Care Home: St George's Nursing Home - Royston

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What the care home does well Information about the home is provided to prospective residents and their families. They are also invited to visit and view the home so that they are able to make an informed choice whether to use the home or not. Individual`s needs are assessed to ensure that the home is able to meet the identified needs prior to admission. Care plans examined were comprehensive and detailed, showing how identified needs were being met. A programme of weekly activities is planned, displayed on the notice boards and residents are reminded of activities taking place on a daily basis. Residents said that they are able to choose whether to participate in the activities provided on the day or not. The environment is homely, comfortable, airy and bright. The home is reasonably well maintained. Residents spoken to said that the food was good. There is a good professional relationship between the staff and the residents and relatives and other professionals. Feedback from residents and their relatives was positive. One resident said `we are being well looked after and cared for` and another said ` staff are caring, food is good and everything is fine for me`. In relation to equality and diversity, the manager has stated in the AQAA that there is an equal opportunity policy and `we work hard to place everyone on an equal footing. We recognise that everyone is different and has different needs and we strive to promote individuality`. What has improved since the last inspection? The home has introduced a policy and procedure and relevant care planning in line with Mental Capacity Act 2005, and the Deprivation of Liberty Safeguards 2009. Named Nursed system has been implemented to compliment the key worker system. Tea and coffee making facilities have been provided for residents, their relatives and visitors. Some of the bedrooms have been fully refurbished and some areas of the home have been fitted with new floorings. The requirements and recommendations made in the last inspection report have been complied with. What the care home could do better: The registered manager should ensure that: Medicine containers are dated when first opened for ease of auditing. Appropriate disposal container is provided so that unused medicines are disposed of safely. Hand written instructions on the Medicine Records Sheets (MAR) should be signed by the person making the entries. Staff should ensure that condiments are readily available for residents at meal times. The complaints record book should include actions taken for each complaint and the outcomes recorded. The wallpapers in the ground floor bathroom and other bedrooms that are pealing off should be replaced to compliment the decor of rest of the home. Training provided for all staff should be certified by a qualified trainer. Fire drills should be carried out for night staff on a regular basis so that they are they are kept up to date with fire safety procedures. The cooker in the main kitchen that is very badly stained with burn marks should be deep cleaned or replaced. Key inspection report Care homes for older people Name: Address: St Georges Nursing Home - Royston 42 Kneesworth Street Royston Herts SG8 5AQ     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: Bijayraj Ramkhelawon     Date: 1 2 0 8 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 28 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 28 Information about the care home Name of care home: Address: St Georges Nursing Home - Royston 42 Kneesworth Street Royston Herts SG8 5AQ 01763242243 01763243285 royston@stgeorgescare.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Newton Chinneck Ltd Name of registered manager (if applicable) Ms Jane Elizabeth Collis Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The registered person may provide the following categories of service: 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 - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is: 24 Date of last inspection Brief description of the care home St Georges is an extended period building close to Royston town centre and its amenities. The home has built up a good reputation for the standard of nursing care provided but does not meet the environmental standards required of homes registered after April 2002 in terms of day space. 0 24 Over 65 24 0 Care Homes for Older People Page 4 of 28 Brief description of the care home Resident bedrooms are on the ground and first floor. A lift provides access to the upper floor. There are currently 5 single rooms, 9 double bedrooms. No rooms have en-suite facilities. There is a small lounge with limited dining space on the ground floor. Access to the kitchen and administrative office is through the lounge. There is not enough space in the lounge to seat all the residents should they wish to use it. In addition there is a very small quiet room. There is one bathroom and two toilets on the ground floor and 2 bathrooms and 3 toilets on the first floor. The laundry and staff room are in the basement. There is a small garden at the back of the home with limited car parking facilities. A portacabin has been installed in the car park as a staff training area. The current fees range from £652 - £800 per week depending on whether a single or shared room is provided (correct on 12/08/2009). Details of the payments appropriate to different funding arrangements are given out to people making enquiries. A copy of the Service Users Guide, Statement of Purpose and the latest inspection report can be obtained on request from the manager. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last unannounced key inspection was on the 9th May 2008. This unannounced key inspection was carried out on the 12th August 2009 and took one whole day. It included talking to people using the service and staff, examining care plans, staff files, medicine records, fire safety procedures, maintenance records, all other records and documents and a tour of the premises. We looked at all the information we have asked for or received about the home, since the last inspection. This information included the Annual Quality Assurance Assessment (AQAA), sent by and returned to the Commission from the homes manager. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also provides some statistical information about the service. The information provided in the AQAA was also checked against the findings as set out in the last inspection report. Care Homes for Older People Page 6 of 28 Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: The registered manager should ensure that: Medicine containers are dated when first opened for ease of auditing. Appropriate disposal container is provided so that unused medicines are disposed of safely. Hand written instructions on the Medicine Records Sheets (MAR) should be signed by the person making the entries. Care Homes for Older People Page 8 of 28 Staff should ensure that condiments are readily available for residents at meal times. The complaints record book should include actions taken for each complaint and the outcomes recorded. The wallpapers in the ground floor bathroom and other bedrooms that are pealing off should be replaced to compliment the decor of rest of the home. Training provided for all staff should be certified by a qualified trainer. Fire drills should be carried out for night staff on a regular basis so that they are they are kept up to date with fire safety procedures. The cooker in the main kitchen that is very badly stained with burn marks should be deep cleaned or replaced. 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 9 of 28 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 10 of 28 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 can be assured that their needs would be assessed prior to an offer of placement being made. Evidence: Information about the service is available to current and prospective residents. A copy of the Statement of Purpose and Service Users Guide is given to each resident on admission. People using the service, their relatives and visitors spoken to said that they were invited to visit and view the home and had received information to help them decide whether to use the services or not. Care plans examined showed that a pre-admission assessment of needs was carried out by senior members of staff. Information was also obtained from hospitals, GPs and social workers so the most up to date information on residents health and social care needs was available. Care Homes for Older People Page 11 of 28 Evidence: As stated in the AQAA, the registered manager will within the next twelve months continue to monitor the implementation of new legislation (Mental Capacity Act) and will update the homes brochure and review the Statement of Purpose and Service Users Guide. Care Homes for Older People Page 12 of 28 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 using the service can be confident that their personal and healthcare needs would be met appropriately. Evidence: People using the service said that their identified needs were being met and were complimentary of the staff and the care they received. All residents looked comfortable, well dressed, groomed and relaxed. Those who were in beds, drinks and call bells were easily accessible. The home has now introduced a Named Nurse system to compliment the key worker system already in place. 3 care plans were examined and these were comprehensive and included residents details on admission, assessments of needs, medical history, risk assessment in relation to manual handling and falls, Waterlow assessment for pressure sores, nutritional assessments, individuals life story, activity plans, daily progress report, care plan monthly reviews, weight charts and other health care observations. Residents who have pressure ulcers, their care plans showed that they were receiving the prescribed treatment and nursing care including provision of appropriate Care Homes for Older People Page 13 of 28 Evidence: mattresses, air alternating cushions, regular changing of positions, wound assessments carried out including monitoring and evaluating of pressure ulcers with sizes, depth and grades. Records showed that the pressure ulcers were healing. Tissue Viability Nurse was contacted and advice sought. Wounds were examined by residents own GP. Care plans for residents who required catheter care was also detailed and indicated how nursing care was being provided. Care plans were reviewed on a regular basis to reflect the changing needs of each resident. A mental capacity assessment was carried out for each individual. The systems in place for managing, administrating and reviewing medication meet the required guidelines to ensure residents receive the medication they are prescribed and are kept safely. However, it was noted that medicine containers were not dated when first opened for ease of auditing; hand written instructions on Medicine Records Sheets (MAR) were not signed by the person making the entries; unused medicines were kept in a large plastic container and the medicine disposal container was not provided. A new metal cabinet (purchased from the supplying company) has been provided and kept in the garden to store Oxygen cylinders. On the day of the inspection there was no resident on prescribed Oxygen. Staff spoken to said that they were aware of the rights of residents to make choices about their lives and the need to ensure their privacy and dignity is respected. The home has reviewed the Continence Assessment and related care planning, and devised a new Palliative Care Protocol and Care of the Dying Procedure to comply with Liverpool Care Pathway. Care Homes for Older People Page 14 of 28 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. People using the service can be confident that their identified needs would be met appropriately and that they would be enabled to live the lifestyle they chose. Evidence: There are two staff who provide activities for residents on a one to one basis and in groups. Each resident has a social and recreational activity