Care Home: Parkside

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What the care home does well Staff surveys gave positive comments: "makes people welcome and assist with clients needs to ensure they are comfortable" "Standard of care is at a good rating" We found a warm and very welcoming environment. People are very content, "best move I ever made" "I was lucky to get a place here" Relatives are confident in the care people receive and that they will be informed of any changes, "very accommodating" "always let me know if there are any concerns" All the staff are very knowledgeable about people`s needs and records are detailed and informative. The home is very welcoming and staff patient and understanding in the way they care for people. People enjoy the food and menus are kept under review to make sure that wherever possible people`s individual needs are catered for. What has improved since the last inspection? There has been some refurbishment, the assisted bathrooms have been completed to a good standard and the dining room has been recently decorated There have been improvements in the medication arrangements with better storage facilities and monitoring systems. Staff have had training in the administration of medication. There has been an overall improvement in the amount of training staff have had to make sure that they know how to look after people properly. What the care home could do better: There needs to be better health and safety monitoring and general maintenance of the premises. This is to make sure that people live in a safe and well maintained environment. There needs to be improvements in staff recruitment - some CRBs for longer serving members of staff need to be updated at the correct level of disclosure. All staff files must have clear evidence of identification checks including a photograph. This is to make sure that people are protected by the safe recruitment of staff. The registered manager/owner of the service is well qualified in business and management and needs to complete a qualification in care. Although staff do monitor people`s nutritional needs, routine nutritional risk assessments are not carried out for everyone. These need to be carried out on admission to give a base line and to make sure that any nutritional needs are not overlooked. Key inspection report Care homes for older people Name: Address: Parkside 5 Park View Crescent Roundhay Leeds West Yorkshire LS8 2ES     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: Catherine Paling     Date: 2 7 1 0 2 0 0 9 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) 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 28 Information about the care home Name of care home: Address: Parkside 5 Park View Crescent Roundhay Leeds West Yorkshire LS8 2ES 01132665584 01132663469 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Parkside Residential Home Limited care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Parkside is a family run concern, providing twenty beds for older people. It is situated in North Leeds. It consists of two Edwardian houses joined together and it still retains many of the original features. Over the years, various alterations have been made to make the home more accessible. All bedrooms are located on the first and second floors, with the floors being accessed via a passenger shaft lift, chair lift or staircase. There are 16 single bedrooms, 13 with ensuite facilities and 2 shared rooms. People living in the home can bring furniture and electrical items, though appliances are inspected for safety before use. All meals are prepared and cooked on the premises. In each persons room a plug point is available for a television and individual telephone lines can be arranged on request. Support services are in place with a choice of General Practitioner, and visiting district nurses, chiropodist, dentist and optician. Further information about the home and the services it provides can be found in the Care Homes for Older People Page 4 of 28 Over 65 20 0 1 0 1 0 2 0 0 8 Brief description of the care home statement of purpose and service user guide. These documents are available at the home. Fees cover the costs of full accommodation, care and laundry facilities and currently range from three hundred and ninety one pounds to five hundred and seventy nine for the largest room. Respite care is currently four hundred and sixty five pounds per week. These figures were given at the time of the October 2009 visit. They do not include chiropody, hairdressing, and personal copies of newspapers, escorts to hospital and other personal requirements. The home should be contacted directly for up to date information about charges. 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: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit by two inspectors who were at the home from 10:00 until 15:45 on 27th October 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people who live at the home and visitors, as well as the staff and the Care Homes for Older People Page 6 of 28 manager. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a self-assessment of the service provided. This was reasonably well completed and gave us most of the information we asked for. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A small number of surveys were returned by the time of this visit. Comments received appear in the body of the report. The last visit to this service was October 2008. 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: 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 Care Homes for Older People Page 8 of 28 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. People have enough information to be able to make an informed decision about moving into the home. The admission process is good and includes introductory visits wherever possible. Evidence: The manager wrote in the AQAA, We provide a package of comprehensive information to all prospective residents We always encourage prospective residents to visit the home prior to admission and have lunch with us to get a feel of the place All people admitted to the home have a full assessment carried out by the manager and there is clear and concise information available to people. People felt that they had enough information to help them make up their mind about moving in. Staff also have access to assessment information from the local authority. This information allows the manager to develop initial