Inspection on 27/01/10 for Tarry's Residential Home

This is the latest available inspection report for this service, carried out on 27th January 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/07/2010.

Key inspection report Care homes for older people Name: Address: Tarrys Residential Home 86 Grand Drive Herne Bay Kent CT6 8LL     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: Joseph Harris     Date: 2 7 0 1 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 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Tarrys Residential Home 86 Grand Drive Herne Bay Kent CT6 8LL 01227367045 01227363363 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Tarrys Residential Homes Ltd Name of registered manager (if applicable) Mr Soomandeeren Paneandee Type of registration: Number of places registered: care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommmodated is: 19 The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) Date of last inspection Brief description of the care home Tarrys residential home came under new ownership in February 2009. The home is located on a residential road close to the centre of Herne Bay with a good range of local shops, amenities and public transport links. Tarrys provides residential accommodation for up to 19 older people and people with a Care Homes for Older People Page 4 of 29 Over 65 0 19 19 0 Brief description of the care home primary diagnosis of dementia. The home is set out over two floors the majority of rooms being single occupancy. Extensive renovations are being completed to the service including a passenger lift and additional communal space. The current fees for the service range from 325.00 pounds to 475.00 pounds per week. Further information on the facilities and services are available in the service user guide and on request from the service. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 key unannounced inspection culminated in a site visit to the service on the 27th January 2010. This was was the first key inspection conducted at the service under the Care Standards Act 2000 and the Care Home Regulations 2001. The site visit commenced at 09:30 hours and concluded at approximately 17:30 hours lasting for around 8 hours. Prior to the site visit a range of information that we have received was reviewed and examined. This included the Annual Quality Assurance Assessment (AQAA), which is a self-assessment tool completed by the service. This document focusses on the outcomes for service users and how well these are being met and also provides us with some numerical and statistical information. We also looked at any notifications received informing us about how the home has managed any untoward occurrences and any complaints or safeguarding alerts received. Information from other people was reviewed including key professionals. During the site visit a tour of the premises was undertaken and discussions held with Care Homes for Older People Page 6 of 29 the manager (who is also the registered provider), deputy manager, staff, service users, relatives and healthcare professionals. A range of documentation was examined including service user plans, health and safety records, medication records, staff personnel files and other documentation relating to the day to day running of the service. Staff were observed in their interactions with service users and care practices and a lunchtime meal service was observed. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: 5 requirements and 6 recommendations have been made as a result of this inspection process. The manager needs to ensure that documentation and processes relating to the assessment and planning of care for service users are appropriately detailed ensuring that the needs of service users can be met. This should include clear guidance for staff and the development of robust risk assessments. The home needs to ensure that healthcare issues and the outcomes of consultations with healthcare professionals are clearly documented and monitored through the care planning process. The home needs to develop an improved programme of activities that meet the individual and collective needs of the service users. It is recommended that the home employ an activities co-ordinator to develop and deliver this programme. There are extensive environmental works on-going and additional environmental issues identified during the inspection. The home needs to submit an action plan detailing the planned works and realistic timescales for completion. It is also recommended that the home provide dedicated housekeeping staff to maintain the cleanliness of the service and enable care staff to concentrate on their duties. Staffing levels should be kept under review as the needs and number of service users change. The manage should continue to develop robust quality monitoring processes and ensure that the staff training matrix is kept up to date. The service users guide should Care Homes for Older People Page 8 of 29 also be reviewed and redesigned to ensure that it is an accessible document for prospective service users and/or their representatives. 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 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users and their representatives are provided with information about the service. The needs of prospective service users are assessed, but this process needs to be reviewed. Evidence: The home has developed a statement of purpose and service user guide. Both documents contained all of the information required describing the services and facilities. The service user guide has not been designed in a user-friendly manner. It is a long document that uses some complicated terminology. The service user guide should be redesigned to ensure it is accessible to prospective service users and their representatives. The home has a process in place for the assessment of prospective service users needs. The pre-admission assessments for one recently admitted service user were examined. The manager stated that the aim is to visit a prospective service user in their own home or place of residence prior to them visiting the service. Background Care Homes for Older People Page 11 of 29 Evidence: information from care managers/referrers is sought. The home has an assessment tool that covers all of the key areas of need. The assessment examined had been completed to an adequate standard, but lacked significant detail about complex needs and the impact that these may have on the delivery of care and support to the individual. An example of this was identified when describing the individuals mental state and condition. The entry in the assessment stated, X can become confused at times over dates and times, but is able to understand. The assessment process needs to be reviewed to ensure that suitable information is gained to determine that the service users needs can be met by the home. The manager stated that in the case of emergency referrals all assessment information and admission processes are carried out within 72 hours of admission. The home does offer a respite care service on an informal basis and does not have dedicated intermediate care facilities. Respite places are offered as and when vacancies arise in the service. It was reported that assessment processes are followed for people requiring short-term care. No service users on respite care were resident in the home at the time of the site visit, therefore this standard could not be fully assessed. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning and risk assessment processes need to be improved. Evidence that healthcare needs being addressed and referred needs to be documented. Medication processes are well managed. Evidence: Three individual service user plans were examined during the course of the site visit. In all cases plans of care had been developed, but the level of guidance for staff contained within the plans needs to be further developed. An example of this was X is unable to wash herself and needs the assistance of one or two staff depending on her mood. The plans should clearly identify the need and what actions staff need to do to support the individual. The plans lacked a person-centred approach and need to reflect individual requirements to a greater extent. There was evidence that plans of care had been reviewed, but no signature had been included to show who was responsible for reviewing the plans. There was no evidence in the plans examined of any service user or family involvement. A family member spoken to confirmed that they had not seen any plans of care, but neither had they asked to see them. One of the care plans had not been updated to reflect the significant changing needs of the individual. Care Homes for Older People Page 13 of 29 Evidence: Risk assessments are in place, but are similarly lacking in detail and require further development. There is evidence that service users have received input from healthcare professionals such as GPs and district nurses. The home keeps a record of healthcare input, but examples were identified where the healthcare needs of service users have not been followed through. A pressure area was identified by care staff for one individual, but there was no evidence to show that this had been monitored or referred to a healthcare professional. The home has a system for recording healthcare appointments and outcomes, but this is not being fully completed in all circumstances. A discussion was held with a district nurse during the visit who stated that care staff respond and listen to advice, following through actions as requested. There is evidence that complimentary healthcare needs such as dentists, opticians and podiatrists are involved with service users care and that residents have access to these services. All service users are registered with local GPs. Medication records and storage facilities were examined. The records viewed had been well maintained and administration records were complete and up to date. Policies and procedures are in place covering medication issues. The storage facilities are adequate for the needs of the service, although there are plans to establish an improved medication room as part of the extensive refurbishment planned for the home. Staff administering medication have received appropriate training. Service users stated that care staff are respectful of their privacy and dignity and staff spoken to demonstrated a good understanding of these issues. A family member stated that care staff had been respectful of their mothers wishes. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A structured programme of activities needs to be developed. Visitors are able to attend the home at all reasonable times. Service users are offered a healthy, balanced diet. Evidence: Records of activities are maintained in service user files, but show that there is a limited activities programme in place. Care staff stated that a group activity is provided every afternoon, but according to the records these were limited to music, TV, reminiscence and chatting. Staff stated that depending on who is on duty in the afternoon determines what activity is provided. There was no record of any visiting entertainers or trips out other than with family members. The manager is developing an accessible garden area in order that service users can spend time outside if they wish. The home needs to establish a varied programme of activities ensuring that all service users have the opportunity to participate in group or individual pastimes. It is recommended that an activities person is employed to plan and deliver arranged activities. Service users and relatives stated that visitors are able to attend the home at all reasonable times. There is sufficient space for people to meet in private should they wish to do so and further space is planned as part of the refurbishment programme. Care Homes for Older People Page 15 of 29 Evidence: One relative stated that they have not been restricted in the times that they visit. They went on to state that some staff are very welcoming and attentive, but at other times they are not made to feel so welcome. The home does not act as a financial appointee for any service users and finances are managed by people independent of the service. Residents are able to bring in personal possessions if they wish. Policies and procedures are in place governing access to records. All service users spoken to stated that the food in the home is of good quality. One person said, the food is excellent, i had a lovely chicken pie today, it was very nice. The home operates a 4 week rolling menu and service users are offered choices at each mealtime. However, none of the residents spoken to were able to state what meal they were due to have for lunch and the menu board was out of date. The home employs two cooks, one of whom is on duty each day. The kitchen, it was stated, is due for refurbishment and additional food storage space planned. Some food was left undated in the refrigerator. The kitchen would benefit from a deep clean and some service require treatment to ensure infection control measures. The lunchtime service was observed. Service users were offered choices and there was a relaxed and unhurried atmosphere. There are plans to develop a new dining room in the planned extension. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home listens to and acts upon complaints and concerns. Processes are in place to protect service users from abuse. Evidence: The home has a complaints procedure in place that is included in the service user guide and on display in the service. A number of residents spoken to stated that they would feel comfortable raising a concern should they need to. The manager stated that no complaints have been raised since the service came under new management. There is a complaints book in place. It was recommended that a complaint file is introduced ensuring confidentiality and recording the outcome of any complaints made. Two complaints have been received directly by us, the details of which formed part of this inspection process. Both complaints were received anonymously. There are policies and procedures in place addressing adult protection and abuse awareness issues. A copy of the Kent and Medway Adult Protection protocols is available in the home. Staff have received instruction through induction processes and additional training in adult protection. One adult protection alert has been raised in connection with the service and currently remains under investigation. The individual this relates to is no longer resident in the home. This issue was briefly discussed with the manager. Care Homes for Older People Page 17 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is suitable for the needs of the service users, but the planned improvements will be of benefit to the service. Evidence: The home is situated on a residential road close to the town centre of Herne Bay. There is street parking available nearby. Herne Bay has a good range of public transport links and other amenities. The home is arranged over two floors and is currently undergoing extensive refurbishment and building works. The service came under new ownership in February 2009 and improvements have been made to the environment in this time. These include a new assisted bathroom and fire detection systems. When the current building work is completed additional communal space will be created along with a new laundry area, a passenger lift, medication room, storage space and an accessible garden. A tour of the premises was undertaken. There is a reasonably sized dining area and an open lounge split into two sections. There are bedrooms on the ground and first floor with a stair lift aiding access to the first floor. Some bedrooms were viewed that are suitable for the needs of the service users. Residents are able to bring in personal possessions. Two service users spoken to said that they are happy with their bedrooms. Toilet and bathing facilities are available throughout the home and a new disabled bathroom has been developed on the first floor with an assisted bath. It was Care Homes for Older People Page 18 of 29 Evidence: noted that some toilets and bedrooms do not have locks, which should be addressed. One relative stated that the cleanliness of the service could be improved. On the day of the visit the home was generally clean and hygienic although this could be improved. The current laundry area is relatively small, although it was reported that all equipment is in good working order. There is a lockable COSHH cupboard in the lounge area. This cupboard was in a disorganised state and the key is not kept in a secure location. The kitchen would benefit from a deep clean and the additional storage space planned will be of benefit. Some exposed and untreated wood in the kitchen and laundry areas presents a risk to infection control. It was reported that the service meets the requirements of the environmental health and fire safety departments. Care Homes for Older People Page 19 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff receive the training that they require to fulfill their duties and recruitment processes are followed. Staffing levels need to be kept under review. Evidence: The home currently operates with 3 care staff in the morning and 2 care staff in the afternoon/evening. There are 2 waking staff on night duty. The manager stated that the staffing levels have recently been increased to 3 in the afternoon in response to the needs of one service user. The deputy manager works throughout the day in addition to these staff. The home employs a full time and a part time cook, who cover the service throughout the week between them. A maintenance man is also employed who also completes some housekeeping duties. It was recommended to the manager that dedicated housekeepers are employed to ensure the on-going cleanliness of the service and to free care staff to concentrate fully on their duties. The home would also benefit from having an activities co-ordinator to develop and deliver a varied programme of activities. The current staffing levels are adequate for the needs of the service, but the manager should keep these under constant review as the needs and numbers of service users change. Discussions were held privately with a number of staff on duty. All demonstrated a good understanding of the needs of the service, their roles and responsibilities. One staff member said, things are changing for the better, but there is still improvements we can make. Staff spoke knowledgeably about service users needs and were Care Homes for Older People Page 20 of 29 Evidence: observed to be respectful in their interactions with service users. 