Care Home: Trinity House Care Centre

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What the care home does well Visiting to the home is open and people living within the home can maintain relationships that are important to them. Aids and adaptations are provided throughout the home so that peoples independence is maintained and promoted whilst maintaining their safety. People are able to personalise their bedrooms to reflect their individual tastes, age, gender and culture so that they feel comfortable in their surroundings. People who lived in the home were observed to be nicely presented and their clothes were well laundered. Money, which is held on behalf of people at home, was accounted for and there were good systems in place to ensure that people`s finances were protected. The home has access to a range of specialist community services should they require them. These include general practitioners, opticians, chiropodists, speech and language therapists and dieticians. What has improved since the last inspection? Medication management has improved but further work is required in this area to ensure that people living at the home have at least a four hour gap between morning and afternoon medications. What the care home could do better: The Service User Guide must include the range of fees people may be expected to pay to ensure they have all the information they need to make an informed choice. Staff need training in a number of areas such as the Mental Capacity Act, Deprivation of Liberty, manual handling and fire safety so they have the skill and competences to meet the needs of people living in the home. Key inspection report Care homes for older people Name: Address: Trinity House Care Centre Mace Street Cradley Heath West Midlands B64 6HP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Karen Thompson     Date: 0 4 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Trinity House Care Centre Mace Street Cradley Heath West Midlands B64 6HP 01384634350 01384412138 trinityhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes Limited care home 35 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: 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 to be accommodated is 35. The registered person may provide the following categories of service only: Care Home with nursing 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) 35 Dementia over 65 years of age (DE)(E) 1 Date of last inspection Brief description of the care home Trinity House Care Centre is situated in a residential area of Cradley Heath, which it close to the shops and local amenities.The home has three storeys and accommodates service users on all three floors. There are 31 single bedrooms and 2 double bedrooms all of which have en suite facilities. There are two lounges within the home situated on the first and ground floor. A large conservatory adjoins the lounge and is used as a dining room.The grounds are well maintained and there is a small car park to the rear of the property. The home is well maintained and is pleasantly decorated.The home Care Homes for Older People Page 4 of 29 Over 65 1 35 0 0 Brief description of the care home had published information about fees stating fees vary between £334 and £719* and are dependant on the needs of the service user and the type of room that will be occupied. Items that are not covered by the fee include hairdressing, toiletries, chiropody and newspapers. * Please note fees will include the free nursing care contribution when applicable. 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: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection; the home did not know we were coming. It was carried out by one inspector over two days. The focus of the inspection undertaken by us is upon outcomes for people who live in the home and their views of the service provided. The process considers the care homes capacity to meet the regulatory requirements and minimum standards of practice and focuses on aspects of service provision that need further development. Prior to this fieldwork visit taking place a range of information was gathered to plan the inspection, which included notifications received from the home and an Annual Quality Assurance Assessment (AQAA). This is a questionnaire that was completed by the manager and it gave us information about the home, staff, people who live there, any developments since the last inspection and their plans for the future. We were supported throughout the inspection process by the management team at Care Homes for Older People Page 6 of 29 home. At the time of the inspection twenty eight people were living at the home. Information was gathered by speaking to and observing people who lived at the home. Three people were case tracked which involves discovering their experiences of living at the home by meeting or observing the care they received, looking at medication and care files and reviewing areas of the home relevant to these people in order to focus on outcomes. Case tracking helps us understand the experiences of people who use the service. Staff files, training records and health and safety files were also examined. 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 order line 0870 240 7535. Care Homes for Older People Page 8 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 9 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. The pre-admission information gathered by the home gives staff sufficient information to allow them to assess whether they can meet peoples needs upon moving in. Fees need to be included in the Service User Guide so that people can make a fully informed choice about the home. Evidence: The current registration certificate was on display in the reception area, demonstrating the home is registered to provide nursing care for long stay and respite. We viewed copies of the home-s Statement of Purpose and Service User Guide. These documents clearly set out the aims and objectives of Southern Cross and provided good clear information about the home. These documents provide prospective people who may use the service with information about the service that the home provides to assist them in decision making. The Service Users Guide was reviewed October 2009 but did not contain the list of current fees the home charges. The home provides care Care