Inspection on 15/03/10 for Lands House Care Home

This is the latest available inspection report for this service, carried out on 15th March 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lands House Care Home 24/04/08

Lands House Care Home 27/04/07

Lands House Care Home 03/07/06

Lands House Care Home 17/03/06

Lands House Care Home 06/02/06

Lands House Care Home 18/01/05

Lands House Care Home 14/09/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/05/2010.

Key inspection report Care homes for older people Name: Address: Lands House Care Home New Hey Road Rastrick Brighouse West Yorkshire HD6 3QG     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: Mike ONeil     Date: 1 5 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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: Lands House Care Home New Hey Road Rastrick Brighouse West Yorkshire HD6 3QG 01484716633 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Georgina Copley care home 30 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Lands House, which is registered to provide nursing and personal care for up to 30 older people, is a spacious detached property situated on New Hey Road in Rastrick with easy access to the town centres of Halifax, Brighouse and Huddersfield. Local community facilities are nearby. The property is generally well maintained provides accommodation in single and double rooms. Safe and accessible garden areas with seating are available for the service users to enjoy, especially in the summer months. The weekly charges at the home range from 361 to 502.25 pounds per week and additional charges made for personal toiletries, newspapers, hairdressing and podiatry. This information was provided on 15th March 2010. The home should be contacted directly for up to date information about charges. 0 Over 65 30 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: The inspection process included looking at the information we have received about the home since the last key inspection in April 2009. Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the service was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. The AQAA also included data as to when utilities and equipment at the home were serviced. Information from the AQAA is included in the main body of the report. Before the visit we sent surveys to the home to distribute to people using the service, visiting health care professionals and staff. Seven surveys were returned to us 2 from staff and 5 from people who live at Lands House; some of their relatives had helped them complete the surveys. The information from the surveys is included within this report. Care Homes for Older People Page 5 of 28 We made an unannounced visit to the home. This was carried out on the 15th March 2010 over a period of six and a half hours. We talked to 6 staff about their work and the training they have completed. We checked some of the records, policies and procedures the home has to keep. We also looked at some parts of the home and observed staff as they carried out their duties. The registered manager was in charge of the home at the time of our visit. The registered provider was also present throughout our visit. We spoke with 8 people who use the service and 4 peoples representatives during our visit, their views are included within this report. During this visit we found the surface temperature of three gas fires were well in excess of a hazardous 43 degrees centigrade. None of the fires were guarded and no risk assessments had been completed to assess or minimise the risk of burns to people or staff. We wrote a letter to the provider on 16 March 2010 instructing them to send us a copy of a risk assessment and planned action over the gas fires and to let us know the measures they intended to take to keep people safe. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 6 of 28 What the care home does well: What has improved since the last inspection? The service has recently gained the Gold Standard Framework for palliative care. This provides evidence that staff at the home can work effectively with other health care professionals to help ensure peoples end of life care will be of a very high standard. This award has also helped staff to develop solid working relationships with the palliative care team and other health care professionals. Work is continuing to improve the environment. New furniture has been purchased and some areas have been redecorated and refurbished. People are supported and protected by the homes recruitment policy because all the required checks are now carried out before new staff start work. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We found that the staff were very enthusiastic and keen to improve the service further. They all agreed that things are better at the home and that the amount of training available has increased. The management team of Lands House have improved the ways in which to check out the quality of the service that they are providing. Regular staff meetings are now held. Care Homes for Older People Page 7 of 28 There are also meetings planned for people who use the service to meet with the management of the home. Peoples views have also been sought through satisfaction surveys that have recently been sent out to them by the home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 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. Assessments were carried out to ensure that the home could meet peoples needs. This home does not provide intermediate care. Evidence: When we looked at peoples surveys it told us people had received enough information about the home before they moved in so they could decide if the place was right for them. When we spoke to the representatives of people who had moved in they said, We choose Lands House because of its nice atmosphere, homeliness and the friendliness of the staff . We looked at three peoples files to check that pre admission assessments had been undertaken. This told us that prior to the admission taking place, staff from the home carried out an assessment of peoples needs. This confirmed that the service was appropriate for the person and provided staff with information to formulate an individual plan of care. Care Homes for Older People Page 10 of 28 Evidence: We also saw in the files, the home was consulting with and requesting reviews from health care professionals when the persons needs were changing. 