Care Home: St Catherine`s Home

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What the care home does well Residents had very positive things to say about the home. One resident said it was "pretty good so far", another said the home was "very good", with nice food. He said his personal care was "perfect". A resident said she "could not speak highly enough" of the home and that all the carers were "very good". The service is well run, with good systems which are well joined up. The manager is very aware and involved. The environment of the home is pleasant. It has a lift and a large garden. What has improved since the last inspection? The home now has a registered manager in post. It has met almost all the requirements of the previous inspection and has improved the bathroom and kitchen facilities, which are now good. What the care home could do better: The inspection resulted in six statutory requirements and four good practice recommendations. The home needs to gather social history information for residents, to help with their sense of identity. Medication administration must be properly recorded and risk assessments must be undertaken before bed rails are used. There is some outstanding maintenance work and the manager needs to obtain some Control of Substances Hazardous to Health (COSHH) data sheets. Key inspection report Care homes for older people Name: Address: St Catherine`s Home 35 Derby Road Enfield Middlesex EN3 4AJ     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: Anne Chamberlain     Date: 0 8 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: St Catherine`s Home 35 Derby Road Enfield Middlesex EN3 4AJ 02088041136 02088041136 emilyrose1st@yahoo.co.uk(personalmanagerem ail) Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): ADR Care Homes Ltd Name of registered manager (if applicable) Ms Jade Tara Lewis Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 16 The registered person may provide the following category of service only: Care Home only - Code PC, 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 - Code OP, Dementia - Code DE (maximum number of places: 4) Date of last inspection Brief description of the care home St Catherines Home is a care home for sixteen older people of either gender who are in need of personal care only. The home is a large detached house in Enfield, which was extended and opened in 1986. There are shops and bus and rail routes a short Care Homes for Older People Page 4 of 29 Over 65 4 16 0 0 1 4 1 0 2 0 0 8 Brief description of the care home distance away. The home has twelve single bedrooms and two double bedrooms on the ground and first floor. A lift is available to access both floors. On the ground floor there is a good size kitchen, a large through lounge and a dining room. At the front of the home, there is off street parking for several vehicles and to the rear, there is a large well-kept garden with two large sheds. The fee range for residents living in the home is #398 - #420 per week depending on their needs. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection is written on behalf of the Care Quality Commission and the terms we and us will be used throughout. This unannounced inspection took place over one afternoon and the next day. The home has sixteen beds and twelve are currently occupied. We spoke to several residents and two relatives and were assisted by the manager of the home. We looked at key documentation and three service user files. We looked at personnel files and training records of three members of staff who work with the three residents. We inspected medication administration arrangements and toured the environment of the home including the garden. We would like to take this opportunity to thank the residents, relatives, manager and staff of the home for their co-operation with the inspection. Care Homes for Older People Page 6 of 29 Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: 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 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience 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 not offer placements to prospective residents unless they have been assessed and it is confident it can meet their needs. However they need to include social history information in assessments. Evidence: The manager advised that usually referrals come from social services and often people are in hospital awaiting discharge. The manager or the senior carer will assess the individual in hospital or at home. The home will not offer a place to people with learning disabilities or mental health issues, or people who are physically very frail. The assessment includes gathering information from social workers and talking to the family members. There is no difference between the assessment for respite or permanent placement. Some people come to visit the home before they move in, but by no means all. We noted that there was good assessment information on the three files we viewed. Care Homes for Older People Page 10 of 29 Evidence: However there was very little social history or cultural information. This had not been taken in the initial assessment and had not been gathered later. The home regularly accepts temporary residents for respite care. As previously mentioned they are assessed in exactly the same way. We met a resident who was having respite care and her needs were well understood. She was receiving regular care from district nurses and the home were working closely with them. We felt that the home treats all residents including respite care residents, individually and works with them towards appropriate goals. The homes statement of purpose and service user guide need some amendment to reflect the change of name and address for CQC. Care Homes for Older People Page 11 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and risk assessments are good as is health care. Medication administration is well structured but recording had errors. Privacy and dignity are well supported. Evidence: We looked at the care plans and risk assessments of three residents. In this home these are combined, but there are also general risk assessments for specific areas, like smoking. The plans and assessments were generally good being divided into a number of relevant areas, like teeth, hair, dressing, and quite detailed. The home had also completed screening tools, like Waterlow charts and Barthel Indexes. The recording was clear and unambiguous. We noted a lack of social history on the files. The manager stated that it can be difficult when assessing people in hospital to collect a social history for them. However this can be addressed