Care Home: West Lodge Care Home

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What the care home does well Potential new people benefit from a pre- admission assessment that allows for only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to individuals in such a way that promotes and protects their privacy and dignity. People who use the service benefit from an activities calendar that is stimulating and arranged according to their choice. People who use the service experience mealtimes that are unhurried, whilst all meals are home cooked with an alternative option being available for each mealtime. People who use the service can be assured that there is an efficient complaints procedure in place and that the homes processes and staff training should protect individuals in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose and the ongoing refurbishment plan promotes a homely, comfortable and odour free environment. Staffing numbers are satisfactory to meet the needs of those currently accommodated. What has improved since the last inspection? The Registered Person has made arrangements for safe handling and keeping of medicines in the care home and creams are now stored safely at all times. The Registered Person has ensured that the home is well decorated and maintained. A written programme of maintenance and redecoration, with clear timescales is now in place. This ensures that the premises are kept in a good state of repair. There is a system of regular checks on fire systems and equipment in place, which is kept up to date. The Registered Person has ensured that all fire doors can be quickly opened at all times in the event of an emergency and that all staff are aware how this is done. The Registered Person has ensured that all areas of the home are suitably heated, including the conservatory area. The Registered Person has completed a written risk assessments concerning the use of window restrictors. Window restrictors are now in place where potential risk is identified to vulnerable people living at the home. The Registered Person has ensured that all chemicals are securely stored and chemicals in use are not left unattended at anytime.All staff providing care are receiving up to date training in all mandatory courses including moving and handling, fire safety, first aid, safeguarding adults, food safety, infection control as well as dementia care training. The Registered Person has ensured that all confidential records are kept secure at all times. What the care home could do better: The Registered Person must ensure that care plans are reviewed on a consistent monthly basis, in order to ensure that care plans are reflective of the individuals changing needs. Care plans must be signed to indicate the involvement of the individual that they are written for. Where a person lacks capacity and a representative is involved, this must be also be documented. The Registered Person must ensure that self medicating risk assessments are reviewed on a monthly basis, in order to ensure that they remain effective. The Registered Person must ensure that the Nursing and Midwifery Council PIN numbers of Registered Nurses employed are checked on an annual basis, in order to further safeguard the people using the service when recruiting staff. In order to ensure the safety and welfare of staff and people who use the service, the Registered Person must ensure that fire drills are held on a consistent basis and records are maintained of all drills held. It is recommended good practise that the Statement of Purpose and Service User Guide is updated to reflect the name change of the Care Quality Commission (CQC) and to include the correct contact details for the CQC. Self medicating risk assessments should be signed and dated by the person using the service, in order to provide a clear audit trail of when the assessment was conducted and agreed by all parties. Daily care entries should be clearly dated and timed for each entry. The Complaints Policy should be updated to reflect that the Care Quality Commission can be contacted at any time during the event of a complaint and not after all internal processes have been conducted. The Registered Person should ensure that copies of minutes maintained for meetings held for staff and people who use the service are made available for inspection. All fire checks should be clearly recorded onto a recognised format. In that this will enable a clear audit trail of when and how checks are conducted and whether any issues were noted. Key inspection report Care homes for older people Name: Address: West Lodge Care Home 238 Hucknall Road Sherwood Nottingham NG5 1FB     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: Rebecca Shewan     Date: 1 8 0 8 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: West Lodge Care Home 238 Hucknall Road Sherwood Nottingham NG5 1FB 01159606075 01159606075 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ms Razma Vanessa Alishan care home 27 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service suers who can be accommodated is 27. The registered provider may provide the following category of service only:- Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admision to the home are within the following category: Old age, not falling within any other category - Code OP Physical Disability - Code PD Dementia - Code DE Date of last inspection Brief description of the care home West Lodge Care Home was established in 1987. Located on a main road in Sherwood, it is on a main bus route into Nottingham city centre. The home consists of a large converted house, with a purpose built conservatory. 