in a safe manner, namely that applicants had filled out an application form, provided two Care Homes for Older People Page 19 of 27 Evidence: written references and had had a Criminal Records Bureau check. The documentation showed that the recruitment policy and procedure had worked to protect the people living there. Discussions with three members of staff about their recruitment showed that they had gone through all of the pre-employment checks, and had not started working until those checks had been completed. The staff training records showed that the staff were receiving the training to help them to do their jobs, including the mandatory training in moving and handling, fire safety and food hygiene. The staff training records are held in individual files, which means that checking them is currently time consuming, a centralised training record, would provide instant access to training information for all staff. discussions with three staff members provided evidence of the training courses staff had attended, including training in dementia and health & safety. Some staff training records were not up to date, with training courses having been attended, and the information not recorded. The training records also did not accurately reflect an individual member of staffs training requirements, not just the courses they have attended, but also those needed (a training plan.) Care Homes for Older People Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Masson House has management systems in place, however there are shortcomings in those systems, which potentially could leave people who live at the home at risk. Evidence: Hazel Boam is the Registered manager and owner of Masson House. She has been judged by the Care Quality Commission to be a fit person to run a care home. Hazel has been the manager/ owner of Masson House for twenty years. The Annual Quality Assurance Assessment (AQAA) was received in June 2010, within the time frame asked for by the Commission. The document lacked depth, and while providing basic information, it did give a clear picture of the activity at Masson House. The last key inspection was in March 2009, and three statutory requirements were found to be still outstanding/ not havving been addressed to a standard where the requirement had been met. Care Homes for Older People Page 21 of 27 Evidence: Masson Houses quality assurance system is currently being re-developed with input from the County offices. There are numerous audits of the activity that takes place at Masson House, and questionnaires are also given to people who live at the home and relatives and visitors. Discussions with the manager highlighted that there is an acknowledgement that the current system is floored, and hence the input from the Council. Masson House do hold meetings for the people who live there, and minutes of previous meetings were seen. In addition there is a suggestion box in the hall way, at the bottom of the stairs for visitors to place comments. Currently only one person has their small cash needs monitored on their behalf by the staff. This persons finances were checked at random. All of the cash tallied with the records, and receipts were seen, which enabled a clear audit trail of the individuals financial expenditure to be followed. Masson House has a formal staff supervision system in place, in which staff receive supervision, either with the manager or with one of the other senior members of staff. This is usually in a one to one meeting. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. Three members of staff were asked about formal supervision, and they all said they felt well supported. The staff supervision records showed that staff were not having formal supervision in line with the National Minimum Standard, which is a minimum of six times a year. A range of different health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) records, all were found to be correct and up-to-date. Evidence was seen that routine health & safety checks are being carried out, and the staff training records showed that staff were receiving relevant training in health & safety related issues. Care Homes for Older People Page 22 of 27 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 2 14 All assessments must be reviewed on a regular basis. This to ensure the home can still meet the persons on going care needs. 30/04/2009 2 7 12 Risk assessment must 30/04/2009 provide sufficient information for staff and appropriate strategies for must be in place for the identified areas of risk. This is to ensure stafff have the knowledge to care assist the person and minimize the hazards or risk. 3 7 15 Comprehensive individual 30/04/2009 care plans must be developed for each person to demonstrate their assessed need . This is to ensure they will receive the appropriate level of care. Care Homes for Older People Page 23 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 3 14 Assessments of peoples individual needs must be kept under review, and updated when necessary. This is to ensure that peoples changing needs are identified and their care needs are being met. 30/08/2010 2 3 14 Assessments of need for individuals living at the care home must be dated and signed, and in sufficient detail to allow staff to be able to identify and understand what needs people have. To ensure that people living at the care home have their needs identified and they can then be met. 30/08/2010 3 7 15 Care plans must contain enough detail to ensure that staff know how to meet peoples needs, and what is 30/08/2010 Care Homes for Older People Page 24 of 27 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 required of them to meet those needs. This is so that people living at the care home have all of their needs fully and competently met by the staff caring for them. 4 16 22 The contact details for the Care Quality Commision within the complaints procedure must be correct and up-to-date. This will ensure that people living at the home, their relatives and visitors will be able to contact the Commission if they so wish. 5 33 24 A functional quality assurance system must be in place to monitor the quality of the home, and identify areas for improvement. This is so that improvements in the quality of service, and in the car home can be identified and their progress measured. 31/08/2010 31/07/2010 Care Homes for Older People Page 25 of 27 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 When care plans are being reviewed, the information recorded should be in sufficient detail to demonstrate on what basis the judgement to ammend or continue unchanged was based. The identified individual who has care plans from another care home, should have this changed over to Masson House documentation. Specific information should be recorded in the care plan, rather than in the daily notes. This will make it easier to find, and for important information related to health, for example, it will ensure that information is together in one place. Better recording and use of photographs that are captioned and dated would provide strong evidence of the range and type of activity on offer at Masson House A central register of safeguarding adults training for staff, with names, dates and details relating to who provided the training will provide clearer evidence that staff have attended this essential training, and that the training is up to date. Plans to upgrade and refurbish the bathrooms should be made a priority. The seat on the bath hoist in the first floor bathroom should be replaced, as this potentially could harbour harmful bacteria. 50 of the staff team should be qualified to National Vocational Qualification (NVQ) level II. A centralised staff training record should be introduced to provide quick and easy access to those staff training records, making monitoring easier for managers and inspectors. Staff training records should be up to date, and accurately reflect both the individual staff members training achievements (training courses attended) and training requirements (training courses required.) Staff should receive formal supervision a minimum of six times a year, with the outcome recorded and available for inspection. 2 7 3 7 4 12 5 18 6 7 19 19 8 9 28 30 10 30 11 36 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. 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