Care Home: Monks Haven Residential Home

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What the care home does well The premises are clean,warm and odour free. People using the service said that staff are kind, patient and provide them with good care. What has improved since the last inspection? Since the last inspection of the service, the following requirements have been complied with: the Care Quality Commission is kept informed of any significant occurrences within the home; appropriate pre-employment checks are carried to ensure only suitable staff are employed within the home; written information provided to service users has been improved to ensure that they know what to expect once they move into the home; appropriate records are kept of staff training to demonstrate that they are now receiving the training needed to care for older people. The acting provider has devised an interim action plan to improve the home`s environment, the quality of care received by people using the service and the training and support given to staff. What the care home could do better: Make sure that an application to register the acting manager is submitted. This will help to ensure that the home is being run by a competent manager who provides staff with strong leadership and direction. Improve and further develop people`s care plans and risk assessments so that staff are clear about how to meet each person`s needs and keep them safe. Introduce a continuous quality improvement system which gathers, records and evaluates the quality and safety of the premises and care received by people using the service. This will help to make sure that people benefit from safe quality care and support. Provide people with opportunities for stimulation through leisure and recreational activities in and outside the home which suit their needs and preferences. Ensure that there are robust arrangements for managing people`s finances and that people can safely store their valuables. This will help to make sure that people`s financial rights are safeguarded. Make sure that staff employed at the home receive training that is appropriate to the work they are to perform, including structured induction training. This will help to make sure that people`s health and welfare needs are met by competent staff who properly trained. Replace or refurbish worn furniture in line with the home`s improvement plan. This will help make sure that people are able to benefit from living in a home where all of the furniture they have access to is of a good standard. Carry out a review of the home`s safeguarding policy and procedures to ensure that they are up to date and compliant with recent changes in legislation. Make sure that the acting manager completes advanced safeguarding training. This will help to protect people from abuse, or the risk of abuse, happening within the service. Key inspection report Care homes for older people Name: Address: Monks Haven Residential Home 55-57 Beverley Terrace Cullercoats Tyne & Wear NE30 4NX     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: Elizabeth Gaffney     Date: 2 7 0 1 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 28 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 28 Information about the care home Name of care home: Address: Monks Haven Residential Home 55-57 Beverley Terrace Cullercoats Tyne & Wear NE30 4NX 01912521957 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): geoshineltd@aol.com www.monkshaven.co.uk Geoshine Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The Home may admit up to one person, 55 years of age and above within the SI category of registration, (not exceeding total number of places registered) Date of last inspection Brief description of the care home Monks Haven is situated on the sea front at Cullercoats and is a large, older style adapted building. The Metro and other transport links are close by. The home provides residential care for up to 33 older people, of whom up to 10 may have dementia care needs. Nursing care is not provided. Bedroom accommodation is spread over three main and two mezzanine floors. There are 27 single bedrooms of which three have ensuite facilities. There are also three double bedrooms. There is a passenger lift to the three main floors and a stair lift has been installed between the top floor and the second mezzanine floor. Access to some bedrooms, bathrooms, and toilets is via a Care Homes for Older People Page 4 of 28 Over 65 10 23 0 0 0 4 0 6 2 0 0 9 Brief description of the care home small number of steps. The following communal facilities are also provided: two lounges and a dining room; two bathrooms and one shower room; nine toilets; a kitchen, small conservatory and adjoining utility rooms. The home has a small, attractive paved area to the front and a yard area to the rear of the building. Street parking is available at the front and rear of the home. Inspection reports are available from the home on request. The current scale of charges is 374 to 424 pounds. Additional charges are made for hairdressing, chiropody, newspapers, and taxis. Care Homes for Older People Page 5 of 28 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: We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Before the visit we looked at: * Information we have received since the last key inspection visit on the 04 June 2009; * How the service dealt with any complaints and concerns since the last visit; * Any changes to how the home is run; * The views of people who use the service, staff and other professionals. Care Homes for Older People Page 6 of 28 An unannounced visit was made on the 28 January 2010. During the visit we: * Talked with people who use the service, some of the staff and the acting manager. We also spoke with the acting provider, Wright Care Home Solutions, who have only been responsible for managing the day to day performance of the home for three and a half weeks; * Looked at information about the people who use the service and how well their needs are met; * Looked at other records which must be kept; * Checked that staff have the knowledge, skills and training to meet the needs of the people they care for; * Looked around the building to make sure it was clean, safe and comfortable; * Checked what improvements have been made since the last visit. