Care Home: Suffolk Court

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What the care home does well People and their relatives spoke very well of the service and particularly the staff. They made the following comments on what the home do well: “The staff are very kind and look after us well” “I’m happy that my mum is here. They know what she likes” “I am happy with the care and service” “All the staff are very caring and do all they can to help me” “The food is very good and every where is lovely and clean”. “My family and I are very happy with Suffolk Court” Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 One person said they and their relative had been well supported when they moved into the home. Visitors said that they could visit at any time and were made welcome. The atmosphere in the home was warm and friendly. It was clear that there were good relationships between staff, people living in the home and their visitors. The lunchtime meal was well presented and people said it was good. There was some quiet conversation between people and staff were good at encouraging and assisting people. Policies are in place aimed to set out how the home protects people, and prevents harm or abuse and this includes a whistle blowing policy. What has improved since the last inspection? Staff involved in the administration of medication make sure they follow polices and procedures so that people at the home are not placed at potential risk. What the care home could do better: The care plans and risk assessments must provide evidence to show, where possible, people living in the home or their representatives have been involved with developing the care plans and risk assessments. This will ensure agreement to provide the care package has been gained. All care plans and risk assessments must be reviewed regularly and changed to reflect the care needs of the person receiving the care package. This will help ensure the appropriate care is provided. People must be provided with social and recreational opportunities that help stimulate their well-being. All planned activities should be based around the needs and choices of the people living in the home. This will help to improve the holistic needs of the individuals. The fire officer inspected the home 11/08/09 and some issues requiring attention were highlighted. These should be addressed to help to promote the safety and welfare of people. Comments on what the home could do better:Suffolk CourtDS0000033240.V378445.R01.S.doc Version 5.2 “The meals are not bad but I find there are too many sandwiches on the menu at tea time” “I would like more fresh meat and less processed also fewer carrots and more green vegetables”. “Because of Health and Safety you can’t have a soft fried egg”. “I am 85 and have had soft fried eggs all my life. Its do as I say not as I do”. “I like it when musicians come, need more activities”. Key inspection report CARE HOMES FOR OLDER PEOPLE Suffolk Court Silver Lane Yeadon Leeds LS19 7JN Lead Inspector Hebrew Rawlins Key Unannounced Inspection 5th November 2009 09:00 DS0000033240.V378445.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 Page 2 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 Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Suffolk Court Address Silver Lane Yeadon Leeds LS19 7JN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2509540 P/F 0113 2509540 fiona.wood@leeds.gov.uk Leeds City Council Department of Social Services Sandra Hook Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (1) of places Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2008 Brief Description of the Service: Suffolk Court is a local authority home providing personal care primarily for older people of both sexes. There are 33 permanent places and seven places dedicated to respite services. The home is a two storey building on two floors with stairs and a passenger lift providing access to the first floor. Accommodation is in single rooms, all of which have en-suite facilities and there are well-equipped and large assisted communal bathing facilities. There are plenty of toilets situated throughout the building. Lounge and dining facilities are situated on both floors with the main large dining and lounge area on the ground floor. There is level access to the enclosed gardens with some rooms overlooking this attractive area. The home is situated in Yeadon and is close to many local amenities. Information about the service is available in a Statement of Purpose and Service User Guide. Copies of the inspection reports are available on request. The fees range from £108.10 to £510.30 per week. There are additional charges for hairdressing and newspapers. This information was provided by the service on the 9th November 2009. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star – adequate service. This means the people who use this service experience adequate quality outcomes. The accumulated evidence in this report has included: • • A review of the information held on the home’s file since the last inspection. Information obtained from people who use the service, relatives, staff and other health care professionals. One inspector conducted an unannounced visit to the home. The majority of time was spent speaking with people who live in the home, management, staff and relatives. A number of documents were looked at and some areas of the home used by the people living there. The information required from the service in the form of the Annual Quality Assurance Assessment (AQAA) was obtained before this report was written. Feedback was provided at the end of the inspection to the temporary manager. What the service does well: People and their relatives spoke very well of the service and particularly the staff. They made the following comments on what the home do well: “The staff are very kind and look after us well” “I’m happy that my mum is here. They know what she likes” “I am happy with the