Care Home: Shalom Residential Home

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What the care home does well The atmosphere in the home is relaxed and one visitor said ‘The home feels calm and staff are very good’. There are areas in which residents can relax with one area being for the television and others offering quiet comfortable seating. There is an enclosed courtyard that has a pond and we were told that residents had enjoyed tea in this area when the sun was out. Meals are chosen on a daily basis and the meal on the day of this inspection consisted of cheese and potato pie or pasta with vegetables. There was apple crumble and custard for dessert and meals looked appetising. One person said ‘I enjoyed my meal’ and we saw staff offering alternatives and asking if people had eaten enough. Staff were encouraging and supporting residents in an appropriate manner during the course of this inspection with due consideration for dignity and choice. What has improved since the last inspection? The previous inspection identified areas that were in need of attention to improve the environment and support the safety of residents. These areas are being addressed through an ongoing programme and improvements have been made that include the following – Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 • • • •Every room now has a lockable safe for the secure storage of personal items The kitchen is being totally renovated and this was in progress at the time of this inspection. The carpet that was previously identified as a risk has been make safe The laundry area now has hand washing facilities to combat cross infection and this area also now has additional space.Further details of improvements can be found in the full body of this report. What the care home could do better: Discussions were undertaken regarding the daily reports and review of care plans. These documents need to contain more factual information to provide a full picture of the person and how they have spent their day. Staff also need exact information on each care plan to enable them to fully meet individual needs. One area used for the storage of medication was found to be disorganised with additional medication and medication that is to be returned being muddled together. This area requires organisation to ensure the appropriate stock control is undertaken and that staff are able to find what is required easily. Key inspection report CARE HOMES FOR OLDER PEOPLE Shalom Residential Home 147 Yarmouth Road Norwich Norfolk NR7 0SA Lead Inspector Brenda Pears Unannounced Inspection 11th June 2009 10:00 DS0000046100.V376036.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 2 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 Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalom Residential Home Address 147 Yarmouth Road Norwich Norfolk NR7 0SA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01603 432050 01603 432576 lineashalom@btconnecnt.com Medicare Corporation Ltd Manager post vacant Care Home 24 Category(ies) of Dementia (24), Old age, not falling within any registration, with number other category (24) of places Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Old age, not falling within any other category (24) persons. Care Home only. Dementia (24) No new admissions of service users who are wheelchair users to be accommodated on the first floor until the registered person ensures the establishment complies with regulation 23(2)(n). All service users accommodated on the first floor must have written risk assessments regarding the use of the stair lift. 15th July 2008 4. Date of last inspection Brief Description of the Service: Shalom is a large period residence located well back from the road on the outskirts of Norwich and overlooking the Yare Valley. The house has been carefully extended and adapted to provide residential accommodation to a maximum of 24 older people. There are 20 single and 2 double rooms. Two of the single rooms within the extension offer a bed sit type accommodation and the majority of rooms are spacious. Both the double rooms and 12 of the single rooms have en-suite facilities. The upstairs is accessed by a new lift. The care home has a large garden at the front though this is not very accessible for residents. A small courtyard in the middle of the building provides an area for sitting outside. Current fee levels are decided following a full assessment of needs and are dependent on the staffing levels required to meet these needs. Further details including a statement of purpose, a service user guide and a copy of the last report can be obtained from the home on request. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. This was an unannounced inspection undertaken on the 11th June 2009 and started at 10.00 am. The focus of this inspection was on the previous requirements, on the core national minimum standards and on the quality of life for people who receive support in the home. The methods used to complete this inspection consisted of looking at the care a resident receives and the records that support this. Information was provided to us by the home on an assessment form known as an Annual Quality Assurance Assessment (AQAA). During the visit to the home we spoke to the manager, with members of staff and also with five residents. These methods and previous findings all inform the outcomes of this report. What the service does well: The atmosphere in the home is relaxed and one visitor said ‘The home feels calm and staff are very good’. There are areas in which residents can relax with one area being for the television and others offering quiet comfortable seating. There is an enclosed courtyard that has a pond and we were told that residents had enjoyed tea in this area when the sun was out. Meals are chosen on a daily basis and the meal on the day of this inspection consisted of cheese and potato pie or pasta with vegetables. There was apple crumble and custard for