Homes for Older People Page 10 of 29 Evidence: for people who require long term nursing care. The Care Manager has recently obtained a portable hand held digital photo frame for use when visiting people who are considering moving into the home. The photograph is automatically changed every 20 seconds. The care manager uses this device to supplement the Service User Guide and Statement of Purpose and feels it is a useful alternative format for those thinking of moving into the home. The AQAA stated that: The home manager or competent registered nurse carries out the pre admission assessment for all potential service users. We looked at a sample of case files of people recently admitted to the home, which demonstrated a pre admission assessment had been carried out and met the standard. This information is then used to draw up a care plan which outlines the actions required by staff to ensure peoples needs are met appropriately. The home does not provide intermediate care. Care Homes for Older People Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have a care plan, which outlines their needs and the action required by staff to meet these. We saw that there were a range of risk assessments that highlighted potential risks and the actions required to reduce the risk so people can lead a meaningful life and risks reduced. Each person we case tracked had their own care plan. Care plans were generally updated monthly and whenever possible staff tried to involve the person or their representative in the review. We looked at the care of a person needing to be nursed entirely in bed. This person was being cared for on a nursing profile bed, which would minimise some of the discomfort when needing a change of position. The home has a named nurse and key worker system, which should enable staff to establish special relationships and work on a one to one basis. As at the previous inspections it was evident that people living at this home have access to a range of specialist community services should they require them. These include general practitioners, opticians, dentists, chiropodists and dieticians. This ensures that peoples health care needs are being monitored adequately to promote Care Homes for Older People Page 12 of 29 Judgement: their well being. We looked at the homes systems for the administration of medicines for people living at the home. We saw that there were two medication trolleys available for medication. We discretely observed the administration of some peoples medicines, which was done sensitively and in a person centred way. However the morning medication round was not completed till 11:20am. There needs to be a minimum of four hours between each medication round to ensure medication is evenly spaced. Medication management at the home has improved significantly, the majority of audits were found to be correct. We observed good interaction taking place between people living at the home and staff. Evidence: The arrangements for meeting peoples health and personal care needs are consistently and appropriately met. Medication management needs further work to ensure that it does not pose any risks to people living at the home. Care Homes for Older People Page 13 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. There are no rigid rules or routines and visitors can visit at times to suit them enabling people living at the home to maintain contact as they wish to. Activities are in place to ensure that people living at the home lead a stimulating and fulfilling life. Evidence: The home has arrangements in place to provide activities for people living in the home. The home has two activities co-ordinators that work part time. We spoke to one of the activities co-ordinators in depth. This person spoke positively about their role and they were able to demonstrate they knew the social needs of people living in the home. We saw that there was a key worker system, which operated well and enabled closer relationships between staff and the people living at the home, where likes, dislikes and needs were known about and met. Key workers and the activities co-ordinator used the information and their knowledge of people to plan activities, which each person enjoyed. We spoke to the activities co-ordinators working in the home and they gave us a list of recent activities that had taken place which included arts and crafts, Halloween and Guy Fawkes night and so forth. Care Homes for Older People Page 14 of 29 Evidence: There are church services provided in the home by local church groups. We were told that there had not been many opportunities for trips and outings. There was no evidence of rigid rules or routines in the home and people who live there can go outside on their own or with friends, family or care staff as they choose, depending on ability. There is flexible visiting at the home to enable people living at the home to maintain contact with friends and family at times that suit them. When we looked around the home and in some bedrooms we saw that people were encouraged to bring in their personal possessions to personalise their rooms. Breakfast and lunch were observed on the first day of the inspection in the main dining room area on the ground floor of the home. Staff were observed to assist people living at the home discreetly and appropriately. One person living at the home was observed helping in the kitchen, the home has risk assessed this and has made arrangements for this person to attend training in (Control Of Substances Hazardous to Health) COSHH and a Health and Safety course. We were told that there is at present a vacancy for a catering assistant. The Care Manager was observed serving the lunch time meal on the first day of the inspection, (this had come about due to staff illness). The Care Manager told us she likes to help serve meals as it was one of the activities that helped her maintain contact with people living in the home. Care Homes for Older People Page 15 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 living at the home can be confident that their concerns will be listened to and taken seriously. Processes are in place to help protect people from harm and abuse. Staff training and knowledge base in specific subjects regarding capacity would help protect people further. Evidence: The homes AQAA stated the following