care plans of how care staff can meet peoples needs. Care Homes for Older People Page 11 of 28 Evidence: In the AQAA the manager wrote about plans for the next twelve months, Our statement of purpose needs to be reviewed and rewritten to reflect changes made in the service over the past 12 months. It also needs to be made more innovative and user friendly so that more prospective residents have access to its information. Care Homes for Older People Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is enough information in care plans for staff to know how to look after people properly. People are protected by safe medication procedures. Evidence: The manager wrote in the AQAA, Every resident in this home has an individualised plan developed from their pre-admission needs assessment. Plans are developed and intended to be as holistic as possible including the residents full range of care and support needs. We saw detailed information for staff about how to look after people and people felt that they were looked after properly. We looked at care plans for three people with varying needs. We spoke with them, observed staff supporting them and looked at their bedrooms, where possible. One persons care plan was very specific about his preferences and wishes regarding his care. It was stated that a particular member of staff was to get him up on a weekend, however that staff member has left and the care plan had not been updated. On speaking to the staff it transpired that he has accepted another member of staff to do this. This person had a very detailed risk Care Homes for Older People Page 13 of 28 Evidence: assessment about wheelchair use. It described the safe use of the wheelchair, for example, making sure his feet are on the footrests. Staff were later observed moving him in his wheelchair, which had had the footrests removed. On questioning the manager later, he said that these had been removed because the man did not like to use the footrests and insisted on them being removed. This needs to be documented to cover staff who are not complying with safe use of equipment. One lady with dementia was assessed as being at risk from social isolation, because she spends the majority of her time in her bedroom. The manager and staff said that this was to minimise the agitation she experiences when in the larger group. Staff said they spent ten minutes with her throughout the day. This lady was spoken with in her room. She appeared to be contented and glad of the chance of a chat, although not really able to express an opinion because of her dementia. One lady was distressed and worried as her husband had gone off to hospital for an appointment and she was upset because she didnt know where he was. Staff showed flexibility, in that they brought her lunch to the sitting room instead of insisting she go to the dining room, but some approaches seemed a bit brusque, for example,Stop crying. It would benefit the people living at the home if the staff had some specific training in dementia care. Staff were seen applying some good techniques to supporting someone with Parkinsons Disease with their walking. We spoke with one man and his visitor, who comes regularly to the home. She said that he always tells her how happy he is with the home. He confirmed that and said that in his opinion everything was good, the staff, the food and the home in general. We spoke with other visitors who were very happy with the care their grandmother received. There had been some teething problems initially, but these had been resolved to everyones satisfaction. Although there was information in peoples care records about any dietary needs, nutritional risk assessments were not carried out routinely. This was recommended so that there is a base line for staff and to make sure any potential risks are not overlooked. Since the last inspection the medication arrangements have been reviewed. There is now improved storage and the overall majority of staff have had training with the exception of a small number of new staff. New starters have had some in-house instruction. The supplying pharmacy are providing good support to the home and we were told by the manager that all staff will complete a distance learning package provided by them. Care Homes for Older People Page 14 of 28 Evidence: One person takes the lead in ordering and overseeing medication administration. Care Homes for Older People Page 15 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 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 in maintaining contact with family and friends and to make choices. People are provided with a good and varied diet and individual choice is taken into account. Evidence: The manager wrote in the AQAA, We are proud that relatives can visit at any time and can have meals in the home if they wish. The small number of surveys returned to us gave mixed views on activities available at the home. Some felt that there were usually activities they join in with, while other felt that there should be more occupation and stimulation for people. People are able to spend their time in the way they want and many clearly said that they were content at the home, best move I ever made I was lucky to get a place here Visitors also expressed satisfaction with the home saying they found it accommodating. One visitor regularly ate a meal at the home on their weekly visit. Care Homes for Older People Page 16 of 28 Evidence: We spoke with one lady whose care plan said that she likes gardening. She said that she had her tools stored in the garden shed and staff helped her by getting them out for her. She said she would be planting lilies soon and her daughter had brought her the bulbs. Regarding her opinion of the home she said Its the best thing I ever did. She was happy that she could still do the things she enjoyed doing and did not feel restricted. We saw that some planned group activities and entertainment were advertised in the main areas of the home. However, it was not clear what activities, if any, were being done with people who spent their time in their rooms. Again, staff would benefit from some specific training in dementia care so that it would give them more ideas for doing brief and varied activities with people. The last residents meeting took place in April 2009. We spoke with one person with visual impairment who said he missed being able to read the newspaper or books. However, he said that he would not