Care Home: Sherwood View Care Home

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What the care home does well Individual written needs assessments were in place before people were admitted to the Service so that their diverse needs were identified and planned for. People who use the Service had individual plans of care which demonstrated that their health and care needs were being met. They were being treated with respect and their right to privacy was upheld. The Service provided activities and services that benefited people living here. Meals were varied and enjoyed by people. Good procedures for handling complaints and abuse were in place ensuring that people who live at the Service were fully protected. People were living in a comfortable and homely environment. The Service had a good level of well trained staff to ensure that the people living here were safe and their needs were met. The Service`s management ensured that systems were in place that promote the interests of people living here. What has improved since the last inspection? Care plans have improved and a larger controlled drugs cupboard has been fitted. Hygiene and cleanliness have also improved and several areas have been redecorated. Cleaning materials are stored safely and staff recruitment and selection practices are safer. What the care home could do better: There were no requirements made at this inspection. Good practice recommendations are made in areas of care planning, risk assessments, medication protocols, social activities, recording practices, the environment, infection control, staff training, quality assurance and the registration of the Acting Manager. Key inspection report Care homes for older people Name: Address: Sherwood View Care Home 29 Village Street Derby DE23 8TA     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: Anthony Barker     Date: 1 1 1 1 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 25 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 25 Information about the care home Name of care home: Address: Sherwood View Care Home 29 Village Street Derby DE23 8TA 01332271941 F/P01332271941 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.europeancare.co.uk European Care (SW) Ltd care home 39 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: To allow Sherwood View Care Home to accommodate one individual named in the proposal notice dated 13/01/06, who is under the age of 65 years old. Date of last inspection Brief description of the care home Sherwood View is a purpose built care home providing nursing and personal care for up to 39 people aged 65 years and over. The Service is located next door to another care home owned by the same company. The Service has 30 single and 3 double bedrooms located on the ground and first floor. All rooms except one have en-suite facilities. Access to the first floor is by stairs and a passenger lift. Sherwood View is approximately three miles from the Derby City Centre, and is close to local shops and facilities. Communal areas consist of a large lounge and dining area and a quiet room on the ground floor. Additionally there is a large conservatory and a garden area. 1 2 1 1 2 0 0 8 0 Over 65 39 Care Homes for Older People Page 4 of 25 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The time spent on this inspection was 9.25 hours and was a key unannounced inspection. Survey forms were posted to people living at the Service, their relatives, staff and external professionals before this inspection and 9 people responded. We spoke to several people living at the Service - one of these in more depth - and, briefly, to one relative who was visiting. We also spoke to the Acting Manager, one senior care assistant and the Activities Co-ordinator. Records were inspected and there was a tour of the premises. Four people living at the Service were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last key inspection on 12th November 2008. The Acting Managers pre-inspection, Annual Quality Assurance Assessment (AQAA), self assessment form was reviewed prior to this inspection. She informed us that the Services fees ranged from £368 to £474 per week. Care Homes for Older People Page 5 of 25 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 order line 0870 240 7535. Care Homes for Older People Page 6 of 25 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 7 of 25 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. Individual written needs assessments were in place before people were admitted to the Service so that their diverse needs were identified and planned for. Evidence: One of the people case tracked had been very recently admitted and their file was examined. A Social Services pre-admission written assessment of this persons needs was on file and provided staff with information about the individuals particular needs and preferences so these could be met. The Service had also completed a full assessment of needs within 48 hours of the persons admission. People who completed a pre-inspection survey were positive about their decision to choose Sherwood View for them or their elderly relative to live. One Social Services community care worker commented, in their pre-inspection survey, on the good quality of care provided by the Service. The Service was not providing intermediate care. Care Homes for Older People Page 8 of 25 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the Service had individual plans of care which demonstrated that their health and care needs were being met. They were being treated with respect and their right to privacy was upheld. Evidence: Four people living at the Service were case tracked so as to identify the standard of care provided from their own perspective and from individual records and discussions with the Manager and staff. The files of these people were examined and these included care plans that clearly and comprehensively set out how peoples health and personal care needs should be met by staff. In one file, a Social Care Assessment had been partially completed and, in another, there was a Work and Play care plan. This indicated that somewhat limited priority was being given to setting out goals for meeting peoples social, psychological or emotional needs and of some inconsistency between peoples care planning records. The Acting Manager accepted these points when we raised them with her. With care plans generally limited to meeting peoples health needs staff may find it difficult to