assessment undertaken and a care plan devised to support each resident with their preferred activities. Staff said they took residents out to local shops, pub lunches, walks and outside entertainers visit the home on a planned bi-monthly basis and on special occasions. The priest and the vicar visit the home regularly and offer a service with Holy Communion. Staff spoken to said that they were aware of the cultural and religious needs of individuals. Each resident has a named nurse and a key worker. The limited day space reduces the choices residents can make about where to spend their time. The main lounge is an access route for staff so TV programmes and conversations are regularly interrupted. Residents are able to have personal possessions in their room and staff encourage residents to use headphones in the shared rooms when televisions are in use. Care Homes for Older People Page 15 of 28 Evidence: A well-balanced and nutritious menu is provided based on a four-week seasonal menu. The meal on the day of inspection was well presented and enjoyed by the residents. Sensitive and discrete assistance was given to those who needed support to eat their meal. Residents have access to drinks and snacks between meals. However, condiments were not readily available nor offered. Staff said that residents are able to ask if they preferred any condiments. Tea and coffee making facilities have now been provided for residents, relatives and visitors. As stated in the AQAA, the manager will within the next twelve months introduce a wireless internet system and explore the possibility of getting a computer for the residents. Care Homes for Older People Page 16 of 28 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. People using the service can be assured that their concerns and complaints would be listened to and acted upon and that they would be safeguarded from abuse, neglect and harm. Evidence: People using the service and their relatives spoken to, confirmed that they feel they are able to raise any concerns and staff would listen to what they have to say and take appropriate action. 6 complaints have been received and followed up by the home. However, it was noted some pages of the complaints record book were torn and these pages were not numbered. The process for dealing with the complaints did not indicate the actions taken and whether the outcomes were satisfactory. The home invites residents and relatives to contribute their views as part of the quality monitoring procedures they have in place. The directors of the company have regular contact with residents and their relatives so they are aware of their experiences. The complaints procedure is also available in large prints. Staff confirmed that there is an open culture within the home and that they understand their role in reporting any concerns should they arise. The training records provide evidence that issues regarding the safeguarding of residents are regularly considered. Care Homes for Older People Page 17 of 28 Evidence: As stated in the AQAA, the registered manager will within the next twelve months develop the residents meeting further to ensure appropriate assistance is given to those who find it difficult to express their views. Care Homes for Older People Page 18 of 28 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 using the service are cared for in an environment that is comfortable and safe. Evidence: The home was kept clean and fresh. Resident bedrooms are on the ground and first floors. A lift provides access to the upper floor. There are currently 5 single rooms and the rest are shared bedrooms. No rooms have en-suite facilities. Some rooms have been redecorated with new vanity units, new flooring, new curtains and paintwork carried out. However,we saw that wallpapers in the downstairs bathroom and other bedrooms was pealing off and should be replaced to compliment the decor of the rest of the home. There is a lack of day space, which means residents have a limited choice of where and who to spend their time with. The absence of an adequate dining area also impacts on the residents quality of life and social interaction, as they are not able to sit at a dining table or change where they are sitting. Residents spoken to said that although we are used to having our meals in the lounge, it would be nice if we could sit at a table for meals. But this is not a problem. There are limitations on what personal possessions people can bring into shared rooms. Dividing curtains are provided in shared rooms. Staff are sensitive to the issues this raises but for residents it means they are carrying out intimate functions in Care Homes for Older People Page 19 of 28 Evidence: close proximity to another. A relative said that because her husband can be very restless at times, he would not know which bed to sleep in. This would be a problem if another resident occupies the other bed. She said that the manager and staff were aware of her concerns. Staff spoken to said that they had undertaken training in infection control. Protective clothes and gloves and hand washing facilities were provided. However, it was noted that the cooker in the main kitchen was very badly stained with burn marks and in need of a deep clean or replacement. Care Homes for Older People Page 20 of 28 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. People using the service does benefit from the care and support they receive from a competent and qualified staff team and that they feel protected by the homes recruitment policy and practices. Evidence: Residents and staff spoken to felt that, generally, there were always enough staff on duty and praised the care they received. The interaction between staff, residents and visitors was professional and staff were knowledgeable about the needs of individuals and provided support in a sensitive and professional manner. Six staff files were examined and these were found to have all the necessary documents including two written references for each employee and the Criminal Records Bureau (CRB) checks were carried out before an