be interested in the talking books scheme. He also said that he had only been out once since he came to live at the home, but then said that he did not really want to. He described the meals as average. Other people said they enjoyed the meals, especially that most things are homemade, for example, the corned beef slice that was being served for lunch on the day of our visit. We spoke with the cook and looked at the menus. We saw a good variety of meals served at lunchtimes, whereas there were more convenience foods or sandwiches at teatime. Apart from at breakfast and teatime, the cook said that people are not routinely offered a choice, as it is too small a home to be able to do this economically. However, she does know what peoples individual preferences are and buys alternatives for them. One example given was that one person dislikes salmon, so a piece of cod or smoked haddock is bought for them instead, which they enjoy. The cook said that the kitchen is available to staff all night, so that they can make snacks if anyone is hungry. The dining room and kitchen are centrally situated and a lot of people were seen having a word with the cook as they passed by the serving hatch, to and from the bedrooms and toilets. She appears to have a good rapport with people and readily picks up on their likes and dislikes. Care Homes for Older People Page 17 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 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 at the home and their relatives know how to raise concerns and feel confident that they will be listened to and that any concerns will be acted upon. Staff training and safeguarding policies protect people. Evidence: The manager wrote in the AQAA, The home has in place a clear and straightforward complaints procedure which gives details of who will deal with any complaint All our residents are aware of the complaints procedure The majority of the staff have had some training in safeguarding vulnerable adults and further training is planned in the near future. Following discussion with ancillary staff we recommended to the manager that all staff, whatever their designation, should be included in safeguarding training. We looked at the abuse policy in the homes policy and procedures file. The policy was satisfactory but there no procedure for staff to follow in the case of any suspected abuse. We spoke with some visitors and asked if they knew how to make a complaint. They said that had not needed to as when concerns had arisen, they had felt confident to raise things with the staff and now know that they will resolve any issues. Care Homes for Older People Page 18 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 live in a clean and comfortable environment. Some practices around fire safety mean that people do not always live in a safe environment. Evidence: The manager wrote in the AQAA, In this home we place a very strong emphasis upon quality of life and upon safety and we are confident that the home provides a comfortable, homely, safe and secure environment for our residents to live in and enjoy their surroundings. A programme of annual maintenance is in place in the home. We keep the home odour free. The dining room has recently been re-decorated and the manager wrote in the AQAA that they operate a continuous programme of maintenance and refurbishment. We visited all areas of the home used by the people who live there and saw that some areas of the home are in need of decoration and refurbishment, including the outside areas. However, as we discussed with the manager at the visit the immediate priority must be close attention to health and safety issues and general maintenance of the building. We saw that although doors were held out with approved devices, door wedges were Care Homes for Older People Page 19 of 28 Evidence: also in common use throughout the home. This means that the approved devices would not work in the event of the fire alarm sounding, putting people at risk. This was discussed with the manager who gave an explanation as to why this was happening during the day. He agreed that some working practices would be urgently reviewed and changed to make sure that fire safety arrangements are not compromised at any time. We also saw that two fire exits were obstructed at the time of our visit and that one route down some stairs was unlit. The manager was able to show us that all the fire safety systems were properly maintained and all the staff had received fire lectures and taken part in drills, including the night staff. The manager told us that officers from the local fire station had visited during the summer as a routine to familiarise themselves with the building. The manager showed us his fire risk assessment, which was dated 2006 and should be reviewed. We spoke with the housekeeper and it was clear that she takes pride in her work and has her own systems in place for ensuring every area of the home is regularly and thoroughly deep cleaned. She was observed to have good hygiene practices as well as a very good rapport with people living in the home. People said: the home is fresh and clean Staff have had infection control training and use anti-bacterial hand gel. Soap dispensers are fitted in all areas and it was recommended that disposable hand towels be provided. Care Homes for Older People Page 20 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. People are cared for by trained and competent staff. Overall, people are protected by recruitment procedures. Evidence: The manager wrote in the AQAA, We have in place a range of recruitment policies and procedures which ensure that new employees have POVA and CRB checks and that we obtain two written references for them. All our staff have job descriptions and a contract of employment when they start with us. All new staff also go through a induction programme which links into ongoing training. The care staff are friendly and professional in their approach to people. They show patience, skill and understanding when attending to peoples needs. There is a training plan in place which addresses mandatory training such as safeguarding, infection control, medication administration and health and safety. We looked at recruitment files for staff and found these in order for the majority of staff with the correct checks having been carried out. However, there were a number of files that did not include evidence of identification checks of