care and service” “All the staff are very caring and do all they can to help me” “The food is very good and every where is lovely and clean”. “My family and I are very happy with Suffolk Court” Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 Page 6 One person said they and their relative had been well supported when they moved into the home. Visitors said that they could visit at any time and were made welcome. The atmosphere in the home was warm and friendly. It was clear that there were good relationships between staff, people living in the home and their visitors. The lunchtime meal was well presented and people said it was good. There was some quiet conversation between people and staff were good at encouraging and assisting people. Policies are in place aimed to set out how the home protects people, and prevents harm or abuse and this includes a whistle blowing policy. What has improved since the last inspection? What they could do better: The care plans and risk assessments must provide evidence to show, where possible, people living in the home or their representatives have been involved with developing the care plans and risk assessments. This will ensure agreement to provide the care package has been gained. All care plans and risk assessments must be reviewed regularly and changed to reflect the care needs of the person receiving the care package. This will help ensure the appropriate care is provided. People must be provided with social and recreational opportunities that help stimulate their well-being. All planned activities should be based around the needs and choices of the people living in the home. This will help to improve the holistic needs of the individuals. The fire officer inspected the home 11/08/09 and some issues requiring attention were highlighted. These should be addressed to help to promote the safety and welfare of people. Comments on what the home could do better: Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.2 Page 7 “The meals are not bad but I find there are too many sandwiches on the menu at tea time” “I would like more fresh meat and less processed also fewer carrots and more green vegetables”. “Because of Health and Safety you can’t have a soft fried egg”. “I am 85 and have had soft fried eggs all my life. Its do as I say not as I do”. “I like it when musicians come, need more activities”. 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. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with good information that assists them when making their choice about taking a place in the home. The staff ensure people are assessed before they are admitted. EVIDENCE: People said they were able to come and look around the home before they made a choice about taking a place. They said they were provided with enough information by the home to assist them with making their choice. We spoke with a visitor whose relative had been living at the home for a few months. They chose the home after looking around a few. The family and their Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 10 relative came to look round a few times and the person’s care needs were assessed during one of these visits. They said that they had been given all the information they needed to make an informed decision. They said their relative has short-term memory loss and this was why they needed to be in a care home. However, the section that looks at the individual’s mental state and cognition did not have anything in it. We looked at assessment information for people recently moved into the home and found that although there is documentation to show people’s needs like social needs, mental health needs, risk of falls, mobility, nutritional, pressure sore, skin integrity with body maps to identify any skin damage. Information in these were not always recorded. The manager was reminded that the information from the pre-admission assessment must be used to make sure that the person’s care needs can be met by the home. Information from talking to other people: • One person said they and their relative had been well supported when they moved into the home. • They were satisfied with the services received. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, personal and social care needs are set out in care plans. But links between the health care assessments and guidance in the care plans are not always being made. This means that there is a risk people’s healthcare needs might not be identified or met. EVIDENCE: The manager said training and guidance about how to use care plans has been given to staff. The aim is to make sure that all people living in the care home have detailed, individual, person centred care plans that provide staff with all the information needed to meet their needs. The manager has a system for auditing care plans and making sure they are detailed and individual. She has Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 12 identified that some of them need to be more person centred and include more information. We looked at several people’s care plans. We found that generally the written information could be improved. People were at risk of their care being overlooked. Care plans had not always been reviewed, to make sure people’s needs had not changed. In some cases when people’s needs had changed there were not always a plan in place to show the changes. There was little or no information about people’s social care needs which is required to help staff to stimulate people in the home. In one case the only thing recorded was that the person smokes. Some people religious wishes or information about their funeral arrangements were not recorded. There were no end of life care, which would make sure people get the care and support they would like at that time. In some cases identified risks such as falls and mobility there were no plan of action to show how the risk could be minimised or managed. In one person file it said she “wears glasses, does not have an optician and is not concerned about seeing one” there was evidence that the home had taken any other action. Although there was information showing what to do to meet people’s nutritional need, such as the involvement of the dietician and weekly or monthly weight checks. Some people’s weight has not been checked within the timescale stated in their plans. This should be done so that any significant weight loss can be dealt with. Care plans and risk assessments did not show consistent evidence that people or their representatives have been consulted about the care provided by the home. People spoken to said, “I haven’t seen her care plan for over 18 months” another relative said “I would like to see the care plan, but I am not sure if I could”. Some plans did not show who was involved in the reviews. They were not dated and signed by staff. Many did not go into details of how personal care and support would be carried out. A relative said “I would like to be told about my mother whether she is improving etc. without having always to ask. I think once a month or every six weeks the manager could have a one to one meeting with each relative for a mutual discussion/update”. Staff were observed providing the care to people living in the home. There were many examples of good practice seen. Examples of this were, staff getting down to the eye level of people when they were speaking to them, staff providing people with time to answer questions, staff being polite and helpful Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 13 when interacting with people living in the home. Some positive comments were made about the staff group and the care they provide: • “I am happy that my mum is here. The staff know how to look after her”. • “I’m please with the care I’m getting”. • “All the staff are very kind and look after all of us very well”. • “Staff are always in demand they work ever so hard”. Medication sheets and the controlled drug records were checked against the medication held and were found to be in order. The medication records include a photograph of each person alongside their medication sheet. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s choices are respected and contact with family and friends is encouraged. People are not provided with structured activity programmes that meet their needs. The systems in place ensure all people living in the home receive a nutritious diet. EVIDENCE: We looked closely at the care documentation of nine people during the inspection. These showed that not all people’s social interests are assessed at the beginning of their stay at the home. Families don’t appear to be involved with writing pen pictures of their relatives. These pictures would help staff to understand the previous life history of the person they are caring for and what their likes and dislikes are in relation to things such as activities and food. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 15 The home has a number of people with dementia care needs. We observed no activities provided to this group in the home during inspection. Relatives expressed concerns about the provision of activities in the home. They said: • • • • “When I visit all I see is people watching the TV”. “Most just seem to be sitting in their chairs”. “When there is activity it’s very good but there isn’t much going on”. “It’s fine for those who can get out and about”. In the conversations with some people who are more active they clearly expressed that they follow their preferred way of living – getting up times, going to bed, whether to spend time alone or with others, what activities to join in and what to wear. People looked well cared for were happy with the arrangements for hair care and foot care. They said that if they need little things the staff would get it for them. The people living in the home talked positively about the food provided. The menus are traditional English food and although they are asked regularly if they would like to try different dishes this was the preferred option for all of the people spoken with. They said that the meals are good, they have plenty (too much sometimes) and that they have a choice. Other people said; “The meals are not bad but I find there are too many sandwiches on the menu at tea time” “I would like more fresh meat and less processed also fewer carrots and more green vegetables”. “Because of Health and Safety you can’t have a soft fried egg”. “I am 85 and have had soft fried eggs all my life. Its do as I say not as I do”. The lunchtime meal was well presented and people said it was good. There was some quiet conversation between people and staff were good at encouraging and assisting people. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the 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 people who live at the home feel confident that they will be listened to and that appropriate action will be taken when necessary. There are safeguarding procedures which staff have awareness of and understand and people can be assured that they can feel safe at the home. EVIDENCE: It was clear from the conversations with people living in the home that they feel that staff are very approachable. People said that any requests were always listened to and they feel safe and well treated. Policies are in place aimed to set out how the home protects people, and prevents harm or abuse and this includes a whistle blowing policy. The manager was aware of the need to report any suspected or alleged abuse to the local authority and other relevant authorities and has done training for this. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 and 26. People using the 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 living at the home live in a clean and comfortable environment. EVIDENCE: A tour of the building was made. All communal areas were seen. These are comfortable and well decorated. Previous inspection report have referred to a number of people’s bedroom windows that are letting in draft making some people’s room feel cold. It is understood that Local Authority is looking to address this. People are encouraged to personalise their rooms and to bring familiar pieces of furniture in with them. All the people living in the home and Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 18 their relatives spoken with said they were happy with the standards of cleanliness. The home has robust policies and procedures that help to manage any infection control issues that may arise. They have notified us of any incidences of infections. These have always been managed appropriately and the relevant health professionals have been involved at the time. The home had an inspection by the fire service report dated 11/08/09 a number of things was raised, which the manager said are currently being addressed. Failure to complete the work identified could place people in the home at risk. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the 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 are protected by the home’s recruitment procedures and staff are, in the main, trained and skilled to meet the needs of people at the home. EVIDENCE: Staff were observed to be confident in the roles they were expected to perform. The staff know the individuals well and they are cared for in a consistent and personalised way. Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to ensure staff are eligible for work. The personnel records for three staff members were looked at to make sure that the appropriate checks had been made and the other documentation that Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 20 must be sought before someone starts work was completed. This proved to be the case. The home makes sure that new staff follow the induction training programme. There was evidence of this in the staff records and also evidence of ongoing training to keep staff up to date with safe working practices. Most of the care staff have completed their National Vocational Qualification (NVQ) level2 in care. Other staff are also working towards this. Some of the comments from staff who returned the survey on what the home does well are; “I feel I get the training and support to enable me to do my job well and I think the people at the home benefit from this”. “Some staff group are providing excellent care for a sometimes difficult group of people”. On what could the home do better? “The home needs better facilities and equipment to meet the needs of a changing group” “Staffing levels could be improved” and “people would benefit if the manager/officers had more input in the day to day running of the home (i.e. the care). Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People using the 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 running the home in the best interests of people living there. However more evidence is needed to show that people’s care and support is well managed. EVIDENCE: The home has had a change of manager since the last inspection. The registered manager has been away from the home for sometime. The new manager started around four days before this inspection. She has identified Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 22 where gaps in care plan and the recording of information for caring for people is need improving and has arranged for staff training to address this. It is positive that the manager has responded quickly and positively to the concerns raised around peoples care plans. People said “although the manager is new she is approachable and helpful”. They also said the home has a friendly and open atmosphere which is conducive to people and their visitors expressing their views. The home employs a maintenance person to make sure all the day to day minor repairs are carried out and that the home is kept safe for the people who live there. Records of financial matters are maintained within Social Services departmental procedures and audit requirements. People are encouraged to manage their own monies, where achievable. Records looked at showed that formal staff supervisions are being provided at regular intervals. All the necessary maintenance checks are carried out annually. Staff said they had received fire safety and other health and safety training. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The care plans and risk assessments must provide evidence to show, where possible, people living in the home or their representatives have been involved with developing the care plans and risk assessments. This will ensure agreement to provide the care package has been gained. All care plans and risk assessments must be reviewed regularly and changed to reflect the care needs of the person receiving the care package. This will help ensure the appropriate care is provided. Timescale for action 01/02/10 2 OP8 15(2)(b) 01/02/10 3 OP12 16(2)(m) 01/02/10 People must be provided with social and recreational opportunities that help stimulate their well-being. All planned activities should be based around the needs and choices of the people living in the home. This will help to improve the holistic needs of the individuals. Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations As much information from the pre-admission assessment should be recorded and used to make sure that the person’s care needs can be met by the home. A number of people’s bedroom windows that are letting in draft which makes some people’s room feel cold. It is understood that Local Authority is looking to address this. The fire officer inspected the home 11/08/09 and some issues requiring attention were highlighted. These should be addressed to help to promote the safety and welfare of people. 2. OP19 3 OP19 Suffolk Court DS0000033240.V378445.R01.S.doc Version 5.3 Page 26 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. 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