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Inspection on 15/04/10 for Little Hayes Care Home

Also see our care home review for Little Hayes Care Home for more information

This is the latest available inspection report for this service, carried out on 15th April 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The people who live in this home and their relatives speak very highly of the staff telling us that "they are very kind" and "always helpful". They say that "they provide stability" for residents who are often very confused and that this has been appreciated while there is some uncertainty about the future of the home due to the administration process.

What has improved since the last inspection?

At this visit we have acknowledged that improvements have been made since the last inspection and generally the requirements that we made have been addressed. We are told that equipment in the home has been serviced according to current guidelines. Financial records are now more robust and there is a clear accounting process for residents money. The management company now provide evidence of visits made to the home, in accordance with Regulation 26 of The Care Standards Regulations. These visits are to monitor the running of the home and the views of the people who live and work there. Work has been undertaken with residents regarding how they would like to spend their days and a new activities coordinator has been appointed. Documentation that shows how individual residents need to be supported has improved so that everyone is aware of their preferences. A refurbishment plan has begun and we are told that this will be ongoing. Both communal areas and residents bedrooms will benefit from redecoration and bathrooms and toilets will be improved. Shortfalls in staff training are being addressed, staff say that they have already attended some sessions and we are told more are being planned.

What the care home could do better:

Although we have acknowledged that improvements have been made we have raised some issues about the administrative processes in the home. The provision of organised activities has increased since we last visited. However residents or their relatives are being asked to make financial contributions for this. We have made a requirement for this to be included in the homes Statement of Purpose so that everyone is made aware of it. Staffing levels have been amended so that there is only ever one trained nurse on duty in the home. We are told that this is because of reduced occupancy levels however, the layout of this home has always made it difficult to manage and we are concerned particularly about the length of time that medication rounds are taking. We have asked the manager to provide us with evidence that despite these reductions people are still receiving their medication at the times that it has been prescribed. Although we have commented on the enthusiasm and commitment of the current manager she is is not a registered nurse. We were told that a nurse would be appointed to support her as a clinical lead, to supervise staff and oversee the nursing care in the home. To date this has not happened.

