Inspection on 28/07/09 for St Anne`s Rest Home

This is the latest available inspection report for this service, carried out on 28th July 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Anne`s Rest Home 06/02/08

St Anne`s Rest Home 14/03/07

St Anne`s Rest Home 06/02/06

St Anne`s Rest Home 30/03/05

St Anne`s Rest Home 05/08/04

St Anne`s Rest Home 20/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE St Anne`s Rest Home Grange Lane Burghwallis Doncaster DN6 9JL Lead Inspector Marina Warwicker Key Unannounced Inspection 28th July 2009 09:50 DS0000007964.V376838.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 2 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 St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Rest Home Address Grange Lane Burghwallis Doncaster DN6 9JL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01302 700 319 01302 708 752 www.stannesresthome.org.uk Hallam Diocesan Caring Service Mr James Kelly Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number 28 The maximum number of service users who can be accommodated is: 28 5th August 2008 2. Date of last inspection Brief Description of the Service: St Anne’s Rest Home is situated in the village of Burghwallis to the north of Doncaster. The home is a grade 2 listed building with parts dating back to the 11th century. Many original and interesting features remain throughout the building. Bedrooms vary in size and shape and accommodation is provided on a number of levels. There is a passenger lift and a chair lift to the different levels. The home is set in large grounds on the edge of a quiet hamlet. The nearest shops can be found in the next village. The home is owned and managed by the Diocese of Hallam Trust. The home has no specific admission criteria relating to faith. However, a Mass is said daily and the residents have the option of attending. The home is registered to accommodate 28 residents needing personal care and support. Information about the home can be found in the statement of purpose and the service user guide. These documents are available from the manager. The weekly charge was between £288.00 and £485.00 depending on the needs of the person requiring care. There were no additional charges other than those for hairdressing, private chiropody treatment, toiletries, newspapers and magazines. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 5 St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. 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. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. An inspection of St Anne’s rest home was carried out on Tuesday 28th July 2009 between 10am and 4 pm. The staff, the management and the people using the service were not informed of our visit and therefore it was unexpected. On the day of the site visit seven people were consulted, some others were observed in the communal areas. We spoke with six staff on duty. We sent out surveys to some staff working at the home and the members of the multi-disciplinary professionals who were in contact with the service users seeking their views of the service. Comments received from the surveys have been included in the body of the report. Time was spent observing, chatting with people using the service and the staff to find out the daily routine. We gave feedback throughout the day to the manager and the staff who participated in the inspection process so that they were able to take action or verify identified issues. The premise was inspected, which included some bedrooms of the people using the service, the communal areas and the service areas. The outside areas surrounding the building were also checked. Nineteen people were using the service on the day of the site visit. Fifteen of them were permanent residents and four were on respite care. Samples of individuals’ care plans, daily records by the staff on care, staff recruitment and training files were some of the records that we checked. We would like to thank the people who live at St Anne’s, their relatives, the staff and the management for their contribution towards this process. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 7 What the service does well: The staff at St Anne’s are very caring and deliver a good standard of personal care based on individuals’ needs. The staff maintain the principles of respect, dignity and privacy when caring for people who live at the home. The people who live at St Anne’s are able to make choices about their lifestyle, and are given support to maintain their life skills as much as they are able to. There are arrangements for social, cultural and recreational activities to enable people to occupy their time usefully. The residents are able to express their concerns and speak to the staff and resolve them. What has improved since the last inspection? The home now has an adequate number of aids and hoists for its purpose so that the staff are able to move and handle people safely. The people are able to sit out of bed as part of the daily routine by using appropriate aids. The management committee has agreed on a programme of maintenance, essential redecoration, renovation and refurbishment work to be completed to ensure that the home is safe and comfortable for the people who live there. All new admissions are accepted by the home manager only if the person is able to integrate and live alongside the others without disruption and the staff are able to meet the identified needs of the individual. However, if individual’s needs change over time then reviews take place to decide on the best way to accommodate those individuals. The communal areas are accessible to people living at the home. The furnishings of communal rooms are domestic in character and some have been replaced. The management have introduced safe procedures to promote control of infection within the home. A full time manager has been appointed since the last site visit. This has given the staff confidence, security and has helped them focus on improving the standard of care delivered to the residents. The staff supervision is ongoing and the staff structure is evolving to meet the needs of the service. The monthly monitoring and action plans (i.e. Regulation 26 visits) by the responsible individual have brought about continuity for the residents and the staff. The staff and the residents, now receive feedback during their meetings with the present registered manager on the ongoing progress made at the home. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 8 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. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 &5, 6not applicable. