Care Home: No. 1 Northbourne

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What the care home does well The home provides personalised care to meet people`s diverse and changing needs and respect their dignity. It works closely with other professionals to make sure individual`s health needs are met. Trained staff follow procedures to give medication safely. People engage in a good range of social activities and are encouraged to maintain contact with the community. There are clear systems in place to make complaints and safeguard people from being harmed. The home is clean and comfortable and generally well maintained. There are sufficient staffing levels to provide the support that people require. What has improved since the last inspection? Person centred care plans are being recorded to an improved standard. Menus are clearer and nutritional advice from professionals has been sought and is followed for people who need special diets. Staff have received updated training on protecting vulnerable people. Further permanent staff have been employed to provide greater stability to the team and the recruitment process is now more robust. Staff are regularly supervised by management. What the care home could do better: Some people`s care and health action plan recording still needs to be brought up to date. The staff training programme is to be brought up to date to show the training undertaken and planned for each staff member. The manager should be allocated time each week off the rota to carry out her management duties. Methods of monitoring the quality of the service are to be set out in an annual quality development plan. The system and records for fire safety need to be better organised. Key inspection report Care homes for older people Name: Address: No. 1 Northbourne Durham Road Low Fell Gateshead Tyne & Wear NE9 5AR     The quality rating for this care home is:   two star good 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: Elaine Malloy     Date: 1 9 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 26 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: No. 1 Northbourne Durham Road Low Fell Gateshead Tyne & Wear NE9 5AR 01914914643 F/P01914914643 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.c-i-c.co.uk Community Integrated Care Name of registered manager (if applicable) Mrs Christine Rowell Type of registration: Number of places registered: care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability sensory impairment Additional conditions: The maximum number of service users who can be accommodated is 5 The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care need on admission to the home are within the following categories: Learning Disability, Code LD, maximum number of places 5 Physical Disability, Code PD, maximum number of places 3 Sensory Impairrment, over 65, Code SI(E), maximum number of places 1 Date of last inspection Brief description of the care home No 1 Northbourne provides personal care for up to five people with a learning disability. Nursing care is not provided. The home is situated in the Low Fell area of Gateshead and is close to local shops, main bus routes and other community facilities. Care Homes for Older People Page 4 of 26 0 1 0 2 2 0 0 9 5 0 0 Over 65 0 3 1 Brief description of the care home The home is a purpose built bungalow attached to a care home for older people. No 1 Northbourne is managed by Community Integrated Care although Anchor Trust owns the premises. People using the service are able to access all parts of the bungalow. Single bedroom accommodation is provided and there is a range of communal space. Service users have use of a large lounge and dining area, a kitchen and a separate smaller lounge. A range of aids and adaptations are provided such as specialist bathing facilities and hoisting equipment. A guide to the homes services, details of fees and inspection reports are available from the home. Care Homes for Older People Page 5 of 26 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: The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. The inspection was carried out by: Looking at information received since the last key inspection on 1 February 2009. Getting the providers view of the service and how well they care for people. An inspector visiting the home on 19 January 2010. Talking to the management about the service. Looking at records about the people who live at the home and how well their needs are Care Homes for Older People Page 6 of 26 met. Looking at a range of other records that must be kept. Checking that staff have the knowledge, skills and training to meet the needs of the people they care for and support. Looking at the resources that the home has to operate the service. Getting the views of people living at the home and staff by talking to them, and from surveys they completed. Getting the views of health professionals who are involved in peoples care from surveys they completed. Checking if improvements required at the last inspection had been made. The inspection was carried out over eight hours. 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. Care Homes for Older People Page 7 of 26 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 Care Homes for Older People Page 8 of 26 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 26 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 26 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 home demonstrates good capacity to provide people with flexible support to meet their assessed and changing needs. Evidence: People living at the home told us they received enough information about the home before moving in so they could decide if was the right place for them. There have been no new people admitted to the home in the period since the last inspection. The manager was aware of the process to be followed in this event including pre-admission assessment of needs and risks and providing a phased introduction the home. The needs of some of the people living at the home have changed over time and they require greater support from staff due to their dependency levels. The manager is making request to the Local Authority for individuals needs to be reviewed by care Care Homes for Older People Page 11 of 26 Evidence: management. Staff told us they are always given up to date information about the needs of the people they support and that the ways they share information always or usually