Inspection on 22/09/09 for Broomhouse Nursing Home

This is the latest available inspection report for this service, carried out on 22nd September 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broomhouse Nursing Home 30/01/07

Broomhouse Nursing Home 23/01/06

Broomhouse Nursing Home 17/10/05

Broomhouse Nursing Home 21/02/05

Broomhouse Nursing Home 08/09/04

Broomhouse Nursing Home 18/02/04

Broomhouse Nursing Home 25/09/03

Similar services:

Hillside

Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Broomhouse Nursing Home Broomhill Road Old Whittington Chesterfield Derbyshire S41 9EB     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: Nancy Bradley     Date: 2 2 0 9 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 Adults (18-65 years) Page 2 of 30 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 Adults (18-65 years) 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 Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Broomhouse Nursing Home Broomhill Road Old Whittington Chesterfield Derbyshire S41 9EB 01246260697 01246268065 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Intacare Limited care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 40 The registered person may provide the following category/ies of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD Date of last inspection Brief description of the care home Broomhouse home provides accommodation and personal care with nursing for up to 40 people with learning disabilities. The home is located in the village of Whittington close to the town of Chesterfield. There are shops, pubs and other amenities nearby. The home is divided into four named `houses? on two floors. Service users are accommodated in each house in accordance with assessed needs and compatibilities. There are well-maintained grounds with mature trees overlooking fields to the rear of the home. Car parking space is provided. Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 40 Brief description of the care home Charges are between #392.70 and #1,211.19. Extra charges are made for hairdressing, toiletries, and holidays. Care Homes for Adults (18-65 years) Page 5 of 30 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection and took place over a total of five hours. We spoke with the registered manager, care staff and people living at the home. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. We looked at all the information that we received or asked for, since the last key inspection. This included the following: The Annual Quality Assurance Assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Care Homes for Adults (18-65 years) Page 6 of 30 Three people living at the home were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the person. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. There were thirty nine people living at the home on the day of the visit, there is one vacancy. We received nine completed Have Your Say questionnaires from the people living at the home. The surveys indicated the people living at the home were very happy there, were supported by the staff on a daily basis and liked living at Broom House. Care staff had assisted the people with completing the questionnaires. Completed questionnaires from relatives were very positive about the home and indicated they were happy with the care their relatives received and the home. We received three staff questionnaires which indicated they were happy working at the home. Care Homes for Adults (18-65 years) Page 7 of 30 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 Adults (18-65 years) Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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. Arrangements are in place to ensure that peoples needs are fully assessed and met prior to admission. This ensures that all peoples holistic needs are appropriately met. Evidence: The majority of the people who are admitted to the home have their needs assessed by social workers or through the care management system. The single assessment then forms part of the planned care people receive. Also the home undertakes its own individual comprehensive needs assessments. This was in accordance with a recognised care model and provides a person centred record of individual needs, including identified strengths and needs, long-term goals, and evaluation. Family and carers interests were also recorded. We viewed the care records of the most recent admissions and noted that the home was not always signing and dating their care needs assessments. There was evidence to indicate the referring agency is reviewing people care on an annual basis. The home has a clear admissions procedure which includes people being invited to the home and spending time there, meeting people , staff and seeing whether they like it Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: or not. At present the home has one vacancy. The registered manager stated they have a waiting list. Information in the AQAA indicates the home takes emergency admission and they are reviewed with twenty four of the admission. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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 is a care planning and review system in place, which ensures that peoples individual needs are met. Evidence: During this site visit the care plans of three people were seen. These were the most recent admissions to the home. The nursing staff had compiled the care plans for each person and evidence was seen of care plans being reviewed on a regular basis. A more formal system for reviewing care plans was discussed with the registered manager. All of the people case tracked had a comprehensive care plan, which was in accordance with their assessed needs and formulated within a risk assessment framework. All care plans were very detailed and comprehensive including peoples individual lifestyle preferences and choices in the My Wish List document, and interventions prescribed by outside healthcare professionals. Daily and night records are also maintained on each person. People living at the home or their representatives had signed the care plans. Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: Information in the AQAA indicates the home is seeking to develop a more person centred care planning model and life story books. Discussion with the people and information in the AQAA indicated that they have access to an independent advocate who visits the home on a regular basis. Information about the service is displayed on an information board within the home. People indicated that they discuss with the Advocate things that affect their lives. Peoples files also contained a wide range of related risk assessments in such areas as behavioural/psychological issues, matters affecting physical health, tissue viability, nutrition, mobility, risks associated with health and safety and social activities. However the risk assessment and intervention plan for one person was not up to date. . The registered manager confirmed she would follow this up with this up with the psychologist. All other risk assessments were had been updated as required. All the people at the home have a named nurse and key-worker. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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 were arrangements in place to enable people to maintain and develop appropriate relationships and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. Evidence: During the visit the inspector spoke with people who live at the home and the staff who look after them about the activities which are offered to them. The home employs a full time activity organiser who is responsible for group activities, outings and general entertainment. The care records of all of the people provided detailed needs assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. The peoples personal goals, choices and preferences were identified and properly Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: recorded risk assessments were in place for each person in relation to the activities they were engaged in. On the day we visit we joined the people for a game of bingo. People spoken with indicated how they look forward to the activities and to the trips. The organiser attends house meetings to discuss with the people what activities they would like to do. Information in the AQAA indicates the home has a mini bus for trips and outings however present this can not be used for people with wheelchairs. The home is waiting for new tracking in the mini bus to be fitted so the wheelchairs can be secured whilst travelling. Information on peoples records indicated that contact with family and friends was appropriate and that they play an important part in their lives, the home maintains good contact with them. The home has an open door policy for friends and family who are encouraged to take part in activities within the home. Examination of the menus indicates the home is providing a healthy well-balanced and nutritious diet with some people on special diets. There is a choice if they do not like the options on the menu. The cook compiles the menus in consultation with the care staff and people who live at the home. Care Homes for Adults (18-65 years) Page 15 of 30 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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 receive personal and health care support in a way, which promotes their independence and is in accordance with their preferences and beliefs. Evidence: Many of the people were not able to express themselves verbally and to directly contribute to this site visit. During the tour of the home several people spoke with us indicating that the staff cared for them and that they liked it at the home. Also they get appropriate help when they need it and are able go out to the shops and on trips. Those people who were less able to express themselves looked relaxed, and were involved in the days activities. People were all dressed in clothes appropriate to their age and personal preference. During the visit it was clear that the peoples privacy and dignity are respected, and where they need supervision during personal care this is recorded in their care plan. Staff were routinely observed knocking on peoples bedrooms doors and bathrooms before entering. Examination of records and discussions with staff indicated that peoples health and Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: personal needs were being met. Peoples health was maintained and records showed that staff promptly contacted the appropriate medical services when necessary. All people attended services within the community including optician, podiatry, and dentist. Records examined showed that specialist advice and relevant reviews were routinely obtained from Ash Green Community Hospital for people with learning disabilities. The home maintains a record of peoples weight as part of maintaining a healthy life style. The home monitors peoples medication, as none of them are able to do so themselves. The home has a named person responsible for the medication. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to satisfactory at the time of this site visit. The AQAA indicated that only fully trained staff administer medication. Medication administration is recorded on Medication Administration Records (MAR sheets). Families of the people at the home have been contacted regarding their relatives End of Life plans. Care Homes for Adults (18-65 years) Page 17 of 30 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. Arrangements are in place to safeguard peoples welfare and ensure that their concerns are listened to and acted upon. However the lack of training in safeguarding may leave people vulnerable. Evidence: People are made aware of the homes complaints procedure through the service user guide and via their named key worker. A copy is displayed on the homes notice board. The Registered Manager has developed an easy read format for the complaints procedure. Any concerns and complaints made by are investigated within the agreed time scales. The home maintains a record of all complaints made by people; this includes details of the investigation action and outcome. The policy did not show the current contact details from the Care Quality Commission. The procedure displayed informs the complainants that they are able to contact the Commission for Social Care Inspection at Leicester at any stage of the complaints process if they wish to do so. Completed questionnaires confirmed that they would talk with care staff and family about any concerns they may have. Records seen indicated that no complaints have been received from people who live at the home or their representatives about their care since the previous Annual Service Review. Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: The home has a vulnerable adult protection policy and procedures however this does not make reference to local procedures, or reflecting the change of policy to the Safeguarding of Adults and to whistle blowing procedures. There has been one report incident under safeguarding vulnerable adults which was investigated by the local Social services Department the under Derbyshires Safeguarding Vulnerable Adults procedures. This investigation has now been concluded. The home failed to recorded this in the AQAA dataset. The majority of staff still need to complete training on safeguarding vulnerable adults. At the time of doing this site visit sixteen out of the staffing compliment of forty had complete the training. This did not include the fourteen ancillary staff. None of the care staff have received training on physical intervention techniques. People personal finances were seen and at the time of this site visit were found to be satisfactory. Care Homes for Adults (18-65 years) Page 19 of 30 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. 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 home provides a comfortable environment which suits the people who live there and their needs . However the full implementation of the refurbishment programme will further enhance the standard of the home. Evidence: A full tour of the home was undertaken and all communal areas were seen. Peoples bedrooms were inspected with their agreement and several of them rooms are being re decorated. Bedrooms were furnished to their peoples own choice and were being personalised. There are substantial grounds with space for people to sit outside when the weather is fine. The home employs a maintenance man to undertake minor decoration and repairs. The home has a rolling programme for repairs and decoration the registered manager has identified that the two up stairs bathrooms require attention. There was an unpleasant odour in some bedrooms and communal areas of the home. This was raised with the registered manager. The registered provider has replaced carpets in some areas and vertical blinds to windows. The home has satisfactory hygiene procedures in place. Care Homes for Adults (18-65 years) Page 20 of 30 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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 robust recruitment and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people. Evidence: The home has a good percentage of staff who hold a NVQ level 2 or above. The home has registered with the Skills for Care Council national data set. The home operates with two qualified nurses on each shift and eight care staff each day. Staffing levels at the home were examined and remain satisfactory and meet the needs of the people living at the home. The home has a robust recruitment procedure in place, which ensures that their staff are suitable to work with vulnerable people. Several staff personnel records were examined which confirmed that thorough employment checks were carried out. All new staff provides two references, a full employment history, have a clear Criminal Records Bureau clearance and complete a three-month probationary period. As part of providing a full employment history applicants need to provide an accurate chronology of their employment history with the days date month and year. From recent staff recruitment records examined, applicants were only providing the month and year. The records contained all required information has detailed in Schedule 2 of the Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: National Minimum Standard, Care Homes for Adults 2001. The staff personnel records were well presented and organised. From discussions with the staff and from examination of records the home is providing good training and development opportunities. Details of staff training together with training planned were provided by way of the Annual Quality Assurance Assessment questionnaire and the homes training matrix. Information in the AQAA indicates that all new staff completes induction training with six weeks off appointment. The home has appointed a member of staff to oversee all of the staff training. Training on the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLs) is scheduled. Records examined and discussions with the staff confirmed that the home has a formal structure for supervision of staff. Annual appraisals are undertaken. Care Homes for Adults (18-65 years) Page 22 of 30 