Care Home: The Dell

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What the care home does well Staff were observed to be kind and attentive to the people living at the home. Positive comments were received from staff, a relative and from people living at the home about the care given. One visitor said that the staff ‘really care about everybody’ and one member of staff said that ‘it’s like a small community here’. The majority of comment cards from people living at the home indicated that they always receive the care and support they need. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Staff and a relative spoken to said that where possible people are encouraged to make their own choices around their day-to-day lives. The visitor spoken to said that she was able to visit whenever she liked and staff always made her feel welcome. She also said that staff were good at keeping her informed of any issues concerning her relative. People have an assessment of their needs before being admitted to the home to make sure that all of their needs can be met and people are encouraged to come and visit the home before making a decision to move in. People spoken to were all complementary about the food provided and the received comment cards indicated that people liked the food. What has improved since the last inspection? This was the first inspection since the service has been registered with the providers Inspirit Care Limited. What the care home could do better: No requirements were made during this visit. However a couple of recommendations have been made. To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include as assessment of any specific religious or cultural needs. Internally and externally the home is looking tired and worn, particularly the exterior of the building. However the manager confirmed that a complete refurbishment of the home is due to be undertaken. Key inspection report CARE HOMES FOR OLDER PEOPLE The Dell 55 Sibley Street Gorton Manchester M18 8LN Lead Inspector Geraldine Blow Unannounced Inspection 5th May 2009 09:30 DS0000072947.V375011.R01.S.do c Version 5.2 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. The Dell DS0000072947.V375011.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 The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Dell Address 55 Sibley Street Gorton Manchester M18 8LN 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) 0161 223 4709 0161 2308558 Inspirit Care Limited Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 40 Date of last inspection First inspection Brief Description of the Service: The Dell is a residential care home owned by Inspirit Care Limited. The home provides accommodation for up to 40 people who require personal care only. The home is situated in a quiet residential area of Gorton in Central Manchester, set in mature gardens with outside seating for people and ample car parking to the side aspect. The home is close to public transport links into Stockport town centre and Manchester City Centre. The home is within easy walking distance of Gorton Market, library and there are a variety of shops close by. Accommodation is provided in 36 single rooms and 2 double rooms. None of the bedrooms have en-suite facilities. Accessible toilets and bathrooms are located on the ground and first floors. The home has a large lounge and a separate dining room on the ground floor. In addition there are two smaller lounges located on the first floor. A separate lounge is available to residents who smoke. The inspection report is available in the main reception area for people to read. The charges for fees range from £382 to £433 per week. There are additional The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 5 charges for magazines, papers and hairdressing. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2. This means the people who use this service experience good quality outcomes. This report is the first inspection report since Inspirit Care Limited was registered with the Care Quality Commission (CQC) in November 2008. This report is based on information gathered by the CQC during the unannounced visit on the 5 May 2009 and supporting information received in Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. The visit took place on Tuesday 5 May 2009. This report is an overview of what the inspector found during the visit. References to we or us in this report represent the CQC. Staff and some people living at the home were sent comments cards so that we could get their views on how the home is run. We received three completed comment cards from staff and six comment cards from those sent to people living at the home. Some of the comments are included in the body of the report. As part of the visit we spent time examining relevant documents and files. We also spent time talking with several people living at the home, some members of staff and a visitor to the home. We also walked round the home and looked at the communal areas and some bedrooms. Feedback was given to the manager during the course of the visit. What the service does well: Staff were observed to be kind and attentive to the people living at the home. Positive comments were received from staff, a relative and from people living at the home about the care given. One visitor said that the staff ‘really care about everybody’ and one member of staff said that ‘it’s like a small community here’. The majority of comment cards from people living at the home indicated that they always receive the care and support they need. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 7 Staff and a relative spoken to said that where possible people are encouraged to make their own choices around their day-to-day lives. The visitor spoken to said that she was able to visit whenever she liked and staff always made her feel welcome. She also said that staff were good at keeping her informed of any issues concerning her relative. People have an assessment of their needs before being admitted to the home to make sure that all of their needs can be met and people are encouraged to come and visit the home before making a decision to move in. People spoken to were all complementary about the food provided and the received comment cards indicated that people liked the food. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 8 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 9 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 The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 10 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): 3&6 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. There are systems in place to make sure that people’s needs are assessed before admission to ensure their care needs can be met. EVIDENCE: The manager confirmed that admissions to the home are only made after a pre admission assessment of the persons needs has been undertaken, to ensure that those needs can be met. In addition to the homes own assessment they also receive information from the care managers assessment of the placing The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 11 authority. Evidence was seen of these assessments on the three care files looked at during this visit. However it was noted that the homes own pre assessment document did not include an assessment of people’s specific religious or cultural needs. To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include as assessment of any specific religious or cultural needs. The manager stated that people who are thinking about moving into the home and or their relatives are encouraged to visit, have a look round, meet staff and other people living at the home. Information received in the completed comment cards confirmed that the majority of people had received enough information before making a decision to move in. The Statement of Purpose is available in the main reception for people to look at. The manager confirmed that the marketing department was currently updating the Service User Guide to include the details of the newly registered provider. Once the document has been produced it is the manager’s intention to include it into a welcome pack which will be given to all existing people living at the home and anybody new. The Dell does not provide an intermediate care service. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 12 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 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 health, social and personal care needs of people were being met by staff that respected their privacy and dignity. EVIDENCE: The manager confirmed that it was the intention of the new providers to implement new care plan documentation. Three support plans were looked at during this visit to see how information is received and maintained to evidence how people’s needs are being met. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 13 The support plans contained details of peoples personal choices and preferences. For example the files looked at contained information about preferred getting up and retiring times. They contained information about whether people preferred baths or showers, what they liked to wear, what they liked to eat and where they preferred to eat their meals. There was documented evidence that the individual support plans had been reviewed regularly. However some of the plans had not been updated to reflect the changes in care needs that were documented in the review. To ensure that people’s needs are appropriately met the support plans should be updated when a change in need has been identified. It was of some concern that in one file looked at not all of the support plans had been completed. For example the support plan for ‘getting out and about’, ‘comfort, rest and relaxation’ and ‘preparing for sleep’ were blank. However the review had documented ‘no changes’. This was discussed with the manager. There was no formal assessment for oral hygiene needs. To ensure that peoples needs are appropriately met it is recommended that an oral assessment is undertaken on admission and then incorporated into the support plan. Risk assessments relating to nutrition, falls and risk of pressure sores were completed where appropriate. The manager confirmed that it was her intention to implement a system to regularly audit the care plans to ensure peoples needs are being met. This would be considered good practice. Procedures relating to safe storage, administration and recording of medication were assessed and found to be in order. A visual check and a random count of boxed medication was found to be correct. Recording of does administered were accurate and the correct coding had been used. This indicates that people are receiving their medication as intended by the GP. To ensure that people are not put at risk the manager confirmed that staff with responsibility for administering medication had received appropriate training. To ensure that people were receiving creams and lotions as intended by the GP there were clear instructions included alongside the medication administration record. The manager confirmed that at the time of this visit nobody was self administering their own medication. She was aware of the need to complete a risk assessment prior to anybody self administering medication to ensure they would be safe to self administer. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 14 Staff, people living at the home and a relative spoken to confirmed that people are treated with respect and dignity. One staff comment received via the comment cards was we are champions in promoting dignity in care The majority of received comment cards received from people living at the home identified that staff do listen and act on what they say. One person said the staff are ‘very kind and always help you if you need it’. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 15 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 & 15 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. Activities are provided and people are able to maintain contact with family and friends. People have a choice of varied, well-balanced meals. EVIDENCE: The home employs the services of an activity coordinator. The planned activities are on display on a notice board in the main lounge. Some of the activities included bingo, outside entertainers and exercises. The manager stated that they were in the process of arranging a trip to Blackpool in August 2009. The coordinator keeps a record of the activities arranged and the names of the people who take part in the activity. This ensures that the activities provided matches peoples social, cultural and recreational interests. The care files have a ‘my past experience’ assessment. This includes details of people’s hobbies and interests as well as spiritual and religious needs. The The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 16 manager confirmed that the home has good links with local churches and day centres. People are encouraged to maintain contact with family and friends and all people spoken to confirmed that they could visit the home whenever they wanted. One visitor spoken to said that she is always made to feel very welcome and staff keep her informed of any issues relating to her relative. From speaking to people living at the home, staff and a visitor it appeared that people are encouraged to exercise choice and control over their lives. The support plans documented peoples personal preferences around their day to day lives and people were free to access their rooms or any of the communal areas without restriction. Promoting Equality and Diversity leaflets were available in main reception for people to access. The manager has recently completed Deprivation of Liberty Safeguard training (DoLS), which came into force on 1 April 2009 and forms part of the Mental Capacity Act. The manager stated that she has discussed both of the above with staff on a one to one basis. Training has been arranged for staff so that they can ensure that peoples capacity to make decisions is assessed and recorded as required under the Mental Capacity Act. In addition all staff have been given a booklet regarding the DoLS and a booklet is available in the main reception for people to access. A daily menu is on display in the main reception and in the dining room. The menu offers a choice at each meal time and people spoken to confirmed that the cook speaks with people on a daily basis to get their choice of meals for that day. If people don’t want what is on the menu then they can have any other reasonable alternative. The manager said that she was in the process of reviewing the menu and after consultation with people the time of the main meal was due to be changed from lunchtime to evening time. Jugs of juice are available in the lounges and staff spoken to confirmed that hot drinks and snacks are available on request. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 17 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 & 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. People living at The Dell are able to raise concerns and are confident that they will be listened to. This means that people are protected from harm and abuse. EVIDENCE: There is a complaints procedure, which is on display on the notice board and on each person’s room on the inside of their bedroom door. All returned comment cards indicated that people knew how to make a complaint and knew who to speak to if they are not happy. All the returned comment cards from staff indicated that they knew what to do if somebody wanted to raise a concern or complaint. The manager took up post in January 2009 and has not received any complaints. However she was able to describe the action she would be required to take if a complaint was made. The manager stated that when she took up post in January 2009 she sent out anonymous quality assurance questionnaires to people living at the home, relatives and staff to see if there were any complaints or concerns that needing The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 18 addressing. She confirmed that she encourages people to raise any concerns they may have so that they can be addressed. There was a copy of the Manchester Safeguarding Guidance and the manager was able to clearly describe the correct actions to be taken in the event of an allegation of abuse being made. The training matix evidenced that all care staff have received safeguarding adults training and staff spoken to confirmed this. Two allegations of abuse have been reported and both were appropriately reported and investigated. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 19 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 & 26 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. Not all areas of the home are well maintained to provide a clean and comfortable environment for the people living there. EVIDENCE: During the course of this visit a tour of the building was undertaken which included the communal areas and some peoples bedrooms. The general cleanliness of the home was good. However some areas of the home were not well maintained and much of the furniture and carpets were tired and worn. In addition the exterior of the building, in particular window frames, facia boards and soffits are rotting and needing replacing. However the manager The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 20 confirmed that a complete refurbishment of the whole building both internally and externally is due to commence. The home employs the services of a gardener and some landscaping is due to be undertaken to make the outside area more pleasant for people to sit and enjoy the warmer weather. To reduce the risk of cross infection personal protective equipment (PPE) such as gloves and aprons are wall mounted outside toilets and bathrooms. This is seen as good practice. The manager has an infection control audit that she is due to implement in the near future and has implemented a recording procedure to ensure that all wheelchairs are kept clean and in good working order. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 21 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 & 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. Peoples care needs are met by the numbers and skill mix of staff. EVIDENCE: From observations during the visit and from information supplied in the returned comment cards there was enough staff to meet the needs of the people living at The Dell. The manager confirmed that 21 care staff are employed. Twelve care staff have successfully completed training in the National Vocational Qualification (NVQ) Level 2 or above and one staff member is currently undertaking NVQ Level 4. A sample of staff files were looked at to see whether the required documentation was in place and if the necessary checks had been made. Three files were looked at for staff that had been recruited since the last inspection visit. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 22 All the files seen contained the required documentation. The files contained some photocopied documents but there was no evidence that the original documents had been seen. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. Evidence was seen that a set interview assessment form is completed during the interview to assess knowledge and experience of the candidate. This is seen as good practice. The manager confirmed that all new members of staff must attend induction and shadow a senior member of staff for the first two weeks of their employment. This is considered good practice. One of completed staff comment cards indicated that induction covered everything very well and two indicated that it mostly did. There was a training matrix for staff. The training records indicated that training was ongoing and this was confirmed by staff spoken to and by information received in the returned comment cards. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 23 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 & 38 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 home is managed in the best interests of the people living there. EVIDENCE: The manager has been in post since 26 January 2009 and is in the process of applying for registration with CQC. She has the Registered Manager’s Award, a Diploma in Management and Management in Leadership Skills. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 24 People living at the home benefit from a committed workforce and manager. People spoken to were confident that the manager is available if needed and they felt she would listen and act on what is said. The majority of returned staff comment cards indicated that the manager meets with them to give support and people spoken to confirmed that they felt supported by the manager. From observations on the day of this visit the manager was approachable and supportive to staff, the people living at the home and visitors to the home. Systems are in place for people’s finances to be managed. The system was secure and records provided evidence of running totals for individual people and included receipts for any purchases made on peoples behalf. However to ensure people are fully protected it is recommended that the policies and procedures regarding people’s finances are reviewed and updated to accurately reflect the procedures and processes used in the home and that agreements are made for staff to make purchases on people’s behalf. The manager confirmed that there is a monthly news letter on display for people to access to keep them updated on relevant issues. So that people can express their opinions on the quality of the service being delivered there are regular meetings for the people who live at the home and staff meetings. Relatives and visitors meetings are due to commence in the near future. The new providers are in the process of implementing their own policies and procedures to ensure they reflect current legislation and good practice advice, which staff will have access to. The manager recently sent out anonymous questionnaires to staff, people living at the home and relatives to obtain their option of the quality of the service being delivered. The results have been analysed by the manager and some changes have been implemented as a result. For example some changes to staff rotas, and the pending change of time for the main meal of the day. The manager confirmed that it is her intention to undertake an annual quality survey. In addition there is a suggestion box in situ and the manager said she encourages constant feedback from people. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Evidence was seen that fire safety checks were regularly undertaken. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 25 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x 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 2 x 3 x 3 x x 3 The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include as assessment of any specific religious or cultural needs. To ensure that people’s needs are appropriately met the support plans should be updated when a change in need has been identified in the monthly review. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. It is recommended that the policies and procedures relating to finances are reviewed and updated to clearly set out the systems to be followed. It is also recommended that written agreements be developed between people and the home setting out permission for DS0000072947.V375011.R01.S.doc Version 5.2 Page 27 2. OP7 3. OP29 4. OP35 The Dell the staff to purchase personal items for that person and the receipt be signed by the person purchasing items. The Dell DS0000072947.V375011.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. 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