Care Home: Micron House

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What the care home does well People who may wish to come to live at the home are provided with good information about the service and opportunities to visit and/or spend a trial period at the home. Their needs are assessed and care plan is produced to ensure the staff team are aware of how these are to be met. A comfortable, clean and well maintained environment is provided for people to live in and the atmosphere is homely and relaxed. Support is provided to enable them to maintain their independence where possible and assistance is provided where required. Good arrangements are in place to ensure people`s individual health, personal and social care needs are met and their visitors are made to feel welcome by staff. There is a good variety of food and menus meet dietary needs and personal preferences. People are encouraged to express their views. There are procedures and systems in place for handling complaints and protecting people who live in the home. There is a stable staff team made up of people who receive ongoing training and supervision. The manager is committed to maintaining high standards and making improvements where possible. What has improved since the last inspection? The service continues to review its care planning and social programme to ensure all people`s needs and preferences are identified and met. Improvements have been made to the ground floor toilet and bathroom, providing better access to people with limited mobility. The manager/proprietor is supported by an assistant manager who has previous experience working in a care setting. Staff practice continues to be monitored and training is arranged to meet their needs and update their knowledge and skills. What the care home could do better: The service continues to address issues to improve the environment. An annual programme for refurbishment and decoration should be produced and include work needed to improve the first floor bathroom and a ground floor toilet. The service manages medication on behalf of all people living at the home. There are exceptions where people are managing some of their prescribed medication/creams. This should be clearly detailed on her/his file. A protocol should be produced, in some circumstances, for individual`s who are prescribed "as required" medication to ensure a consistent approach to administering this is followed by staff. Practices should be regularly reviewed with staff to ensure they remain familiar with all aspects of managing medication. The service has monitoring systems for different aspects of care. However, it would benefit from a more planned approach to monitoring and reviewing all aspects of the service in order to assess its own overall performance and produce a plan for future development. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Micron House Micron House 41 Halesowen Road Netherton Dudley West Midlands DY2 9QD     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Linda Elsaleh     Date: 0 3 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Micron House Micron House 41 Halesowen Road Netherton Dudley West Midlands DY2 9QD 01384230504 01384230504 gail@activecareservice.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Gail Benita Butcher care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: One service user (female) identified in the variation report dated 6 July 2005 may be accommodated at the home in the category MD(E). This will remain until such time that the service users placement is terminated. Date of last inspection Brief description of the care home Micron House is registered to provide personal care to a maximum of ten older people. It is located in Netherton, near Dudley and situated near to a number of amenities and facilities, such as a variety of shops, library, arts centre and park. The main Netherton Health Centre is close by. The home is on a main bus route leading to Cradley Heath in one direction and Dudley in the other. The building is a traditional, detached property. The ground floor houses the lounge, dining area, conservatory, kitchen and laundry. Care Homes for Older People Page 4 of 29 Over 65 10 0 Brief description of the care home Bedrooms are situated on both floors and consist of six single bedrooms, four of which have en-suite facilities, and two double bedrooms. Toilet and bathroom facilities are located on both floors. There is a generous sized rear garden which is on two levels with a ramp leading to the lower level. A small car park is available at the rear and a public car park is opposite the home. The reader is advised to contact the service for up to date information about the fees for this service. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection visit was undertaken by an inspector from the Commission for Social Care Inspection (CSCI). The purpose was to assess the services performance against the key standards in the National Minimum Standards for Care Homes for Older People and report on the progress made to address issues raised at the previous inspection. Our findings are based on the information received by us about the service, the Annual Quality Assurance Assessment completed by the service, comment cards returned by people who live at the home and their relatives. During the visit we spoke to the manager, staff and some people who live at the home and looked at a sample of documents and records kept by the service. Here are some of the comments we received from people about the overall service. Care Homes for Older People Page 6 of 29 Ive been at Micron House now nearly 3 yrs and are very happy here, Very happy with care home and staff and it is a good home I am glad I came here. What the care home does well: What has improved since the last inspection? What they could do better: The service continues to address issues to improve the environment. An annual programme for refurbishment and decoration should be produced and include work needed to improve the first floor bathroom and a ground floor toilet. The service manages medication on behalf of all people living at the home. There are exceptions where people are managing some of their prescribed medication/creams. This should be clearly detailed on her/his file. A protocol should be produced, in some circumstances, for individuals who are prescribed as required medication to ensure a consistent approach to administering this is followed by staff. Practices should be regularly reviewed with staff to ensure they remain familiar with all aspects of managing medication. The service has monitoring systems for different aspects of care. However, it would benefit from a more planned approach to