Care Home: Sovereign Lodge Care Centre

Similar services:

• The Shelley
• Springfield House
• Sutton Lodge Nursing Home
• St Helier`s Residential Hotel
• St Joseph`s
• Ridgemount
• Wingham Court
• Old Hastings House

What the care home does well Sovereign Lodge provides residents with a comfortable and homely environment, with space for residents to sit comfortably or walk around if they choose. The home aims to encourage residents to make choices about all aspects of their day to day lives, and some are able to decide how they spend their time and what meals they would like to eat. Relatives and visitors are welcome at any time, those involved in the inspection were very positive and they said the `staff are very good`. What has improved since the last inspection? Some of the requirements listed at the last inspection have been addressed or partly addressed, and improvements have been made with regard to the policies and procedures for medication. What the care home could do better: Whereas some residents make decisions about aspects of their lives in the home, some residents are not supported to do this, in particular those with a dementia type disability. They are unable to make choices about the food they eat, and are not offered activities based on their preferences. Several concerns were identified during the inspection and these were discussed in detail with the management, who advised that audits had identified some of these and action would be taken to address them. A number of requirements have been made concerning the care planning system and staff training, to ensure the support and care provided for residents meets their assessed needs. Key inspection report Care homes for older people Name: Address: Sovereign Lodge Care Centre Carew Road Eastbourne East Sussex BN21 2BF     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Kathy Flynn     Date: 2 2 0 7 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 30 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 30 Information about the care home Name of care home: Address: Sovereign Lodge Care Centre Carew Road Eastbourne East Sussex BN21 2BF 01323412285 01323438423 sovereignlodge@lifestylecare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Life Style Care (2005) Plc care home 64 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: 1 The registered person may provided the following category/ies of service only: Care home with nursing (N) to service users 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 (OP) Dementia (DE) 2 The maximum number of service users to be accommodated is 64 Date of last inspection Brief description of the care home Sovereign Lodge Care Centre is owned and run by Life Style Care PLC and is registered to provide care for 64 residents in total, 26 for frail and disabled older people requiring nursing care, and 38 for frail older people with dementia who require nursing. The home is situated in a residential area serviced by local bus services providing good links to the town centre and surrounding areas. Eastbourne train station and town centre is also within walking distance. Car parking is available on site. The home was purpose built and residents accommodation is found on the ground, first and second floors. On the ground floor there are 26 single bedrooms for those residents needing Care Homes for Older People Page 4 of 30 64 0 Over 65 0 64 Brief description of the care home general nursing care. The first and second floor have 38 single bedrooms for those residents that have a dementia. All rooms have en-suite facilities and disabled access is available throughout the home with the provision of ramping and passenger lifts. Varied communal space is available along with outside space for walking and sitting. Information regarding the fees can be obtained from the home. Additional costs are charged for hairdressing, chiropody newspapers/ magazines some outings and toiletries. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term service user to describe those living in care home settings. For the purpose of this report those living at Sovereign Lodge will be referred to as residents. This was a key inspection that included an unannounced visit to the home. A range of documentation was reviewed including care plans, medication charts, staff files, and menus. The deputy manager, registered nurses, care staff and cooks discussed the support they provide for residents. Care Homes for Older People Page 6 of 30 Surveys were sent to the home for completion by residents and their relatives as well as staff. Four resident and three staff surveys were returned. The information received has been incorporated into the report, with the comments received from visitors on the day of the inspection. The Annual Quality Assurance Assessment (AQAA) was completed by the manager, within the required timescale, and identified areas where improvements have been made, and where others are planned for the benefit of residents. Care Homes for Older People Page 7 of 30 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 8 of 30 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 9 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes statement of purpose and service users guide provide information about the care services at the home, and prospective residents are given this information to help them decide if the home offers the support they want. Evidence: The statement of purpose states that the home has separate units on three floors. The second and first floor offer nursing care and support for people who have dementia, and the ground floor provides nursing care for people over 55 who are frail. At the time of the inspection it was found that people who have dementia, and require specialist support and care, had been admitted to each of the three floors. Any change in the admission process should be reflected in the statement of purpose, which needs to be reviewed and updated, so that people have correct information on which to base their decision to move into the home. Care Homes for Older People Page 10 of 30 Evidence: The deputy manager confirmed that prospective residents are assessed before they are offered a place in the home, the assessments are completed with the involvement of prospective residents and their relatives, and a place is confirmed in writing following this. Residents in the home have specific needs that require specialist support from both registered nurses and carers. The deputy manager is aware that staff need to have further training in respect of these care needs and this is being arranged. However this has been identified as a concern and the home should review their admission process to ensure they have the capacity to meet prospective residents needs. The assessments are included in the care plan following admission and