Care Home: Victoriana Residential Home

Similar services:

• Claremont House
• Oak Ridge
• Sun Court Nursing Home
• Ashville House
• Bilney Hall
• Hill Barn
• Mabbs Hall Nursing Home
• Henrietta House

What the care home does well The manager understood the need to ensure that people could be cared for appropriately at the Victoriana, before they moved in. An assessment was obtained before people went to live at the home to make sure staff the staff team were able to care for them. Staff were polite and respectful to people living at the home. They took their time and didn`t hurry people. The home was in a good location and nicely decorated and there were no offencive smells. There were sufficient staff on duty at all times and staff appeared to enjoy working at the home. What has improved since the last inspection? All but one of the requirements made at the last inspection had been fully met. Since the last inspection there had been an improvement to the way care plans were written, although staff need to keep working on these so they continued to improve and include more information. Areas of risk had been identified and we saw that these areas were now kept under review, although there had been a time when the reviews were not as frequent as they should have been. The way medication was stored, administered and the records that were kept had improved considerably since the last inspection. We saw a plan for activities in the home, but we were still not sure that people were stimulated as much as they would wish. The menus had been revised and the menu plans took account of nutritional needs. A maintenance person was ensuring that odd jobs were seen to as soon as the staff became aware of them. An extra member of staff had recently been appointed to night duty to ensure that if two staff were working together in a residents bedroom there remained someone to answer calls. All new staff completed an induction period and what they did during their induction was documented. What the care home could do better: The requirement and recommendations made as part of this inspection include:Care plans must include information as to how conditions should be managed. For example if a person has diabetes it should be clear to staff what to look for and how to react to a change in the condition. This also applies to staff knowing what that should do if, when routinely assessing a resident, they record a deviation, such as weight loss. Medications that at the end of the month are not returned to the pharmacy should be carried forward on the MAR chart to ensure that the manager has a clear record of the medications held in the home. Staff should ensure that what happens in the home is what residents want, and at a time they want it. There should be evidence that people want to just sit and doze in the lounge during the morning and this is not because they are bored and staff do not have the time to interact with them. A record must be kept of all complaints and how they have been dealt with. The provider must support the manager to undertake the process of registration as soon as possible. This has been outstanding for a long while. The registered person must establish a system to review and improve the service and evidence that this has been done. We found that although a survey had been carried out people living at the home had not heard the results or what action has been taken to improve or develop the home. Key inspection report Care homes for older people Name: Address: Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sally Snelson     Date: 1 0 1 1 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 28 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 28 Information about the care home Name of care home: Address: Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE 01582484177 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: victoriana@heritagecarehomes.co.uk Heritage Care Homes Ltd care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home The Victoriana is located in a pleasant residential suburb of Luton that is close to Wardon Park and a library. The town centre, which is a short bus or car ride away, has shops and national rail and bus links. Mr and Mrs Hussain have owned the home for a number of years. They formed a limited company Heritage Care Homes Ltd to operate the Victoriana and two other care homes in the vicinity. There is presently no registered manager for this home. The property was originally a domestic dwelling that had been converted and extended to provide a homely and comfortable environment. The home has three floors with a shaft lift and staircases for access. The fees for the home at the time of the inspection were £431-£490 per week. Additional items such as hairdressing and chiropody have to be paid for as extra. 1 9 0 1 2 0 0 9 0 0 Over 65 15 33 Care Homes for Older People Page 4 of 28 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 inspection was carried out in accordance with the Care Quality Commissions (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. This inspection was carried out on the 10th of November 2009 from 09:30 hours The manager Ms Erin Bermingham was not at the home at the start of the inspection but arrived very soon after. Verbal feedback was given periodically throughout the inspection and at the end of the visit. Care Homes for Older People Page 5 of 28 During the inspection the care of three people, including the most recent admission to the home, were case tracked. This involved reading their records and comparing what was documented to the care that was being provided. Documentation relating to: staff recruitment, training and supervision and medication administration, complaints, quality assurance and health and safety in the home were also examined. We also had a tour of the premises and spent some time in the communal areas of the home, talking to the residents and observing the care practises and interventions that were carried out during this inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. Care Homes for Older People Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: The requirement and recommendations made as part of this inspection include:Care plans must include information as to how conditions should be managed. For example if a person has diabetes it should be clear to staff what to look for and how to Care Homes for Older People Page 7 of 28 react to a change in the condition. This also applies to staff knowing what that should do if, when routinely assessing