Care Home: The Worthies

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well We received five surveys from people living at the home and they said that they were provided with sufficient information to make decisions about moving into the home. They also said that staff were available when they needed them, they receive the medical care they need and they know who to approach with complaints. People giving feedback at home said they home catered for their special diets, the staff were good and knew how to meet their needs. Additional comments from a district nurse through the surveys indicated that there are good communication links between health care professionals and staff at the home. What has improved since the last inspection? We spoke to the staff about the changes that have taken place since the last inspection. They said that there is a feeling that staff know what their responsibilities are and are working in a professional manner. The increase in staffing levels have made it easier to care for people with dementia. Staff are using their skills to ensure people with dementia can maintain their independence. Visual signposts are being used for people that need prompts to find their way around the property. It was evident during the inspection that staff have the skills and competence to manage difficult and complex situations. The deputy manager and senior care assistant are to be commended for the way they managed these situations. What the care home could do better: There were three requirements arising from this inspection with a repeated requirement from previous inspections which must be actions. Fire risk assessments is a repeated requirement, the manager must ensure that fire risk assessments say the training and practices that staff must attend to ensure people at the home are protected. Training and practices must then take place within the specified time to ensure that staff know the procedure to follow in the event of fire at the home. The two other requirements are based on care planning and a programme of activities. Care plans must have more detail about the way the care is to be delivered by the staff to meet the assessed needs. In terms of activities the manager must provide activities that are more meanigful and suited to the needs of the people with dementia. Key inspection report Care homes for older people Name: Address: The Worthies 79 Park Road Stapleton Bristol BS16 1DT     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: Sandra Jones     Date: 0 7 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: The Worthies 79 Park Road Stapleton Bristol BS16 1DT 01179390088 01179655881 shenbutt@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Worthies Residential Care Home Ltd Name of registered manager (if applicable) Ms Sehnaz Bi Butt Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 24 The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) Date of last inspection Brief description of the care home The Worthies is a care home registered with the Commission for Social Care inspection to accommodate 24 individuals. The home is located in Stapleton village situated on a bus route, within quarter of a mile to shops, libraries and health centres. The accommodation is arranged over three floors, with shared space on the ground floor Care Homes for Older People Page 4 of 29 Over 65 0 24 24 0 0 2 0 4 2 0 0 9 Brief description of the care home and bedrooms on all floors, accessible to all floors by a passenger lift. There is a courtyard at the rear of the house. However, this area is not enclosed With two exceptions, bedrooms are single. The double bedrooms are en-suite offering privacy with personal care. The fees range from #348.00 - #415.00 per week and extra charges are made for chiropody, hairdressing, etc. Currently this information is initially only provided verbally prior on admission. 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: This key inspection was conducted unannounced over two days in April 2010. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined and feedback sought from individuals, their relatives and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the Annual Quality Assurance Assessment (AQAA). This information was used to plan the inspection visit. Six people were case tracked. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The homes policies and procedures were also used to confirm the findings. The views of the deputy manager, staff and people using the service were gathered Care Homes for Older People Page 6 of 29 through face- to- face discussions. 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: 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 Care Homes for Older People Page 8 of 29 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. People at the home have sufficient information to make decisions about moving into the home. People at the home can be reassured that the admission process will ensure that staff are able to deliver the services it undertakes to provide Evidence: A Statement of Purpose is in place and says that the aims and objectives of the home is to provide professional and individual care for older people and people with dementia in a secure and homely environment. The Admission policy in place supplements the information contained in the Statement of Purpose about the criteria for admission at the home. The Admission policy defines the assessment staffs that will ensure that the individuals needs can be met at the home. There are twenty-four people currently accommodated with one vacancy and a referral Care Homes for Older People Page 11 of 29 Evidence: is pending on this vacancy. The case files of the two most recent admissions to the home were examined to confirm that the assessment followed establishes that the individuals suitability to live at the home. Social workers needs assessments were provided for people funded by the Local Authority. It is evident from the information held that the staff at the home undertake initial assessments for people wishing to live at the home. This will ensure that they are able to meet the needs identified. Personal profiles are then developed based on lifestyle choices and personal details. 