a number were examined during the inspection. They were found to include information about the residents individual medical and social needs, with details of their interests and hobbies, but there was no a clear link between this information and the actual support provided for people living in the home. Refer to Standard 7. Some of the residents involved in the inspection said they had picked the home when it first opened and had been very pleased with their choice. For other residents relatives had chosen the home after visiting and talking to the management and staff. Prospective residents and their relatives can visit the home at any time and some were looking around with the deputy manager during the inspection, although they were not introduced to the residents in the room they viewed. Management should be aware that Sovereign Lodge is the residents home, they should be introduced to any visitors and informed if anyone is visiting their home. Care Homes for Older People Page 11 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning system contains a considerable amount of information about the assessed needs of people living at the home. However there is little evidence that the information is used by staff to provide appropriate care and support. Policies and procedures are in place regarding medication to protect residents. Evidence: Six care plans were examined and found to contain a pre admission assessment, as well as assessments completed after people have moved into the home, life stories, hobbies and interests, risk assessments, including those for nutrition, falls and mobility, and information about the specific physical support and care needs of each of the residents. There was evidence that the care plans had been reviewed, although no evidence that this had been done with the involvement of the residents. The registered nurses are responsible for completing the daily record of care. On viewing these it was observed that some staff were writing short statements such continence care provided or usual day. Daily records are a good source of evidence to show that care is being provided, as detailed in the care plan, however short Care Homes for Older People Page 12 of 30 Evidence: statements are not helpful or adequate. When well written care plans help ensure a consistent approach and good quality of care for residents. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review, and to record that they are following the assessment of needs. The care plans are available for all staff to read so that they have a broad understanding of each of the residents needs. However some of the care staff had not read these, they said they do not have the time, therefore they do not know the individual preferences of each of the residents. Consequently they are unable to offer care that is based on staff working with residents to decide together what is best for each of them, on a day to day basis. It was noted that one resident had lost weight over the previous month, but the care plan had not been reviewed and therefore no plan of action to address this had been developed. Paperwork from the Gold Standard Framework for end of life care had been included in all the care plans, the home has not been approved to use this, consequently records are kept of decisions that are made on behalf of residents that are not appropriate. The registered nurses stated that they are unable to allocate enough time to ensure that the care plans are up to date, and reflect the support needed by residents and offered by staff. The relationship between staff and relatives was noted to be comfortable and positive. A number of relatives said the support and care provided by the staff is very good, all stated that they are kept informed of any changes, and they are involved in decisions about the care of their relatives. Residents are registered with GPs and staff said that residents can access allied health professionals as required, with visits recorded in the care plans. Policies and procedures are in place with regard to medication. Trained nurses are responsible for the ordering, storage and administration of medicines and systems are in place to enable an audit trail to be made if required. The Medicine Administration Record (MAR) charts viewed were completed appropriately and photographs of residents are kept with the charts. Staff involved in the inspection stated they aimed to provide a good level of care for residents and their conversations with them were friendly and relaxed. However it was noted that their use of moving and handling aids was inappropriate. In particular the handling belt was used to lift residents rather than assist them to stand up, and this did not protect the residents dignity at times. Care Homes for Older People Page 13 of 30 Evidence: Staff need to be aware that discussions about a residents personal care needs in the lounge shows a lack or respect for their privacy, as they can be heard by other residents and visitors to the home. Care Homes for Older People Page 14 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities are available for some residents to participate in if they wish, however the social support needs of residents with dementia are not met, and there was evidence of a lack of stimulation. The meals are good and choices are available for residents who are able to make choices and staff assist residents if required. Evidence: An activity programme is published weekly for groups of residents and individuals, and these include manicures, craft work and films, and staff said residents can choose to attend if they wish. The activity coordinators advised that they would like to develop a system of recording what residents like to do in terms of activities, so that they can plan a programme that meets everyones individual needs. Currently they do not have this information, they have limited facilities, which affects the range of activities they can offer, and the care staff have minimal involvement in supporting residents to take part in activities. There were clearly many residents with a wide range of needs relating to different stages of dementia and further appropriate stimulation and socialisation, over and above the general day to day care duties and limited activities is required to promote a person centred approach to care. Staff spoken said that more staff are needed, so Care Homes for Older People Page 15 of 30 Evidence: that they can ensure all residents are given the same opportunities to take part in activities they enjoy, which also involves staff receiving relevant training. Friends and relatives can visit the home at any time, and those involved in the inspection said they are made to feel very welcome, they are offered a drink when they arrive, and can join residents for lunch if they wish. Staff