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. People were treated with respect and said they were very happy with the care they received. Peoples health needs were met and medication procedures ensured that people were protected. Care plans did not fully reflect peoples care needs. Evidence: The overall feedback from people and their relatives was that the care delivered by staff at Lands House was very good. Risk assessments were included within the documentation and included moving and handling, skin integrity, and other risk factors. The care plans identified that a range of health care professionals visited the home to assist in maintaining peoples health care needs. People said they had regular contact with their GP and other health care professionals. We saw that people looked clean, well dressed and had received a good level of personal care. Care Homes for Older People Page 12 of 28 Evidence: When we spoke with staff they showed a very good knowledge of peoples diagnosis and could verbally describe the health and personal care needs of the people they cared for. The two care plans we checked however did not reflect or provide enough evidence that staff were providing the care people needed. Also the plans did not fully reflect peoples changing health care needs. The following inadequacies were found with the documentation: A persons risk assessment identified that they were at risk of developing pressure sores. However despite this assessment staff failed to formulate a detailed care plan which would offer guidance and instructions to staff of how to minimise the risk and monitor the skin condition of the person. We found evidence that staff, in the care they were providing, were taking action to minimise the risk of the person developing pressure sores. However none of these care interventions were recorded in the persons care plan. Staff must evidence the care each person needs to minimise the risk of peoples needs being overlooked. Some people and /or their representative said they were aware of care plans and that they were involved in discussions about their care.This means that most people can have a say in how they receive care or support. However there was no evidence recorded in the care plans to show that the person was involved in drawing up and reviewing their plan. This may mean that this person cannot have a say in how they receive care or support. A persons records identified that they were losing weight. However despite this staff failed to update the persons care plan which would offer guidance and instructions to staff of how to minimise and monitor the persons weight loss. We found evidence that staff, however, had sought specialist help and the person was now receiving nutritional supplements and other health care professional support. However none of these care interventions and additional actions by staff were recorded in the persons care plan. Staff must clearly evidence the care each person needs. One persons care plan gave conflicting advice to staff. The care plans stated that a persons blood sugar level should be monitored weekly and monthly. Clear unambiguous information must be recorded in peoples care plans so that staff are clear about and can meet peoples individual health care needs. We spoke at length with the manager and provider about the inadequacies in the care Care Homes for Older People Page 13 of 28 Evidence: plan documentation. The manager had already identified the shortfalls in peoples care plans and felt that the current documentation used had led to conflicting guidance for staff and there was a lack of space in the files for staff to update them. The manager and owner assured us that new care plan documentation would be set up and start to be used within the next two months. Medication was securely stored in locked cupboards in a locked room. Medication Administration Records (MAR) were up to date with no gaps. The Controlled Drugs Register was checked and this had been completed correctly with two signatures and a diminishing total. Qualified nursing staff dispense all medication. Guidance from the Nursing and Midwifery Council on the administration of medication is available to staff at the home. We observed staff working to observe how staff valued and respected the privacy of people. There was clear and respectful communication between people and staff and staff treated people in a kind manner. Staff spoke clearly and at a steady pace with people. The service has recently gained the Gold Standard Framework for palliative care. This provides evidence that staff at the home can work effectively with other health care professionals to help ensure peoples end of life care will be of a very high standard. This award has also helped staff to develop solid working relationships with the palliative care team and other health care professionals. These positive links and relationships will help to ensure that people have good access to the specialist care and support they need from health care professionals. Despite the inadequacies in the care plan documentation evidence shows that people at Lands House experience some good outcomes relating to health and personal care. This is why the overall rating for health and personal care is adequate as opposed to poor. This judgement is also based on the evidence that the manager has given assurances that the areas in need of improvement will be addressed and managed promptly. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a choice of lifestyle within the home and are able to maintain contact with family and friends ensuring that they continue to be involved in community life. People are able to make choices about daily living and be involved in some social activities. Meals served at the home are of a good quality and offer choice to ensure people receive a balanced diet. Evidence: People said they are able to get up and go to bed when they choose and generally how they spend their day and evenings. They said they often went out with their families. Relatives said they were able to visit at any time and were made to feel very welcome. People and their representatives said that the home is a friendly and welcoming place this was very evident on the day of our visit. Some people said they enjoyed some of the activities available at the home, whilst other people said that they chose not to join in with the activities arranged. We found people have been consulted about their interests and what activities and trips they would like to take part in. There is also some information recorded in peoples care plans about how people like to spend their day. Care Homes for Older People Page 15 of 28 Evidence: We found that during the week some activities are arranged and during the last few weeks there had been some trips out organised. We observed the meal service at lunch time. The tables were nicely set, the meal service was well organised and people were given plenty of time to enjoy their food. People told us they had enjoyed their lunch. Staff were supporting people, who needed help with their meal, in a sensitive and discreet way. People also said they always enjoy the food and were offered a choice of meal. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate systems in place to make sure that peoples concerns/complaints are taken seriously and acted on and to make sure that people are protected from abuse. Evidence: Information about the complaints procedure is available in the home. People told us they know how to make a complaint if they need to and know who to speak to if they are unhappy. Several people said Id soon say if I was unhappy, but Im not. The home told us they had not received any complaints in the last year, no complaints have been referred directly to us. Records are kept of any previous complaints made and action taken to resolve concerns. There are procedures in place to make sure that people are protected from abuse. Staff said they are aware of protection polices and procedures. Records were seen of previous adult safeguarding training staff had undertaken. Other staff said they are attending safeguarding training in the next few days. We saw this training had been arranged and was advertised on the staff notice board as mandatory training. This ensures people who use the service are safe and protected. Care Homes for Older People Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and work is continuing to improve the environment and make it a pleasant and suitably equipped place for people to live. Evidence: People living in the home and their representatives told us the home is always clean and it was clean when we visited. Refurbishment of the home is required as an ongoing project. Some parts of the home look tired and in need of brightening up. Some paintwork around the home is chipped and some walls damaged. Carpets in some bedrooms and communal areas are in need of replacement. However work is continuing to improve the environment. New furniture has been purchased and some areas have been redecorated. This refurbishment should continue so that people can live in improved surroundings. Care Homes for Older People Page 18 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to meet peoples needs and people are protected because all the required checks are done before new staff start work. Not all of the staff have the training required to make sure that they can look after the health, safety and wellbeing of people who live at the home. Evidence: People and their representatives spoke highly of the staff team and said staff listened and acted on what they said. People said that staff were available when needed. Staff all said that staffing levels were adequate for the current number of people at Lands House. On the day we visited staff sickness had meant there was a temporary shortfall in staffing numbers. However staff cover was soon found and we saw that staff were available to attend to peoples needs when needed. The manager told us that all the required checks are done before new staff start work. This was confirmed by the three staff files we looked at. There has been a marked improvement in the standard of staff files since our last visit. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We found that the staff were very enthusiastic and keen to improve the Care Homes for Older People Page 19 of 28 Evidence: service further. They all agreed that things are better at the home and that the amount of training available has increased. Over the past 6 months training has taken place on a variety of subjects including nutrition, palliative care and dementia care. However, there is still a shortfall in staff training including some statutory training such as moving and handling, fire safety and basic food hygiene. The manager is trying to manage peoples training through regular supervision, staff appraisals and formulating a training plan. Care Homes for Older People Page 20 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. People are benefiting from improvements that have been made to the management and running of the home and their views are being listened too. The homes policies and procedures do not fully promote the health, safety and welfare of people who use the service. Evidence: The registered