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. Individuals are more central to their care and care planning is essential to the delivery of care. Risk assessents are in place for activities that may involve an element of risk and Medication systems are safe Evidence: Since the last inspection, significant steps have been taken to develop the care planning process. Case files are better structured and are sectioned into personal information, care planning, risk assessments, medical, social and daily reports. Overall care plans list the assessed need, the persons abilities to meet their identified needs is described and show a more person centred approach to meeting needs. Within the care plans there are guidelines for staff and this require more detail. In some instances the guidelines can be generic. For example, staff are to monitor, encourage or reassure the person. Guidance to staff must be specific about the way the care is to be delivered, for example, care plans must explain to staff how to monitor, the signs and symptoms that they must look for. Care Homes for Older People Page 13 of 29 Evidence: Members of staff were consulted about their responsibility with care planning. A care assistant told us that staff on induction do not act as keyworkers; they will undertake personal care, read care plans and write daily reports. Senior care assistants said that they have care planning responsibilities and act as keyworkers to specific individuals. Senior care assistants said that care plans are clearer and benefit from having information that can be conveyed and risk assessments are updated as needs change. From the case files examined it is evident that it was established that three people have no capacity to make decisions. However, their abilities to make decisions is not part of their care plan. Where individuals lack capacity to make decisions, care plans must be devised to show how decisions are made on behalf of the person. The agencies involved with the multi-agency approach must be incorporated into the care plan. People with dementia and short term memory are accommodated at the home. For these individuals, care plans say the way their dementia manifests itself and guide the staff on the actions that must be taken. Where individuals may be at risk of neglect or become aggressive, risk assessments are in place. These risk assessments would benefit from more detailed guidance about de-escalation techniques for people that may express themselves using aggressive and violent behaviours. Risk assessments supplement care plans and are based on mobility, nutrition and activities that may involve an element of risk. Mobility risk assessments are undertaken and include the risk of falls and mental health care needs to assess the level of risk. Other risk assessments completed include nutritional, skin integrity, physical and mental health care needs. These assessments then form part of the personal overview risk assessment which determines the level of risk and highlights where further action is required. Where medium to high levels of risk are identified, risk assessments that include an action plan to lower the risk identified are devised. Action plans need to be more detailed to show the way level of risk is to be lowered. Records held in case files show that people access NHS facilities and reports from opticians, dentists and chiropodists confirm their visits. A separate record of health care professionals visits is maintained and confirms that people see a GP, visit specialist in hospitals and community nurses visit people that need nursing care procedures. People with dementia have input from psychiatrists at the Memory Clinic, to monitor the effectiveness of dementia medication. Care Homes for Older People Page 14 of 29 Evidence: Comments were received through surveys from a district nurse that visits the home. The surveys said that the staff usually the staff and manager have the right skills to support the social and health care needs of people at the home. It was also stated that there is good communication between them and the staff at the home. The Privacy and Dignity policy is included within the Statement of Purpose and informs people about the ways they can expect their rights to be respected. Care plans say about the way individuals care is to be delivered which supports a person centred approach to care. For examples, respecting someones choice not asking them repeatedly to make an alternative choice. We asked a group of individuals about the way their privacy and dignity was respected and they confirmed that staff knocked on their bedrooms doors before entering and provided personal care in a discreet manner. Records of medications administered where checked and staffs signatures indicate that medications have been administered and use codes to explain the reasons for not administering the medication. A separate record of when required medications is maintained. Protocols that guide staff on administering these medications are in place. However, protocols must be updated to include the maximum medicines that can be administered in one day and further action that must be taken for prolonged use. A record of medications no longer required is maintained and signed by the pharmacist to indicate receipt of the medications for disposal. Medication profiles are in place and the name of the medication is included, the purpose of the medication must be incorporated to fully inform staff about the prescribed medication. 