dessert and meals looked appetising. One person said ‘I enjoyed my meal’ and we saw staff offering alternatives and asking if people had eaten enough. Staff were encouraging and supporting residents in an appropriate manner during the course of this inspection with due consideration for dignity and choice. What has improved since the last inspection? The previous inspection identified areas that were in need of attention to improve the environment and support the safety of residents. These areas are being addressed through an ongoing programme and improvements have been made that include the following – Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 6 • • • • Every room now has a lockable safe for the secure storage of personal items The kitchen is being totally renovated and this was in progress at the time of this inspection. The carpet that was previously identified as a risk has been make safe The laundry area now has hand washing facilities to combat cross infection and this area also now has additional space. Further details of improvements can be found in the full body of this report. 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 order line – 0870 240 7535. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the 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 does assess the needs of any new resident to make sure individuals can be fully supported before an agreement is undertaken. EVIDENCE: Records seen at this time and discussions confirm that the admission process does include an assessment being undertaken prior to any admission into the home. One new resident was admitted during this inspection for a short stay and a relative confirmed that sufficient information had been provided about the home and assessments had been undertaken. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the 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 care plans contain sections with full information, however, not all sections contained full and up to date information to inform staff exactly what care needs are current. Medication is handled and stored correctly for the safety and well being of those living in the home. EVIDENCE: We reviewed four care plans and these were found to be well organised with divided sections and information was easily accessed. Records contained a history of the person and descriptions of the occupations they had undertaken. Files also contained information about activities that had been enjoyed, daily living needs and the support that is required. Risk assessments were also seen Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 10 for such areas as moving and handling. Where any difficulty may arise due to a person’s disposition, instructions were provided for staff on how to address this. For instance, one file stated ‘spend a little time and the resident will eventually communicate their requirements and requests to you’. Another person was having some difficulty with the fit of their false teeth and the care plan clearly identified this and again instructions on how to support this resident were available. Records gave direction for staff to make certain ‘all meals soft but nutritious, not mashed or mixed together’ and ‘Important that food looks inviting, cook to discuss options daily’. Some time was spent discussing the impact of this problem on the person and how they are currently getting distressed about the situation. When we spoke to this person they brought this problem into the conversation and expressed their unhappiness at this time and how they did not feel like socialising in the home. The manager explained that a dentist is to be contacted and arrangements made to fully enable this person to access appropriate treatment if the resident chooses to do so. Time was also spent discussing the dignity and choice for this resident and that full support must be provided to address any matters needing attention. Another file did contain information about dealing with any difficulties regarding the administration of medication. However, the records did not detail how staff were to carry out the instructions of ‘To develop trust and why medication is needed’. While files did contain appropriate information, daily records are very scant and the same sentence is repeated on many files with very little individual information available to identify how the person spent their day or how the person was feeling. For instance, one entry stated ‘OK today, came out for meals, no problems’. There were also essential details missing where observations were that a person was not in the best of health and there were also conflicting statements. For example the record stated ‘not feeling very well today ate and drank well, Refused bath. No problems’. Following discussions with the manager, it was explained that a review of care plans is about to be undertaken. While recognising that this is required to be completed at least monthly, the manager stated that a review will also be carried out regarding the current methods used to record daily notes. Records on care plans do confirm that residents have access to appropriate healthcare professionals such as district nurse, GP and the local mental health team. Records contained details of appointments and their outcomes. Any cases of bruising or skin problems are closely monitored. Records showed that one person who has a pressure area developing has been seen by the district nurse and a new support mattress is on order. Regular checks are Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 11 recorded on the care plan with a description of actions that staff are to regularly undertake and these records were signed and dated. Care plans had specific information regarding guidance under the mental capacity act and how to encourage choice and for staff to know the balance between leaving if a resident becomes aggressive and when it may be a case of neglect. Medication ready for dispensing was stored appropriately and found to be in good order. Records were up to date, signed and clearly recorded on the medication administration records (MAR) sheets. Records contained a picture of the resident and morning and afternoon medication was colour coded. However, the medication store cupboard was found to be very disorganised, stock had not been reviewed and staff stated that some medication was due to be returned. It was not easy to identify what were returns or additional medication that was needed. Observations at this time and discussions with visitors and three residents confirm that staff do undertake support with consideration for dignity in a respectful manner. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to take part in leisure activities, to maintain contact with family and friends and are offered a variety of healthy meals that they have chosen. EVIDENCE: The home continues to invite family and visitors to main events in the home. There is currently an open invitation on display in the front entrance of the home for a forthcoming garden party. Each year there is a firework display on the front lawn and the manager is currently deciding between having trips out during the summer months or providing entertainment on the front lawn. The senior carer on duty has the responsibility of ensuring there are activities offered each day. The home currently does not own a vehicle for outings. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 13 Those choosing to spend time in their room have regular visits by staff and records were seen of how long staff had spent talking with residents in their room. The manager stated that staff also offer activities to those residents who stay in their room and this is also recorded. The lunch time meal served at this time looked and smelt appetising with meals being served in an appealing way. Residents are asked each day what they would like to eat and as previously stated in this report, soft diets are also presented on a plate to look appealing. Meals can be eaten in rooms or in the dining room as the resident chooses. The manager explained that staff do encourage some meals to be taken in the dining room to prevent isolation and enable people to have some contact during the day. Special diets are catered for and all desserts are suitable for any one with diabetes. Records are kept regarding how much a person eats, staff ask if people want any more and a selection of drinks were offered before meals were served. The results of the quality assessment recently undertaken by the home also show that the majority of people are pleased with the food and only five responses felt that the food or meal times could be improved. There was no information available on how this could be achieved. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents know how to complain and a complaints procedure is on display. EVIDENCE: There is a complaints procedure in place in the front entrance but this does need updating as this is clearly quite old. We had discussions with the manager about the full recording of any complaints that are received, no matter how small, identifying how these were processed and details of the outcomes. The manager stated that he has not received any complaints since he has been in post. The home continues to develop good relationships with family members and visitors to encourage open communication at all times. Regular resident meetings are held to allow for any concerns to be raised. Staff have undertaken training about identifying any areas of abuse and what action is to be taken if this occurs. Discussions with residents and two visitors Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 15 at this time and at previous inspections, shows that people feel they can discuss any problems with staff at any time. The handling of money for residents was discussed and that good practice dictates any money used from the office must be accompanied by two signatures. The manager stated that currently money is held for the chiropodist and the hairdresser and a list is provided by both these services to allow for an audit trail. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 People using the 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 does provide a safe, clean environment and an ongoing programme continues to improve both internal and external areas of the home. EVIDENCE: The manager confirmed that a full environmental risk assessment has been undertaken since the last inspection. The fire safety officer has also been assessing the fire safety in the home and alterations to the home were in progress at this time. These included newly positioned fire extinguishers, a new fire alarm is to be installed with more detectors in place and a new fire risk assessment has now been completed. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 17 A new emergency call system is to be installed that will alert staff to any external doors being opened, the door bell will be heard in all areas of the home, detailed information will be provided to staff about exactly were the alarm is ringing and the fire doors are also on this new system. New fire alert signs are to be in place around the home and more fire detectors installed where appropriate. The laundry area that was found to be unsuitable at the last inspection has been adjusted to provide a little more space in which to deal with the laundry. A sink has been installed to protect against cross infection and this area was seen to be much more orderly. Items are sorted into those needing to be washed on a cool temperature and an allocated member of staff deals with these to ensure they are laundered correctly. Windows on the first floor have been identified as needing replacement where these currently do not fit correctly and cannot be opened. The external parts of the home have also been reviewed and again, work on identified areas is planned. The manager explained that a risk assessment has identified what work is needed first and timescales reflect this prioritising. Rooms are redecorated and refurbished with consultation being carried out with the occupant. The ground floor bathroom is also to be fully refurbished to further meet the needs of residents. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 People using the 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 have their needs met by a consistent staff team who are well trained and regularly supervised, providing stability and continuity of care. EVIDENCE: The staff on duty at the time of this inspection consisted of the manager, one senior carer, three care staff, a cook and two domestic staff (one being part time). Domestic cover also extends to weekends. The staff rota must identify who is the senior member of staff on shift, copies seen at this time did not provide this information. There is an induction programme in place and staff are issued with information relating to codes if practice and training needs are also identified at this time. Three staff files were reviewed at this inspection. While files did contain criminal record checks and information relating to the recruitment process, Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 19 there were no references found on files seen at this time. This was discussed with the manager who stated that all recruitment he undertakes will be in line with requirements and he will also be completing a review of staff files. Staff confirmed that they do have regular staff meetings for both senior carers as well as for all staff. Minutes of the last meeting were seen on the staff notice board. Supervision is also being undertaken and staff stated they feel confident to bring any matters to the manager and feel these will be dealt with appropriately. One member of staff is aged 16 and discussions took place regarding the need for the manager to ensure that any duties undertaken by this member of staff fully comply with regulations set out under employment law. It is noted that at the time of completing this report, the manager had verified the requirements in this area. The manager stated that all senior staff, plus one carer, dispense medication and a refresher course for the administration of medication has been identified. The manager explained that he is in the process of reviewing all staff training to book refresher courses where needed. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is managed by a suitable person and is run in their best interests. EVIDENCE: The current manager has been in place for almost two months and was awaiting the result of his registration interview at the time of this inspection. However, since this inspection took place, it has been confirmed that Daniel Smithson was successful in becoming registered as the manager of the home. The manager has experience in the care field that includes shadowing the previous manager in the home since September 2008, working previously with Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 21 younger adults and also in an advisory capacity identifying appropriate training for people to work towards becoming fully independent. Service folders were available that contained confirmation of regular servicing of equipment and all certificates seen were up to date. The fire details showed that random fire drills are carried out with accompanying details of the outcomes and which staff attended. Regular testing is carried out on fire alerts and additional alarms are being added to the home. A fire risk assessment is also on file. Accident forms are completed and files showed information relating to any injuries with a full description of the events. These are retained in an orderly folder that is sectioned to enable easy access to required information. Policies and procedures are in place and these are indexed, dated when issued and contain information relating to such matters as complaints, recognising abuse, definitions of abuse and the actions to be taken. Discussions took place at this time regarding the regular assessment of the home that is required under regulation 26. This applies if the registered provider is not in day to day charge of the home. The provider is then required to visit the home in accordance with this regulation to assess the quality of the service delivery and also the condition of the property. A record of this visit is to be available for inspection in the home. The manager is currently unaware if these visits are regularly carried out and stated that this would be checked. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (c) Requirement Care plans to contain full and appropriate information in all sections to meet the needs of the individual. In this instance with regard to directions for staff on care plans and fuller, detailed information on daily records. (This is a repeated requirement from 31/10/08. The new manager is due to address the current recording practices) That the healthcare needs of residents are met. In this instance ensuring the choices and needs of the resident are promoted at all times. Procedures are to be followed with regard to the storage of medication. In this instance that any over prescribed and unused medication is dealt with in a timely manner. That appropriate recruitment practices are followed. In this instance ensuring there are at DS0000046100.V376036.R01.S.doc Timescale for action 30/11/09 2. OP8 13 (b) 31/07/09 3. OP9 13 (2) 31/07/09 4. OP29 19 (1) (i) 11/06/09 Shalom Residential Home Version 5.2 Page 24 least two references on all staff recruitment files. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP18 Good Practice Recommendations That all financial transactions be accompanied by two signatures to further protect residents. Shalom Residential Home DS0000046100.V376036.R01.S.doc Version 5.2 Page 25 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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