said that residents are able to make choices about how they spend their time, some remained in their rooms while others used the lounges or dining areas. However this was difficult to evidence during the inspection, some of the support offered by staff was limited to personal care and the provision of meals, with very little planned using the information available in the care plans about their individual interests and preferences. This lack of choice was noted during meal times. It was noted that residents were not asked what they would like for the meals, although the head chef confirmed that choices are available for the residents, and staff are provided with these on each of the floors where the individual meals are given out from the serveries. The feedback from some residents was that they do not always receive what they have asked for; it was noted that residents were asked to sit in the dining areas some time before the meals were given out and a number became unsettled and moved away from the tables; some were given their meals before others at the same table; some were assisted to eat while others who require assistance, and were sitting at the same table, had to wait for staff to be available. There is considerable opportunity to make meals a pleasant and positive time, with appropriate planning, staff training and sufficient staff numbers meals can be a valuable social experience for residents. The serveries on each floor enable staff to offer drinks and snacks throughout the day, and staff prepared drinks for residents in addition to the organised tea and coffee times. Bread, spread, jam, crisps and biscuits are available for staff to use, and although the kitchen is locked when the kitchen staff leave the trained nurses have access to the keys if they need to make more substantial meals. Care Homes for Older People Page 16 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has policies and procedures in place to enable residents or their representatives to make complaints, however people involved in the inspection said that they did not think staff listened to their concerns. Training in protecting vulnerable people is provided for staff to protect residents. Evidence: Residents and their representatives are provided with information about raising concerns, or making complaints about the service provided at the home, in the Statement of Purpose and Service Users Guide. The deputy manager advised that policies and procedures are in place, these include details of the time frames for responses to complaints, and who can be contacted if the complainant is not satisfied with the homes response. Some people involved in the inspection said the concerns they raised with staff included the lack of choice at mealtimes and not providing the care and support they want, for themselves or other residents. They also said staff did not address these concerns when they were raised, and consequently there have been no improvements in the home. Staff said that they attend training in protecting vulnerable adults as part of their induction, and the deputy manager confirmed that they are all required to attend Care Homes for Older People Page 17 of 30 Evidence: updates yearly. The staff were able to demonstrate that they understood types of abuse, and were quite clear about what action they would take if they had any concerns. The deputy manager confirmed that policies and procedures are in place in line with the multi agency guidelines, with details of the lead authority. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sovereign Lodge provides residents with a comfortable place to live. Training in the prevention of infection is provided for staff to protect residents, however not all staff were following the homes procedures. Evidence: Sovereign Lodge is regarded as a purpose built care home near Eastbourne town centre, on a busy road with parking spaces in the grounds. The building structure is H shaped, and on the ground and first floor residents rooms are spread out on either side of the corridors, with lounge/dining rooms separated by the servery that contains facilities for staff to make residents drinks and snacks. On the top floor there are eleven residents rooms with a dining/lounge room and servery, as well as an activity room, staff room, laundry and kitchen. Entrance to the home, the shaft lifts and rooms not used by residents are accessible using security keypads, staff confirmed that these are in place to ensure the safety of the people living there. Stand aids, hoists, assisted toilets and baths are in place to enable staff to transfer residents safely. However it was noted that staff were not following the homes procedures for the correct use of handling belts and a stand aid. Additional training had been organised by the second day of the inspection, but a requirement has been Care Homes for Older People Page 19 of 30 Evidence: made to ensure that appropriate training and ongoing support is provided for staff. Refer to Standard 38. Some of the people involved in the inspection choose to remain in their own rooms, they said their rooms are very nice and they were able to bring pictures, ornaments or furniture with them when they moved in. The home was clean, well decorated and there is an ongoing maintenance programme. Murals have been used to make the walls of the top floor interesting and decorative, with pictures attached using Velcro so that residents can re arrange the pictures if they wish. The deputy manager explained that different colours and pictures are used to involve residents in decisions about the decoration of their home. There is a secure garden that residents use when the weather permits, and they are planning a number of activities over the summer months, including barbeques and afternoon teas. Staff also said that some of the residents enjoyed gardening before they moved into the home, a greenhouse has been provided for their use, and they are being encouraged to grow plants of their choice. Training is provided for staff with regard to preventing cross infection, and those spoken with have attended this. However staff were noted to be using gloves and aprons incorrectly by wearing them when not actually providing personal care. A requirement has been made for further training and support for staff. Care Homes for Older People Page 20 of 30 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. Robust recruitment procedures are used when employing staff to protect residents. Training is provided for staff but this should be reviewed to ensure they are aware of their roles and responsibilities. Evidence: There are different staffing levels on each of the floors of the home and the deputy manager advised that this is based on the needs of the residents. However the feedback from residents, relatives and