Care Home: St Davids Residential Care Home

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What the care home does well People living at the home are looked after by well-trained and appropriately qualified staff. People told us that staff were very kind and always available if they needed help or support. One person said "I like the staff, they are kind and helpful". Another person said the staff were "very good". The environment is homely and well maintained. Improvements to the environment have been made as a result of comments made by people living at the home and staff. All areas of the home were clean and warm and there were no unpleasant odours. People told us they enjoyed the food provided and said there was plenty of variety and choice. All the food provided is freshly prepared using fresh ingredients where possible. Throughout the inspection we discreetly observed the interraction between staff and people living at this home. It was warm, friendly and very caring. People were laughing and joking with staff, resulting in a very relaxed atmosphere. We were struck by the warmth of the welcome we were given by staff and the people living at this home. What has improved since the last inspection? We were able to see some improvements since the last inspection. For example, all people living at the home now receive a contract of residence that reflects the terms and conditions of their stay. Some improvements have also been made to the care plans developed for people using the service, although it has been identified that further improvements could be made particularly, to the daily records. Medication recording has also improved although some concern was expressed about the practice of dispensing medicines into pots to put on an trays for some of the residents at breakfast. This is an unsafe practice and staff were aware they needed to change this. Other improvements taken place, with the arrangements for people who wished to have a key to lock their door. All people living at the home are now offered the key to their door and this is recorded. The home now regularly checks emergency lighting systems and hot water temperatures. At the last inspection, fire doors had been seen wedged open but it was noted that all fire doors were closing freely and were unimpeded at this inspection. What the care home could do better: There remain some areas that need improvement. The service has failed to meet the requirements set at last inspection regarding the adult protection policy. This document does not comply with best practice or the practice followed locally. The manager, Mrs Hamlin, is aware this matter remained outstanding and undertook to complete this work by 11 February 2010. The service is still not demonstrating that proper pre-employment checks are being taken before new staff commence working at the home. This requirement was set at the last inspection and remains outstanding. Because of the state the staff documents were kept in, it was very difficult to confirm all the necessary checks had been undertaken. As a result, there needs to be some urgent work undertaken so that staff files are put together consistently and in a way that makes the retrieval of information easier. Unfortunately, the standard of record keeping at this service does not reflect the good quality outcomes and experiences enjoyed by people living here. Because of this, the overall quality rating remains one star (adequate). Key inspection report Care homes for older people Name: Address: St Davids Residential Care Home 36-38 Nelson Road South Great Yarmouth Norfolk NR30 3JA     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: Geraldine Allen     Date: 1 1 0 1 2 0 1 0 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 27 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 27 Information about the care home Name of care home: Address: St Davids Residential Care Home 36-38 Nelson Road South Great Yarmouth Norfolk NR30 3JA 01493842088 01493842088 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Gayatri Verma,Dr Ajit Kumar Verma care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: One (1) Service User, over the age of 65 years who has a mental disorder and is named in the Commission`s records, may be accommodated. Total number accommodated not to exceed eighteen (18). Up to eighteen (18) Older People, not falling into any other category, may be accommodated. Up to ten (10) services users, over the age of 65 years, who have dementia may be accommodated. Date of last inspection Brief description of the care home St Davids is registered as a care home providing personal care and accommodation for 18 older people. The home is a three-storey building with access to the bedrooms by a Care Homes for Older People Page 4 of 27 Over 65 10 1 18 0 0 0 1 8 0 3 2 0 0 9 Brief description of the care home shaft lift; only stairs can access two of the bedrooms. There are 12 single bedrooms and 3 shared bedrooms some of these have en-suite facilities. The communal rooms are situated on the ground and basement floors. The home is owned by Dr and Mrs Verma and it is located 100 metres from the seafront in Great Yarmouth. It is half a mile from the town centre where local shopping and amenities are found. The home has a small patio area at the front of the premises with off street parking. Please contact the manager for the current fee rates. Copies of CSCI reports are available upon request from the home?s office. Care Homes for Older People Page 5 of 27 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: This inspection took place over a period of two days and lasted a total of 9 hours. During the course of this inspection we obtained information from a variety of sources including looking at records, speaking with people using the service and staff, observing practice and a tour of the building. We also ate lunch with people living at the home. The home had failed to return their completed AQAA (Annual Quality Assurance Assessment) before we did our inspection. We sent a reminder letter and also telephoned the home about this. The AQAA was collected on the first day of our inspection on the 29 December 2009. The contents of the AQAA we used to inform this inspection report.. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: There remain some areas that need improvement. The service has failed to meet the requirements set at last inspection regarding the adult protection policy. This document does not comply with best practice or the practice followed locally. The manager, Mrs Hamlin, is aware this matter remained outstanding and undertook to complete this work by 11 February 2010. The service is still not demonstrating that proper pre-employment checks are being taken before new staff commence working at the home. This requirement was set at the last inspection and remains outstanding. Because of the state the staff documents were kept in, it was very difficult to confirm all the necessary checks had been undertaken. As a result, there needs to be some urgent work undertaken so that staff files are put together consistently and in a way that makes the retrieval of information easier. Care Homes for Older People Page 7 of 27 Unfortunately, the standard of record keeping at this service does not reflect the good quality outcomes and experiences enjoyed by people living here. Because of this, the overall quality rating remains one star (adequate). 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 27 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 27 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. People receive good information about the service that helps them to make an informed choice to live there. Each person receives a contract of residence so that they know what the terms and conditions are and also the responsibilities of each party. People receive a full assessment of their needs before moving into the home so that they can be assured their needs can be met in full. This service does not provide intermediate care. Evidence: We were able to confirm that all people are provided with a copy of the homes Service User Guide and Statement of Purpose so that they can make an informed choice to live at St Davids. We were given a copy of the current Service User Guide and Care Homes for Older People Page 10 of 27 Evidence: Statement of Purpose and it contained all of the information people would need to have in order to make their decisions. Some of the information contained within the Service User Guide was not up to date. Specifically, the services complaints procedure did not have the correct contact information for the Commission but were told this was due to be updated. The service user guide contains a blank copy of the contract of residence and Mrs Hamlin, confirmed that all people receive a contract when they move into the home. The contract sets out all the terms and conditions of residence, including the responsibilities of each party. Mrs Hamlin confirmed that all people have a full assessment of their needs completed before they move into the home. The only exceptions to this arrangement would be if somebody was being admitted on an emergency basis, when assessments and care plans produced by social services would be obtained. The preadmission assessments looked at all matters about the persons physical needs to ensure the home could meet them effectively. The assessments also included information about social interests. We were told that all people were admitted to the home on a trial basis and trial periods last for one month. This was to ensure that people were happy with the facilities and care they received and also to give the service an opportunity to ensure all needs could be met. This service does not provide intermediate care. Care Homes for Older People Page 11 of 27 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 have a plan of care that sets out what care and support is needed and how it should be given. People have access to health services and referrals are made appropriately and in a timely way. For the most part, people are protected by good practice with the storage, administration and recording of medicines. People are treated with dignity and respect and their privacy is safeguarded. Evidence: We looked at three care plans in detail and were able to see that improvements had been made to the way these were recorded since the last inspection. The information that had been gathered at the time of the preadmission assessment had been used to inform the care plan, and we saw evidence that the resident had been involved in reviewing their plan of care. The care plans set out clearly what care and support the Care Homes for Older People Page 12 of 27 Evidence: person needed and how this should be delivered by staff. We saw an improvement in the way daily records were kept, although these would benefit from more information being kept about how and where the person spent their day. By doing this, staff would be able to demonstrate an holistic and individualised approach to the care given. We were able to see information that confirmed staff referred people to health professionals in an appropriate and timely way. People were supported so that they had access to visitng health professionals such as chiropodist, optician and physiotherapist and we saw evidence in the care plans that this happens. We observed the arrangements for storing, administering and recording medicines and for the most part we saw good practice. We discussed the practice of secondary dispencing with one of the senior staff and what needs to be done to eliminate this from current practice. Secondary dispencing is regarded as unsafe as it increases the risk of medicines being given to the wrong person. We spent time talking to people who use the service, about their experiences of living at this home. We received very positive comments about the staff, with all the people we spoke to saying that staff were kind, helpful and very good People told us that staff were always about to help them and nothing was too much trouble. One person said the staff are my friends. We also observed the interraction between staff and people using the service. This was friendly, appropriate and respectful. People told us they were very well treated by staff and described how their privacy and dignity was always upheld. Care Homes for Older People Page 13 of 27 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. Routines within the home are flexible and reflect peoples choices and preferences. Social activities need to be better recorded within the care plans and daily records. People are able to maintain contact with friends and relatives and the local community as they wish. People are able to make choices around their daily living and are confident these will be respected and supported by staff. People enjoy a varied and nutritious diet. Evidence: People told us they could spend their day where and how they wished. Some people told us they had enjoyed a game of Bingo during the morning of the inspection. We looked at peoples care plans and whilst they included some information about the persons hobbies and interests, these need to be developed so that they give far more information. This will help staff to support people in meaningful activities and pastimes. The daily records also need to include information about how the person has spent their day so that staff can ensure