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: Make sure that an application to register the acting manager is submitted. This will help to ensure that the home is being run by a competent manager who provides staff with strong leadership and direction. Improve and further develop peoples care plans and risk assessments so that staff are clear about how to meet each persons needs and keep them safe. Introduce a continuous quality improvement system which gathers, records and evaluates the quality and safety of the premises and care received by people using the service. This will help to make sure that people benefit from safe quality care and support. Provide people with opportunities for stimulation through leisure and recreational activities in and outside the home which suit their needs and preferences. Ensure that there are robust arrangements for managing peoples finances and that people can safely store their valuables. This will help to make sure that peoples financial rights are safeguarded. Make sure that staff employed at the home receive training that is appropriate to the work they are to perform, including structured induction training. This will help to make sure that peoples health and welfare needs are met by competent staff who properly trained. Replace or refurbish worn furniture in line with the homes improvement plan. This will help make sure that people are able to benefit from living in a home where all of the furniture they have access to is of a good standard. Carry out a review of the homes safeguarding policy and procedures to ensure that they are up to date and compliant with recent changes in legislation. Make sure that the acting manager completes advanced safeguarding training. This will help to protect Care Homes for Older People Page 8 of 28 people from abuse, or the risk of abuse, happening within the service. 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 9 of 28 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 28 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. The arrangements for assessing peoples needs before they are admitted into the home are good. This means that people can be sure that staff will know how to meet their needs when they move into the home. Evidence: Appropriate arrangements are in place to make sure that admissions do not take place until a full assessment of need has been carried out. The acting manager, who is an experienced practitioner, will carry out pre-admission assessments to make sure that Monks Haven is able to offer a suitable placement. As there have been no recent admissions, the homes practice in this area has not been reviewed in any further detail. Care Homes for Older People Page 11 of 28 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. The arrangements for meeting peoples healthcare needs are satisfactory. However, care plans could be further improved to include the level of detail necessary to make sure that people are fully supported in all aspects of their lives. Evidence: Since the last inspection, there has been limited development of the homes care plans. In part, this has been due to instability in the arrangements for managing the home. Although each person has a care plan, some of those looked at do not provide staff with clear guidance about how they should meet peoples needs, including their future End of Life needs. Although peoples care plans have generally been reviewed monthly, the reviews carried out do not provide a good overview of how effective peoples care plans have been in meeting their needs. Some peoples care plans have not been updated to reflect changes in their needs. The acting provider is in the process of introducing a new care plan format which will address the Care Quality Commissions concerns about the homes approach to care planning. Peoples care records do not contain clear information about their capacity to make Care Homes for Older People Page 12 of 28 Evidence: decisions. The acting provider has already identified this as a piece of work that needs to be completed. Carrying out capacity assessments will help staff to be clear about how people want to be cared for and what their role is when people are unable to make their own decisions. Following the last inspection, the provider was asked to produce a policy outlining how staff should implement the Mental Capacity Act and Deprivation of Liberty Regulations within Monks Haven. This recommendation has not been met. People are able to access health care services both within the home and in the local community. Each person is registered with a GP practice. People receive optical, dental, GP and chiropody care as and when required. Preventative health care assessments addressing the risks posed by falling, pressure sores, self-neglect and poor mobility have been completed for each person. Following the last inspection, the provider was asked to use a standardised assessment tool to assess the risks posed by peoples susceptibility to developing pressure sores. This recommendation has not been met. However, the acting providers new care plan format includes a standardised risk assessment tool which will be used within the home. The home has a medication policy that is