when people are at the home. One file had no information for how the resident likes to be addressed. Care Homes for Older People Page 12 of 29 Evidence: We observed one resident to have bed rails but could find no risk assessment in his file for these. The homes poilicy on Use of Bed Rails states that A risk assessment must be carried out prior to the use of rails, with signatures by the named nurse or manager the service user or family. This must be kept in the notes and evaluated monthly. The manager agreed that a risk assessment had not been undertaken for the rails. She made enquiries with the staff and stated that the rails are actually not used and would be removed immediately. Records indicated that residents have baths or showers usually twice a week. They are also supported to have a strip wash every day. A hairdresser visits the home and the residents we saw looked well groomed. We concluded that personal care needs are well met. The manager stated that care plans are reviewed once a month and this was evidenced in the files we viewed. The home does not use health action plans but there was a substantial amount of health information over the files, daily sheets, and the diary, to evidence that peoples health needs were being met. When carers or relatives escort service users to medical appointments they feedback significant information to the manager who records this in a report which is filed in the relevant part of the care plan. We saw an example of this on file. Home visits by the G.P. are recorded in the daily sheets. Residents also had medical letters in their files which evidenced consultations with specialists. While we were at the home the district nurse called and we were able to have a discussion with her. She was positive about the home and said that the carers are friendly and helpful. Her view is that the care is good and she said that the home gets in touch with her quickly if there is a need. We noted that the home has separate resident files for the district nurse to record her information in. The manager stated that an optician calls twice a year and a dentist also twice a year. There are two carers on duty at night, one sleeping and one waking. We saw hourly night checks and pad changes recorded. We did note however that in one file the place to record any allergy had been left blank. For clarity this should be completed no allergies if this is the case, and we pointed this out to the manager. Care Homes for Older People Page 13 of 29 Evidence: We felt that health care needs are well met and noted that one resident who has been at the home for six years looked extremely well cared for. We inspected the arrangements for the administration of medication. The home has a medication policy but we could not see details for the receipt, storage and disposal of medications. The manager showed us another medication policy which contained this. We suggest that the policies either be combined or one signposts to the other, to avoid confusion. We asked the manager how medications are received into the home. She stated that when residents come from hospital and sometimes from home they have a medications list on a green sheet with them. If the resident comes in with loose medications then the manager goes through this and checks it against the green sheet. They then call the GP and ask for a prescription for the resident. The drugs the person comes in with are only used for four or five days until the new prescription can be dispensed by the pharmacist. Any unused medication is returned to the pharmacy when the new supply arrives. The manager stated that prescriptions are FAXED to the pharmacist and dropped off by them later in the day. We saw a prescription being FAXED in this way. The pharmacist produces the Medication Administration Record (MAR) sheets for the home. The bulk of the medications come on a twenty eight day cycle. They are checked into the home and recorded by the manager. Medications are stored in a locked cabinet and we were satisfied with these arrangements. We viewed the medication folder and noted that there were no photographs for residents with their MAR sheets. We have made a recommendation that these are added. We also noted that there was no specimen signatures sheet for staff. On one MAR sheet there were two boxes signed which were impossible to identify as they looked crossed out. The manager stated that these were staff signatures. We have made a recommendation that a specimen signature sheet be added to the file, so that staff can be identified by their signatures. The home uses the blister pack system and there were few loose medications. We balanced several medications, checking that the stock held was correct. We found Care Homes for Older People Page 14 of 29 Evidence: a discrepancy on a stock of Warfarin tablets. According to the MAR chart there should have been 17 tablets left but there were twenty-two - five too many. The manager stated that she knew that the cyle for these drugs had started five days later than the chart showed and the carer had made a mistake on the MAR sheet, completing five too many boxes. This could not have happened if the carer had initialled the box only when she had given the tablet, so she had actually filled in boxes retrospectively. This is falsification of a record. The manager stated that she would interview this carer and if the record had been falsified this would lead to disciplinary action for the carer. On one MAR chart we noted that carers had signed carelessly, not in the boxes, but over them, so it was difficult to balance the medications accurately. On a MAR chart we noted that there were strikes in boxes for no admission but this was not consistent as there was no signature or strike for the day of the inspection and the time for administration of the drug had passed. One MAR chart had a gap in a box, and one had four boxes not signed for the administration of sudacream. We understand that Sudacream cannot be balanced like a medication, but if it is prescribed for use and a MAR chart created then the chart must be signed when the cream is used. The manager stated that the senior carer is responsible for medications but she herself undertakes a monthly audit. However she does not make any record of this. We recommend that the manager makes a note of her audits and any irregularities she finds. In assisting us with the inspection the manager counted the number of tablets in a bottle, without wearing protective gloves, although she said that carers wear protective gloves when dispensing medications. We recommend that the home purchase a tablet counter. In our view this is a