Care Home: Sunrise Operations Weybridge (Assisted Living)

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What the care home does well The home has a very varied activity programme and each resident has a copy of the month`s events and activities. Residents are kept informed of any changes to the programme and encouraged to take advantage of what is on offer. As well as activities such as craft, pottery, quizzes, exercises, card games including whist and bridge, entertainers come into the home, give talks, play music or just facilitate a good old sing song. The home has a buddy scheme in operation, this is where a resident has agreed to meet and greet new residents when they come into the home. The buddy is able to answer questions about the home and explain what life there is like from their perspective. The buddy introduces the new residents to other people living in the home and explains what goes on in the home, activities, social events etc. The home`s environment, furnishings and fixtures are provided and maintained at a high standard. All areas of the home and grounds are wheelchair accessible and there are lifts and stairs to the first floor. The communal areas of the home are spacious and offer various areas to sit relax or entertain in. there is a bistro where residents can make themselves and guests a drink or staff will facilitate this for them. The dining area is light and bright and looks out on to well tended garden. Here there are seating areas, planted areas giving interest all year round and a shed which is used for pottery. Residents individual rooms are well furnished however residents are encouraged to personalise them and bring in some of their own items, pictures, ornaments etc. there are a range of baths including spar spa baths and all rooms are en-suite with a shower or bath. What has improved since the last inspection? The menus have improved, with more choice available on a daily basis. The dining room has been rearranged to give more space for wheelchairs and residents who use walking aids. The home has appointed a dining room manager and residents all agreed this has improve their dining experience. The care plans are more person centred in their approach. Residents can be more confident that they will receive the medication they are prescribed. What the care home could do better: Information on residents files must be clear and accurate to ensure residents receive the care and support agreed and required . It is disappointing that improvements seen in the random inspection undertaken in February 2010 have not been sustained in the following areas. Care plans must be reviewed on at least a monthly basis and reflect any changes in the needs of the resident to ensure they receive the care and support agreed and planned. PRN protocols for medication prescribed for residents on an as and when necessary basis must be available for all such prescribed medication to ensure these medications are given for the reason they are prescribed. Risk assessments and management strategies must be available for all residents with identified risks so staff have clear information on how to minimise risk and ensure residents welfare. Key inspection report Care homes for older people Name: Address: Sunrise Operations Weybridge (Assisted Living) Ellesmere Road Weybridge Surrey KT13 0HY     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: Sally Hall     Date: 1 2 0 4 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 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Sunrise Operations Weybridge (Assisted Living) Ellesmere Road Weybridge Surrey KT13 0HY 01932871100 01932871101 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Sunrise Operations Weybridge Ltd Name of registered manager (if applicable) Manager Post Vacant Type of registration: Number of places registered: care home 81 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 81. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home This residential home has been purpose built to high specifications and offers accommodation and care to 81 service users in tastefully decorated and furnished surroundings. The rooms are over three floors and there are passenger lifts for those who cannot manage the stairs. The bedrooms vary in size and some come with two rooms, these can be used for couples or can be used as a bedroom and lounge. There are a number of communal areas that service users can choose to sit or dine in. There Care Homes for Older People Page 4 of 29 Over 65 81 0 Brief description of the care home is also an area where service users and or there families can make tea and coffee. The gardens are interesting, well maintained and accessible to those less mobile. There is plenty of seated areas for service users and their visitors to enjoy the views. The home has a concierge service at front of house for both visitors and service users living at the home. The home offers a range of activities and has a minibus for regular outings. Fees for this home are dependent on the type of accommodation and the care provision and are available upon request from the home Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: We agreed and explained the inspection process with the appointed manager at the start of the inspection. The focus of this inspection was to assess Sunrise Weybridge Residential Home with Nursing in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older People in relation to all key standards. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, preinspection information such as notifications sent to us by the provider of incidents, any issues raised by the public or Social Services in discussions or correspondence with the registered provider was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had Care Homes for Older People Page 6 of 29 completed an AQAA an annual quality assurance assessment questionnaire, this provided us with information relating to what the home considers it does well, what they could do better, what has improved within the last 12 months and further plans for improvement. Survey questionnaires were also sent to the home prior to the inspection for distribution to residents, staff and other health professionals Documentation and records were read. Time was spent reading of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, staff rota, training records and recruitment records. We identified five people who use the service for case tracking, speaking with one of them whilst assessing the available information held in the home pertaining to the care provision for them. We also sampled specific information in other residents files in order to evidence common practice. In addition the Inspector met with the other residents who use the service and families visiting, which gave a good opportunity to observe the quality of care being provided by the home and understand the impact the care provision has on their quality of life. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Information on residents files must be clear and accurate to ensure residents receive the care and support agreed and required . It is disappointing that improvements seen in the random inspection undertaken in February 2010 have not been sustained in the following areas. Care plans must be reviewed on at least a monthly basis and reflect any changes in the needs of the resident to ensure they receive the care and support agreed and planned. Care Homes for Older People Page 8 of 29 PRN protocols for medication prescribed for residents on an as and when necessary basis must be available for all such prescribed medication to ensure these medications are given for the reason they are prescribed. Risk assessments and management strategies must be available for all residents with identified risks so staff have clear information on how to minimise risk and ensure residents welfare. 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 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are given sufficient information by the home to make an informed choice about whether the home is right for them. Service users can feel confident that it offered placement at the home following the assessment process the management of the home is confident they can meet their needs. Evidence: People who are considering moving into the home are provided with informative information. This contains a statement of purpose and service user guide. These documents which have been reviewed recently inform people about what it is like to live in the home. It also includes a description of the care that will be provided for both residential care and nursing care as required during the last visit. Two people who had recently moved into the home and a relative were spoken with. They Care Homes for Older People Page 11 of 29 Evidence: confirmed that they had received the information they required to make an informed choice about the home. They said that they had felt very welcome and had been impressed with the warm and friendly atmosphere. This home has a buddy scheme where by a resident at the home welcomes new people and spends time showing them around and answering any queries. People who move into the home can be confident that their needs will be met. Four pre assessments were viewed. Evidence from these demonstrated that a pre admission assessment is carried out to enable the unit manager to make a judgement as to whether the home will be suitable for and can meet the needs of the individual. These assessments include information gathered from health professionals. Upon admission, a further assessment is undertaken by the manager. The persons GP is also asked to complete a questionnaire to ensure the home has a full medical history and an up to date confirmation of the medication they be taking. Information from all the assessments informs care planning and risk assessment. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from being assessed and supported with regard to their health and personal care needs However they cannot be confident all their needs are recorded on care plans / risk assessments or that they are up to date and accurate. This could lead to residents not receiving appropriate care and protection from staff Residents who require assistance with medication administration receive their prescribed medication, however documented PRN protocols would be of further benefit to residents. Evidence: People who live in the home confirmed that arrangements are made for them to see the chiropodist, doctors and other health care professionals when they need to. Those who need help to manage their medication are supported by trained staff. The medication records viewed confirmed that service users are receiving the medication they are prescribed and MAR (medication administration record) sheets had been completed fully. It was noted however that not all residents prescribed medication Care Homes for Older People Page 13 of 29 Evidence: PRN (as and when necessary) since the last inspection have not had the required protocols in place indicating the home has not maintained the improvement seen at the random inspection in February. All the residents spoken to confirm that their privacy is respected and that staff knock on doors before entering, many residents prefer to lock their doors, knowing staff can enter in an emergency and are happy with this arrangement. Observation of interaction between staff and residents throughout the visit confirmed that privacy and dignity is respected in the home. Confidential information is handled discreetly and sensitively. Care plans were viewed. All care plans viewed contained evidence of individual needs, however not all were person centred, the appointed manager confirmed that care plans are in the process of being changed. One relative spoken with explained that she had been involved in their relatives care plan. Five service users were spoken with regarding their care plans also stated they had been involved but of those two said that they were not aware of there care plan. It was recommended that wherever possible, care plans and risk assessments are signed by the resident The resident files did have evidence of regular reviews, however all seen said no change for all entries. Further evidence showed that the updating of care plans to reflect changing needs was not evident. Residents would benefit from reviews detailing the outcomes and any support need changes, to ensure care plans remain current and reflect a true picture of the residents individual needs. Again this indicates the home has not maintained the improvement seen at the random inspection in February. It is also important to ensure that information recorded on the residents file is accurate, for example on one file seen a list of foods for a service user was in fact items of food that should not be eaten given there medical history. Shortfall in risk assessments were noted. Current risk assessments are available in many cases, but some have not been completed when indications in the care plan suggest there is a possible risk. The management strategy is contained with in the care plan and it is not always clear that staff need to follow the instructions to minimise a possible risk. Residents spoken with were generally happy with the support they receive although a couple felt there was still room for improvement, and it could depend on the individual staff member. One stated they were satisfied with the care they receive and praised Care Homes for Older People Page 14 of 29 Evidence: staff for the way in which they carry out their duties. Another stated that they came to this particular home because they expect staff to be available when they want them and they are most of the time. Several said the staff are on the whole friendly and obliging. One resident said they give, one, time to do what, one, can for, ones, self with out feeling rushed, other residents agreed with this. Other residents did say that were not always confident that staff fully understood what they wanted them to do for them, and they had to explain each time. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from being supported to make choices and have a wide range of activities available to them. Residentscan feel confident overall that they are offered a well balanced diet and will supported to eat their food where necessary. Evidence: Residents are supported to live their lives as they choose. Routines are flexible. There is a variety of activities on offer such as art and craft, bingo, knitting, pottery, exercise, card games including whist and bridge, entertainers come into the home, give talks, play music or just facilitate a good old sing song which they may choose to take part in if they wish. There are activity coordinators employed in the home. Individual records are kept of all activities undertaken or refused by residents. This full activity programme that is arranged on a monthly basis is given to residents and displayed around the home. If changes are made then residents are informed on the day when they are reminded of what is happening that day. When residents were asked what they thought about the activities they said that the activity programme varied and there was plenty to choose from including regular Care Homes for Older People Page 16 of 29 Evidence: outings. Activities are available at various times during the day and includes some things happening in the evenings. While it is accepted that there is a strong emphasis by the home to encourage residents to participate in activities, it is very much down to individual choice. The activities are discussed at the residents monthly meetings when suggestions are added to the following months programme. A relative commented that the home is always welcoming to visitors and that staff and management are helpful. The home has a bistro which can be accessed during the day to make drinks and visitors are encouraged to help themselves or staff are happy to serve refreshments in their relative/friends room. The home has improved the menu to offer a lot more choice and residents were very complimentary during this visit about the meals that are now available. The menu which is displayed on all tables looked nutritious, and included a choice of drinks including wine. Residents are asked what they would like for each meal when seated, rather than choosing in advance. Most meals are freshly cooked in the home and takes account of specialist dietary needs. There is also a salad bar from which residents can help themselves to a range of cold cooked meats, fish and a wide range of salad items and sauces. The dining room is well laid out with tables attractively set, although residents can choose to take their meals in their rooms. The dining room has been rearranged recently to give more space for wheelchairs and residents who use walking aids. However space is beginning to become limited and with the increase of residents with mobility difficulties the area may need to be extended to accommodate more wheel chairs etc more easily. Residents spoken to agree that the appointment of a dining manager has greatly improved there dining experience. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an effective complaints system in place and service users can be confident their complaints will be taken seriously. Service users are protected by adult safeguarding policies and procedures Evidence: The home has a complaints procedure, which was seen. Feedback received from residents spoken with and comments made within residents surveys confirmed they were aware of the contents and felt free to voice their concerns. The home has received several complaints since the last inspection, on information received from the manager complaints received have been dealt with in a positive way to achieve the best outcomes for the complainant. The way complaints are recorded however has been changed recently with complaint forms now being available from the concierge. There have been no complaints since this change to see how well this is working. The home has a safeguarding adults policy and Whistle blowing procedures for staff which has been reviewed recently. These include procedures for the reporting of suspicion or evidence of abuse with instructions for the recording of any allegations and action to be taken. Full training is provided in abuse for all staff and is updated yearly. Staff spoken to showed a good understanding of their responsibility regarding abuse. Care Homes for Older People Page 18 of 29 Evidence: The home operates a robust recruitment procedure to further protect residents. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a home that provides a safe high quality and homely environment. Residents choose from a variety of accommodation to suit the individual with very comfortable indoor and well tended outdoor communal areas. Evidence: The home provides a choice of accommodation and this includes, single occupancy bedrooms which have en-suite bathrooms, Companion suites/bedrooms can be occupied by two people who chose to share toilet/bathing facilities. Bedrooms are carpeted and decorated to a very high standard and meet the National Minimum Standards re furniture requirements. Residents rooms are lockable and residents may have their own key. Each residents room has a window which they can open and see out of but is restricted for safety. Each suite has a heater which can be adjusted by the resident. There are also communal toilets with disabled access and spa baths around the building. The communal areas around the home can be used by all residents and include a tastefully decorated dining area, a number of lounge areas, and bistro where residents and visitors can make drinks during the day. There are other seating areas about the home that the residents can choose to sit in. Residents and family members spoken with said that the home is always very clean Care Homes for Older People Page 20 of 29 Evidence: and there are never any unpleasant smells. There is an area where activities often take place. There are garden areas which can be seen from most of the homes windows, all are well maintained and give a pleasant outdoor space consisting of well maintained planted beds, grassed and paved areas with seating and is accessible to all residents. The home has a well equipped laundry in a secure part of the home away from the residential areas which undertakes the washing of bed linen, table cloths etc using the red sack system for fouled linen to ensure staff handle this as little as possible. They have a small laundry in the residential area for washing resident personal laundry. Residents can be involved in the washing of their personal items or they can leave these to staff. The appointed manager confirmed the home has the equipment necessary to provide appropriate nursing care, with nursing beds, specialised mattresses and other items that may be required. The home has policies and procedures for infection control, and staff have access to PPE (Personal Protective Equipment) such as gloves and aprons. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can feel confident that their care, social and emotional needs will be met by care and nursing staff in sufficient numbers who have the skills, knowledge and training to meet those needs. Residents can be confident that they will be protected by the homes robust recruitment policy and procedure. Evidence: The ratios of care staff to residents are determined according to the assessed needs of residents. Following discussions with the appointed manager, a review of the rota and observations made during the visit, sufficient care staff were on duty to support residents to meet their personal needs and take all reasonable steps to ensure their health and safety. Residents spoken with were happy and content with the number of staff. Feedback from surveys confirmed that residents are generally well supported with their needs. The home employs a number of ancillary staff such as cleaners, laundry, cooks, gardener/ maintenance staff. Thus allowing care staff the time to meet the needs of residents The staff training records indicated undertaken training. Individual and group staff training needs had been identified. From documentary evidence seen the standard of Care Homes for Older People Page 22 of 29 Evidence: individual required training was good overall with the majority of staff completing basic courses but however at present the home has not achieved an NVQ (National Vocational Qualification) Level 2 or above care qualification for at least 50 of care staff. This was seen as a shortfall. The appointed manager is aware of this and further staff will be registering for the course in the near future. The home also has kitchen staff undertaking NVQs and concierge is doing an NVQ in customer care. The home has a development programme for all new staff, which meets Sector Skills council workforce training targets and ensures staff fulfill the aims of the home and meet the changing needs of residents. The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The homes recruitment files were seen and included all the information as required under schedule 2 of the Care Home Regulations 2001 on information given. All qualified Nurses working within the home on evidence seen are currently registered with the Nursing and Midwifery Council. All staff have a current CRB or POVA (Protection of Vulnerable Adults) check. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that the registered manager has the necessary qualification and experience to run the home, however they can not be confident that improvements in the home can be sustained. Residents can be confident that their views and opinions effect how the home is run. Evidence: The home has an appointed manager currently they have undertaken a (CRB) Criminal record Bureau check, once this has been received the appointed manager confirmed an application to become the registered manager will be forwarded for consideration. The appointed manager is a qualified nurse and has been a registered manager of a care home previously. There have been a number of improvements made However it was disappointing that the home has not been able to sustain the improvements in documentation noted during the random inspection in February 2010. Quality assurance was discussed and the views and opinions of many of the resident are sought. Residents spoken to also talked about the meetings they have with the Care Homes for Older People Page 24 of 29 Evidence: chef, activity co-ordinator and the management of the home regarding what they are happy with and areas they would like to see changed. They confirmed a great deal of satisfaction in living within the home and felt confident that the staff and management valued their views and opinions. This was confirmed in the surveys returned by residents living at the home. The appointed manager confirmed that the home does undertake quality assurance by means of asking residents to complete questionnaires, this is done locally and by the main organisation in America. Visits are also arranged to the home by the area manager who completes what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). Residents identified there have been a number of improvements made recently. However improvements need to sustained, it is important that staff treat care plans for example as a living document and make changes reflective of the residents situation in a timely way during the review process. The home has developed a health and safety policy to meet health and safety requirements and legislation. The AQAA Annual Quality Assurance Assessment was used to verify that Health and Safety Procedures are reviewed, and maintenance and servicing are taking place in a timely way. The home has two maintenance persons who make sure fire checks take place and complete the Fire Log book. This includes evidence that checks and servicing of fire safety equipment / emergency lighting had been undertaken at the required frequency. They also make sure that servicing takes place throughout the home and ensure day to day maintenance issues are attended to. Care Homes for Older People Page 25 of 29 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 31 18 The registered person must ensure that the appointed manager of the service submits an application for registration with the Commission 20/02/2010 Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 7 12 The registered person must 30/05/2010 ensure all service users have a plan of care detailing their needs, wishes and preferences regarding the support they wish to receive. To support service users to be an integral part of the formation of their plan of care to include their needs and wishes. 2 8 12 The registered person must ensure the assessment of service users is kept under review and is revised when their needs change 30/05/2010 To support service users with their ongoing changing care/nursing needs. 3 8 13 Where risks are identified, an 30/05/2010 assessment along with a management strategy to minimise that risk is documented and kept under review. To minimise the risks to service users wellbeing. 4 9 13 Staff must be given clear 30/05/2010 instructions and guidance on when to administer medicines that are prescribed for service users on an as required needed basis All medication to be given Page 27 of 29 Care Homes for Older People 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 PRN when necessary must have a detailed protocol instructing staff when the medication should be given. 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 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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