3 0 0 3 2 0 0 9 27 0 27 Over 65 0 27 0 Care Homes for Older People Page 4 of 29 Brief description of the care home There are six double bedrooms and thirteen single rooms, four of which have en-suite facilities. There is ramped access to the building and a passenger lift serves all three floors. The homes grounds are mainly to the front of the building and are well maintained although there is open access to the road. There is car parking space at the front of the home. A copy of our last inspection report is available in the foyer of the home. The current fees range from £333 to £515 per week. Newspapers, toiletries, hairdressing and private chiropody are not included in the fees. 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 unannounced inspection took place during the morning and afternoon of the 18th August 2009. The homes Annual Quality Assurance Assessment (AQAA), incident reports and previous inspection reports, held by the Care Quality Commission, were read before the inspection. The inspection of the home took seven hours. Records such as care plans, staff files and medication records were also viewed. Twenty people were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Registered Provider/Manager, a Cook, two people who use the service and two relatives/representatives were spoken with. The CQC also conducted surveys of staff and people who use the service. One survey was received and the reponses were positive in all areas of care and provisions. Care Homes for Older People Page 6 of 29 What the care home does well: What has improved since the last inspection? The Registered Person has made arrangements for safe handling and keeping of medicines in the care home and creams are now stored safely at all times. The Registered Person has ensured that the home is well decorated and maintained. A written programme of maintenance and redecoration, with clear timescales is now in place. This ensures that the premises are kept in a good state of repair. There is a system of regular checks on fire systems and equipment in place, which is kept up to date. The Registered Person has ensured that all fire doors can be quickly opened at all times in the event of an emergency and that all staff are aware how this is done. The Registered Person has ensured that all areas of the home are suitably heated, including the conservatory area. The Registered Person has completed a written risk assessments concerning the use of window restrictors. Window restrictors are now in place where potential risk is identified to vulnerable people living at the home. The Registered Person has ensured that all chemicals are securely stored and chemicals in use are not left unattended at anytime. Care Homes for Older People Page 7 of 29 All staff providing care are receiving up to date training in all mandatory courses including moving and handling, fire safety, first aid, safeguarding adults, food safety, infection control as well as dementia care training. The Registered Person has ensured that all confidential records are kept secure at all times. 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. Care Homes for Older People Page 8 of 29 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home povides appropriate informtaion to new people that allows them to make an informed choice about thier admission to the home. There are processes in place for assessing potential new people with services being offered to only those individuals whose needs can be met. Evidence: We observed the homes Statement of Purpose and Service User Guide, both documents are well written and give the reader a good overview of the how the home is operated and the services that are offered. We observed that both documents were due for an annual review in April. This review did not take place and the documents require amending to reflect the name change of the Care Quality Commission (CQC) and to include the correct contact details for CQC. Care Homes for Older People Page 11 of 29 Evidence: From the records inspected we observed that pre- admission assessments are carried out on all new and potential people. Documentation relating to the most recent admissions to home were viewed and were found to have been completed fully and conducted with the involvement of the person to be accommodated and/or their representatives (where applicable). Intermediate care is not provided by this service. 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 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 service are offered a good provision of health care and personal support by the home. All care is administered in way that protects the individuals privacy and dignity. Medication procedures ensure that medication are stored and administered safely. Evidence: We sampled care plans (including risk assessments) and we evidenced that they were comprehensive, detailed in content and covered all aspects of the individuals needs. We observed that consistent monthly reviews had not been conducted on all elements of the care plans sampled. We evidenced that individuals and/or their representatives involvement in the care plan generation and review process had also not been documented. We observed that daily records are maintained and are reflective of the care plan, although entries are marked as D or N and were not time or date specific in all Care Homes for Older People Page 13 of 29 Evidence: cases. We evidenced that care plans include reference to equality and diversity and clearly addresses any needs identified in the strands of diversity, which are: gender (including gender identity), age, race, religion or belief, and disability. Records viewed and discussions with the Registered Manager provided evidence that the service has good access to