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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 home was generally well managed, with staff seeking the views of the people who live there. However the lack of a management structure may affect the overall running of the home. Evidence: The Registered Manager has considerable knowledge and experience in caring for adults with a learning disability and challenging behaviour and has worked at Broomhouse for a number of years. Discussions with the registered manager indicate she had a contract and relevant job description detailing her role and responsibilities. From direct observation the Registered Manager has a good working relationship with the staff. At the previous site visit we recommended that a deputy manager be appointed to assist the registered manager in the general running g of the home. The registered provider decided against this and enhanced the role of the registered nurses. The registered manager has completed a recognised managers award. The registered manager stated the Regulation 26 visits are carried by the registered provider; however the reports for the last few months were not available at this site Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: visit. The registered manager has been absent from the home and the registered provider covered during her absence. The notification of her absence and subsequent notifications of incidents involving people living at the home were not received by the Care Quality Commission. Then registered manager is undertaking the homes annul quality assurance assessment. Questionnaires are given out to staff, people living at the home, family, friends and stakeholders. The registered manager also reviews the homes aims and objectives and compiles an annual report. The registered manager indicated that the home is seeking to make public its findings and to produce a news letter. Several of the review dates from the policy and procedures on the dataset have not been completed. A sample of service/maintenance records was examined (including gas and electricity services) and there was confirmation that all the equipment had been properly maintained. Evidence of checks having been carried out was provided by way of the AQAA Dataset. Systems were in place for the monitoring and maintaining the hot water temperatures. The homes insurance expires on the 30th September 2009. Care Homes for Adults (18-65 years) Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Adults (18-65 years) Page 25 of 30 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 22 22 The homes complaint procedure must include the contact details for the Care Quality Commission. This is to ensure people know who they can make a complaint to and their views are listened. 31/10/2009 2 23 18 All staff must receive training in safeguarding vulnerable adults This is to ensure staff are appropriately trained and people ate fully protected. 31/10/2009 3 23 18 All staff must receive training in physical intervention. This is to ensure staff are appropriately trained and people ate fully protected. 31/12/2009 4 23 22 The homes protection policy must make reference to safeguarding and the 31/10/2009 Care Homes for Adults (18-65 years) Page 26 of 30 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 different areas of safeguarding people need protecting from. This is to ensure people are protected from harm. 5 23 22 The homes safeguarding policy must make reference to the homes whistle blowing procedure. This is to ensure the safety and protection of the people who live at the home. 6 23 13 The homes safe guarding policy must make reference to local safeguarding procedures This is to ensure people are fully protected. 7 24 23 The registered provider must have an ongoing maintenance plan and renewal programme for the home. This is to ensure the home is maintained to a good standard. 8 24 23 The home must be suitable for the needs of the people who live there and be maintained both internally and externally. 31/12/2009 31/12/2009 31/10/2009 31/10/2009 Care Homes for Adults (18-65 years) Page 27 of 30 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 This is to ensure people live in a comfortable and safe environment. 9 37 38 The registered provider 31/10/2009 must ensure that the Care Quality Commission is notified of an absence of the registered manager under regulation 38. This is to ensure the effective operation of the home. 10 39 37 The home must ensure that 31/10/2009 the Care Quality Commission is notified of all events under regulation 37. This is to ensure the safety of the people who live at the home. 11 39 26 The Registered Provider must undertake a visit to the home at least once a month, prepare a written report and ensure a copy is available for inspection by the Care Quality Commission. 31/10/2009 This is to ensure the home is run efficiently. Care Homes for Adults (18-65 years) Page 28 of 30 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 2 3 7 23 34 The home should implement a formal care planning review system. The homes policy should include the contact details for the Social services Department. The homes application form should be amended to indicate that applicants need to provide the days date month and year when supplying a full employment history. All staff should undertake complete training on the Mental Capacity Act and Deprivation of Liberty Safeguards. he home should consider appointing a qualified deputy manager. The home should produce a newsletter giving information about the quality assurance findings and general news about the home. 4 5 6 35 37 39 Care Homes for Adults (18-65 years) Page 29 of 30 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. 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