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. People at the home are offered activities and members of staff must use techniques learnet to engage with people that have dementia. Meals at the home are suitable Evidence: The deputy manager told us that staffing levels were organised so that two staff are designated to undertake activities with people. Activities take place mid-morning and in the evenings to ensure people are engaged. A record of group and individual activities is maintained and confirms that staff engage with people on an individual and group basis. People at the home play board games, listen to music, DVDs, knitting and 1:1 time with people that do not participate in group activities. There are three lounges for people to spend time together or individually. Staff told us that one lounge is used for activities, while the other two are used as television lounges and visitors room. The Visitors policy is included in the Statement of Purpose and confirms that staff will support people to maintain contact with friends and family. Visitors were observed Care Homes for Older People Page 16 of 29 Evidence: during both days of the inspection visit and were seen using lounges and bedrooms for additional privacy. One person leaves the home unsupervised and staff will accompany people to visit local shops. We were told that trips have not been organised recently because of the weather. Some time was spent in the lounge where activities generally take place and while people were alert and engaged with the staff, a more varied programme could be developed. People giving feedback said that they go on walks with staff and there are activities taking place in the lounge. When we spoke to a senior care assistant we were told about the recent dementia training that was undertaken by all staff. At the training staff learnet the techniques that they could use to encourage people to participate in activities, and the benefits of communicating with photos. Activities must be better organised so that people can undertake activities that ensure they are engaged with their surroundings. For example, history books, photo albums. Menus are prepared with the cook and service provider which are changed to reflect the seasons. The menus in place show that people have a continental style breakfast, a choice of two cooked meals at lunch and a lighter tea. The cook was consulted about special diets served and we were told that currently diabetic and West Indian diets are offered. One person that has a special diet confirmed that West Indian food is served at the home. There is a good range of frozen and tinned foods and we were told that the budget is adequate for the number of people accommodated. At a recent Environmental Health visit the home was awarded 4 Stars, 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. People at the home know how to complain and are safeguarded from abuse. Evidence: The Complaints procedure in place informs people about the commitment to ensuring that feedback is welcome and taken seriously. Copies of the procedure are on display in bedrooms to raise awareness about the steps that will be taken when complaints are raised. There were two complaints received from people living at the home about each other. Details of the investigations with the actions to be taken are recorded in the complaints log. While appropriate action was taken to resolve these complaints, the service provider must be clear of other procedures that could be used as a result of complaints received, for example, Safeguarding Adults procedure. One person giving feedback said that the deputy or service provider would be approached with complaints. Five completed surveys comments indicate that people know who to approach with complaints and were received from people at the home. The Whistle blowing policy in place confirms to staff that they will be protected if they report poor practice. Also specified are the implications to those staff that witness poor practice and dont report it. Local Authoritys Safeguarding Adults procedures define the forms of abuse and lists the contact details of agencies that must be contacted when reporting allegations of Care Homes for Older People Page 18 of 29 Evidence: abuse. The homes policy needs to be reviewed to include the actions to be taken if an allegation of abuse is made against staff and the contact details of agencies that must be notified when alerting alleged abuse. There are no outstanding Safeguarding Adults referrals. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely environment and new technology is used to ensure their care is dignified. Evidence: The Worthies is located in Stapleton Village close to bus routes and fairly close to shops and library. The accommodation is arranged over three floors, accessed by a passenger lift, with bedrooms on all floors and shared space on the ground floor. Shared facilities comprise of three lounges sited at the front of the property and dining room to the rear of the home. Since the last inspection, carpets on the downstairs corridor were replaced, the ceilings in the lounge were repainted and assistive technology was used restrict people from going upstairs without staff support. It is clear that the service provider knows what needs to be done to the property so that people can live in a homely environment. The homes Service User Guide, risk assessment and complaints procedure is available in each bedroom. Bedrooms contain a combination of the homes furniture and personal belongings and are furnished and equipped to meet the needs of the individual. Privacy is promoted through lockable doors with additional lockable space in bedrooms. Care Homes for Older People Page 20 of 29 Evidence: There are toilets on each floor and a bathroom on the second and third floor. Equipment and aids are provided to assist less mobile individuals with moving around the home. There is level access into the home and the passenger lift ensures that individuals can access bedrooms on the first and second level. 