offer of employment was made so that residents are safe and protected. New staff undergo a programme of induction and staff are provided with training relevant to their work. Staff spoken to confirmed that they received formal supervision on a regular basis. They also said that they received support from senior members of staff and the management team was approachable and helpful. The manager has devised a training matrix and training are arranged for staff on a rolling programme. Residents and relatives spoken to said that there was a good staff team working in the Care Homes for Older People Page 21 of 28 Evidence: home. Residents also said that call alarms were answered in good time and that care staff did not rush their personal care. All staff have completed basic training courses and more updates have been planned by the manager. However, training provided to staff should be checked that the trainer is qualified. Staff are encouraged to undertake NVQ training and at present, there are 24 care staff in post of whom 4 have completed the NVQ Level 2, 6 have completed the Level 3. Currently, 1 staff are undertaking the NVQ Level 2. The personal identity numbers of the registered nurses were also checked as part of the recruitment procedure and then annually to ensure they remain registered with Nursing & Midwifery Council (NMC). National Vocational (NVQ) training is made available to the care staff and domestic staff. The role of the senior carer has been developed and they have achieved qualifications in assessing staff studying for their NVQ. One of the Directors takes a lead on training. The nursing staff have access to clinical updating as part of their requirement for continued professional development. St Georges is also audited by Anglia Ruskin University, Cambridge as being a suitable learning area for student nurses. As stated in the AQAA, the registered manager will within the next twelve months provide staff training in the Deprivation of Liberty Safeguards (DoLS), Dementia and Stroke. Care Homes for Older People Page 22 of 28 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. People using the service can be assured that their health, safety and welfare are protected by the systems and practices in place. Evidence: The manager has the required qualifications and experience over many years to carry out her role. In addition to her nursing qualifications she has achieved the Registered Managers Award, which is the standard set by the Commission for all care home managers to achieve. Staff spoken to said that the management was supportive and promoted the interests and well being of residents. They also said that they received formal supervision on a regular basis. There is a quality assurance system in place covering all aspects of the service provided including residents rights and quality of life. The auditing systems provide evidence that action is taken to address any shortfalls identified. Care Homes for Older People Page 23 of 28 Evidence: The system for the management of residents money was not checked on this occasion as the director said that on the day of the inspection there was no money being managed by the staff at the care home on behalf of the residents. Staff receive the required statutory health and safety training to carry out their jobs and protect residents. Records of accidents, incidents and checks on health and safety and fire equipment are recorded and regularly reviewed. Fire drills are carried out on a quarterly basis. However, all fire drills so far have been done during the day shift and not for night staff. All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. Staff spoken to were aware that people using the service can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of people using the service and staff are promoted and protected. These records were accessible to all staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The Commission has been kept informed of all accidents and admissions to hospital. Regular checks on hot water temperatures and moving and handling equipment were recorded. A valid insurance certificate was displayed in the reception area and this offered cover of no less than £5 million and expires on 31/05/2010. Equality and diversity issues are understood by the organisation and addressed for individuals through their care plans, which describe how their needs, and preferences are to be met. Policies and procedures are adjusted in response to changing legislation and guidance. Care Homes for Older People Page 24 of 28 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 28 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 38 23 Fire drills must be carried out for night staff on a regular basis. So that they are they are kept up to date with fire safety procedures. 25/09/2009 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 3 4 5 9 9 9 15 16 Hand written instructions on the Medicine Records Sheets (MAR) should be signed by the person making the entries. Appropriate disposal container should be provided so that unused medicines are disposed of safely. Medicine containers should be dated when first opened for ease of auditing. Staff should ensure that condiments are readily available for residents at meal times. The complaint record book should have numbered pages so that pages torn could be identified and the recording of complaints should include the actions taken for each complaint and what were the outcomes. Care Homes for Older People Page 26 of 28 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 6 7 19 19 The cooker in the main kitchen was very badly stained with burn marks and in need of a deep clean or replacement. The wallpapers in the ground floor bathroom and other bedrooms was pealing off and should be replaced to compliment the decor of the rest of the home. The registered manager should ensure that training provided for staff is certified by a qualified trainer. 8 30 Care Homes for Older People Page 27 of 28 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. 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