evidence of what was done well: All complaints are logged and acknowledged personally by the Home Manager within 24 hours of the complaint being raised. All complaints are investigated and responded to within 28 days. There are no outstanding complaints on file at this time. All staff under go Abuse awareness training annually and have access to the POVA procedure and contact at all times. The AQAA stated that there were improvements in the last 12 months: There is now an organised paper trail of complaints and Safeguarding referrals. All investigations are acknowledge and commenced immediately. We have carried out appropriate staff counselling and commenced the disciplinary procedure if necessary. We saw that Trinity Care Centre had an up to date Southern Cross Healthcare complaints procedure, which was displayed in the reception area and was contained in the service user guide. Information supplied as part of the Homes AQAA indicated that the home had received two complaints in twelve months, which had been investigated by the provider within 28 days. One of these complaints was upheld. We Care Homes for Older People Page 16 of 29 Evidence: looked at the homes complaints log and noted that there were a total of two complaints. We were able to audit these complaints and they were investigated and responded to appropriately. There was a copy of the Sandwell (Metropolitan Borough Council) MBC multi-agency procedure relating to safeguarding vulnerable persons living in the home. Staff spoken to had received safeguarding training and when questioned were aware of their responsibility in reporting safeguarding concerns. Twenty seven of the thirty six members of staff working at the home have received safeguarding training in the last twelve months. The home has made four safeguarding incident referrals in the last twelve months. Staff spoken to had not received training in respect of the Mental Capacity Act and were not aware of this important piece of legislation and how it impacts on care to be delivered. The training matrix supplied to us demonstrated that no staff had received training on the Mental Capacity Act. This was also found to be the case for Deprivation of Liberty awareness. All staff should be provided with training in respect of the Mental Capacity Act and Deprivation of Liberty safeguards, commensurate with their role in the home to ensure they have the knowledge to support people effectively that lack capacity to make decisions. Care Homes for Older People Page 17 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. The service provides a safe, homely and comfortable envorinment for people living there. Evidence: Trinity Care Centre Nursing home was purpose built and has three floors. A number of improvements have been made to the environment as part of ongoing refurbishment and redecoration. The homes AQAA cited the following evidence of improvements made in the last 12 months; we have decorated communal toilets and bathrooms and had a new assisted bath. The service users are currently having their front doors painted in their choice of colour. We saw different coloured bedroom doors in some parts of the home. We asked to see the refurbishment plan for the home and was told they did not have one. To maintain and keep the home in good order priorities need to be drawn up in relation to refurbishment and redecoration. The home had a courtyard garden, which could be accessed via the conservatory, which was paved to enable people in wheelchairs access. Bedrooms are personalised and people are able to bring in their own possessions to reflect their tastes and interests. Bedrooms visited were clean and tidy, however we Care Homes for Older People Page 18 of 29 Evidence: did find a bed had been re made with soiled sheets. The Care Manager rectified this at the time of the inspection. The laundry areas were well equipped with commercial washers and a tumble dryer. We note that an additional tumble dryer which had been a previous recommendation at our last key inspection has not been purchased. This would enhance the service to people living in the home. The sluice facilities need upgrading to comply with modern standards. We saw staff wearing disposal gloves and aprons to reduce the risk of cross infection. Care Homes for Older People Page 19 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. Recruitment procedures are robust therefore protecting people who use the service. Peoples lives may be improved further if they were always supported by suitably trained staff to meet their needs. Evidence: The homes AQAA cited the following as evidence of what they do well. 89 of staff hold or are working towards level 2 or 3 awards. The homes manager has completed the Registered Managers award. There is a comprehensive recruitment process in place within the home to ensure that people employed are competent and able to do their job to a standard that residents expect and deserve. The homes AQAA also identified improvements, which could be aimed for over the next twelve months. These were, All care staff to receive NVQ level 2 training. Domestic staff to complete NVQ. All staff to receive Yesterday, Today and Tomorrow training (which is accredited dementia care training). The home still employs five registered nurses to cover all shifts each week. Three are employed to work on nights and two day shifts. We noted that these nurses generally worked long days shifts. We were able to verify some good practice from observations, discussions and Care Homes for Older People Page 20 of 29 Evidence: examination of samples of records during this visit. There were 28 people living at the home at the time of the inspection with a variety of health care needs. The home has a relatively stable staff team of 37 people including care staff, domestic staff, laundry staff, housekeeper, activities co-ordinator, administrator, nurses, catering staff and the Registered Manager. The homes AQAA told us that over that last three months prior to inspection they had to cover 9 nursing shifts and 16 carers shifts with agency or temporary staff. We were told that the home had a vacancy for kitchen assistant and trained nurse. We looked at a random sample of staff personnel files, which were satisfactory. Interview questions and answers were retained on staff personnel files as a