the appropriate support is given to people on Care Homes for Older People Page 14 of 27 Evidence: a day to day basis. The service does not display an activities programme, so it is difficult for people to know what activities are taking place and there would be benefit from activity posters being put in place. People told us that they were able to make decisions about how they spend their day and were able to make choices that were always respected by staff. They told us they could come and go as they pleased and that staff were flexible about the care and support they gave. People said they could get up and go to bed when they pleased. We had lunch with 11 people in the dining room and this was a relaxed and unhurried meal. The dining room tables were attractively laid with flowers and napkins, although the appearance was spolit by ill-matching crockery. Mrs Hamlin told us that the dining chairs were being replaced and this will improve the appearance of the dining room. The meal was clearly enjoyed by all and people told us that the food provided was always tasty and there was plenty of it. The service continues to serve meals ready plated but people told us they were happy with the arrangement and staff knew what they liked and how much. Choices of food were available for all meals. No people were requiring support from staff to eat their food. However, it was noted that people who were slow to eat were not hurried, but were offered help if they needed it. Care Homes for Older People Page 15 of 27 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 service has a complaints procedure that is available to all people using and visiting the service. Elements of the procedure need to be updated. People are protected by staff who have received training about safeguarding adults. The homes policies about this need to be developed to reflect correct practice. Evidence: All people receive a copy of the complaints procedure within their Service User Guide. The procedure is also displayed in the entrance hall for visitors to the home to see. Unfortunately, contact details for the Commission were out of date and needed to be amended so that people knew how to contact us if they wanted to. Mrs Hamlin said this was in hand and the updated complaint procedure would be in place very soon. At our last inspection, a requirement was made that the homes Safeguarding Adults policy and procedure guidance was inadequate and needed to be rewritten to reflect current practice. This had not been completed at the time of this inspection and the requirement has been repeated. It is important that the home has the correct guidance in place about this important matter so that the right action is taken at the right time whenever there are concerns about possible abuse. We saw evidence that all staff receive training about abuse and safeguarding adults and good knowledge about this was demonstrated by staff spoken to. We discreetly Care Homes for Older People Page 16 of 27 Evidence: observed staff practice throughout this inspection and it was respectful and appropriate. Care Homes for Older People Page 17 of 27 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 live in a safe and well maintained environment that is kept clean and free of unpleasant odours. People using the service are able to personalise their own rooms as they wish. There are sufficient washing and bathing facilities available so that people can make choices. Evidence: We made a tour of the home accompanied by Mrs Hamlin and all communal areas and some bedrooms were seen. All areas of the home were clean, tidy and free of unpleasant odours. We looked at some of the records kept about the premises and were able to see that it was well maintained and service contracts were in place so that equipment and systems ran efficiently. Mrs Hamlin told us that all people living at the home are offered a key to the lock on their bedroom door so that they can maintain their privacy if they wish. With permission, we saw some of the bedrooms. Some people had brought in a variety of furniture, pictures and other items important to them and these had made their rooms highly personalised. Mrs Hamlin told us that people are encouraged to bring in items if Care Homes for Older People Page 18 of 27 Evidence: they wish and this is also stated in the Service User Guide. We saw the newly installed shower room, which has been put in following suggestions from people living in the home and also staff. The shower room has been fitted to a good standard and it only requires the radiator cover to be fitted. We were told this would be done very shortly. Baths were also available for people who preferred a bath to shower. We looked at the communal areas of the home. As previously stated, Mrs Hamlin told us the dining room chairs were due to be replaced and this would significantly improve the appearance of the dining room. The lounge was welcoming and cosy. There is also a library, which Mrs Hamlin told us was seldom used by people using the service. Consequently, this has become rather cluttered with items such as the new hoist and a photocopier. Staff need to make sure this room is kept tidy and inviting for people and their guests to use if they require it. All laundry is done on site and the laundry room, which is accessed via the library, contained appropriate equipment. The washing machines had programs that ensured all laundry was thoroughly cleaned and disinfected so that the risk of infection was reduced. Mrs Hamlin has told us about some of the improvements that have been made to the environment since the last inspection. As well as the new shower, these include a large screen TV, new gas and electric cookers, new curtains and bedspreads, and new dining room chairs. Care Homes for Older People Page 19 of 27 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. Staff are employed in sufficient numbers to meet the needs of people using the service. Staff receive training and achieve qualifications that ensure people are cared for by well trained staff. Staff records are stored in such a way that it is not possible to confirm recruitment procedures adequatetly protect people using the service. Evidence: Mrs Hamlin provided us with a copy of the staff roster for the day of inspection and this showed that the home employees sufficient staff during the day and at night to meet the needs of people using the service. The service has a very positive approach towards NVQ qualifications, with the vast majority of staff qualified to either level two or three. At the time of inspection, we were told that three staff were waiting to start NVQ training at level IV. This commitment to qualifications ensures people are