staff during the inspection and from surveys is that the staff are very busy, there are not enough of them, and they are unable to offer the level of care they think the residents need. There are clear procedures followed by the home when employing new staff. Four staff files were examined and they contained the relevant information including application forms, two references, interview notes and POVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks. All staff are required to complete induction training when they start working at Sovereign Lodge, new staff involved in the inspection said they have done this and the records kept in staff files support this. The deputy manager confirmed that there are opportunities for them to go on to the National Vocational Qualifications (NVQs), and a number are working towards these or have successfully completed them. However Care Homes for Older People Page 21 of 30 Evidence: there was no evidence that as part of the training programme staff are supported to develop their practice in terms of a person centred approach to care. A team leader and key worker system has recently been introduced and the care plans viewed list the staff that are regarded as each residents key worker. However this is still in the early stages of development, and there is a considerable amount of work to be done if this system is to be used for the benefit of residents and their relatives. Staff attend the mandatory training required and this includes first aid, food hygiene, moving and handling and fire training. There was some confusion when discussing additional training to support people who have dementia, and the managements view was that this is not a mandatory requirement. However if a home is registered to offer nursing care for people who have specific needs then the legislation is quite clear, staff are required to have the appropriate skills and expertise. Some training about dementia has been provided for staff. But following discussion with staff and the management it was agreed that an understanding of the types of dementia, and the behaviour linked to these, may not be sufficient for staff to develop a care planning system that enables residents to make choices and be involved. A requirement has been made for the training to be reviewed and adapted accordingly, to ensure all staff aware of their roles and responsibilities when providing care for the residents. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management approach aims to involve the residents, relatives and staff in decisions about the development of services at the home. Evidence: The manager of the home is a registered nurse with considerable experience of providing support and nursing care. She has been managing Sovereign Lodge for under a year, and has the support of a deputy manager who has worked at the home for over one year. She was not available during the inspection but was contacted and the concerns noted during the inspection were discussed in detail. She was quite clear in her view that improvements were required, and they could be made over the next few months. Sovereign Lodge is one of a group of homes owned by Life Style Care PLC, and there are management systems in place to audit the services offered at the home, as part of a quality assurance and monitoring programme. During the feedback session of the Care Homes for Older People Page 23 of 30 Evidence: inspection the operations manager advised that a number of concerns had been identified, regarding the care plans and the support offered to residents, and they are looking at addressing these. However some of the concerns identified during the inspection had been noted during the Annual Service Review for the home in 2008, and there was no clear evidence that the company had actively addressed these. The deputy manager confirmed that the home does not take responsibility for the residents finances. Systems are in place to ensure the home is well maintained and the facilities are safe for residents use. However the residents health and safety is not protected as staff do not always follow the homes procedures regarding moving and handling and infection control. Care Homes for Older People Page 24 of 30 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 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 4 14 That the assessment process 31/08/2009 ensures that the home has the capacity to meet the needs of prospective residents. To protect prospective and current residents. 2 7 15 That care plans are 30/09/2009 developed on the basis of a person centred approach to care, with evidence of the involvement of residents and appropriate support for staff. To ensure the individual needs of the residents are met. 3 10 12 Staff training to be used 31/08/2009 effectively to ensure the residents privacy and dignity is protected. To ensure the home protects the privacy and dignity of residents. Care Homes for Older People Page 26 of 30 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 4 14 12 That residents are encouraged to take decisions about all aspects of their day to day lives. To ensure the home meets the assessed needs of the residents. 31/08/2009 5 15 16 That residents are enabled to have choices with regard to the meals provided. To ensure residents are involved in decisions about the facilities provided. 31/08/2009 6 16 22 That the home follows their own complaints procedures and responds accordingly to concerns raised by the residents. To ensure the concerns of the residents are addressed. 31/08/2009 7 26 13 That infection control 30/09/2009 training is reviewed and update to ensure staff follow the homes procedures. To control the spread of infection in home and protect residents 8 27 18 That staffing levels are 31/08/2009 reviewed and changed as required too meet the assessed needs of residents. Care Homes for Older People Page 27 of 30 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 there are sufficient staff to support residents. 9 30 18 That training is provided for all staff to ensure they have the skills and knowledge to support residents, and are aware of their roles and responsibilities. To ensure residents receive the care and support they require. 10 33 24 That regular assessments of 30/09/2009 the services and facilities are made and action taken to address any shortfalls. To ensure residents receive the support and care they need. 11 38 13 That staff training is reivewed and updated to ensure that the homes procedures regarding moving and handling are followed by staff. To protect residents and staff. 31/08/2009 30/09/2009 Care Homes for Older People Page 28 of 30 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 29 of 30 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 30 of 30 - 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!