matter of good practice. The registered manager demonstrated robust recruitment practice, with very well ordered staff files and comprehensive documentation. There was good evidence that the (Personal Identification Number) PIN numbers of registered nurses were verified, recorded with expiry dates and were monitored appropriately. We were given the home training matrix and statistics documentation. We evidenced that just under fifty percent of care staff had NVQ 2 or above, but also a number of staff were registered for this training. We were told that staff had annual appraisal and saw evidence of a formal structured supervision system, dates to show that staff, including nurses received regular supervision meetings and support and action plans where needed to develop and improve. There was an induction training programme available and this meets the standards of the Social Skills Council. Carers undertake a three day induction programme and gradually work through a training booklet over a 12 week period. Staff confirmed this training took place. Approximately a third of staff needed a renewal of fire safety training and a quarter needed a refresher in moving and handling according to the home own training matrix. Care Homes for Older People Page 21 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 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 being run in the best interest of people living there. Evidence: The manager is a Registered General Nurse (RGN), with the Registered Managers Award (RMA) and she has considerable nursing and managerial experience. There were clear lines of accountability within the home, and through the management structure. We saw evidence that the registered manager had used comprehensive self auditing systems, some introduced by Southern Cross Healthcare. These included monthly audits of areas such as peoples case files, staff personnel files, incident and falls with remedial actions to minimise risk identified. The home sends out surveys to both people living at the home and families and completed forms have been returned with results collated and published. We saw evidence that the results had been acted upon in any areas where there were Care Homes for Older People Page 22 of 29 Evidence: concerns or where performance needed improvement. We saw records of relatives meetings which were taking place four times a year. We noted that people who came to live at the home were offered the opportunity to manage their own money if they wished, and the home provided facilities to help keep it safe. Where the home managed money on each persons behalf a system was in place to record transactions and accounts for spending. We looked at a sample of heath and safety, fire safety and maintenance documentation which was satisfactory and very well organised. Care Homes for Older People Page 23 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 9 13(2) The registered persons must 01/04/2009 ensure that the records of the receipt, administration and disposal of all medicines for the people who use the service are robust and accurate to demonstrate that all medication is administered as prescribed. This is to safeguard the health and well being of people living at the home. 2 9 13(2) The registered persons must 01/04/2009 take action to ensure that Staff who administer medication are assessed as competent and their practice must ensure that people living at the home receive their medication safely and correctly. This is to safeguard the health and well being of people living at the home. 3 9 13(2) The registered persons must 01/04/2009 ensure that appropriate information relating to medication is kept, for example, in risk assessments and care plans to ensure that Page 24 of 29 Care Homes for Older People 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 staff know how to use and monitor all medication including when required and as directed medication to ensure that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. This is to safeguard the health and well being of people living at the home. 4 30 18 The registered persons must 01/04/2009 take action to ensure staffing levels are reviewed in conjunction with occupancy and dependency levels to ensure that each persons needs are consistently being met throughout the day and night. This is to safeguard the health, well being and safety of people living at the home. 5 38 13(4) The registered persons must 01/05/2009 make the following improvements to the environment: 1) Replace the heavily stained sluices with equipment which will promote good infection control measures 2) Replace the defective Care Homes for Older People Page 25 of 29 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 flooring in the first floor bathroom. This is to safeguard the health and well being of people living at the home. 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 9 13 At least four hours must elapse between medication rounds to reduce the risk of potential overdose. This is to safeguard the health and well being of people living at the home. 31/01/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The Service User Guide should include the range of nursing home fees so that people can make an informed choice about moving into the home. It is recommended that the home obtain a copy of the Dept of Health guidance Mental Capacity Act 2005 core training set published July 2007 and staff are provided with training, so that staff are aware of their responsibilities and peoples rights are protected. It is strongly recommended that an additional tumble dryer be provided to enhance the laundry service for people living in the home. Shortfalls identified in training needs such as mental capacity, fire and manual handling must be addressed in Page 27 of 29 2 18 3 19 4 30 Care Homes for Older People 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 the appropriate learning style so that training embeds. This will ensure that staff working at the home have the skills and competence to meet peoples needs. 5 38 The registered persons must make the following improvements to the environment: 1) Replace the heavily stained sluices with equipment which will promote good infection control measures 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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