Healthcare providers. Records viewed confirmed that the people who use the service are registered with a GP of their choosing and have access to a Dentist, Optician, Audiology, Occupational Therapy, Physiotherapy and the Dietician. We observed that the home has established a good link with the local hospitals fall team. From records viewed we evidenced that the service has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. The stores for medication were viewed and we found them to be clean and orderly manner. Medication Administration Record (MAR) sheets were viewed and we evidenced that these provided a clear audit trail for all medications administered or omitted. We audited the controlled medications and found them to be correct. We observed that all controlled drugs are stored and recorded in the appropriate manner. We observed that daily medication fridge temperatures are maintained consistently. From records viewed and from discussions with people who use the service, we evidenced that the service enables people to self administer, where they are able. People spoken with said that they feel appropriately supported to self medicate. We observed that self medicating risk assessments were in place, although these had been signed by the individual they had not been date and had not been reviewed on a monthly basis to ensure that they remain effective and appropriate. Staff were observed providing personal support to individuals in such a way that promoted and protected their privacy and dignity. We observed that individuals bedroom doors were knocked before staff entered them and that people were called by their preferred choice of address. People spoken with said that staff of the home are kind and very caring. Care Homes for Older People Page 14 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 who use the service are able to enjoy a full and stimulating programme of activities to choose from. The home provides a wide range of social, cultural and recreational facilities for the people who use the service. A wide variety of meals and specialist diets are provided for the people who use the service, with individuals choice and wishes being respected in relation to food. Evidence: We observed that there is an Activity Coordinator employed by the service, people who use the service therefore benefit from having activities provided seven days a week. Each individuals care plan contains a life plan, which details their life, occupation, relations and hobbies/interests etc throughout their lives. The content of life plans are considered and activities are organised around the individuals preference and previous interests. Although there is a published list of activities in place, these may be changed due to requests from the people accommodated. Records are maintained of all activities Care Homes for Older People Page 15 of 29 Evidence: conducted. Peole and thier friends/relatives spoken with confirmed that they pick and choose which activities to attend. From records viewed and discussions with the Registered Manager we noted that individuals religious wishes are observed. The management of the home believes in promoting an equal and diverse culture among staff and people who are accomodated. From the records viewed and observations made we observed that outings such as trips to lunch with relatives and places of local interest are arranged for the people who use the service. There is currently one person who is supported to attend a day centre at present. People accommodated and friends and family spoken with confirmed that contact with family and friends is positively encouraged, with visitors being able to attend the home at any time and in accordance with the individuals wishes. The Cook confirmed that the homes menus are devised on a four weekly basis. Menus and records viewed confirmed that meals for all cultures were catered for. We observed that all meals are home cooked with an alternative available for each mealtime. The Cook said that mealtimes can be varied upon request and that there is rolling breakfast system in place, which allows people who use the service to have breakfast at a time of their own choosing. People spoken with stated that meals can be taken in their bedroom or in the communal dining rooms. We observed that medical, therapeutic and religious diets are provided as needed. Both the lunch time and teatime meal served during the inspection were ample in quantity and attractively presented. The lunchtime meal was observed and was unhurried, with those requiring assistance with feeding being treated patiently and encouragingly. We noted that drinks and snacks are available at all times. Care Homes for Older People Page 16 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 who use the service benefit from an efficient complaints procedure, whilst the homes procedures, processes and staff training should protect individuals in the event of an allegation of abuse. Evidence: We observed that the home has an established complaints procedure in place. We noted the current Complaint Policy will need revising, to reflect that the Care Quality Commission can be contacted at any time during the event of a complaint and not after all internal processes have been conducted. The Registered Manager reported that there have been no complaints received by the service since the previous key unannounced inspection. The Registered Manager reported that not all staff have attended training in the Safeguarding of Vulnerable Adults within the last twelve months and that training provided by Nottingham City Council, is currently being sourced. This was also evident from the staff files viewed. The homes AQAA and the Registered Manager stated that have been no Safeguarding Alerts raised by the home since the previous key unannounced inspection. 