monitoring and reviewing all aspects of the service in order to assess its own overall performance and produce a plan for future development. Care Homes for Older People Page 8 of 29 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 set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering moving into this home are provided with the necessary information to make an informed choice about where to live. Assessments and visits to the home ensure that people know, before they move in, that their needs can be met by the service. Evidence: The service has a Statement of Purpose and Service User Guide that is provided to people who may wish to come to live at the home. A pre-admission assessment is undertaken by the service to ensure it is able to meet the individuals needs and preferences. The files of three people living at the home with different needs were selected to be case tracked. Each contained a copy of their assessment and risk assessments. People living at the home told us they were provided with information before they came to live here. All staff are supported by the service to obtain the National Vocational Qualification (NVQ) in Health and Social Care. A training programme is produced for staff to continue to develop their skills and update their Care Homes for Older People Page 11 of 29 Evidence: knowledge. The service encourages people to visit the home and have a trial stay before a placement is agreed. Details of visits and stays are kept on the persons file. People we spoke said introduction to the home was a positive experience. Two comments we received were A number of visits were made to the home and I was shown the home given a book about it and came for a trial. Relatives were also positive about their experience. One relative reported they, visited a few homes. Micron House seemed the most suitable - my relative has been here eight years. The service does not offer an intermediate care service. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care needs are set out in their care plans and are met according to their personal preferences. A varied programme of activities is provided to meet peoples social needs. They are treated with respect and their privacy and dignity is maintained. Suitable arrangements for the ordering, receiving and returning medication are followed. However, to ensure peoples health and well being is more fully promoted and protected the service needs to address the shortfall in its procedures and practice. Evidence: Care plans are produced by the service based on the assessment information. The plans provide staff with details of the individuals needs and how these are to be met. Recording systems are in place to inform the internal monthly monitoring of the plans. Risk assessments as changes are identified and on a planned regular basis. One persons record shows the service has sought advice from the NHS Rehabilitation Team about meeting her/his needs. Details are also available on another persons file about the recent review held of her/his care plan. Comments received from the Care Homes for Older People Page 13 of 29 Evidence: majority of people living at the home told us staff are available when they need them. I can ring staff from my bed with bell. People who live at the home are registered with a GP of their choice and are supported to access community-based health care services, such as dentist, optician, and chiropodist. One person received a visit from the community nurse during our visit. We heard another person checking with staff the day their doctor had arranged to visit. All the people we spoke to and those who responded to our surveys told us they always receive the medical support they need. An example of the comments made is They call the doctor or nurse when I want them. A relative told us If I am unable to take my relative to a hospital appointment they (staff) always make sure there is a carer available. The majority of medicines are provided by the pharmacist using a monitored dose system. There are adequate arrangements for storing medication. The documents seen show suitable systems are in place for recording all medication received by the service and returned to the local pharmacist. At present, there are no controlled drugs on the premises. The service manages the medication on behalf of all people living in the home, with the exception of some creams. Staff identified a person who applies their own cream. This was not detailed in her/his care plan. The manager should ensure clear details of this arrangement (ie: cream applied by individual with/without staff support and where it is being stored ie: in the persons bedroom) is included their plan. A risk assessment should be undertaken for the self-administering of creams/medication and a system for monitoring this, where applicable, should be agreed. The medication administration record (MAR) sheets show some people are prescribed medication as required. Protocols for how decisions are made for administering these are not produced. Again this is an area that needs to be addressed to ensure a consistent approach is followed by staff. Some medication is not dispensed in monitored dosage system. The reasons for this may be it is not suitable for this system and/or has been prescribed outside the usually delivery time (ie: a short course of antibiotics). Medication is only managed by staff who have been trained to do so. Discussions held show they are familiar with procedures and practice for most areas of their work but did not fully understand issues in respect of secondary dispensing and what is/is not acceptable practice. The manager and deputy assured us this will be addressed and additional training provided. The medication policy was last reviewed in 2008. The manager is consulting with the local pharmacist about good practice issues and this will be incorporated into her review of the medication procedures to ensure all aspects of managing and administering medication is included. One person, whose medication is managed on her/his behalf, said I have my tablets the same time every day. Care Homes for Older People Page 14 of 29 Evidence: People were observed being treated with respect by staff who addressed them by their preferred name. Staff told us they feel supported in meeting peoples needs and respect the individuals right to dignity and privacy. We observed staff knocking peoples bedroom doors before entering. A person was seen by the community nurse in the privacy of her/his own bedroom. Care Homes for Older People Page 15 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home are supported to exercise choice and control over their lives and offered a varied activity and social programme