Key inspection report Care homes for older people Name: Address: Little Hayes Care Home 29 Hayes Lane Kenley Surrey CR8 5LF     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: Alison Ford     Date: 1 5 0 4 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 27 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Little Hayes Care Home 29 Hayes Lane Kenley Surrey CR8 5LF 02086606626 02086682449 littlehayes@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Diplotec Ltd Name of registered manager (if applicable) Julia Barbara Christodoulides Type of registration: Number of places registered: care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Daytime staffing levels would have to be:- 4 Qualified nurses and 8 care assistants between 8:00am and 2:00pm. 3 Qualified nurses and 7 care assistants between 2:00pm and 8:00pm. Nighttime staffing levels would have to be: - 2 Qualified Nurses and 3 Care assistants between the hours of 8:00pm and 8:00am. Date of last inspection Brief description of the care home Little Hayes is a 50-bed home, which offers nursing care to the elderly. The home is situated in Kenley, an attractive semi-rural area that is in close proximity to a mainline rail station and good road and bus links. The only potential difficulty with access is that the visitors on foot would have to climb a short, but steep hill to the home. The home offers 36 single bedrooms and 7 double bedrooms over two floors, some with en-suite Care Homes for Older People Page 4 of 27 Over 65 10 40 0 0 1 0 0 3 2 0 0 9 Brief description of the care home facilities. There are two passenger lifts for ease of access although the home is very spread out in its layout and it is quite disorientating at first. There are various communal areas available for all of the residents and a garden. The stated aim of the home is to provide its residents with a secure, relaxed and homely environment in which their care, well being and comfort is of prime importance. Copies of the Statement of Purpose for the home and the latest inspection report can be requested from the home. Inspection reports can also be obtained from The Care Quality Commission via their website. We do not have up to date information about the fees charged however, at the time of the last inspection, they ranged from £425 - £680 depending on the room occupied and the dependency of the resident. We are aware that they have been increased since that time and would be discussed prior to admission along with any extra charges for services such as hairdressing or private chiropody. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This report follows an unannounced visit to the service. However we also took into consideration other information that we have asked for or received since we last visited in December 2009. This has included comments made by people that live or work in the home and notifications that we have received about things that have happened there. The manager also sent us the homes Annual Quality Assurance Assessment ( AQAA). This is a self assessment which tells us how well they believe that they are meeting the aims and objectives of the home and about their plans for the future. The home is currently in administration and management responsibilities are being overseen by Healthcare Management Solutions who were appointed by the receivers. Currently placements by the local authority have been limited and The Care Home Support Team have been working closely with the staff to improve outcomes for those who live in the home. Care Homes for Older People Page 6 of 27 When we visited we spent time walking round the home and speaking with residents and staff members. As it was only a short time since we last visited the home, we concentrated on the things that had been happening and the improvements that were being made. We also looked at some of the documentation that the home is required to keep. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: Although we have acknowledged that improvements have been made we have raised some issues about the administrative processes in the home. The provision of organised activities has increased since we last visited. However residents or their relatives are being asked to make financial contributions for this. We have made a requirement for this to be included in the homes Statement of Purpose so that everyone is made aware of it. Staffing levels have been amended so that there is only ever one trained nurse on duty in the home. We are told that this is because of reduced occupancy levels however, the layout of this home has always made it difficult to manage and we are concerned particularly about the length of time that medication rounds are taking. We have asked the manager to provide us with evidence that despite these reductions people are still receiving their medication at the times that it has been prescribed. Care Homes for Older People Page 8 of 27 Although we have commented on the enthusiasm and commitment of the current manager she is is not a registered nurse. We were told that a nurse would be appointed to support her as a clinical lead, to supervise staff and oversee the nursing care in the home. To date this has not happened. 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 9 of 27 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 27 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No-one is admitted into the home without having their needs properly assessed to ensure that they can be met. Evidence: We are told that no-one is admitted into the home unless an assessment has been undertaken by the manager or a senior nurse. This would include a full medical and social history and take into account the assessment from a persons care manager, should they be funded through the local authority. Relatives would be involved in the process and a visit to the service would be encouraged. In this way the suitability of the placement can be judged and the risk of inappropriate admissions is minimised. Currently, the written information that is available for people to take away is out of date. The manager is intending to produce a new brochure in the near future. The recent concerns about the home have resulted in placements being limited so it was not possible to judge the effectiveness of this process. Only one new resident had Care Homes for Older People Page 11 of 27 Evidence: been admitted and that placement was an emergency one, initially for respite. Since the management company took over the home extra charges have been introduced to help to pay for activities. This information must be made clear to current and potential residents and The Statement of Purpose amended to reflect this fact. The home does not offer intermediate care therefore this standard does not apply. Care Homes for Older People Page 12 of 27 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. Peoples health care needs are generally being met in a way which suits them. Medication procedures need to be monitored in order to ensure that medication is being given as it has been prescribed. Evidence: At our last inspection we raised some concerns about the way that peoples health care needs, particularly psychosocial, were being addressed. We acknowledge that improvements have now been made within