manager, Julie Banks has been in post at Lands House for about 5 months. The manager has many years experience in care, management and the nursing profession. She has completed her Registered Managers Award. All staff, people, and relatives spoke very highly of the manager. They said the manager is very supportive and she listens and tries to resolve any problems. One person said We see the manager every single day; she is always around the home making sure everything is alright. Care Homes for Older People Page 21 of 28 Evidence: Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA). The AQAA was received within the agreed timescale. This shows that the service works in a cooperative manner with us. The management team of Lands House have improved the ways in which to check out the quality of the service that they are providing. Regular staff meetings are now held. There are meetings planned for people who use the service to meet with the management of the home on a more formal basis. The owner, Georgina Copley, visits the home every day. People and staff said they saw her all the time and were able to talk to her at any time. However, a report, as required, isnt being written following these visits. A report should be written, at least every month and kept at the home. The owner said she would start the writing of a written report immediately. The service has sent out satisfaction surveys to people and their families. All the surveys havent been returned yet. The manager confirmed that the results of these surveys will be published and made available to people. The manager said she has attended training on the Mental Capacity Act and the deprivation of liberty legislation. Other staff however had little knowledge of the legislation and needed training. Information booklets were available in the home but staff said they had not read them. The manager confirmed that all staff would receive training on the Mental Capacity Act and the deprivation of liberty legislation as part of their training schedule. The manager said that no one in the home was being deprived of their liberty when we visited. The manager is aware of procedures to follow in relation to this legislation. However the lack of staff training relating to deprivation of peoples liberty may mean that peoples rights are not fully protected and promoted. A sample of monies that was looked after on behalf of people living at the home was checked. Records and receipts are kept and money tallied with the records. The AQAA completed by the home indicated that the required maintenance and servicing of equipment is up to date; a sample of records we looked at confirmed this. As mentioned earlier in this report some staff said they had not received recent fire safety and other health and safety training. This training must be completed by all staff to maintain the safety and welfare of all staff and people. We saw several potential health and safety hazards around the home that may pose a risk to people and staff. We saw trailing wires, wires to the nurse call system that were taped up using electrical tape, gates at the top of stairs that were on occasions Care Homes for Older People Page 22 of 28 Evidence: left open and gas fires in three lounges that were not guarded. Despite these potential hazards no risk assessments were available for any of the above mentioned and there was no evidence of any internal auditing of the homes environment, services and records. There were no records available to show that hot surfaces around the home were being monitored. An environmental risk assessment must be undertaken and action taken to correct any hazards.This will help to ensure that all parts of the home to which people have access are so far as reasonably practical free from hazards to their safety. Care Homes for Older People Page 23 of 28 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 Older People Page 24 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 15 The care plans must set out in detail the action, which staff need to take to minimise the risk of people developing pressure sores. To ensure peoples health care needs are met. 01/06/2010 2 8 15 Peoples care plans must be clear to read and reflect any changing health care needs of the person. To ensure peoples health care needs are met. 01/06/2010 3 30 18 Staff must be given the training they need to enable them to work safely and meet the needs of people living in the home. To meet peoples needs. 01/08/2010 4 33 29 The registered provider must produce a monthly 01/06/2010 Care Homes for Older People Page 25 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 written report on the conduct of the care home as required by regulation 26 of the Care Homes Regulations. To help ensure the home is run in the best interests of people. 5 38 13 An environmental risk 01/05/2010 assessment must be undertaken and action taken to correct any hazards.This will help ensure that all parts of the home to which people have access are so far as reasonably practical free from hazards to their safety. To keep people safe. 6 38 13 All hot surface areas around 01/05/2010 the home must be regularly monitored and action taken to minimise the risk of injury to people. To keep people safe. 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 7 7 The new care plan format should be fully implemented as soon as possible. Documentation should show that people and/or their Page 26 of 28 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations relatives have been involved in drawing up and reviewing the care plans. 3 4 19 33 The programme of renewal of the fabric and decoration to improve the environment should continue. To protect peoples rights and choices staff should receive training on the mental capacity act and deprivation of liberty. 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. 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