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 physical design and layout of the home enables the people who use the service to live in a well-maintained and comfortable environment, that is odour free. Evidence: From the tour of the premise we observed that the size, location and layout of the home are suitable for its stated purpose. From our record and from the tour of the premises we observed that the home is now well decorated and maintained and that a written programme of maintenance and redecoration is in place, in order to ensure the home remains in a good state of repair. We observed that the majority of individuals bedrooms had been redecorated. Discussions with the Registered Manager confirmed that the maintanance and redecoration plan is on schedule. The homes AQAA provided evidence that that there are plans for further bedrooms to be redecorated, new vinyl flooring to be laid and a walk in shower to be installed. We observed that the people who use the service benefit from having specialist equipment and adaptations in place. We observed that all areas of the home are suitably heated, including the Care Homes for Older People Page 18 of 29 Evidence: conservatory area. We observed that an additional heater has been installed in the conservatory. We observed that the home has an infection control policy in place and that staff are trained in infection control procedures, staff training records viewed confirmed this. Staff were observed adhering to infection control procedures. We observed that there is a daily cleaning schedule in place and that the laundry has all the necessary equipment to ensure individuals clothes and linen are laundered appropriately. 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. The home has a staff team that have the necessary skills and experience to the meet the needs of the people accommodated. Staff training is being updated, in both mandatory subjects and in accordance with the needs of the individuals accommodated. Evidence: From records viewed and discussions with people who use the service and their relatives/friends, we observed that a competent staff team meets the needs of the individuals accommodated. We observed that there is a staff rota in place, which details staff hours of working and staff job designations. Records viewed confirmed that the home has a permanent staff team of the Registered Manager, four Registered Nurses (RNs), twelve Carers, two Cooks and two Kitchen Assistants, two Cleaners and a Handyman. We observed from the homes AQAA and from discussions with the Registered Manager that nine care staff are National Vocational Qualification (NVQ), level 2, trained in care and a further three are currently completing the NVQ level 2 in care, training. Staff recruitment files were viewed and we evidenced that these files contain the Care Homes for Older People Page 20 of 29 Evidence: majority of items required under the Care Homes Regulations 2001. We observed that RNs who are employed by the service, have the necessary Nursing and Midwifery Council (NMC) PIN checks conducted on recruitment but that these are not checked routinely on an annual basis. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. We observed that there was evidence in staff files that staff who are recruited from overseas are subjected to the appropriate checks and have the necessary work permits in place prior to commencing employment. We observed that the home has an Equal Opportunities policy in place and is an equal opportunities employer. We observed that a multi cultural staff team meets the diverse needs of the people accommodated. Training records were observed and we evidenced that staff receive effective induction training. All staff providing care must have up to date training in all mandatory courses including moving and handling, fire safety, first aid, safeguarding adults, food safety, infection control as well as dementia care training. The homes AQAA and discussions with the Registered Manager confirmed that staff training has improved and that dates for further mandatory training are being established. 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. People who use the service do not always benefit from a home that is well managed and administrated. The health, safety and welfare of staff and the people who use the service are protected most of the time. Evidence: The Registered Manager is also the Registered Provider of the home and has owned and operated the service for twenty three years. She is a qualified Registered General Nurse and a Registered Sick Children Nurse. The Registered Manager reported that issues relating to documentation and Health and Safety checks records could be concentrated on more thoroughly, once a suitable Deputy Manager had been employed. The Registered Manager reported that it is difficult to ensure that everything that requires doing can be completed, when she is the whole mamangement team and conducts care duties also. Care Homes for Older People Page 22 of 29 Evidence: Peole spoken with said that the Registered Manager is friendly, approachable and always takes concerns or comments raised about the service and its provisions seriously. We observed that the Quality Audit Tool for recording environmental issues, that was sourced prior to the previous inspection, remained in place but had not been implemented completely. We observed that Regulation 26 visits are not conducted by the Registered Provider, as she is in the home everyday of the week. The Registered Manager reported that staff meetings are held six monthly, that