proactively meet peoples holistic needs in a person centred way. Records did not reflect a fully person centred approach that Care Homes for Older People Page 9 of 25 Evidence: would ensure that peoples preferred lifestyles are identified. Also, individual files, apart from medicine records, did not contain peoples photographs - which would be of benefit to new staff. However, overall, there was evidence of improvements in care planning documentation since the last inspection. Files showed that care plans were being reviewed on a regular monthly basis to ensure monitoring that reflects peoples changing needs and were up to date. Recorded risk assessments covered areas such as risks associated with falling, tissue viability, continence management and nutrition and provided a means of measuring and minimising these risks. There were care plans that addressed peoples mobility needs - one was particularly well worded. However, there were no actual risk assessments associated with Moving & Handling, which would provide more explicit detail on managing such risks - the use of hoist slings, for example. Those risk assessments in place were being regularly reviewed on a consistent basis. Peoples health needs were being met by appropriate contact with external health professionals and evidence of this was seen on files and provided by the Acting Manager in the preinspection self assessment form. She made reference to contact with health professionals involved in, tissue viability, palliative care, occupational therapy, continence specialists, etc. One relative, of a person living at the Service, told us in a pre-inspection questionnaire, that Sherwood View is, professional in their caring and medical approach. The administration of prescribed medicines was being recorded accurately and medicine records contained a photograph of each person living at the Service in order to minimise mistakes. Medicines were being securely and appropriately stored. Controlled drugs were being stored securely in a more suitably sized cabinet than at the last inspection. They were being accurately recorded in a controlled drugs register. There was no recorded protocol for the administration of one case tracked persons diazepam. Putting such a protocol in place would ensure consistent and safe practice from staff when the person displays agitation. The Acting Manager told us that creams are only requested from GPs when people actually need them. This has addressed the potentially unsafe practices, found at the last inspection, of prescribed creams being found in places other than peoples own bedrooms. The Acting Manager also informed us that the Services pharmacy provides staff with six-monthly training in the safe use and recording of medicines. A pharmacist told us, in a pre-inspection questionnaire, that, the prescriptions are always ordered in good time and any missing items are chased up immediately. People living at the Service were well dressed. One case tracked person confirmed that their privacy needs were met by staff and felt respected, adding, staff are Care Homes for Older People Page 10 of 25 Evidence: excellent...you only have to ask and they do it for you. The senior care assistant spoken with described how she meets the privacy and dignity needs of people living at the Service. Care Homes for Older People Page 11 of 25 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 Service provided activities and services that benefited people living here. Meals were varied and enjoyed by people. Evidence: The Service was providing a range of activities, for the people living here. In the preinspection self assessment the Acting Manager said that, the Activities Co-ordinator is arranging themed days based on the nationality of people here. She gave us an example of this as being the cultural party to whom all relatives were invited, some by cards written by the people themselves. There was only a moderate turnout to this event. However, there was a better turnout at a recent bonfire party. At the last inspection we recommended that people should be offered more meaningful stimulation during the day. We saw evidence on case tracked peoples files, and from the Social Activity Logs, of improvements in this area. However, some people living at the Service, and their relatives, expressed in their completed pre-inspection questionnaires, an opinion that, more activities, indoors and outdoors, could be provided. The Activities Co-ordinator works two days a week at Sherwood View. She described a good range of activities that she leads including accompanying people out into the local community and some innovative work. The Activities Co-ordinators work was not based on individual care planning goals as, we have already mentioned in this Care Homes for Older People Page 12 of 25 Evidence: report, there were very few of these reflecting peoples social needs. The case tracked person we spoke with in some depth felt that there were enough activities provided including cards, dominoes and DVD shows. The Acting Manager told us that only six or seven people living at the Service have visits from friends and relatives. The Activities Co-ordinator told us she takes a central role in talking to visiting relatives and encouraging relatives to have more involvement in the Service. One case tracked person told us that neighbours, known prior to the persons admission to Sherwood View, have visited a few times and confirmed they could stay as long as they like. We spoke briefly with one relative who was visiting during this inspection. The Acting Manager said that one person living at the Service has the independence to go out, unaccompanied, to visit relatives by means of a taxi. This activity has been risk assessed, she added. The Acting Manager said in the pre-inspection self assessment that, Two of our clients have independent care workers who take them shopping and on seaside trips. We spoke to one of these people who personally pays for an advocate from South Derbyshire Advocacy Alliance. This person was looking forward to a visit from the advocate soon. This advocate visits once or twice each week. The Acting Manager also told us that a third person has a voluntary advocate who has introduced a local Anglican church to Sherwood View. The Acting Manager also said in the pre-inspection self assessment that, Rotas ensure there is a Punjabi speaking member of staff on shift at all times. This helps people, whose first language is Punjabi, to