available for all staff to read. All medication is appropiately stored in a locked trolley and cabinet to which only senior staff have access. A new monitored dosage system has been introduced which staff said works well. Identification photographs have been placed in peoples medication records. Records covering the administration and disposal of medication are generally satisfactory. Staff administering medication have received accredited training and were observed to administer medication in a safe and professional manner. Assessments of staffs competency to administer medication have been completed. The Care Quality Commission has not been informed of any incidents involving the mis-administration of medication. No requirements were issued following the last pharmacy inspection of the home. However, there was evidence that some people are not always taking the medication that has been prescribed for them. People using the service said that staff are polite, helpful and considerate. They also said that they are well looked after and have no concerns. People said that they are respected and staff treat them in a dignified manner. Care Homes for Older People Page 13 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to maintain relationships with their families and are encouraged to make choices affecting their daily lives. However, opportunities for stimulation through leisure and recreational activities in and outside the home, are limited. Evidence: Information about peoples leisure interests and activities is obtained at the point of admission into the home and used to devise a social needs care plan. There is a limited activity programme which is publicised within the home. Also, details of the activities planned for each day are now displayed on a white board located in the main lounge. However, staff did not carry out any organised activities on the day of the inspection. Also, opportunities enabling people to access external activities are limited. People said that they are generally satisfied with the activities arranged by the home. One person said that it would be nice if more entertainment could be arranged within the home. People who use the service are supported to maintain important personal and family relationships. Visitors can be seen in private or meet with their relatives in the lounge and dining areas. No-one spoken with could recall the home placing any restrictions upon their visitors. However, there are no care plans providing staff with guidance on Care Homes for Older People Page 14 of 28 Evidence: how to support people to maintain important personal relationships. The home has a varied menu that offers choice. People said that they enjoy the food served and are consulted daily about what they would like to eat. People have access to snacks and drinks in-between meal times. The inspector observed people taking their tea-time meal. The meal served looked nutritious and appetising. Staff responded to peoples needs in a caring and sensitive manner and provided them with the assistance they needed to eat their meal. The atmosphere was relaxed and unhurried. The kitchen and food storage areas are generally clean and tidy. Food stock levels were good. The acting manager confirmed that all crockery continues to be washed by hand. Providing a dishwasher would enable staff to reduce the amount of time they spend in the kitchen following meal times and enable them to spend more time with people. Care Homes for Older People Page 15 of 28 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. People using the service are confident that their complaints or concerns will be listened to, taken seriously and acted upon. Satisfactory action has been taken to address shortfalls in the care received by people and this has helped to keep people safe. Evidence: The service has a complaints procedure which is up to date and displayed in the homes reception area. Staff said that they would know what to do if someone has concerns about the home. Neither the home nor the Care Quality Commission (CQC) have been notified of any complaints since the last inspection. Staff have received safeguarding training and are clear about the action they would take to keep people safe from harm or abuse. The acting manager has a good understanding of safeguarding procedures and how they work. However, the acting manager has not completed advanced safeguarding training. People using the service said that they are satisfied with the care and support they receive. The home has policies and procedures for safeguarding people who use the service. However, they have not been updated to reflect changes in recent legislation as previously recommended by the CQC. This might result in staff being unclear about the action they need to take to safeguard the welfare of people who use the service. Care Homes for Older People Page 16 of 28 Evidence: The CQC has been notified of two safeguarding concerns. Both concerns have been dealt with under the local councils safeguarding procedures. The previous registered manager carried out investigations and informed the CQC of the outcome. Following one of the safeguarding concerns, an action plan was produced to address practice shortfalls. Appropriate action was taken to address the concerns identified. Care Homes for Older People Page 17 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to live in a home which is safe and where they have access to the equipment needed to meet their needs. However, the quality and condition of some of the homes furniture and fittings is not fully satisfactory. Evidence: The home provides a physical environment that meets the needs of people living at Monks Haven. The home is generally clean, tidy, odour free, well lit, warm and comfortable. The