6 care staff have achieved National Vocational Qualifications at level 2 in care and some staff have now progressed to the level 3 award. The home has achieved the 50 percent target for NVQ qualified staff and the manager stated that this will be exceeded. All new staff are expected to undertake NVQs. Three staff personnel files were examined all of which contained the required recruitment information including two written references, CRB and POVA checks, proof of identity and employment history amongst other records. All new staff work through an induction programme based on the Common Induction Standards. It was recommended that the evidence documented should reflect the knowledge and understanding gained by staff going through this process. The organisation has a training manager who, it was reported, holds relevant teaching qualifications to deliver much of the mandatory training. The homes training matrix was examined, which needs to be updated, but does provide evidence that the majority of staff have completed all required training. Additional courses covering adult protection, abuse awareness, dementia care and medication amongst other courses are provided. A training schedule has been developed for 2010. Care Homes for Older People Page 21 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is experienced and well qualified. Quality monitoring processes need some further development. The health and safety of service users is maintained. Evidence: The manager/owner of the service is an experienced qualified nurse, who has been involved in the care sector for many years. He has managed and owned social care services in the Kent area for a number of years. He has achieved all of the required qualifications for his role. He is assisted on a day-to-day basis by the deputy manager of the home who has achieved an NVQ level 3 and aims to begin her NVQ 4/RMA in the near future. Some quality monitoring processes have been established. There is evidence that improvements have been made to the environment and other developments in this area are on-going. It is recommended however, that monitoring systems are formalised to ensure that all aspects of the service are regularly audited and action plans developed. The manager stated that there are plans to issue satisfaction surveys to residents, relatives, professionals and staff in the near future. Care Homes for Older People Page 22 of 29 Evidence: The home provides a safekeeping service for resident finances, but does not take a financial appointee role for any individuals resident in the home. Records are maintained of all incoming and outgoing transactions and of personal possessions brought into the home. All records relating to health and safety issues were up to date and in place. Service safety certificates have been issues covering electrical wiring, gas safety and other utilities and equipment. Policies and procedures are in place covering safe working practices. Fire safety and accident records are maintained. It was reported that the home complies with all relevant health and safety legislation. A number of issues were identified, such as unlabelled food and an insecure COSHH cupboard, during the course of the site visit all of which were rectified and addressed. Care Homes for Older People Page 23 of 29 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 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The registered person shall not provide accommodation to a service user at the care home unlessa) the needs of the service user have been assessed by a suitably qualified or suitably trained person. The pre-admission assessment process needs to clearly identify the needs of the service user. 10/03/2010 2 7 13 (4) The registered person shall ensure c) unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The home must ensure that risk assessments clearly identify all perceived risks and detailed guidance is provided to minimise these risks. 11/03/2010 Care Homes for Older People Page 25 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 7 15 (1) Unless it is impracticable 11/03/2010 to carry out such a consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. (2) The registered person shall a) make the service users plan available to the service user. b) keep the service users plan under review. The home must ensure that service user plans provide clear guidance to enable staff to meet needs reflecting changes in care. 4 8 13 (1) The registered person 11/03/2010 shall make arrangements for service users b) to receive where necessary, treatment advice and other service from any healthcare professional. The home must ensure that healthcare issues are monitored, recorded, addressed and referred to Care Homes for Older People Page 26 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action the appropriate health care professionals. 5 12 16 (2) The registered person 11/04/2010 shall having regard to the size of the care home and the number and needs of the service users n) consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. The home must develop a varied and structured programme of activities to meet the individual and collective needs and wishes of the service users. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 1 12 16 To develop the service user guide ensuring that it is accessible to service users and/or their representatives. To employ an activities co-ordinator responsible for the planning and delivery of activities. To introduce a system of managing complaints that ensures confidentiality and identifies agreed outcomes. Care Homes for Older People Page 27 of 29 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 4 5 6 27 30 33 To keep staffing levels under review and provide additional ancillary staff support. To ensure that the staff training matrix is kept up to date. To continue to develop robust quality monitoring processes. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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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