works well. Health care professionals told us the services assessment arrangements always ensure that accurate information is gathered and that the right service is planned for people. Care Homes for Older People Page 12 of 26 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. People are well supported to meet their health and personal care needs and records are being improved to reflect the personalised care that is provided. Evidence: The standard of recording in the care records examined was variable. Some peoples care plans, evaluations of plans and risk assessments were not up to date whilst others were well recorded and described the persons current needs and risks. The manager said that she was in the process of updating and transferring care records into person centred documentation. Care records that had been updated were detailed and well organised and personalised with pictures and photographs. Support plans addressed a wide range of needs such as personal hygiene, appearance, mental and physical health, food preparation and diet, support with living skills, activities/hobbies/interests, communication, social contacts, and personal finances. The plans included identified risks and areas of concern and any related behaviour patterns and reasons. Ongoing daily reports were comprehensively recorded and set out into sections covering health, Care Homes for Older People Page 13 of 26 Evidence: home and leisure activities, personal care, goal plans and night time support. People living at the home told us they always receive the care and support they need, including medical care. Staff spoken with were knowledgeable about individuals and the care and support they require. A relative spoken with said, It is a very good home and the care is wonderful. People have a choice of GP and are supported to access a range of physical and mental health care services. Care records showed good evidence of recognition of health needs, and referral and input from a range of health care professionals for advice, treatment and specialist support. Health care professionals told us that peoples health care needs are properly monitored, reviewed and met by the service. They said, The service has always acted upon my professional recommendations, and, Acts on episodes of ill health promptly, provides a warm, friendly environment and an excellent standard of care. Individuals have their own aids such as moving and handling equipment, wheelchairs, special mattresses to aid pressure relief and bed rails, and the the home has a mobile hoist, an assisted bathing facility and shower. Continence management is promoted and there are facilities to launder soiled items and dispose of clinical waste. Dietary needs and preferences were well recorded and identified people who are nutritionally at risk and provision of soft diets. There was evidence of detailed guidance for an individual who has specialist eating and drinking needs, including a risk management plan from a speech and language therapist and lists of suitable foods and foods to avoid. Some staff have received training on malnutrition and screening, and healthy eating. Sitting weighing scales are being purchased to enable regular weight monitoring. Peoples psychological health needs are monitored and support is provided by health professionals including the local community health learning disability team. A staff member said a psychiatrist had met with staff to advise them about approaches to a persons challenging behaviour. Support plans for this person demonstrated clear understanding of their characteristics, behaviour and anxieties. The home uses a monitored dosage medication system. Only staff who have completed medication training and had their competency assessed administer Care Homes for Older People Page 14 of 26 Evidence: medication. Individual medication records have a photograph of the person for identification purposes and details of their medication history. Administration records were appropriately recorded and completed. A sanitiser foam dispenser has been fitted where medication is stored as there is insufficient space for a hand washing facility. Each person has a single bedroom. Personal care and treatment is provided in the persons own room and an annex lounge can be used to meet with family, friends or professional visitors. A portable office telephone is available for people to make or receive calls in private. Staff assist people to manage personal mail. Care plans described sensitive support with personal care and some aspects of maintaining privacy and dignity. The plans also include individual preferences regarding clothing and appearance. People are supported to go shopping to buy clothing and personal items. The home provides services to people of different age, gender, disability, religion and beliefs. Some staff have received training on person centred planning, equality and diversity, mental capacity and deprivation of liberty to give them understanding of peoples diverse needs and rights, and how legislation affects their practice. Staff told us they have the right experience and knowledge to meet the different needs of the people who live at the home. Care Homes for Older People Page 15 of 26 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 are provided with flexible support to help them live their preferred lifestyles and meet their social and dietary needs. Evidence: Routines of daily living are flexible to suit peoples preferences and capacities. The inspector observed a relaxed start to the day with some people being assisted to get up, bathe and have breakfast later in the morning. There was good interaction between staff and people living at the home and visitors. People are encouraged to retain independent skills and help out in the home if they are able and want to. One lady helped with setting the dining table and preparing lunch and was supported and encouraged by a staff member to do so. Peoples social needs and interests within the home and in the community are identified. A central activities record is kept and each person has an individual weekly activity planner. These showed mainly one-to-one activities such as personal and food shopping, going to a coffee morning at the local church, going out for local walks, cleaning bedrooms, baking sessions, music and visits from family. The records also indicated the staff member or volunteer who would support the person. Care