necessary piece of equipment for auditing medication. The manager stated that the driver who collects medication to be returned to the pharmacy signs and we saw a proper book where a sheet is completed and a copy is kept by the home. We felt that the systems and structures for the receipt, storage, administration and disposal of medications were sound. However errors had been made and the recording Care Homes for Older People Page 15 of 29 Evidence: of administration needs more staff supervision. The home has a policy on residents rights which states that people should retain personal dignity and independence irrespective of the severity of physical or mental informity. We noted that interaction between carers and residents was respectful. All the residents we met looked very clean and well care for and were well dressed. The manager stated that the residents had asked th change hairdresser because the previous one cancelled a lot. This had been done with an improvement in reliability. At the previous inspection there was a requirement made that all bathrooms and toilets have locks. This has been met and the home have improved their bathroom facilities. We noted that not all residents files contain information relating to their afterlife wishes or as to whether or not they wish to be resuscitated and in what circumstances. But one resident has written a letter for her family and the home which is kept in her file. We feel this is very good practice. The manager said that this is a difficult area which some residents do not want to talk about. The manager must give all residents the opportunity to record their views regarding resuscitation and their end of life wishes and if they choose not to give their views this should be recorded instead. We asked the manager how she would manage the death of the muslim resident they have at the home. She was able to describe very well how she would ensure that the cultural needs of this person would be met and we were quite satisfied. Care Homes for Older People Page 16 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social contacts, community contacts and activities are supported and promoted at the home. Residents have autonomy and choice and they enjoy their mealtimes. Evidence: We noted that some cultural information had been recorded on the files of residents. One resident wanted to eat italian food a few times a week, another resident likes to watch football on television on Saturday afternoons. We met two visitors at the home, they both praised and complimented the care their relatives receive. We heard about other relatives and friends who visit residents. The home had arranged a trip to South End, a destination which had been chosen by the residents, for later in the month. The home is taking a large bus and some relatives are going along too. The money for this trip had been raised by a local primary school. They visit the home regularly, and the residents visited the school last Christmas. The manager stated that the home tries to have one special occasion each month like a barbecue or an entertainer. We talked to one resident about going out and he said Care Homes for Older People Page 17 of 29 Evidence: his family took him out about once a month and this was enough for him. The manager gave a list of the kinds of activities available in the home and this was quite varied. On the day of the inspection a resident was bowling a soft ball at skittles from her chair. The manager stated that recently a DVD player had been purchased for the home and the residents had been watching Norman Wisdom films which they enjoyed. She said that they would gradually build up a library of films. There were a large number of music CDs in the lounge. One resident who is blind has talking books supplied by the Royal National Institute for the Blind (RNIB). We noted one resident has a newspaper delivered. Two gentlemen particularly like the television and have their chairs arranged in a good position to view it. The garden looked very inviting on the day of the inspection but no residents had chosen to sit in it. There are plans to build a sensory garden which may encourage the residents to use the garden more. We felt that residents have autonomy and choice. One resident likes to do her own laundry and sits in the laundry room whilst the machine completes the cycle. Residents meetings are held and we saw the minutes for June, July and August this year. They evidenced that residents asked for a DVD player and this has been obtained. We observed a resident choosing her supper with staff. A resident told us he thought there was too much mince on the menu. We checked the menu. There is a good variety of foods but there were two mince type meals on consecutive days so perhaps this was the trigger for that remark. The menu evidenced three good meals a day with choices and most residents said the food was good. There is a preferences list pinned to the wall next to the kitchen which indicates residents likes and dislikes. The fridge and freezer were well stocked and clean. The home has a particularly nice dining room with two large tables where residents sit. Some residents prefer to eat in their rooms and the manager stated that they have appropriate tables for this. We observed such a table in the room of a resident who likes to stay mostly in his room. Care Homes for Older People Page 18 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are properly processed at the home and residents are safeguarded. Evidence: The home has a complaints policy and procedure and these need minor amendments to reflect the fact that the CQC can be approached at any time with a complaint, and to reflect the recent change in name and address of the CQC. The rate of complaints is low but there is a form and if people do not want to complete it staff are quite happy to write a complaint down for them. The manager cited as a good example the complaint which the residents had about the unreliability of the hairdresser and the way this was resolved. This was a very positive outcome because the new hairdresser is not only reliable, she gives the residents one to one time in their own rooms as she does their hair. The home has a policy regarding safeguarding adults. The policy refers to whistleblowing and states that it is to be followed in conjunction with the local authority policy. The home has a copy of this. There is also a separate policy on whistleblowing. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are good, well maintained with a pleasant fresh environment. The home is clean and hygienic. Evidence: We toured the environment of the home including the garden. The home is generally well maintained and the decor is good. We were able to see several residents rooms and they are very pleasant, bright and personalised. One resident is blind and we were told that he had his room was arranged by the RNIB to be like his room at home, so that he can get around it as easily as possible. The manager told us that all the staff have done a sensory deprivation course. Another resident has had a ramp made outside his door so that he can access the outside for smoking. We commend the home for doing this. The kitchen was very clean and tidy and was well fitted out to produce meals for the residents. The home now has a wheelchair accessible wetroom on the first floor and an adapted bathroom on the ground floor. Both are well fitted out. There is a broken back window in a room which is currently vacant. This must be replaced. Some of the windows at the back of the house need repainting. Care Homes for Older People Page 20 of 29 Evidence: The home employs a cleaner for nine hours a week, and night staff also undertake cleaning duties. We noted that there were almost no unpleasant odours in the home so we believe that any incontinence which people experience to be well managed. The home is clean and hygienic. There was information posted regarding swine flu and the manager was aware of hospital acquired infections and the risk of them being brought into the home with discharged patients. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a good complement of well trained and skilled workers who are safely recruited. Evidence: The homes statement of purpose says that there are ten care assistants, one cook and one cleaner. The manager stated that this is correct. There are usually two carers on duty plus the manager when she is there. There are two carers on duty at night, one waking and one sleeping, but available if needed. We inspected the records of staff training for three staff. We were pleased to see evidence that staff have induction training and their training in core basics including health and safety, infection control, first aid, manual handling, safeguarding of vulnerable adults, food hygiene and fire was up to date. The manager stated that 50 of the carers have NVQ LEVEL 2 or above and we saw some evidence of this. We asked the manager to describe the recruitment process to us. This offered equal opportunities and was safe and robust with references taken up and Criminal Records Bureau (CRB)disclosures. We were satisfied from inspecting the three files that the recruitment process is followed. Care Homes for Older People Page 22 of 29 Evidence: The manager stated that all the carers underwent medication training on two days 27th May and 24th June and we saws this noted in the home diary. Unfortunately the certificates had not come through. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is qualified and competent to run the home. Quality assurance is monitored and measured in the home and the working practices are safe. Evidence: The manager of the home has a registered managers award and signficant years experience in the field. She told us that she had a morning routine where she reads the daily recording from the day before and tours the home checking on each resident. This information, her general grasp of issues of care and the well structured systems, evidenced the managers ability to manage the home well. The statement of purpose gives an organisation plan for staffing. At the inspection we met a director of the company and the manager explained that she is answerable to her. The home asks residents and relatives to complete questionnaires for quality assurance every year and we saw an example of this years. The manager stated that Care Homes for Older People Page 24 of 29 Evidence: there is a bi-annual audit of facilities and it was done on 26/7/09. We were satisfied that quality assurance is undertaken at this home. We were told that the residents at the home manage their own monies with their families, or it is managed by social services. The home does not keep cash for residents or get involved in their personal allowances. The home has a comprehensive health and safety policy. It is simply written with clear subject headings. There is a fire safety inspection and assessment and this is updated annually. We saw a gas safety certificate from an outside contractor dated 19/4/09. The fire alarms and call bells and emergency lighting were tested in May 09. The extinguishers were checked on 16/3/09. The local authority undertook a food hygiene inspection on 12/1/09 and the lift was inspected on the same day. There was no electrical hardwire inspection available but there was evidence of remedial works carried out on 7/6/09. Portable Appliance Testing (PAT) was carried out on 7/6/09. We viewed the arrangements for the storage of Control of Substances Hazardous to Health (COSHH). They were properly stored under lock and key but the home had no data sheets for the products. We have asked the manager to rectify this. Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 2 14 The manager must ensure that social history is included in the assessment information. To help with residents sense of identity. 01/11/2009 2 7 7 The manager must ensure that a risk assessment is always completed before bed rails are fitted to a bed. To ensure the safety of the resident. 01/10/2009 3 9 9 The manager must ensure the safe administration of medication is properly recorded. To medicate residents safely and keep an accurate record of administration. 01/10/2009 Care Homes for Older People Page 27 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 11 12 The manager must ensure that residents can give their views regarding their resuscitation and afterlife wishes. So that their wishes can be followed. 01/12/2009 5 19 23 The broken window at the back of the house must be replaced. For the safety of residents and staff. 01/11/2009 6 38 38 The manager must obtain data sheets for COSHH products. For the protection of residents and staff. 01/11/2009 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 9 9 There should be a sheet of specimen signatures for staff so that they can be identified on MAR sheets The manager should keep a record of her audits of medication. So that she can track the level of medication error and identify carers who make medication errors. There should be photographs of residents with the MAR sheets to assist with identification. The home should purchase a tablet counter to use when auditing medications. 3 4 9 9 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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