Care Home: Pratt House

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• St Vincents
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• The Maypole Nursing Centre
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What the care home does well The service has good processes in place to assess prospective users prior to admission, with opportunities to visit the service beforehand to ensure it meets their needs. Activities are available to people using the service to provide them with stimulation and contact with family, friends and the community is supported to maintain social links. Food is well prepared and presented attractively to make sure that nutritional needs are met. The health and personal care needs of people living at the service are well met, promoting health, well-being, taking into account their preferences and ensuring that they receive medication in a safe and consistent manner. Complaints and safeguarding are effectively managed to listen to views of people who live at the service and reducing the risk of harm to them. The premises are clean and homely, promoting a positive environment for the people who live at Pratt House and which are suitable for the range of disabilities that people have. The service provides staff cover to meet needs and has recruitment procedures in place to protect people from harm. The management and administration of the service promotes continuity and quality of care for the people who live there and ensures that risk is safely managed to reduce the likelihood of injury or harm. What has improved since the last inspection? This is the first Key Inspection since registration in April 2009. What the care home could do better: Controlled Drugs, must be stored in a Controlled Drugs cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973. Ensure suitable secure facilities are made available for people who are able to self medicate. Follow up on any references received on unheaded paper or without a company stamp for verification of their authenticity and ensure any gaps in employment history are explained. Documentary evidence of any relevant qualifications and training must be held in staff personnel files at all times. Ensure that appropriate records and receipts are kept for hairdressing services that service users receive to ensure service users financial interests are safeguarded appropriately. Key inspection report Care homes for older people Name: Address: Pratt House Pratt House Quill Hall Lane Amersham Bucks HP6 6LU     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: Jane Handscombe     Date: 1 4 1 2 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 29 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 29 Information about the care home Name of care home: Address: Pratt House Pratt House Quill Hall Lane Amersham Bucks HP6 6LU 01494722940 01494725504 m.barzotelli@abbeyfield.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Abbeyfield Society Name of registered manager (if applicable) Michelle Anne Barzotelli Type of registration: Number of places registered: care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of people who can be accommodated is 29 The registered person may provide the following category of service only, Code PC, to people of the following gender, either, whose primary care needs on admission to the home are within the following categories, Old Age, not falling within any other category, Code OP Date of last inspection Brief description of the care home Pratt House is a care home providing personal care and accommodation for 29 frail older people. The home is located in Amersham close to shops, pubs the post office and other amenities. Public transport is not easily accessible. The home consists of four floors basement, ground, first and second floor. Service users have access to the ground and first floors only. All the homes bedrooms are single with en suite facilities. Care Homes for Older People Page 4 of 29 Over 65 29 0 Brief description of the care home There are two passenger lifts and extensive gardens that are well maintained and easily accessible. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection was conducted over the course of a day from 11.20 am until 6.30 pm and covered all of the key national minimum standards for older people. This was the homes first key inspection since registering with the Commission in April 2009. Prior to this inspection, a detailed self-assessment questionnaire, the Annual Quality Assurance Assessment (AQAA), was sent to the manager for completion. It provided information about the service and statistical information needed to plan the visit and assess the standards of care being provided. Surveys were sent to relatives, staff and visiting professionals. Five completed surveys were received, two from people living in the home and three from relatives. Information received by the Commission since the last inspection was also taken into Care Homes for Older People Page 6 of 29 account, such as notifications and any complaints or safeguarding issues. The inspection consisted of discussion with the manager and other staff, opportunities to meet with people using the service, examination of some of the required records such as care plans, medication administration records, staff recruitment files, policies and procedures and risk assessments. We also observed practice and toured the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. We would like to thanks the manager, staff and people who use the service for their co-operation and hospitality during this unannounced visit. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Controlled Drugs, must be stored in a Controlled Drugs cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973. Ensure suitable secure facilities are made available for people who are able to self medicate. Follow up on any references received on unheaded paper or without a company stamp for verification of their authenticity and ensure any gaps in employment history are explained. Documentary evidence of any relevant qualifications and training must be held in staff personnel files at all times. Ensure that appropriate records and receipts are kept for hairdressing services that service users receive to ensure service users financial interests are safeguarded appropriately. Care Homes for Older People Page 8 of 29 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A full assessment of prospective users of the service is carried out as part of the admission process and a range of information is available in various formats including large print and braille