a resident, they record a deviation, such as weight loss. Medications that at the end of the month are not returned to the pharmacy should be carried forward on the MAR chart to ensure that the manager has a clear record of the medications held in the home. Staff should ensure that what happens in the home is what residents want, and at a time they want it. There should be evidence that people want to just sit and doze in the lounge during the morning and this is not because they are bored and staff do not have the time to interact with them. A record must be kept of all complaints and how they have been dealt with. The provider must support the manager to undertake the process of registration as soon as possible. This has been outstanding for a long while. The registered person must establish a system to review and improve the service and evidence that this has been done. We found that although a survey had been carried out people living at the home had not heard the results or what action has been taken to improve or develop the home. 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 28 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 28 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 manager understood the need to ensure that people could be cared for appropriately at the Victoriana, before they moved in. To this end she and/or the deputy carried out a comprehensive assessment on all prospective residents. Evidence: The home had a Statement of Purpose and residents were provided with Service User Guides. These documents were kept updated and held electronically so that changes could be made, and they could be produced in large print. During the inspection we looked at the files of three residents; two had been admitted since our last inspection earlier in the year. Pre-admission assessments had been carried out in advance of the admission. These documents contained sufficient detail to ensure that staff would be able to meet the residents needs. The staff undertaking the assessments were signing and dating documentation and we had a clear picture as to how decisions had been made. Care Homes for Older People Page 10 of 28 Evidence: Contracts were checked and were all signed and dated appropriately. This home did not provide intermediate care. Care Homes for Older People Page 11 of 28 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. Further work needs to be done to make sure care records give staff enough guidance to be able to meet all the needs of the residents in a consistent way. On the whole medication records and procedures were good. Evidence: We looked at the plans of care for three of the people using the service. One plan was for the newest resident who had been at the home since the 30/07/2009, approximately 15 weeks. The manager told us that this plan would be very basic because it was considered a temporary plan. We had identified the practise of temporary plans, written for residents on respite care and when they first came into care as causing problems, at another home owned by the same provider. We were disappointed that our concerns had not been passed to all the homes in the group. Each person had a plan that gave staff members information about what they need to do to meet most of the identified needs. Information about goals and how much a resident should be supported to do themselves was very sparse and there was little Care Homes for Older People Page 12 of 28 Evidence: evidence of the plans being person centred. Although care plans gave staff information, they did not give advice about what staff should do in the event of a problem. For example, one persons records indicated a history of diabetes that needed regular insulin injections to control the condition. There were no care plans to advice staff about this condition or what they should do if the diabetes became out of control, outside of the community nurses visit to administer the insulin or check the blood sugar levels. We spoke to the manager about this and our concerns that staff may not have the relevant information to act correctly. An updated plan was sent to us within days of the inspection. At the last inspection we discussed with the manager having individual pages for each different plan of care to avoid confusion. This was only put into place following this visit when we could not clearly identify how plans were being updated. This was because although care plans were reviewed every month, because the reviews were recoded away from the main care plan and the reader may not read the most recent updated information. Risk assessments were completed for moving and handling, falls and continence. Again there was evidence that staff did not know how to react to certain signs of risk. For example the overall effect of a resident who was loosing a small amount of weight each month had not been taken account of, and over a 12 month period the loss had been quiet significant. We also became aware at a strategy meeting between the last inspection and this inspection that risk assessments had not been regularly updated. There was information in care records to show health care professionals, such as specialist nurses, opticians and chiropodists, were contacted for advice and treatment. Residents in this home were relaxed, happy and well presented. Observations of care, identified people being treated with respect, and addressed in a way that was their preference. Call buzzers were being answered by staff in a timely fashion. During this inspection we examined the Medication Administration Record (MAR) sheets for the three residents whose care we tracked. These were tidy and well completed with signatures and omission codes where necessary. All the medication dispensed in blister packs, and the medication prescribed on a regular basis and dispensed in boxes reconciled correctly. However for some of the as required medication such as paracetamol, it was not always clear how many tablets had been carried forward from month to month, and therefore it was difficult to reconcile. We discussed this matter with the carer responsible for medication and the Care Homes for Older People Page 13 of 28 Evidence: manager, and an auditing process was considered. The distribution of the night carers could mean that at times there was no carer trained to give medication at night. Routinely medications were all given by the day, staff but this shortfall could prevent a resident receiving a prn (as needed) medication at night. Staff had been very vigilant when recording