this outcome group. All of the residents have an individual care plan which sets out how their needs will be met. We looked at some of these and could see that the way that documentation is completed had improved. Areas where people needed support have been clearly identified and the care plans would help all of the staff know how they preferred to be cared for. We did note some instances where reviews had not been undertaken as regularly as they should have and recommend that a process should be put in place to monitor that this is taking place. This will ensure that any changes are identified and addressed. Care Homes for Older People Page 13 of 27 Evidence: All of the residents looked well cared for and happy and those being nursed in bed seemed comfortable. Appropriate pressure relieving aids have been supplied where necessary. We were previously concerned about the way that peoples social needs were being met and the lack of stimulation or activities in place for them. At this visit we saw that staff seemed to be more engaged, residents had not been left alone in the lounges and there was a general air of activity.The frailty of many of the residents and their dementia makes their ability to contribute to the inspection process quite difficult however, they displayed positive signs of wellbeing and those who could speak with us agreed that they were quite happy living in the home. Medication procedures and storage have recently been audited by the Primary Care Trust and found to be in order. We were able to see that there is now a weekly audit in place. The current staffing levels mean that there is only ever one trained nurse in the home. We were told that undertaking a medication round can be time consuming, and we are concerned that some people may not be receiving their medication at the times it has been prescribed. For some drugs the timing of administration is very important and we have recommended that an audit should be undertaken in order to identify any problems.We are concerned that the decision to reduce staffing has not taken into consideration the difficulties caused by the layout of the home. Therefore we have asked for evidence to show that people are receiving their medication on time, as it has been prescribed. We did see that staff are very kind and caring towards the people that they are supporting. Personal care is delivered in residents own rooms and they are always addressed in an appropriate and dignified manner. Staff that we spoke with told us that they believe the standard of care in the home is very good and they are finding working with the homes new manager much easier. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally, people seem to find that the daily life in the home suits their needs. Evidence: When we last visited the home we raised serious concerns about how people were spending their days. Reductions in staffing levels meant that people had been left in sitting rooms on their own and there was a lack of structured activities being provided. Since that time we note that staffing levels have been cut again, we are told that this is line with a reduced occupancy. However, at this inspection we did see that care staff were with residents in the sitting rooms and that they were engaging with them. In addition, the home has appointed an activities coordinator, for sixteen hours a week, and we were impressed by her enthusiasm and commitment to providing more stimulation for residents. When we inspected, she was busy helping residents to prepare to celebrate St Georges Day, and they were all chatting and laughing together and seemed to be enjoying themselves. She is also working with residents families to try and find out the sort of things that will interest them and is compiling life story books. Photographs of activities that have been enjoyed will be displayed on boards in the home and in albums for people to look at. Care Homes for Older People Page 15 of 27 Evidence: Unfortunately, funding for activities remains limited. Residents families are asked to contribute but few of them have chosen to. If the management company are to continue with this method of raising money for activities and entertainment this must be made clear to existing residents and also in the homes Statement of Purpose and Service User Guide. Placing authorities will also need to be made aware that this is the the intention. We are told that visitors would always be welcome and completed surveys we received told us that staff were approachable and pleasant although sometimes people said that they had to wait a while for the front door to be opened for them. Residents tell us that the food that is served in the home is very good and that they enjoy it. Traditional British food is served although special diets and preferences can always be catered for. Some carers expressed a concern that, due to staff shortages, they have to leave residents who they are helping at mealtimes, in order to attend to others who may be wanting to use the toilet. The manager is introducing more hot snack items for supper for those people who would enjoy them and is also hoping to introduce picture menus which will help those who have cognitive impairment. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints procedure in place and staff have received appropriate training to help them recognise and report suspected abuse. Evidence: The home has a clear complaints procedure which is displayed in the hall. The manager tells us that the intention is that it will be available in the new welcome packs that are being designed and that it will also be available in large print for easy reading. She has developed an open door policy in the home and is always available should anyone have any concerns. She also holds a weekly surgery when anyone could visit and raise any concerns that they might have. The manager considers that these measures help to address any concerns promptly before they develop into anything more serious and neither the home or The Commission has received any complaints since the last inspection. We are always informed of any incidents that occur that affect the health or well being of any of the residents, in line with Regulation 37. Staff have all received training in recognising and reporting suspected abuse and, in order to help to protect the residents, no one is employed until all of the necessary checks have been carried out. Care Homes for Older People Page 17 of 27 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. Although the location and layout of the home are not ideal, a refurbishment plan has started to ensure that it is comfortable for those people who live there. Evidence: The home will never be ideal in terms of access, it is not close to public transport links and the nearest station is a short walk away but up a very steep hill. The home is a large building with a very spread out layout that makes it quite disorienting and difficult to manage. We walked round the home and, as before, we found that decor and furnishings are looking very tired, some of the curtains are hanging down and carpets are stained and worn. There is little evidence of reality orienting for residents such as appropriate pictures. The front drive remains hazardous being full of bumps and