Inspection on 29/03/10 for Anita Jane`s Lodge

This inspection was carried out on 29th March 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Anita Jane`s Lodge 14/04/09

Anita Jane`s Lodge 24/11/08

Anita Jane`s Lodge 29/04/08

Anita Jane`s Lodge 14/11/07

Anita Jane`s Lodge 09/07/07

Anita Jane`s Lodge 15/06/06

Anita Jane`s Lodge 22/09/05

Anita Jane`s Lodge 12/04/05

Anita Jane`s Lodge 07/10/04

Anita Jane`s Lodge 05/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 03/06/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Anita Jane`s Lodge 126/128 Uppingham Road Leicester Leicestershire LE5 0QF     The quality rating for this care home is:   zero star poor 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: Keith Williamson     Date: 2 9 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © 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 Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Anita Jane`s Lodge 126/128 Uppingham Road Leicester Leicestershire LE5 0QF 01162768071 F/P01162768071 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Samalodge Limited Name of registered manager (if applicable) Mrs Lois Fletcher Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The home may continue to accommodate a named person who falls within category LD as detailed in variation application number 49808. Date of last inspection Brief description of the care home Anita Janes Lodge is a care home providing care for sixteen adults with mental health difficulties, in addition it provides a respite service (short stay) for up to one service user and offers a day care service. There are eight single and four shared bedrooms all without en-suite facilities, located on the ground and first floor. There are bathing/showering and toilet facilities on both the ground and first floor. Communal areas consist of a lounge and dining room/recreational room and kitchen on the ground floor. Anita Janes Lodge has a large rear garden, which incorporates a patio area. Information about the service can be found on site in documents referred to as the Statement of Purpose and Service Users Guide. A copy of the latest published Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 16 1 4 0 4 2 0 0 9 Brief description of the care home report from the Commission for Social Care Inspection can be found in the entrance lobby. Fees at the home are currently £309 per week. Care Homes for Adults (18-65 years) Page 5 of 31 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: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections is on outcomes for people who use the service and their views of the services provided. The main method of inspection used was case tracking which involves selecting a sample number of people and tracking the care they received through talking with them where possible, looking at their records and accommodation, in this case three people were chosen. This visit took place over one day, commencing at 9.30pm and took seven hours to complete. An opportunity was taken to observe the people, talk with the Manager and staff, look around the home, and view records, policies and care plans. Information was also obtained from the Annual Quality Assurance Assessment (AQAA), which gives information on the people, home and the staff group. Surveys were sent to people and staff, though comments were received from staff and have been added to this report. Care Homes for Adults (18-65 years) Page 6 of 31 Three staff were spoken with, and six of the residents were seen, and their exchanges with the staff group observed. The quality rating for this service is 0 star. This means the people who use this service experience Poor quality outcomes. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: The AQAA could be far more detailed, with a greater depth of information. Health and safety checks and the corresponding records, must be regularly maintained. Medication administration and the auditing of what medicine is in stock, must be more Care Homes for Adults (18-65 years) Page 8 of 31 detailed to ensure safety. All files could have up to date copies of residents photographs. Door locks must be repaired to ensure peoples privacy and dignity. Complaints information must include the correct details to enable people to make a complaint. Contracts should be put in place for any restrictions placed on people. T Where monitoring of people health is necessary, staff could write about this on as regular a basis as necessary. Further information could be sought to offer a wider range of suitable activities. Staff records could include an information sheet detailing dates of received documents through the recruitment process. Comments collected from surveys sent prior to, and those made on the day included. What the staff think the home could do better The home needs it own mini bus to get the clients about to doctors, hospitals, days out and shopping, and more staff. The home manager X works very hard 7 days a week, has a hard work staff, who work hard getting If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users, and their representatives, can be assured that the homes admission processes will enable them to make a decision as to whether the home could meet their needs and aspirations. Evidence: The staff have developed a statement of purpose and service users guide, which meets the needs of the current group of people in the home. The information is available in a format which allows people in the home to understand it. The complaints procedure is also included in the guide, however this needs to