medications into the home and had identified some errors made by the supplying pharmacy. Care Homes for Older People Page 14 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally staff were aware of the need to support residents to develop and maintain their social, emotional and communication skills, but at times the residents appeared withdrawn. Evidence: At the last inspection the home did not have a formal activity plan to work from. This had now been rectified and we were shown a proposed plan for each week. The manager told us that this was not always adhered to often because residents did not want a certain activity but it was a prompt for staff. We were pleased to see that staff were recording interactions they had with residents and how any activities had been received. The activity plan included group activities, trips out and one to one time. The home were very pleased that they now had a mini-bus, that they shared with other homes in the group, to take people out in. It was hoped that shopping and theatre trips would be arranged. We spent some time in the lounge during the morning. The television was on even though few of the residents appeared to engage with it, partly because the reception was poor. We were told that a new aerial was to be erected to solve this problem. We were also told that one resident insisted that the television was on at all times, even if Care Homes for Older People Page 15 of 28 Evidence: the radio or other music was playing. We noted that many residents were withdrawn or asleep and unless they requested assistance from staff there was very little interaction during the morning when staff were busy supporting residents. We did see an improvement in the afternoon when staff were more relaxed with residents, possible because they had more time. We were told that friend and family were encouraged to visit at any time and that events were planned that involved residents and their families. At lunch time the meal was served already plated. We were told that people were offered a choice before the meal was served. The meal looked appetising and contained a good variety of food groups. It was braised beef, cabbage, potatoes and mixed vegetables. The cook had a good knowledge of how to improve the calorific content of small portions of food. People living at the home told us that on the whole they enjoyed the food and looked forward to mealtimes. Staff ensured that the residents who wanted it had a snack before bedtime and would often serve toast and porridge in the evening along with a milky drink. Care Homes for Older People Page 16 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure was supplied to everyone living at the home and was displayed in a number of areas within the service. There were policies and procedures for safeguarding adults that gave clear guidance to those using them. Evidence: The home had a robust complaints procedure that was included in the Service Users Guide and displayed in the entrance of the home. It was therefore easily accessible to residents and visitors to the home. It confirmed the expected timescales for responses, and advised people of the process if they were dissatisfied with the outcome. The home had not received complaints since the previous inspection. The manager advised us that she was available for residents or relatives if they had a concern, which she believed prevented concerns becoming complaints. However we were aware of relatives who had reported missing money and concerns over bruising. We would have expected a record of this complaint other than the safeguarding alert that the manager made. On the whole safeguarding issues had been clearly recorded and reported appropriately to the Local Authority. There had been two cases referred to a strategy Care Homes for Older People Page 17 of 28 Evidence: meeting, of which one was still under investigation. Documentation indicated that the manager liaised with the safeguarding (SOVA) team as and when necessary. The manager had attended strategy meetings and had co-operated with any investigations taking a positive approach to learning from these meetings. Staff received SOVA training as part of the induction process and the training was updated appropriately. Care Homes for Older People Page 18 of 28 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 Victoriana presented as a clean home that gave people the opportunity to use communal areas or their bedrooms as they pleased. Residents were encouraged to personalise their bedrooms. Evidence: The following information was taken from the homes AQAA and confirmed during the visit to the home. The home is located in a pleasant part of Luton close to Wardown park, a local attraction to residents. The home is located close to the town centre with public transport available close by. The home has three types of room for prospective service users to choose from. There are basic rooms, room with and en-suite and rooms with attached wet rooms. The home has bathrooms and WC on every floor, which are accessible to the service users in the home. The ground floor bathroom has a spa facility on the bath which allows service users with pain and discomfort a relaxing and therapeutic experience. The home has a communal shower room on the top floor of the building with shower chair access. This enables service users with physical disability to enjoy a shower. Generally the home was clean and tidy and pleasantly furnished, but there were some areas that required upgrading and redecoration. For example some carpets were very patterned, and therefore not the most suitable for people with dementia. The home Care Homes for Older People Page 19 of 28 Evidence: had a second floor lounge that was not well used that could be used as a non television or quiet room. As at previous inspections we noted that the manager spent time answering the phone to calls that were for the owner. This was because the head office (on the same premises) was not manned every day and when it was not manned calls meant for the owner came to the home. The laundry room was clean and tidy and on the whole people were satisfied with the laundry process. We were made aware that all staff were booked on an infection control course later in the month. Care Homes for Older People Page 20 of 28 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. All staff received relevant training that was focused on delivering improved outcomes for residents. There was evidence that the staff were able to put theory into practise. Evidence: Since the last inspection the number of care staff on duty during the night had been increased from two to three. This had not been as a direct result of the last inspection, but as a result of concerns raised at a safeguarding meeting. The night staff continued to support the kitchen and cleaning staff by performing some non care roles in addition to their care roles. The staff team appeared settled and the staff we spoke to were happy working at the home. Approximately 75 of the staff had completed an NVQ qualification to level 2 or above. many of the care staff that we spoke to were enthusiastic about their roles and took a lead in certain areas such as medication. During the inspection we looked at the files of three staff including one that had been appointed since the previous inspection. Each file contained fully completed application forms, appropriate references, Criminal Record Bureau (CRB), POVA first checks, interview notes, job descriptions and terms and conditions of employment. All documents were signed and dated appropriately. Care Homes for Older People Page 21 of 28 Evidence: This home used the services of a training company who had offered to keep and update an electronic training matrix on behalf of the home. The manager told us that the matrix had not been all together satisfactory and she was keeping her own record. We were pleased that areas that we had identified for staff training during this inspection had also been identified by the manager. For example, training for nutritional needs and diabetes had been booked for later in the year. Staff files included certificates that confirmed staff had undertaken a variety of training as appropriate to their roles. Since the last inspection the manager had developed a formalised induction programme which was in use. We would have liked to have seen a risk assessment for a pregnant member of staff. However she confirmed that the manager was planning to do it, and that she was already on light duties and supported by the staff team. Care Homes for Older People Page 22 of 28 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. The manager had the necessary experience to run the home, but had failed to complete the registration process in a timely fashion. She was aware of her responsibility to monitor practise and compliance but more work was needed in this area. Evidence: The manager presently working in this home, Erin Bermingham, has a number of years of experience working in care. She has worked at Victoriana for a number of years and has been manager for about three years without undertaking the registration process. She confirmed that she had a date to take her documents to our London office to start this process. She remains very enthusiastic and committed to improving standards of care. All the staff that we spoke to during this inspection indicated that they felt supported by the manager. We received comments such as she works with us and does what she has to to get staff to do things properly. Letters in two staff files that we looked at confirmed that she manages staff efficiently and effectively through disciplinary processes. Care Homes for Older People Page 23 of 28 Evidence: There were questionnaires that were used to audit the standard of care. However as in previous years these questionnaires had been sent out and we were told that they had been evaluated and the results acted upon but the evaluation was not available. As part of quality assurance the owner had arranged for someone to visit the home on his behalf and produce a report. Care must be taken that this continues monthly as required by Regulation 26. Some meetings for staff residents and relatives, had been carried out, ensuring that the opinions of everyone involved in the home were sought and opinions listened to. Staff files included supervision records and all the staff that we spoke to confirmed that they had regular supervision. Residents personal money that was held within the home was audited against any expenditures and the stored receipts and found to be correct. Accidents and incidents were being appropriately reported via the regulation 37 notice processes, and where necessary referrals were being sent to the Safeguarding team. Health and safety checks including water temperatures, fire call bells, freezer and food temperatures were being recorded appropriately, and issues were addressed in a timely fashion. The fire brigade had made requirements following visits in September and we were told that these had all been addressed. Care Homes for Older People Page 24 of 28 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 33 24 This also relates to regulation 01/03/2009 26 There must be systems in place that measure the quality of the care provided. This is so that routinely problems can be identified and solutions found. Care Homes for Older People Page 25 of 28 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 Care plans must include information as to how conditions should be managed. This ensures that staff are aware of a change in condition and how to react. 01/12/2009 2 16 22 A record must be kept of all complaints and how they have been dealt with. This is to ensure that a clear audit trial is kept. 01/12/2009 3 31 9 The provider must support the manager to undertake the process of registration as soon as possible. This is to ensure that the manager running the home is considered suitable by us. 01/01/2010 Care Homes for Older People Page 26 of 28 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 4 33 24 The registered person must 01/01/2010 establish a system to review and improve the service and evidence that this has been done. This ensures that the service is offering a quality service 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 9 Medications that at the end of the month are not returned to the pharmacy should be carried forward on the MAR chart. Staff should ensure that what happens in the home is what residents want and at a time they want it. There should be evidence that people want to just sit and doze in the lounge during the morning. Consideration should be given to making the environment more suitable for those people with dementia. Any risk assessment of staff should be recorded as soon as possible. 2 12 3 4 19 27 Care Homes for Older People Page 27 of 28 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. 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. Care Homes for Older People Page 28 of 28 - 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!