that satisfies their social, cultural and religious interests and needs. They are encouraged to maintain significant relationships and family and friends are welcome to participate in different activities and celebratory events. Meals are wholesome and meet the nutritional needs and personal preferences of people who live at the home. Evidence: Information about peoples interests and preferred activities were not included in the care plans we looked. However, an activity log is kept detailing the activities a person took part in and whether s/he had enjoyed it. The people who expressed an opinion said the service arranges a varied programme of activities including singalongs and occasional bingo. Some individuals like to go on shopping trips or, when the weather is good, to visit the local park. Entertainers are periodically booked. One person told us they often enjoy a game of dominoes and doing crosswords. Another person told us I watch television and we have parties. There is an extensive photographical record of activities and events such as making Easter bonnets, preparing for Care Homes for Older People Page 16 of 29 Evidence: Halloween, celebrating Christmas and other important occasions. As well as capturing the enjoyment of people who live at the home it also shows relatives and staff enjoying the occasion with them. One relative told us the home always prepares a lovely buffet for these occasions. The service has an open door policy for visitors. People often receive their visitors in the lounge because they like other people living in the home to join in the conversation. They also have the option of receiving their visitors in the privacy of their own room or a communal room that is not being used, for example the conservatory. Local church members visit frequently to give a service and provide companionship. There are no safety concerns about people making their own choices and decisions about the lifestyle they wish to follow. The senior team has recently attended seminars on the Mental Capacity Act and the Deprivation of Liberties Act. The manager told us arrangements will also be made for all staff to attend these seminars. Information is displayed for the Dudley local advocacy service and staff support people who wish to access this service. Bedrooms are personalised with photographs, ornaments and some individuals have brought in small pieces of furniture. One person told us I brought the things that are important to me when I came. All staff has received training in basic food hygiene. Meals served at the home are described by people living here as always or usually to their liking. One person told us Yes, very satisfied and another said If I dont like it they give me something I like instead. The lunch viewed was nicely presented and well received. Records are kept of meals taken by individuals for monitoring purposes, where required. Menus are reviewed in consultation with people living in the home. A choice of meals, such as a light or cooked breakfast and hot or cold evening meal is provided each day. Some lunches, such as Sunday roast, is usually agreed between the residents, although an alternative will be provided on request. Meals are usually served in the dining area and viewed as a social occasion by the residents and staff. Staff was pleased to tell us the home had been awarded a Four Star Healthy Eating Certificate by the Environmental Health Agency. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home and their relatives are confident their views will be listened to and acted upon. The service has systems in place to handle complaints and protect people from abuse. Evidence: The Statement of Purpose and Service Users Guide include copies of the complaint procedure. A copy is also displayed in the entrance of the home. The service has received five complaints and dealt with these in accordance with its procedures. People who responded to our survey and those we spoke to us during this visit tell us they know how to make a complaint and who they would speak to if they were unhappy or worried. Relatives confirmed they also had a copy of this and know who they would approach. One relative told us I have never had any concern for my relatives well being. We visit at least 4 times a week and have never had any complaints. Staff we spoke to also confirmed they know how to deal with any concerns raised by people who live at the home or their relatives. A complaint was been made directly to us and Dudley Metropolitan Borough Council. This is being dealt with under the safeguarding procedures. The service is cooperating with the on-going investigation. A copy of the Department of Health (DOH) document No Secrets and Dudley MBCs Safeguarding Policy is available in the home. The service also has a whistle-blowing policy. Staff records show they have attended training in protecting people from abuse. Staff demonstrated they Care Homes for Older People Page 18 of 29 Evidence: understood the issues and how to report any concerns. Care Homes for Older People Page 19 of 29 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 homely, clean and safe environment which meets their needs. The home is hygienic and free from malodours. Evidence: The rear garden is of a generous size and on two levels. On the top level is a patio for people to sit out if they wish and where barbecues are held in the summer months. The bottom of the garden is accessed by a ramp walkway leading to a lawn area. The manager told us work will be carried out to make it ready for people to enjoy in the finer weather. The communal areas, lounge, dining area and conservatory are decorated and furnished to a good standard creating a homely atmosphere. Since our last visit a ground floor toilet has been refurbished providing easier access for people with limited mobility and a walk-in shower has been fitted in the bathroom. The upstairs toilet and bathroom is in need of similar attention, as is the ground floor toilet that is mainly used by visitors and staff. These areas should be included in an annual renewal and refurbishment programme for the premises. The bedrooms we looked at are personalised with ornaments, pictures and family photographs. People are encouraged to bring some items of furniture with them, space allowing. One person told us I have a lovely bedroom, it is always clean, all the Care Homes for Older People Page 20 of 29 Evidence: home is. There are infection control procedures in place. All staff has received training in this area and we observed good practices being followed throughout our visit, such as wearing the relevant protective clothing when carrying out different tasks. Everyone we spoke to, and those who responded