acting provider has devised an action plan that sets out what improvements will be made to the homes decoration, fixtures and fittings during early 2010. A copy of the action plan has been made available to the Commission. A number of improvements have been made since the last inspection to the overall appearance of the home and its facilities. For example, the dining area has been redecorated and a more domestic atmosphere and setting created. Although the standard of most furniture is satisfactory, some items look worn and are in need of replacement or refurbishment. People have access to a range of aids and adaptations such as grab rails, a bath hoist, a walk-in shower and an adapted specialist bath. In order to provide level access to some areas of the building a number of ramps have been installed. Following the last inspection, it was recommended that an assessment of the ramps on the ground, first and second floors be carried out. The acting provider has carried out a health and Care Homes for Older People Page 18 of 28 Evidence: safety inspection of the ramps and made a referral to the local occupational therapy service for advice and guidance. Individualised risk assessments have not been carried for those people using the ramps. However, the Care Quality Commission has not been notified of any accidents involving the use of the ramps. The main kitchen is clean and hygienic. However, the storage facilities in the front kitchen area are worn and not fit for purpose. The dish washer has been out of order for a considerable length of time. The impact of this is that following the tea-time meal, care staff have to wash all crockery and this detracts from the time that they are able to spend with people. Some of the people living at the home are able to access the front kitchen area in which a bolier is located. There are no assessments identifying how the risks to people who use this area can be avoided or reduced. Care Homes for Older People Page 19 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient numbers of staff are rostered on duty and improvements have been made to the arrangements for recruiting staff. However, the arrangements for providing staff with a thorough induction, as well as appropriate training for the work they are to carry out, are not fully satisfactory. This may result in people receiving care which does not fully meet their needs. Evidence: There is a rota which sets out what shifts are being worked and by which staff. However, the rota does not specify the full names of all staff and the hours worked. Staffing levels have been reduced to reflect lower occupancy numbers. A minimum of two care staff are currently being rostered on duty between 8am and 8pm. In addition to this, the acting manager works between 9am and 5pm each weekday. Domestic and catering staff are also available each day. The acting manager said that care staf levels will rise as the number of people living at the home increases. The rotas show that one of the homes domestic staff is being rostered on duty to cover a small number of care hours each week. The acting manager confirmed that this person has not completed their Skills for Care training. Mrs Darlington confirmed that she had not received a thorough induction on starting work at the home. The acting provider has identified this as an issue and is working with the acting manager to identify and meet their training and support needs. Care Homes for Older People Page 20 of 28 Evidence: Over 50 per cent of the staff team have obtained a relevant qualification in care. Staff have completed a range of statutory training covering such areas as first aid, infection control, health and safety, fire prevention and food hygiene. Some staff have also completed specialist training aimed at meeting the needs of older people, such as dementia awareness, falls prevention and Diabetes training. However, not all staff have received training in managing peoples skin care needs and preventing the development of pressure sores. Although the Care Quality Commission has expressed concerns about staff recruitment processes since the last inspection, there is evidence that recent improvements have been made which will ensure that only suitable staff are employed. For example, job applicants are required to complete an application form, provide two references, an identification photograph and undergo a Criminal Records check. Staff files now include documentary evidence of the statutory training they have completed. The acting provider is in the process of carrying out an audit of all staff files to make sure that they contain the required information. Care Homes for Older People Page 21 of 28 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. Clear leadership is now being provided and there are plans to improve the homes day to day performance. Because of this, people can have more confidence in the home and the way it is being led and managed. But, the arrangements for monitoring the quality of service that people receive are not fully satisfactory. Evidence: There have been changes to the day to day running of the home. The previous registered manager has cancelled their registration and a management consultancy agency, Wright Care Home Solutions, is now responsible for managing the day to day performance of the home. At the time of the inspection, the acting provider had only taken on this new role three and half weeks earlier. A new acting manager has been appointed. Mrs Darlington is an experienced practitioner who is in the process of submitting an application to register. However, she does not have an appropriate management qualification. The acting provider has a clear view of the standards of care they would like see Care Homes for Older People Page 