be updated with the latest information to allow people access to the correct contact information. People have their needs assessed prior to moving into the home, though there has been no one admitted since the last key visit. The assessments seen on both peoples files, allowed a plan of care to be put in place. Care Homes for Adults (18-65 years) Page 11 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of detail in the care plans and risk assessments leaves people at risk in the home. Evidence: We looked at the care records of people. We did not find them to be descriptive of the care and support needed by people. Care plans are compiled with each resident, and this recognises what needs people have. We saw that the instruction for staff to enable care to be followed through appropriately was not in place. For instance one person required their moods to be monitored, yet there was no ongoing monitoring recorded by staff. Care plans are agreed with the Service User or a representative, some being signed to agree the care and intervention offered. Records of what people do and what care is offered on a daily basis are kept securely. We saw that staff have an understanding of the risks relating to each person who lives there, and have put some risk assessments in place to reduce these risks. However there are areas which have not been identified and staff do not have the necessary Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: information to ensure people are made aware how to stay safe. Care Homes for Adults (18-65 years) Page 13 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are involved in the day to day running of the home and can influence their lifestyle and choices. Evidence: The resident group agreed that they participate in activities both in and out of the home. Some of the residents are enabled to go out on their own, and attend local day centres and colleges. Staff indicated they have time to assist with activities and pastimes in the home, one adding we have time to sit and talk to people. Visiting is largely unrestricted, with people being allowed into the home at reasonable times of the day. The case tracked residents had some information in their care plan regarding how they would like to spend their leisure time. This could be greatly enhanced and would offer staff a better knowledge of the persons previous life history. Residents agreed they were involved in the meal and menu choices, and decide what Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: should be included at the regular residents meeting. Staff have a list of dietary likes and dislikes, and use these when preparing meals. Comments collected from surveys sent prior to, and those made on the day included. What the residents think the home does well Cooking Support me Four residents returned forms with no comments, but ticked the boxes to indicate the general satisfaction with the home. What the staff think the home does well We support vulnerable adults to live independently by equiping them with day to day living skills, personal hygiene etc. What the staff think the home could do better The home needs it own mini bus to get the clients about to doctors, hospitals, days out and shopping, and more staff Care Homes for Adults (18-65 years) Page 15 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recording around personal health care and medication is poor leaving residents at risk in the home. Evidence: We looked at how medication is managed in the home. We saw that there are not adequate safeguards in place to ensure medication is administered appropriately. The records for ordering, recording and disposal of medicines are held separately, and would not allow for accurate audits of medication were they in place. The record of what medication is given to what resident at what time (MAR chart), is not completed accurately. There is an ongoing issue of staff not signing appropriately for what medicines were given and this was managed by paperwork at the front of the mar charts, indicating what staff had omitted their signature. This is not adequate as it does not deal with the issue of staff continually missing signatures. Medication audits, where staff ascertain if the prescribed dose has been given over a period of time, are not completed regularly. Medication is delivered in a bulk form, and makes any auditing a much more time consuming process. We looked at controlled medicines, these are medicines that need to be treated in a special way. Staff were unaware where to find the medication that had been delivered, which again highlights a Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: problem with the security of the ordering and receipt system. Some of these tablets needed to be divided, there was no hygienic or accurate system in place to do this, and the way the tablets were broken did not offer the resident a consistent dose on a regular basis. Healthcare is in place with evidence of recent health checks with the General Practitioner, and visits from other health professionals. These are arranged to suit the residents and appointments are arranged to suit individual peoples preferences. Monitoring of some conditions needs to be better, with a lack of recording on a regular basis. Personal support is offered when needed. Residents are largely self caring most only require prompting to undertake personal care tasks. There is a mixed staff group which allows intimate care to be supervised, and when necessary assisted by staff of an appropriate gender, and reflects the choice of the resident. There