to our survey, said the home is always fresh, clean and tidy. We found the home to be hygienic and free from any malodours. Care Homes for Older People Page 21 of 29 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. People who live in this home are cared for by sufficient numbers of staff who are wellmotivated and trained to do their jobs. They are protected by the homes recruitment procedures and practices. Evidence: The service has appointed a new assistant manager who is experienced in working in a care setting. There is a stable staff team who have different life experiences and skills. People are supported by them to maintain their independence and given assistance, where required, in accordance with their care plans. People living at the home told us they were happy with the number of staff on duty and relatives commented a member of staff is always available when needed. The manager said the service does not employ agency staff. Any absences are covered by the staff team and a on call system is in operation to manage short notice absences and/or unplanned for situations. Staff told us this provides people with a consistent approach to their care by staff they know. Information provided by the service show over 66 of the staff team hold a National Vocational Qualification (NVQ) Level 2 or above. New members of staff, who do not hold a recognised qualification, are registered on this course once they have completed a satisfactory induction programme/probationary period. Care Homes for Older People Page 22 of 29 Evidence: A sample of two staff files, including the most recent employed member of staff, show the service has followed a satisfactory recruitment process. These contained written references and appropriate pre-employment checks, such as receipt of a Criminal Record Bureau (CRB) check, prior to the person commencing work. The application form completed by the most recently appointed member of staff states they hold an NVQ qualification. The manager is still waiting for this to be provided. She is advised to request applicants to produce any relevant certificates as part of the interview process in order for these to be verified. The records show a detailed induction programme is carried out with all newly appointed staff. The files show a training programme is provided for staff to develop and update their knowledge and skills. Those we spoke to told us they feel they receive a good level of training. The records show all mandatory training, such as basic first aid, food hygiene, infection control and moving & handling is provided and client-centred training includes dementia care and mental health. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well managed home that is run in their best interests. There are systems in place to promote and protect their health, safety and welfare. While there are systems for regularly reviewing some aspects of the service, a more comprehensive approach would better able the home to assess its overall performance in meeting its stated aims and objectives and plan for its future development. Evidence: The manager is also the proprietor and is well qualified and experienced in home management. She attends training to update her own knowledge and skills. At present she is working towards the NEBOSH certificate and has attended seminars with her deputy on the Mental Health Act and Deprivation of Liberties Act. The service does not generally handle money on behalf of the people who live at the home, preferring they remain independent or for a family member to be responsible. However, there are procedures to ensure residents money and personal items are kept safe. Where small amounts of money are looked after by the service records are Care Homes for Older People Page 24 of 29 Evidence: kept of the amount received, spent and receipts are obtained. The staff team on duty were relaxed and friendly and said they enjoyed their work and had good relationships with visiting health care professionals. They feel supported by senior staff and are provided with regular supervision sessions. Records of these sessions are available on their files. Relatives tell us they are made to feel welcome by staff and the manager is available if they wished to speak to her. We sampled some records for the servicing, maintenance and regular monitoring of appliances and equipment, such as the lift and bath hoist, portable electrical appliances and fire safety equipment. This shows suitable arrangements are made for regular servicing to be carried out by a person qualified to do so. The service has additional monitoring systems that identify and address issues that may arise. The manager told us about its arrangements to minimise any convenience to people living here when work needs to be carried out on the premises. Health and safety, including safe working practices, are included in the training programme for staff. We discussed with the manager systems for assessing the services own performance and producing an annual development plan based on its findings. She told us a comprehensive quality assurance system had yet to be implemented and recognised this was an area the service needed to address. Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 29 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 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 9 Medication procedures and practices should be regularly reviewed with staff to ensure they remain familiar with all aspects of managing medication to ensure the health and well being of people living at the home is fully protected. Protocols should be produced, in some circumstances, for individuals who are prescribed as required medication to ensure a consistent approach to administering this is followed by staff. Care plans and medication records should include details of medication or creams that are looked after and administered or applied by the person and where it is stored. Where required, suitable systems should be put in place to ensure her or his welfare is protected. An annual refurbishment plan, which includes the first floor bathroom and a ground floor toilet, should be produced to ensure the premises continues to be well maintained and meet peoples needs. The manager should request applicants to produce relevant qualification certificates at interview in order for these to be verified. Page 27 of 29 2 9 3 9 4 19 5 29 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 6 33 A quality assurance system should be implemented to ensure the overall performance is assessed and an annual development plan for the service produced. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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