potholes. However, since we last visited some effort has been made to implement a redecoration and refurbishment programme and we have been told that this will continue. Communal area and bedrooms will be refurbished, also bathrooms and toilets. A new activities area is being created. Advice is apparently being taken from The National Dementia Strategy in an effort to improve the environment and stimulate reminiscence and interest. Care Homes for Older People Page 18 of 27 Evidence: Generally the home was clean and tidy and smelt fresh, although one survey form we received told us that the toilets are not always clean. Previous problems with the hot water have been resolved and a new boiler has been installed. We noted that all of the staff are now wearing a uniform and there are adequate hand washing facilities available. Care Homes for Older People Page 19 of 27 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There may not always be enough staff on duty in the home to meet the health care needs of the people who live there. Evidence: Since we last visited the home the staffing allocations have been altered again. We were told that currently there is only ever one trained nurse on duty in the home with five carers in the morning, three in the afternoon and two at night. Although occupancy rates have dropped and The Commission has no definitive guidelines regarding staffing levels, we have concerns that these numbers may not be sufficient, especially with regard to trained nurses. Carers tell us that they are only just able to get everyone up and dressed by lunch time which means that there would not be any opportunity for them to participate in any activities in the morning. They also told us that residents are often very dependent and have to wait a while to be attended to as they are with other people. The nurse on duty seems to spend the majority of her time undertaking the morning drug round which, due in part to the layout of the home, can take well over two hours. There is then a risk that the interval between them and the lunchtime drugs is not as it should be. We have recommended that an audit should be undertaken to monitor whether residents are receiving their medication at the times it has been prescribed. Care Homes for Older People Page 20 of 27 Evidence: In addition, the nurse is left with little time to supervise and teach care staff. The completed surveys that we received were very complimentary about the staff telling us that they are very kind very caring and they treat residents very well however some also said there never seems to be enough of them. We will continue to monitor this situation carefully. The homes manager is aware of the need to improve training for all staff and has begun to address this. Some sessions have already been undertaken and others are in the process of being arranged. It has been difficult to identify staff training needs so a training matrix is being developed which will help to show which staff need to have their training updated. This will include information regarding Deprivation of Liberties Safeguarding and The Mental Capacity Act. There is also a need to encourage more staff to enrol on an NVQ level 2 training course in order for the home to comply with the minimum expected standards. The manager and administrator are currently in the process of auditing all employees personnel files to ensure that all of the necessary documentation is in place and we will monitor this when we next visit the home. Care Homes for Older People Page 21 of 27 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. Although we acknowledge the commitment of the manager to provide a safe service for the people who live in the home there are still some concerns about administrative procedures. Evidence: While we have judged that this a safe service for the people who live there, we have concerns about the administrative procedures in place. The home is being run by a management company, having been taken over by receivers last year. There is an acting manger in place and we would like to acknowledge her commitment and enthusiasm to the home and residents. Staff that we spoke with said that they felt supported and that generally things were better in the home. However, she is not a nurse, has not managed a nursing home before and her training in working with people with dementia has been limited. She is also not able to provide supervision for the nurses who work in the home. Plans to recruit a nurse, as a clinical lead, to support her have so far not materialised. The management company is based in Birmingham and although they are available to provide advice, practical everyday Care Homes for Older People Page 22 of 27 Evidence: support is limited. We are concerned that their decisions to reduce staffing in the home has not taken into consideration the difficulties caused by the layout of the home. We have asked them to provide evidence that this is not having an adverse effect on medication administration. Quality assurance and monitoring systems, based on seeking the views of those who use the service are limited. There have been some meetings held for residents and their families however this is an area which will need to be developed further in order to ensure that people are able to influence the service that is being provided. We were able to see evidence that the management team are now visiting the home every month and writing a report in line with regulation 26. The administrator now has a robust system in place for maintaining records of any financial transactions made on behalf of residents. The information that we have been given tells us that equipment and services in the home have all been appropriately maintained. A private company is currently working with the home to ensure that the home complies with current fire safety regulations. Care Homes for Older People Page 23 of 27 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 27 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 1 6 The Statement of Purpose must reflect the extra charges that are payable for the provision of activities. In accordance with Regulation 6 (a)(b) of The care Standards Regulations 2001 In order that people have clear and accurate information about the care and services that are provided. 30/07/2010 2 9 13 There must be evidence to 30/05/2010 show that medication administration has not been affected by the reduction in staffing levels and is being given at the time it has been prescribed. In accordance with The Care Homes Regulations 2001 Care Homes for Older People Page 25 of 27 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 to show that people are receiving their medication as it has been prescribed. 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 7 It is recommended that a process should be introduced to check that care plans are being reviewed regularly and ensure that they are addressing peoples current needs and that any changed have been identified. It is recommended that an audit should be undertaken which identifies whether medication is being administered at the time it has been prescribed. 2 9 Care Homes for Older People Page 26 of 27 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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