22 of 28 Evidence: operating within the home and are providing strong leadership and direction to achieve this. They have submitted an action plan which sets out what improvements they will make and within what timescales. Plans are in place to increase occupancy levels and ensure the long term future of the home. Inappropriate working practices and staff attitudes are being challenged and addressed. One person said that they felt things were improving at the home with the new manager and company in place. Most people have their money managed on a day-to-day basis by the home. Peoples money is kept secure at all times. Balances matched with the amounts of money recorded on peoples financial records. Better records showing how peoples money is handled are now being kept. Two staff sign the records of money spent on peoples behalf and receipts of any purchases are obtained. Following the last inspection report, the previous registered manager was asked to produce and maintain a record of all valuables held in the homes safe. This recommendation has not been met. The acting provider has put systems in place to monitor the quality of care being provided at the home. They carry out regular weekly visits to monitor the homes performance. A short term action plan to improve the quality of the service has been devised and is being adhered to. The acting manager reports that she is being well supported to introduce necessary changes. Staff are now receiving regular supervision. Basic satisfaction surveys have been issued to people using the service and an analysis of the responses carried out. However, the acting manager said that they did not think that a quality assurance review had taken place, or a written report produced, during the previous 12 months. Arrangements have been made to promote peoples health and well being. The home has a current gas safety certificate and all electrical equipment has been tested during the previous 12 months. Equipment used at the home is checked to make sure it is safe. Appropriate fire prevention checks are carried out and there is an up to date fire risk assessment. Recent maintenance checks of the homes emergency lighting and fire alarm system have been carried out. However, the systems for carrying out workplace risk assessments are not fully developed. Care Homes for Older People Page 23 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 28 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 19 16 Undertake an assessment of the homes furniture to establish which items need to be replaced or refurbished. Take action to replace or refurbish any furniture identified as being of an unsatisfactory standard. This will help make sure that people are able to benefit from living in a home where all of the furniture they have access to is of a good standard. 30/09/2010 2 30 18 Make sure that staff 30/09/2010 employed at the home receive training that is appropriate to the work they are to perform, including structured induction training. This will help to make sure that peoples health and welfare needs are met by Care Homes for Older People Page 25 of 28 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 competent staff who properly trained. 3 33 24 Introduce a continuous 30/09/2010 quality improvement system which gathers, records and evaluates the quality and safety of the premises and care received by people using the service. This will help to make sure that people benefit from safe quality care and support. 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 2 3 8 8 9 Ensure that a MUST preventative nutritional risk assessment is completed for each service user. Use a standardised risk assessment tool to assess peoples susceptibility to developing pressure sores. Where appropriate, make sure that peoples medication care plans specify what staff should do when people do not take their medication at the point of administration. Ensure that the homes End of Life policy and procedures cover the latest guidance issued by the Department of Health. Make sure that each person has an End of Life care plan which can then be adapted to reflect changes in peoples needs. Ensure that a varied and stimulating programme of social activities is available within the home. Devise a programme of external outings and events. Carry out a review of the homes safeguarding policy and Page 26 of 28 4 11 5 12 6 18 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 procedures to ensure that they are up to date and compliant with recent changes in legislation. 7 18 Ensure that the home has a policy setting out how staff will be expected to comply with the Mental Capacity Act and Deprivation of Liberty Regulations. Make arrangements for the acting manager to complete the local councils advanced safeguarding training. Carry out individual risk assessments for those people who use the ramps provided in the home. Also, assess any risks posed to those people who use the kitchen facilities. Repair or replace the homes dishwasher. Make sure that the homes rota includes staffs full names and hours worked. Provide staff with training in how to prevent the development of pressure sores. Take prompt action to register the new manager. Make sure that the acting manager completes the Leadership and Management Award. Ensure that a record is kept which details: what valuables are held in the safe; the date on which valuables have been booked into or out of the safe; the signature of the member of staff responsible for booking valuables into and out of the safe. 8 9 18 19 10 11 12 13 26 30 30 31 14 35 Care Homes for Older People Page 27 of 28 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. Copyright © (2009) Care Quality Commission (CQC). 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