exercise control over their lives. One case tracked person told us that the food was, excellent...I couldnt wish for anything better...theres plenty of it. We spoke to several people in the dining room during lunch time and they were all happy with the quality of food. The lunch meal looked appetising and tables were attractively laid out. Food stocks were at a good level. The Acting Manager told us that the Environmental Health Officer visited in June 2009 and gave the Service a good report. The menu indicated that people were being provided with nutritious and varied meals. Care Homes for Older People Page 13 of 25 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. Good procedures for handling complaints and abuse were in place ensuring that people who live at the Service were fully protected. Evidence: The Service had a satisfactory complaints procedure that was displayed in the entrance hall. A version in Hindi was also displayed. The Acting Manager stated in the pre-inspection self assessment that there had been three complaints received by the Service within the past 12 months. The Acting Manager told us that two of these complaints had been from staff concerned about verbal abuse, of them, by a colleague and the acceptance, by this same colleague, of gifts from the people who live at the Service. This staff member was suspended and later dismissed. There was no paperwork available, at this inspection, concerning these complaints and the action taken. The Acting Manager said the third complaint was from a staff member whistle blowing on a colleague alleged to have slapped a person living at the Service. This matter was appropriately raised with Social Services as a safeguarding matter though it was agreed that no further action be taken. The recording of this complaint was very brief with no clear summary of action taken or outcome. In October 2009, one cased tracked person had made an allegation, of a sexual nature, against another person living at the Service. The allegation was passed to Social Services within an appropriate timescale, by telephone, and an emergency care review was held. There was found to be no evidence of abuse having actually taken Care Homes for Older People Page 14 of 25 Evidence: place. This incident was not recorded as a formal complaint nor was there a record of the telephone conversation referring the matter to Social Services. The recorded language used by staff about the complainants behaviour was sometimes inappropriate and unprofessional - descriptive words such as horrible and mental were used. The Acting Manager stated in the pre-inspection self assessment that she, is available evenings and weekends to give relatives the opportunity to raise any concerns before they become formal complaints. People who responded to the postal survey said they knew how to make a formal complaint. One case tracked person told us they would speak to the Acting Manager if unhappy but have had, nothing to complain about. The Acting Manager provided us with an up-to-date staff training matrix that indicated that half the staff group had been provided with training on keeping adults safe from abuse, within the past three years, and the remaining half would receive this training by the end of this year. The Service had satisfactory Whistle Blowing procedures and copies of these procedures were displayed in the entrance hall and the lounge. The senior care assistant spoken with showed understanding of how to safeguard vulnerable people and of whistle blowing. Care Homes for Older People Page 15 of 25 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 were living in a comfortable and homely environment. Evidence: The Services environment was generally attractive in appearance and homely. Some ground floor communal areas were being redecorated at the time of this inspection and the Acting Manager informed us in the pre-inspection self assessment that, some bedrooms have been decorated. Those bedrooms we visited were of a pleasant appearance. The first floor corridors looked tired in appearance and would benefit from re-painting. We noted a number of light pull cords that were dirty with no end knobs. The Acting Manager told us that both shower rooms were due to be refurbished as well as the two first floor bathrooms with non-assisted baths. The latter are not used due to their inaccessibility for the people who live at the Service. The Acting Manager explained that restrictors had been fitted to all first floor windows to reduce the risk of accidents to the people living here. We discussed with her the benefit of discussing with the police the fitting of restrictors to ground floor windows as a deterrent to potential intruders. Should this action be taken people should still be provided with adequate ventilation. Items identified at the last inspection as needing cleaning had either been cleaned or replaced. At this inspection the interior of the premises was clean and there were no unpleasant odours. The Acting Manager told us that four bedroom carpets had been replaced with domestic style vinyl flooring to address unpleasant odours arising from Care Homes for Older People Page 16 of 25 Evidence: continence management problems. Two bars of soap were found in a first floor bathroom and the Acting Manager immediately disposed of these to address the potential for cross-infection. Action was also taken on the bar of soap and toothbrush found in a bathroom wall cupboard - the Acting Manager thought these belonged to a staff member. The senior care assistant spoken with described good practice regarding the transportation of soiled articles of clothing and bedding within the premises. One relative of a person living at the Service, who responded to the postal survey, commented that the premises were, very clean. Care Homes for Older People Page 17 of 25 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Service had a good level of well trained staff to ensure that the people living here were safe and their needs were met. Evidence: The staffing rota was examined and this indicated sufficient staffing levels. The Acting Manager told us that, staff are flexible about covering shifts. Also, in the preinspection self assessment, she described a stable staff group by stating that, we have not used any agency staff...there has only been one leaver in the past 12 months. The senior care assistant spoken with confirmed that there were adequate numbers of staff on duty. One relative of