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may wish to use the service are able to visit the home and find out the information needed to make their decision about using the service. EVIDENCE: Three people using the service were consulted about their move to the home. These were some of the comments. “I enjoy living here.” “When my family went away I came in here for respite and since I liked the staff I decided to move in.” “My family helped me choose this home. I like living here.” The staff said that there was written information about the home and when people visit they show them around and were honest with the people. We checked three service user files to check whether people have had needs assessment carried out by the placing authority prior to admission. We not St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 11 only saw copies of the assessments but also the manager/staff assessment by the home of the person before admission. Comments from our surveys confirmed that the relatives were happy with the staff and were confident that their loved ones would receive good care. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10&11 People using the 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 health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff and monitored by the management of the home. EVIDENCE: To measure this outcome area we checked three care plans, spoke with people living at the home and the staff on duty. We also used the feedback from the surveys to confirm our decision. The care plans had been generated from the needs assessments and they were drawn up by the senior care staff at the home to meet the individuals’ needs. These had been reviewed each month and changes had been documented in the care plans. One service user said that staff consulted with him/her regularly and updated their files. The three care plans we checked reflected the health, personal and social care needs of the people. Nutrition, tissue viability, mobility and continence were St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 13 some of the areas where risk assessments had been carried out and there were clear instructions of the actions to be taken to minimise the risks. The staff from each shift wrote on the daily records. The daily recording needs to reflect what happened during each shift and if there had been any problems what progress had been made during the shift. The deputy manager was informed of the shortfalls. Two people said that they could see the GP if they wanted to and that sometimes the doctor visited the home. On the day of our site visit one of the GPs was attending to residents. The senior staff administered medication and ensured that the service users had swallowed the medicine before moving on to the next person. Two of the staff we spoke with said that they had completed a course on medication management and that they have had updates on safe handling of medication. We checked three MAR (Medication Administration Record) sheets. We made comments to both the manager and the deputy about some of the recordings on the MAR sheets, which were confusing and needed attention. There was also a lack of evidence of regular medication reviews by the GP. We noted that staff were not informed of the medical diagnosis of the people. However for the staff to be able to deliver person centred care they need to have access to the whole picture of the individual and this includes the information on the illnesses. During the day we noted staff interacting with the people in a caring, friendly respectful manner. The service users were warm and friendly towards the staff. All the service users we came into contact with looked comfortable, clean and cheerful. The comments from the staff feedback informed us that they would benefit by formal end of life care training. These were some of the comments. “We have had deaths at the home. We do what we think we should. It would be useful to get training.” “Although I have looked after people when they were dying what I know I have learnt through my colleagues.” “Palliative care training will be useful. We have had people recently coming in for end of life care.” The manager was informed of this. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in St Anne’s are able to make choices about their lifestyle, and are supported to maintain their life skills as much as they are able to. The arrangements for social, cultural and recreational activities enable people to occupy their time usefully. EVIDENCE: On the day of our visit we saw the activities co-ordinator returning with a service user after an outing/ shopping trip. The people made warm comments about the activities person. We saw a programme of activities displayed near the lounge informing people what had been planned for the week. Three people said that they were able to receive visitors and go out to visit friends if they so wish. Most of the people made arrangements with their families when they wanted to go out visiting. The majority of the residents and/or their family members took on the responsibility for managing personal finances. People had brought in some of their personal possessions to make their bedrooms homely and remind them of their own homes. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 15 All the residents we spoke with said that their meals were varied and tasty. These are some of the comments. “There is plenty for us to eat. Always we get the trolley coming around with drinks and snacks.” “Meals are very good. If I change my mind and ask for a sandwich or an omelette, not a problem they will let me have what I want.” “We have asked for fresh fruit. In fact I would like fresh fruit salad. Many of us have difficulty cutting fresh fruit so I like fruit salad it is something we can all eat without making a mess.” “Care staff are smashing. They help anyone who is having problem cutting up food or difficulty feeding themselves. I have no complaints.” We observed lunch. The staff were ready to help people discreetly and individually. We also observed snacks and drinks offered to all residents during the day. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to a complaints procedure. The people using the service and the staff working at the home are protected from abuse and their rights are protected by the management and the systems in place. EVIDENCE: We consulted four people living at the home, two care staff on duty and the manager about the way complaints were handled at the home. We asked how people were protected from abusive behaviour within the home. We have included some of the comments. The management maintained records of any complaints or concerns raised by the people at the home and how they had investigated and the lessons learnt. People living at the home said, “The staff are very kind they can’t do enough for us. Sometimes there have been misunderstandings and we are happy to sort them out ourselves.” “I have no complaints. I feel very safe here.” “ The front door is kept shut and staff let the visitors in. I am satisfied here.” The staff feedback highlighted that there had been training on Protection of vulnerable adults and safeguarding older people in recent months and that they were confident in how to deal with such situations. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 People using the 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 physical design and layout of the home encourages independence. The ongoing refurbishment is set to improve the residents’ facilities. EVIDENCE: These are some of the comments we have received about this outcome area. “The grounds of the home are spectacular. We are very lucky to live here. We hope the home gets a makeover. It looks tired and run down.” “The staff are very warm and homely. The bedrooms could do with refurbishment and some of the chairs could do with replacement. But it will do.” “The tiled dining room floor can be dangerous. When people move chairs to make room for others, the legs of the chairs get stuck between the tiles and could cause people to tumble over.” St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 18 “The carpets in the communal areas and in some of the bedrooms are very old, worn and difficult to keep clean and smell fresh. Hallam Diocese needs to upgrade this home and its furnishing.” The manager said that there were plans for refurbishment however there has been very little progress made since our last visit. We saw the laundry staff and the domestic staff working towards keeping the home clean and tidy. Two staff were able to inform us how they controlled the spread of any infection at the home. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 People using the 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 staff working at the home are trained, skilled and employed in sufficient numbers so that they are able to support the people who live at St Anne’s and contribute to the smooth running of the service. EVIDENCE: We checked four staff files, spoke to three staff who were on duty and also referred to the feedback we had received from our surveys. We were informed that the staff sickness especially short term sickness had reduced and that most of the time there was enough staff on duty. The manager informed us that he was to recruit two whole time staff to help with the staffing levels. Most staff have completed NVQ level2 and some have requested to progress to level3. These were some of the comments we received. “The care staff will do anything for us. There seems to be enough staff during the week sometimes at the weekends they are a little short.” “Depending on the peoples’ needs the management allows us to have so many staff. Usually there are 4 in the morning, 3 in the afternoon and 2 at night. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 20 Sometimes it could be useful to have 4 in the afternoon because we have had people coming to have end of life care.” “We have had training sessions since the new management took over. If I am not sure I ask the seniors or the manager. He is approachable.” Two people asked whether it was correct to have just 2 staff at night. They said sometimes people get confused and sometimes they have had people who were very ill. We explained that staffing levels should always reflect the dependency levels of people and that they needed to consult the manager. The four staff files checked complied with the Care Home Regulations 2002. The staff training has been recommenced and the three staff we spoke with said that they had attended updates on mandatory topics such as moving & handling, Health & safety, infection control and fire safety training. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36&38 People using the 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 management and administration of the home is based on openness and respect to those who use the service and those who work at the home. EVIDENCE: The present registered manager is a qualified, experienced and competent person who has had previous experience in managing care homes. During this visit we have observed that there was a clear line of accountability within the home. Those people who made comments confirmed that the management approach was respectful, transparent and included the residents in the major decisions about the home. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 22 The registered manager took on this post just over 6 months ago and he was in the process of developing a quality assurance system. However, the responsible individual continues to visit the home monthly and prepare a comprehensive report (i.e. Regulation 26 report) and monitor progress during the following visits. The administrator kept records of all financial transactions. The service users’ moneys were handled correctly and audits had been carried out by the local council. Three staff supervision files were checked and the staff on duty were consulted. We were informed that the manager continued to support the staff and offer supervision. We found evidence through direct observation and consultation with people who live and work at the home that their health, safety and welfare were promoted and protected by the management through staff training, risk management and staff supervision. Whilst checking the care plans we noticed that the staff had mentioned some notifiable incidents i.e. regulation 37 (e.g. falls, cuts, visit to the hospital following a fall) and how they had followed them through. However, these incidents had not been reported to the manager or to the CQC. We ascertained that this was due to the lack of staff awareness and informed the deputy manager who assured us that action would be taken immediately to train the staff and make them aware of notifying CQC. The staff surveys confirmed that they received induction and one person commented that the programme could be updated. We shared this information with the manager. The deputy manager said that they followed the common induction training set out by Skills for Care training standards. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x X X X X x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 3 x 2 St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 37 Requirement Notification of death, illness and other events affecting the wellbeing of residents must be notified to the CQC without delay. The care staff responsible for reporting such notifiable incidents to the manager must be made aware of the process and receive training. Timescale for action 29/09/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The staff at the home should make every effort to find out about the medical conditions of the residents so that they are able to deliver appropriate care and involve the correct health professional in the care. The management should make arrangements for the supplying pharmacist to carry out audits of the medication management at the home. The management should ensure that the medical practitioner reviews all service users’ medications every DS0000007964.V376838.R01.S.doc Version 5.2 Page 25 2. 3. OP9 OP9 St Anne`s Rest Home 4. 5. OP27 OP7 year or six months in some cases. The manager should ensure staffing levels correspond to the dependency levels at all times including the weekends and during night shifts. The daily progress recordings by the care staff during each shift need to reflect what care was delivered and the progress made by the individual according to the planned care. St Anne`s Rest Home DS0000007964.V376838.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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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