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. Staff that are suitable to work with vulnerable adults are employed and are competent to meet the needs of the people living at the home. Staffing levels currently meet the needs of the people accommodated Evidence: Staffing levels have improved since the last inspection, four staff are now rostered from 7:45am-5:00 pm. Three staff are then rostered from 5:00 pm-9:00 pm when the two waking night staff come on duty. Catering and ancillary staff are also employed at the home for cooking and cleaning. The staff at the home told us that the increase in staffing levels have meant that looking after people is easier and they are able to identify the individuals changing needs more promptly. Five completed surveys were received from five people living at the home and three said the staff are always available when needed. They also said that they listen and act on what they say while two said this was usual Staff at the home have vocational qualification of NVQ level 2 and upwards, this means that the staff working at the home are trained to meet the needs of older people. Mandatory training provided at the home includes First Aid, Moving and Handling, Care Homes for Older People Page 22 of 29 Evidence: Safeguarding Adults, Dementia Awareness, Food Safety and Mental Capacity Act (MCA). At the time of the inspection Health & Safety training was taking place. The deputy manager told us that in addition to the mandatory training, there is also specialist training provided, for example, tissue viability, care planning and for senior staff medication training. Deprivations of Liberty Safeguards (DOLS)will be provided to all staff and will form part of the mandatory training for the home. Since the last inspection five staff were employed and the recruitment process followed was checked to establish that a robust process took place for these staff. The completed copies of the homes application forms required full employment history, names of two referees and disclosure of criminal history. Two written references and copies Criminal Records Bureau (CRB) disclosures obtained confirms that the process followed at the home, ensures that only staff that are suitable to work with vulnerable adults are employed. 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. People at the home can be reassured that there is strong leadership and standards of care are subject to ongoing monitoring. People must be reassured that the staff know the procedure to follow in the event of fire in the home. Evidence: The service provider is in overall control of the day to day management of the home and is competent and qualified to act as manager. The staff at the home were asked about the service providers leadership style and we were told that the service provider is supportive and there are systems in place that ensure consistency. We understand that handovers when shift changes occur, staff meeting and individuals supervision are the systems in use that maintain consistency. A senior care assistant said that the home benefits from strong leadership and the service provider is keen to resolve concerns made by people at the home. We spoke to individuals and a group of people about the staff and the service provider. It was stated that the staff were good and the service provider was known to Care Homes for Older People Page 24 of 29 Evidence: them and was approachable. Supervision occurs 6-8 weekly and is individuals with the deputy or service provider and the records show that performance and training is discussed at these sessions. There are facilities for the safekeeping of cash and valuables at the home and records correspond with the cash held in safekeeping. Records of transactions and receipts confirms the purchases made on behalf of the person. The fees charged at the home range from £382.00- £441.00 per week. Fire risk assessments are completed and state the steps that will be taken to ensure that the potential of a fire in the home is reduced. However, the training and practices that will take place to ensure staff know the procedure in the event of a fire is not included within the fire risk assessments. The gap in the information triggered further examination of the records of fires alarm systems, practices and drills. It is evident from the records examined that staff have not attended fire drills in a significant amount of time. The deputy manager was required to conduct fire drills to ensure that staff knew the fire evacuation procedure. The service provider must ensure that staff working in the home attend the correct number of fire drills to ensure that they know the procedure in the event of a fire in the home. Systems are regularly serviced to ensure that people live and work in a safe environment. The gas boiler and lift are serviced by contractors and portable electrical appliances are checked to ensure they function effectively and to show compliance with associated legislation. The service provider operates a Quality Assurance system to seek feedback about the standards of care at the home. Feedback about the delivery of care was last sought in February 2009 and the service provider responded to those individuals that made suggestions through the surveys. We were told by the service provider that surveys were going to be sent sometime in APril 2010. Once the feedback is received the service provider will analyse the information received and produce an action plan on the way the feedback will be used to improve the delivery of care. 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 38 23 (4A) Fire risk assessments must be reviewed to ensure that appropriate steps are taken to prevent the outbreak of fire. Not met 30/04/2008 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 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 The registered person must 16/08/2010 make arrangements for the health and welfare of people at the home. Care plans must be detailed about the way the staff are to meet the needs identified. 2 12 16 The registered person must provide facilities for recreation. The service provider must ensure that the activities available suit the needs of the people accommodated 19/08/2010 3 38 23 The registered person must ensure that the Regulatory Reform (Fire Safety) Order 2005 is complied with. The registered person must ensure that the action plan specified within the Fire riks assessments is complied. This includes staff attending regular fire drills so that 20/04/2010 Care Homes for Older People Page 27 of 29 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 they know the procedure to follow in the event of a fire in the home. 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. If you would like a summary in a different format or language please contact our helpline or go to our website. © 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. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!