a person living at the Service, who responded to the postal survey, commented that, (there are) plenty of caring staff. One case tracked person we spoke with said, (there are) usually plenty of staff. The Acting Manager told us that 71 of care staff had achieved a National Vocational Qualification (NVQ) in Care at least to level 2. Of these, five members of care staff had achieved an NVQ in Care at level 3 and three were enrolling for this level of qualification. The Acting Manager added that two care staff are enrolling for an NVQ in Team Leadership. The file of the most recently appointed member of staff was examined. Matters relating to her recruitment were satisfactory and included a Criminal Records Bureau Care Homes for Older People Page 18 of 25 Evidence: (CRB) disclosure and two written references. This was an improvement over the position found at the last inspection. The Services staff training matrix was examined. Most staff had completed fire training within the past 12 months and the Acting Manager told us that night staff have twice yearly fire training. Additionally, more than half the staff group had completed other mandatory training courses within the past three years. Those who had not were being offered this training before the end of this year. One third of the staff group had received training in dementia and a further half of the staff group will receive this in November/December 2009. The senior care assistant spoken with confirmed she had attended a range of mandatory training courses over the past 12 months. Care Homes for Older People Page 19 of 25 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. The Services management ensured that systems were in place that promote the interests of people living here. Evidence: The Acting Manager informed us, in the pre-inspection self assessment, that she had attained the Registered Managers Award. She has a nursing qualification too and been the Acting Manager at Sherwood View for 12 months. The Acting Manager had not yet made application to be the registered manager of the Service and explained the reasons for the delay. The people who completed our pre-inspection surveys were positive about the Acting Manager and the ethos of the Service. One external professional remarked, I find (the Acting Manager) to be an excellent manager...she is compassionate, caring and knowledgeable. Another external professional told us of, good leadership skills at the Service. One relative spoke of the Service being, warm, friendly and welcoming. The senior care assistant we spoke with said the Acting Manager is, very supportive Care Homes for Older People Page 20 of 25 Evidence: and she also spoke of, good staff morale at the Service. We examined the Services Business Plan and current redecoration and refurbishment plans. The Acting Manager told us that relatives meetings had been held in April and in September 2009 but unfortunately no one attended on either occasion. She added that some relatives did attend the parties already mentioned in this report. In the preinspection self assessment the Acting Manager referred to, Bi-annual satisfaction questionnaires sent to residents and families, in order to find out their views on the quality of service provided. Satisfaction questionnaires were not being sent to external professionals. The senior care assistant we spoke with said that staff meetings were being held every three to six months. Personal money belonging to people living at the Service was being securely held. There was a robust system in place for recording all transactions, including regular balance checks being made. One case tracked persons money was cross-referenced against the current balance figure and was found to be correct. Half of the staff group had completed Health and Safety training within the past three years. Those who had not were being offered this training before the end of this year. The Acting Manager told us that environmental risk assessments were in place and were up-dated every three months. These documents were being held in the adjoining care home. Cleaning materials were being safely stored in a locked cupboard and Product Information Sheets were in place. This was an improvement from the last inspection. The Acting Manager showed us in the pre-inspection self assessment that equipment was being checked and maintained appropriately. Good food hygiene practices were being followed. Care Homes for Older People Page 21 of 25 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 22 of 25 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 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 4 5 6 7 8 9 7 7 7 8 9 12 16 16 16 Care planning records should take a person centred approach. Care records should have consistent care plan sections. Care plans should reflect peoples holistic needs. Risk assessments associated with Moving & Handling risks should be written. A recorded protocol should be provided to address the administration of anti psychotic drugs. Social activities should be planned around individual care plan goals. Any complaint that may refer to an abusive situation should be recorded, in full, as a formal complaint. Staff should not be using unprofessional language in the daily notes they make. Complaints, the action taken in respect of them, and the outcome should be fully recorded and this record maintained within the Service. Care Homes for Older People Page 23 of 25 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 10 11 12 13 14 19 19 26 26 30 Discuss with the police the benefit of fitting restrictors to ground floor windows as a deterrent to potential intruders. Dirty light pull cords with no end knobs should be replaced. Bars of soap should not be used in communal bathrooms. Staff members personal toiletries should not be kept where they can be accessed by the people living at the Service. Plans should be carried out to provide staff with mandatory training, as identified on the up-dated staff training matrix provided to us. The Acting Manager should now give priority to making application to the Commission to be the registered manager of Sherwood View. Satisfaction questionnaires should be sent to external professionals to elicit their views. All documentation relating to this Service should be held within the Service. 15 31 16 17 33 38 Care Homes for Older People Page 24 of 25 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. 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