Homes for Older People Page 16 of 26 Evidence: People living at the home said activities are arranged that they can take part in. One gentleman told the inspector about his varied interests, going to church and planning a holiday and day trips. A visiting volunteer said the manager and staff place great emphasis on providing people with social stimulation and personalised care. Contact with the local and wider community is encouraged. One person has their own car that some members of the staff team can drive. Each person has a care bus membership and taxis and public transport are also used. People use local amenities such as shops and a community centre that provides various activities, and go on walks in the local area. An outing to the theatre was taking place that evening. The manager said the majority of people have regular contact with family and visitors are welcomed. The home has a charter that sets out peoples rights such as the right to be treated with respect and as equal to others. People are encouraged wherever possible to exercise control over their lives and be involved in their care planning. Pictures and photographs were being used in care records to aid communication and understanding. Ongoing individual support is reviewed and discussed at meetings with key workers and house meetings are also held to obtain peoples views. The manager said that relatives advocate on behalf of their family member where necessary to ensure care is provided in peoples best interests, and external advocacy services have been used in the past. The four week cycle of menus was currently being revised in consultation with people living at the home to include greater choice of meals. Separate soft diet menus are in place and staff work to nutritional guidance including fortifying food with full fat milk, cream and cheese for people who are identified as being nutritionally at risk. Records are kept of the meals and drinks that each person has each day. Breakfast consists of a choice of cereals, porridge, toast and fruit juice. Lunch is usually a lighter meal and the main meal is served in the evening with dessert. A variety of snack suppers are provided and additional snacks such as fruit, yoghurt and biscuits are also made available. People told us that they like the meals at the home. Staff dine with people living at the home and offer discreet support with eating. At lunch time the inspector observed a staff member providing specific support to one person with eating and drinking that followed recorded guidance from a health professional. Care Homes for Older People Page 17 of 26 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. There are appropriate systems to protect people from harm and address any complaints about the service. Evidence: The home makes the complaints procedure available and this is discussed with people at meetings with their key worker. People living at the home told us they know who to speak to informally if they are not happy and how to make a formal complaint. Staff told us they know what to do if someone has concerns about the home. One complaint had been made in the past year. This subsequently went to the next stage of the procedure and was investigated by a senior manager. The manager agreed to obtain full details including the written response to the complaint to enable these to be kept on file at the home. A book is also kept to record compliments and this contained four very positive entries about the service. The home has policies and procedures on safeguarding vulnerable adults from abuse and whistleblowing (informing on bad practice). No safeguarding alerts have been raised in the past year. Staff have access to guidance and information on the local authority safeguarding adults procedure, Mental Capacity Act and Deprivation of Liberty. The majority of staff completed safeguarding training during 2009 and this training was being organised for three newer staff members. The manager was booked to attend safeguarding training specifically for managers with Gateshead Council. Care Homes for Older People Page 18 of 26 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 living in the home benefit from a clean and comfortable environment that is generally well maintained and equipped to meet their needs. Evidence: The home was clean, comfortable and nicely decorated and furnished. Suitable equipment is provided to aid people with access, moving and handling and bathing. Internal maintenance is carried out by the provider company and a housing association is responsible for structural works. Bedrooms were nicely personalised with peoples possessions. One bedroom was decorated recently and another was planned to be done. New lounge furniture was being purchased and on the day of the inspection a representative was visiting the home to measure for armchairs according to individuals needs and people were being consulted about style and colours. People living at the home told us the home is always fresh and clean. There are procedures for staff to follow to guide them on infection control and training is provided. Protective equipment and hand washing facilities are available. The manager was in the process of completing infection control audits. One worker is the link person into a nursing and residential group that meets with the local Infection Control Team and cascades information to the rest of the team. Care Homes for Older People Page 19 of 26 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 are supported by trained staff in sufficient numbers to meet their diverse needs. Evidence: People living at the home told us staff are available when they need them and that staff listen and act on what they say. Staff said there was always or usually enough staff to meet the individual needs of people living at the home. Male and female staff are employed and staff have a multi-purpose role of providing care and support, cleaning and cooking meals.The staff team consists of the manager and eight permanent support workers and regular bank staff were used. Staff rotas were planned in advance and showed staffing levels of three support workers across the waking day and one waking night staff. The rotas indicate the staff member in charge of each shift in the absence of the manager. Three staff have achieved National Vocational Qualifications (NVQ) in care at level 2 and one worker has level 3. The manager said more staff are being