meetings involving the people who use the service are held three mnthly and that minutes are maintained of all meetings held. Minutes of meetings were not viewed during the inspection process to confirm this. The Registered Manager reported that the home does not take any responsibility for any of the finances of the people accomodated. The Registered Manager confirmed that all individuals accommodated have family, friends or representatives who protect their financial affairs. From the tour of the premises we observed that all chemicals are securely stored and chemicals in use are not left unattended. From our records we observed that a written risk assessment, concerning the use of window restrictors is in place. On the tour of the premises we observed that all windows are now restricted. The Registered Manager reported that all fire doors can be quickly opened at all times, in the event of an emergency and that all staff are aware of how this is done. We observed that all fire exits and doors were clear and easily accessible. We observed that a system of regular checks on fire systems and equipment has been implemented. Records viewed provided evidence that the home has a copy of the Nottinghashire Fire and Rescue services fire testing recording book in place but that this is not currently utilise. The Registered Manager has created her own proforma for recording fire checks, though entries of satisfactory do not give clear information about the nature of the checks. Records viewed also provided evidence that the last recorded fire drill was held in June 2009. We observed that the records state that one staff member did not know the Care Homes for Older People Page 23 of 29 Evidence: correct procedure to follow and that further training will be provided. This was discussed with the Registered Manager who confirmed that there had been no further fire drills to show that staff had received up to date training and that a further drill was held to ensure that staff knew the correct procedure. We observed that the fire equipment and fire risk assessment had been checked in March 2009. From our records we observed that a written risk assessment ensuring that internal doors within the building are not be locked at night, to prevent people wandering around the communal areas of the home has been implemented. Discussions with the Registered manager confirmed that that these doors are not locked at night and that the risk assessment sent to CQC is in effect. Written confirmation will be received to further verify this. Care Homes for Older People Page 24 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 19 13 The registered person must complete a written risk assessments concerning the use of window restrictors. Window restrictors must be in place where potential risk is identified to vulnerable people living at the home. This is for the protection of vulnerable people living at the home. This requirement was met by the second inspection visit. 02/04/2009 Care Homes for Older People Page 25 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 15 That care plans are signed to indicate the involvement of the individual that they are written for. Where a person lacks capacity and a representative is involved, this must be also be documented. In that care plans must be formulated with the involvement of the person using the service and/or thier representative. 18/10/2009 2 7 15 That care plans are reviewed 18/10/2009 on a consistent monthly basis. In order to ensure that the care the individual receives is in line with their current needs and is reflective of the the care that is planned. 3 9 13 That self medicating risk assessments are reviewed on a monthly basis. 18/09/2009 Care Homes for Older People Page 26 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 In order that they can be monitored for their effectiveness and to provide evidence that the individual remains able to self medicate. 4 29 19 That the Nursing and Midwifery Council PIN numbers of Registered Nurses employed are checked on an annual basis. In that this will further safeguard the people who use the service by having appropriate checks in place for the staff employed. 5 38 23 That fire drills are held on a consistent basis and records are maintained of all drills held. In that this will ensure that all staff will know the correct procedure to follow in the event of a fire. 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 18/09/2009 18/09/2009 1 1 That the Statement of Purpose and Service User Guide is updated to reflect the name change of the Care Quality Commission (CQC) and to include the correct contact details for the CQC. Care Homes for Older People Page 27 of 29 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 2 3 7 9 That daily care entries are clearly dated and timed for each entry. That self medicating risk assessments are signed and dated by the person using the service, in order to provide a clear audit trail of when the assessment was conducted and agreed by all parties. That the Complaints Policy is updated to reflect that the Care Quality Commission can be contacted at any time during the event of a complaint and not after all internal processes have been conducted. That copies of minutes maintained for meetings held for staff and people who use the service are made available for inspection. That all fire checks are clearly recorded onto a recognised format. In that this will enable a clear audit trail of when and how checks are conducted and whether any issues were noted. 4 16 5 33 6 38 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. Copyright © (2009) Care Quality Commission (CQC). 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