photographs. A small number of files of longer serving staff were found to have had criminal record bureau (CRB) checks completed at only a standard level rather than the required enhanced level. The manager agreed to rectify this. Care Homes for Older People Page 21 of 28 Evidence: Three staff surveys were returned to us: all said that checks were carried out before they started work at the home, including CRB checks. Other comments included: NVQ trained and other training like first aid etc we are all NVQ trained also have training in moving and handling etc All Staff members are trained to do medication We asked the housekeeper about training and said she would be attending the First Aid training arranged for the staff in December. She was aware of the Control of Substances Hazardous to Health (COSHH), although it was some years since she had any training in this. She had not had training in safeguarding adults, but would like to, however, she was clear about who she would go to with any concerns. Care Homes for Older People Page 22 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. The home is run in a way the demonstrates value and respect for the staff and the people who live there. Lack of attention to some health and safety practices places people at potential risk. Evidence: The manager wrote in the AQAA, The registered manager has nearly 13 years experience as owner/manager and therefore takes a personal role in the care of the home. Through residents and staff meetings we continually appraise the care service we offer. The manager has been at the home for a number of years as have a core group of the staff. This provides continuity and stability for the people who live at the home. The manager is well qualified in business and management but does not hold any care qualifications. Although he does not give personal care, it is the manager who carries out pre-admission assessments about care needs. He is also very involved in completing risk assessments and care plans. He is very knowledgeable about the Care Homes for Older People Page 23 of 28 Evidence: people who live at the home and their needs. Following discussion during the inspection it was agreed that he should undertake a recognised qualification in care to ensure his credibility in performing the role that he does at the home. We looked at the policies and procedures file. Specific policies were not easy for staff to access as there was no index and they are not arranged alphabetically. Most have been re-written, but there are still some old policies among them, making it difficult for staff to know what the correct procedure would be. We recommended that the manager should either remove the duplications, or incorporate the good elements of the old policies into the new. This is to make sure that staff have easy access to up to date information about practice. The manager has regular contact with people and the atmosphere at the home was welcoming, open and relaxed. People are surveyed on a regular basis and we saw some recently returned surveys and the records of meetings with people who live at the home. Surveys are also sent out to health care professionals who visit the home. In surveys returned to us and the homes own surveys indicated that people felt that there was a need for an identified supervisor in addition to the manager. A senior member of staff left the service and has not been replaced - people feel that there is a need for such a senior person to be identified and the manager agreed to look at this. We saw that there are safe and clear systems in place for the safe keeping of peoples money kept at the home for such things as hairdressing and chiropody services. We had some concerns around health and safety issues as outlined earlier in this report. The manager needs to make sure that he oversees general maintenance issues and health and safety or identifies another individual to do so, to make sure that any issues are spotted and addressed promptly. This is to make sure that any potential risks are kept to a minimum. The manager has addressed the requirements made at the last inspection around medication administration and the refurbishment and redecoration of the home is an ongoing process as financial circumstances allow. The manager is cooperative with us and acknowledged the shortfalls identified at this visit and agreed to address them. Care Homes for Older People Page 24 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 25 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 13 Health and safety practices must be reviewed. Doors must not be kept wedged open as this puts people at potential risk in the event of a fire. Fire exits must be kept clear at all times. 27/11/2009 This is to make sure that fire safety arrangements are not compromised putting people at potential risk. 2 29 19 Recruitment practices must 27/11/2009 be reviewed. All staff must have evidence of criminal record bureau checks at an enhanced level and clear photographs on file as part of identification checks. This is to make sure that people are protected by safe recruitment practices. The manager must undertake an accredited care qualification. 28/03/2010 3 31 9 Care Homes for Older People Page 26 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 This is to make sure that he has the knowledge he needs to carry out his role fully in caring for 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 1 8 Nutritional risk assessments should be completed for all people admitted to the home. This is to make sure that any potential nutritional risks are not overlooked. Staff should have a clear procedure to follow in the case of any safeguarding allegations to make sure that people are kept safe. The programme of refurbishment and redecoration should continue to make sure that people live in a comfortable and well maintained environment. A system should be put in to place to make sure that maintenance issues are reported and and acted upon promptly. This is to make sure that people live in a safe and well maintained environment. The manager should consider identifying a senior member of staff to act as his deputy in his absence and as an identifiable senior for staff and people living at the home. This is so that people are clear about who to talk to at the home if they have any issues. 2 17 3 19 4 31 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. 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