which enables service users to make a fully informed choice about where they would like to live. Evidence: A Statement of Purpose and Service Users Guide is made available to all prospective users of the service which informs them about the home and the services provided. Both documents can be provided in various formats to meet peoples individual needs, which include large print, Braille and is presently being produced on Compact Disc (CD) for those who require. Whilst viewing both documents, it was noted that the contact details of the Care Quality Commission had not been updated, however when mentioned to the manager of the service she took immediate action to update the master copy and assured us that updated copies would be provided to those using the Care Homes for Older People Page 11 of 29 Evidence: service to ensure that they have up to date information. Care needs assessments are carried out by the home before admission is arranged, ensuring that the care needs are clearly identified and care plans put into place to meet the needs of the individual. From the evidence seen and comments received, we consider that this service is able to provide a service to meet the needs of individuals of various religious, racial or cultural needs . Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are in place to guide staff to appropriately address the care and social needs of service users in a respectful way. The home has good procedures and staff training in place for the safe administration of medicines which promotes the health and welfare of the service users. Service users are treated with respect and dignity, thus enhancing their sense of wellbeing. Evidence: Each user of the service has an individual personalised care plan in which they and/or their relatives have been consulted with, which is regularly reviewed and updated. As part of the inspection process we chose to inspect three service users files, all of which gave a good all round picture of the individuals needs and contained detailed instructions for staff to follow to ensure that their needs are fully met. The care plans inspected focused on peoples individual strengths and preferences covering areas such as medical needs, personal care, social skills and leisure, personal hygiene, mobility, Care Homes for Older People Page 13 of 29 Evidence: food and diet, communication and any special care needs. They contained evidence of regular reviews being undertaken and care plans updated where peoples needs change. Suitable arrangements are in place for meeting the healthcare needs of those using the service. Records of contact with healthcare professionals, including GPs and District Nurses are maintained and detailed in the service users care plans. As part of the inspection process we looked at the medication systems within the home. People who wish to maintain responsibility for their own medication are enabled to do so within a risk management process, although at the time of this visit we were informed that no service users were self administering their own medication. We inspected the medication administration records of those service users who were being casetracked all of which were in good order; there were no gaps to suggest that people were not being given their medication as prescribed and an appropriate coding system was in use to explain the reason if medication had not been administered. In situations in which individuals are prescribed controlled drugs, it was found that they were stored in a designated controlled drugs cabinet located inside a large metal medication cabinet. However it had not been affixed to the wall in accordance with current legislation. In 2007 the law changed; all care homes, whether providing nursing or personal care, must now keep controlled drugs in a controlled drugs cupboard fixed to a solid wall or a wall that has a steel plate mounted behind it and it is to be fitted with either Rawl or Rag bolts for which a requirement has been made within this report. Feedback from those using the service indicated that the staff treat them with respect and support their privacy and dignity at all times. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home supports and encourages users of the service to maintain close relations with their friends and families. Users of the service are offered a good variety of wholesome and nutritious meals according to their assessed need and choice, which promotes their health and wellbeing. Opportunities are provided for people to excercise control and choice thus promoting their independence and self determination. Evidence: Discussions with service users was positive acknowledging that the lifestyle experienced at Pratt House matches their expectations and enables them to exercise choice and control over their lives. The service has recently appointed an activities co-ordinator who provides organised activities and regular events for those who wish to take part. Activities are provided in both group settings and on a one to one basis, depending on peoples individual needs and preferences. Care Homes for Older People Page 15 of 29 Evidence: The service has good links with the local community who have recently been involved with the Christmas activities within the home which includes visits from the local school choir, the Brownies and the U3A choir to provide musical entertainment for those using the service. Family members and friends were invited to join their loved ones for a family buffet with entertainment and users of the service enjoyed a Christmas Pantomime. Trips out to places of interest are organised during the warmer months for those who wish to partake, which include visits to the local garden centres, Chenies Manor and other places of local interest. Information provided to us in the completed AQAA informs us that the home is considering organising a holiday for a small number of residents who may be interested, providing them with the same opportunities as any other member of the community. The home will make arrangements to enable people to visit their own church or for someone from their church to visit and we are informed that a monthly communion service is held for those who wish to partake. There is a visiting hairdresser who visits the home three times a week for those who require and a local shop owner visits the home once a week to provide a shop trolley service. People who use the service are provided with good quality food, which is freshly cooked on the premises and are offered a choice. Special diets are available to meet service users health and cultural needs. The chef