cared for by well-trained staff and the service is commended. The last inspection raised concerns about the way new staff were recruited to the Care Homes for Older People Page 20 of 27 Evidence: home and some of these concerns continue. We looked at two staff files and because of the way the papers were stored it was very difficult to retrieve the information we needed. For example, we could not confirm that any references had been obtained for one person, whilst we could find only one reference for the other. The application forms did not have sufficient space for applicants to include full contact details of their referees or full details of previous employment. Because of our continuing concerns, the requirement made at the last inspection has been repeated. We were able to confirm that staff receive good training in addition to their NVQ qualifications. Mrs Hamlin was advised that she needs to keep better records of training completed and the dates when update training is due, so that she can ensure all staff receive the training they need. Care Homes for Older People Page 21 of 27 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 manager is competent and experienced to run the home but needs to complete the registered managers award in order to demonstrate she is suitably qualified. The home seeks the views of people using the service and other interested parties and takes action to reflect the views expressed. All staff receive regular and properly recorded supervision to ensure they are suitably supported. Not all records kept by the service are up to the standard required to demonstrate the effective and efficient running of the home. People using the service and staff working there are protected from good health and safety practices. Care Homes for Older People Page 22 of 27 Evidence: Mrs Hamlin has many years experience in care and has achieved the City and Guilds 325/3, a care qualification. She has not yet completed the managers award but has indicated she will be completing this during 2010. It is important that she completed this as soon as possible so that she can keep up to date with current legislation and best practice. The home has a process in place that seek the views of residents, relatives, staff and other interested parties, about the care and facilities provided. Mrs Hamlin also told us that regular meetings with people using the service take place. We were given examples of where action has been taken as a result of gaining peoples views. Mrs Hamlin stated she would provide us with a copy of the action plan that had been developed as a result of seeking peoples views, but this had not been received at the time this inspection report was written. This service does not look after any personal allowances on behalf of people using the service. All staff receive regular supervision and an annual appraisal from senior staff who have received the relevant training to do so. All staff have a supervision contract and supervision records are kept securely. Staff told us they felt well supported by Mrs Hamlin and the senior team and were able to seek advice and support at any time. We have seen some improvements in the records kept by Mrs Hamlin and the staff team. However, there are still significant areas where improvement is required and these were discussed on the day of inspection. Unfortunately, some of the records kept do not reflect the very good experiences and outcomes for people using the service and this has an impact on the overall quality rating of thgis service. During the course of this inspection, it was clear that Mrs Hamlin and the staff team were very keen to make the adjustments necessary in order to meet this standard. The need to prioritise this was discussed, as it is important improvements are consolidated and staff are fully aware of what is required. We saw evidence that staff receive training about all aspects of health and safety. This included training about moving and handling, fire safety, first aid, food hygiene and infection control. We also saw evidence that Mrs Hamlin keeps accident records under review to ensure any remedial action can be taken where risks are identified. Care Homes for Older People Page 23 of 27 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 16 13 The homes adult protection policy must be updated so that it is in line with the DOHs No Secrets Guidance and the correct procedure is followed in the event of an incident 01/06/2009 2 29 7 Proper pre-employment checks must be undertaken before someone starts working at the home to ensure that only the right people are employed and residents are protected 01/06/2009 Care Homes for Older People Page 24 of 27 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 9 13 The practice of secondary dispencing must stop. This practice is unsafe as it increases the risk of errors and also contamination of medicines. 11/02/2010 2 31 10 The manager must ensure she attends the Registered Manager Award training without delay. This will help her to keep up to date with current legislation and best practice. 07/04/2011 3 37 17 All records required to be 07/04/2010 kept must be reviewed and developed so they are in line with regulations. This will ensure the service is compliant and will aid the smooth running of the home. Care Homes for Older People Page 25 of 27 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 7 Daily records need to contain more information about how the person spent their day. This will help staff to ensure that all health, personal and social care needs are being met consistently. A regular programme of activities need to be established and posters displayed throughout the home. This will mean that people using the service will know when activities are taking place and can attend if they wish. The home needs to ensure that all crockery matches. This will enhance the dining experience for people and improve the appearance of the tables. The updated complaints procedure needs to be provided to all people using the service and clearly displayed. This will mean that people will know how to contact us if they wish to. Staff need to make sure that the library is kept tidy and as clear of clutter as possible. This will mean that people using the service can use the facilities and entertain their visitors safely and in pleasant surroundings. A staff training plan needs to be kept so that the manager can easily identify when update training is required. This will help her to ensure that these training events take place in a timely way. 2 12 3 15 4 16 5 20 6 30 Care Homes for Older People Page 26 of 27 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). 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