enrolled to undertake this training. Staff recruitment files contained appropriate information including photograph, proof of identification, references from last employer and suitable sources and interview records. All staff are employed subject to Criminal Records Bureau (CRB) checks being Care Homes for Older People Page 20 of 26 Evidence: carried out. Staff told us that employment checks were carried out before they started work, and that induction training covered what they needed to know to do the job when they started. They said they are given training that is relevant to their role, helps them understand and meet the individual needs of people, keeps them up to date with new ways of working, and gives them enough knowledge about health care and medication. Most staff said their manager gives them enough support and meets with them regularly or often to discuss how they are working. Some staff told us what they think the home does well. Their comments included, Caring for all service users to a high standard. Giving each service user freedom of choice of foods and activities etc. Making sure the home is very clean and tidy every day. Keeping daily notes up to date. Making sure all meals are taken, Looks after the clients well, training courses, and takes the clients out regularly, Meets the physical, emotional and social needs of the service users despite their needs increasing and ongoing staff shortages, and, The care is very good. They all have a good diet. There is a good atmosphere in the home. Comments from staff on what the home could do better were, More staff on nights, and,Ensure that the home is fully staffed by full time workers rather than depend on bank staff or excessive overtime. This is a senior management issue and may be due, in part, to poor pay rates. An overview training plan is kept though this needed to be brought up to date. Certificates of training are maintained in individual staff files. Training provided in the past year included health and safety and safe working practices updates, protection of vlnerable adults, person centred planning, equality and diversity, malnutrition and screening, healthy eating, and crisis prevention intervention. The manager is a trained moving and handling facilitator and has brought staff up to date with training. Further mandatory and medication training was planned. Care Homes for Older People Page 21 of 26 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. While the home is managed in peoples best interests and promotes their safety and welfare, management resources and clear aims to ensure a quality service are still being developed. Evidence: Christine Rowell has managed the home for the past year and was approved as the Registered Manager in December 2009. She has 30 years care experience and for the last five years has worked at a senior/management level. She has achieved National Vocational Qualifications (NVQ) in care at levels 2 and 3 and was currently studying for NVQ level 4 in management. The manager was currently included in the staffing levels for the home and had not been allocated any supernumerary time off the rota to carry out management duties. This was discussed with the homes service manager at the end of the inspection. Confirmation was subsequently received that the manager had been allocated an initial period of two weeks supernumerary time and then weekly supernumerary time Care Homes for Older People Page 22 of 26 Evidence: would be reviewed in line with funding for the service. Whilst the home has an operational policy for quality assurance there was no annual quality development plan in place and records relating to monitoring the quality of the service through audits and other methods were not completed. Meetings were being held to get the views of people living at the home and staff. Visits and reports on the conduct of the home were mainly carried out monthly and separate performance audits are also conducted by senior management. Some people living at the home and their relatives told us what they feel the service does well, they said, Having good staff, The staff are always happy and helpful. If I have any questions I am always very happy with the outcome, and, Provides a homely atmosphere and good, loving care. Individual records are maintained for each persons personal finances. These were appropriately recorded and receipts are kept. Staff check cash and balances on a daily basis. Individual supervision was now being provided every two months for all staff. The home has a health and safety policy and associated procedures. Staff are provided with health and safety training and training on safe working practices such as fire safety, moving and handling, first aid and food hygiene. Risk assessments for safe working practices were in place and monthly health and safety checks on the environment are carried out. Risk assessments according to the individuals vulnerabilities are also recorded. Fire safety tests and checks were done at the required frequencies but records needed to be better organised and kept together. The process and records for providing staff with in-house fire instructions and fire drills at the correct intervals also needed to be made clearer. Accident and incident reporting was now being completed electronically. This was discussed with manager who agreed to make sure records are also kept in the home. The previous accident book showed a good level of detail to reports. Care Homes for Older People Page 23 of 26 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 26 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 7 15 Each service users person centred care plans and health action plans must be brought up to date. To ensure that service user plans fully reflect current care and support needs. 19/03/2010 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 30 31 33 The staff training plan should be kept up to date to demonstrate all training completed and planned. The manager should be provided with weekly supernumerary hours to carry out management duties. An annual quality development plan should be introduced that sets out measurable methods of monitoring the quality of the service. Systems and records for fire safety checks, tests and instructions should be better organised. 4 38 Care Homes for Older People Page 25 of 26 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). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!