always endeavours to take individual tastes into account and discusses their preferences with them periodically. We took lunch with those using the service, which consisted of chicken in a tarragon sauce, mashed potato, mushroom rice, carrots, brocolli, and peas followed by the choice of bananas and custard or yoghurt. The dining environment was found to be relaxed and comfortable and residents were able to enjoy their lunch at their own pace. People using the service are encouraged to maintain contact with their families, friends and their local community. Service users are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user themselves. Service users are able to entertain their visitors in their own bedrooms or in the communal areas of the home Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate arrangements are in place to protect service users from abuse and to address any complaints or concerns about the service. Evidence: The home has an effective complaints procedure in place which is detailed in the service users guide and is on display within the home. The home tell us that it has received three complaints within the last 12 months, all of which we found to be logged appropriately, detailed the actions taken in response to the complaints and were resolved within the timescale detailed in their policy. They continue to let us know about things that have happened since the last inspection through their notification procedures. Those sent to us since the last inspection were read again as part of this review. There are policies and procedures in place to guide the manager and staff on how to respond to any suspicion of abuse, these are in line with the Buckinghamshire multi agency policies and procedures. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff members responsibility to whistle blow on any poor practice or concerns that come to their attention. Information provided to us in the completed AQAA informs us that there have been no safeguarding incidences during the last twelve months and the Commission has not Care Homes for Older People Page 17 of 29 Evidence: been notified of any information to the contrary. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with a safe, well maintained, comfortable, homely, environment in which to live which is kept to a high standard of cleanliness and meets their needs appropriately. Evidence: People using the service are enabled to access their communal and private space, through the provision of a number of aids and adaptations. The home provides grab rails in corridors, bathrooms and toilets and hoists and assisted toilets and baths are available to meet the service users needs. The home has sufficient toilet, washing and bathing facilities, all of which are accessible and clearly marked. Accommodation for each resident is furnished and equipped to ensure them the right to comfort and privacy in a homely atmosphere. The manager informed the inspector that the home always encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, which was confirmed by those spoken to during our visit and evident on touring the home. Residents spoken to on the day informed us that they were happy with their bedrooms and their surroundings, that the home is kept to a high standard of cleanliness at all times. All bedrooms are individual and contain en-suite facilities and have a call system with an accessible alarm facility, which allows service users to call Care Homes for Older People Page 19 of 29 Evidence: staff in the case of an emergency. Service users spoken to informed us that in situations where they have had to use this alarm they had been answered swiftly and appropriately. Whilst touring one of the service users ensuite facilities there was evidence of a hazardous cleaning substance being stored; upon enquiry it was ascertained that the service user themselves had obtained the cleaning substance and not informed the staff as did not feel it important. The manager undertook the necessary precaution of discussing the incident with the service user, removing the substance and placing it securely to ensure the health and safety of the service user. The service continues to upgrade the environment to ensure comfort and meet the needs of the people living there. Since the last inspection, the service have made improvements to the environment, which includes; the provision of new evacuation chairs on each staircase, replacing the flooring in all the communal bathrooms and replacing the flooring in the kitchen. Further improvements are planned over the next twelve months which include replacing the worktops in the kitchen, replacing over half of the ensuite bathroom floors as they are beginning to look tired and redorating the hairdressing salon. During our visit, the home presented as clean, tidy and homely. Whilst touring the home we found medication being stored inappropriately in an unlocked refridgerator in a communal kitchen upstairs, which is used by visitors and service users. When we highlighted the unsafe storage to the manager, she took immediate steps to ensure the storage of the said medication be made safe protecting the health safety and welfare of the service users and visitors alike until an appropriate lockable refridgerator or other secure facilities be obtained. A requirement has been made within this report to address this issue (see Section headed health and personal care). Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There homes recruitment procedure serves to ensure that only suitable staff are employed to work with the users of the service, although verification of references which do not contain a company stamp needs attention as does the gaining of a full employment history. The staff team are provided with a good range of training opportunities to ensure they have the relevant skills and knowledge to enable them to deliver the care safely and competently, although documentation must be held on staff files at all times to evidence this. Evidence: The staffing levels on the day of inspection were sufficient to meet the needs of the residents. The home has a good recruitment procedure to ensure that suitable staff are employed to look after their vulnerable clients. Application forms are completed, references are collected and face-to-face interviews are undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken to ensure the persons suitability with working with vulnerable people. Three staff files were sampled for inspection, which contained relevant preemployment checks, references and their relevant qualifications. However, it was noted that there were some shortcomings; one file did not contain an up to date Care Homes for Older People Page 21 of 29 Evidence: photograph of the member of staff, there were unexplained gaps in the staff members employment history and one reference which was not accompanied by a company stamp there was no evidence to suggest that this had been followed up and verified. Requirements have been made within this report to address the shortcomings. The registered manager informed us that all newly appointed members of staff undergo induction training upon appointment to their posts, shadow a senior member of staff until both parties feel comfortable that the member of staff is competent and knowledgeable to undertake the tasks alone and that all staff are provided with mandatory training, and ongoing training which equips them to meet the assessed needs of the residents within the home and allow for their personal development. However, whilst viewing three staff members files, it was apparent that one of the staff members training file failed to contain evidence to suggest that he/she had received appropriate training appropriate to the work that he/she was undertaking; the evidence contained within the file suggested that he/she had not undertaken a full induction and had not been provided with all the required mandatory training. The registered manager assured us that evidence had been in the file but was not sure why it had been removed. An immediate requirement was made in response to believing an offence may have been committed in failing to ensure that the staff member received appropriate training to the work that they are performing, including all mandatory training requiring the manager to address this issue and to inform the Commission within 48 hours of the actions taken . The registered manager acted promptly upon the failings and we received confirmation within 48 hours informing us that training records had been removed from the file some three weeks previously for the said staff members NVQ training purposes and returned on December 15th, that the majority of the mandatory training had been undertaken with safeguarding training being the only area in which training had not been provided which the manager had acted upon in providing a one to one training session and informs us that she is booking safeguarding training for the staff member to attend. Furthermore, the registerd manager has put into place procedures to prevent re-ocurrence. Information within the completed AQAA informs us that of the twenty two permanent care staff, fifteen have achieved the National Vocational Qualification at level 2 or above in care. Likewise the registered manager holds the NVQ qualification in direct care at levels 3 and four and has attained the Registered Managers Award. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the manager is qualified and has the experience to run the home competently there was evidence of poor practices taking place namely around the storage of medication, the storage of hazardous substances and a failure to ensure training records are kept in the home. Evidence: The registered manager is experienced, knowledgeable, has the required qualifications and competency to manage the home. Residents and staff spoke in complimentary terms about her management ability and the support she gives. The management approach of the home creates an open, positive, transparent and inclusive atmosphere. Service users and staff spoke in complimentary terms about her management ability as did the feedback from surveys sent out prior to the inspection. The inspector discussed health and safety issues and saw appropriate maintenance records relating to maintaining a safe environment for service users and staff who work at the home. Regular safety checks are undertaken relating to fire safety and Care Homes for Older People Page 23 of 29 Evidence: infectious diseases and regular servicing and maintenance of equipment, all of which were seen to be documented appropriately. The home does not act as agent or manage monies on behalf of residents. The home engages regularly with users of the service to gain feedback on the service it provides; this is undertaken on both an informal and formal basis through feedback from residents meetings,annual surveys, any complaints received and noting any comments or concerns when undertaking residents care reviews. The home offers a personalised service to meet the needs of those using the service. There is a commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 30 19 Ensure that persons 16/12/2009 employed to work at the care home receive training appropriate to the work that they are to perform and inform the Commission of the actions taken in regard to the member of staff whose file did not contain evidence of such training during the inspection. To ensure the health, safety and welfare of those using the service. 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 9 13 The registered manager 26/02/2010 must provide self medicating service users with appropriate facilities in which to store their medication and does not cause a risk of others accessing it. To ensure the health, safety and welfare of those using the service. 2 9 13 The registered provider must ensure a controlled drugs 26/02/2010 Care Homes for Older People Page 26 of 29 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 cupboard, which complies with the misuse of Drugs (safe custody) Regulation 1973 is provided for the secure storage of any Controlled Drugs, which are prescribed for people who use the service. To ensure secure storage of Controlled Drugs. 3 29 19 Ensure that any references 26/02/2010 received on unheaded paper are followed up and verified and any gaps in employment history are explained. This is to ensure their authenticity and provide a more robust recruitment procedure. 4 30 19 Documentary evidence of any relevant qualifications and training must be held in staff personnel files at all times. This is to evidence that staff are appropriately trained to undertake the role that they are to perform. 5 35 13 Ensure that appropriate records and receipts are kept for hairdressing services that service users receive 26/02/2010 26/02/2010 Care Homes for Older People Page 27 of 29 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 To ensure that service users financial interests are safeguarded. 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 Care Homes for Older People Page 28 of 29 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 29 of 29 - 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!