is however an issue over peoples privacy and dignity, with a sample of toilets and bathing facilities not offering adequate privacy to people. Comments collected from surveys sent prior to, and those made on the day included. What the staff think the home does well We support vulnerable adults to live independently by equiping them with day to day living skills, personal hygiene etc. It gives the best are to the service users Care Homes for Adults (18-65 years) Page 17 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of accuracy on the contact details within the complaints literature leaves people without a clear system to report on concerns. Evidence: There is a complaints policy that people are aware of, and is available in the home. Complaints information is made available to people prior to moving into the home, and is contained in the Service User Guide, however the contact details need to be updated as they are out of date. People spoken with at the visit stated they would feel happy about raising issues with the staff. There have been no complaints recorded by the home since the last visit. There have been no complaints or safeguarding issues forwarded to the Care Quality Commission. Staff are aware what to do and who to report onto, issues around safety and protection of the people in the home. Care Homes for Adults (18-65 years) Page 18 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of proper locking facilities does not ensure peoples privacy and dignity is maintained. Evidence: There has been considerable efforts to improve the decor in the in the home is since the last visit. There is no plan in place to refurbish or replace worn items of furniture, fixtures and fittings, and issues are dealt with as they arise, and when funds allow. Toilets and bathing facilities do not offer people adequate privacy, as they do not lock. The staff are aware of cross contamination issues, and are supplied with the appropriate protective clothing to assist in protecting residents. The laundry walls and floor adequate to protect people against cross contamination or cross infection issues. Residents clothes are laundered separately, again further protecting their wellbeing in the home. Care Homes for Adults (18-65 years) Page 19 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the homes recruitment practices, and training programme. Evidence: Staff are provided with a training programme that commences at the point of induction, and leads to the option of a professional NVQ in care. The National Vocational Qualification is a nationally recognised qualification in care. A new member of staff gained a university based professional qualification before commencing work at the home. Staff have periodic training updates in health and safety, fire and evacuation and other statutory training required by law. The recruitment process is good with staff going through a standard process of application form and references being obtained prior to interview. Successful applicants then have a povafirst and CRB (Criminal Records Bureau) clearances prior to starting work. These are required by law to allow staff to work with vulnerable people. Supervision is undertaken periodically, this is where staff are overseen with their working practices. This could be expanded greatly and this was discussed with the manager on the day. Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: What the home does well The home manager X works very hard 7 days a week, has a hard work staff, who work hard getting Care Homes for Adults (18-65 years) Page 21 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Deficiencies in the quality of information produced in the home, and poor quality of monitoring by the responsible person leaves people at risk in the home. Evidence: The registered manager has many years of experience in the care industry. The quality assurance for the home is ongoing with a questionnaire put out to residents, their relatives and staff on a regular basis. The residents and staff meetings also add to the overall quality assurance within the home, where people are asked on how the home could be improved. The AQAA document which is completed annually by the manager was poorly completed and did not fulfill the need for accurate information prior to the visit. Some information was incorrect and some missing. Staff assist in the health and safety checks which are periodically undertaken. The staff continue to complete weekly fire alarm and monthly emergency lighting tests. The fire risk assessment was seen and a recent review had been commenced. There was a requirement at the last inspection regarding bedroom doors being able to close properly. Though this work had been completed, a bedroom carpet had been fitted to Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: a bedroom three weeks prior to this visit. Again the door was not adjusted properly and this resulted in the fire precautions to that room, being ineffectual. This puts the lives of people in the home at risk. The door was adjusted on the day of the inspection, which then made the area safe. We asked to check the monies that the home held on behalf of two residents, this was accurate and agreed with the paper record held. We looked at the policies and procedure documents. These policies are comprehensive and cover a wide range of topics. However thee are not backed up by procedures that staff could follow to ensure consistency in working practices and ensure safety of people in the home. For example the policies relating to the administration of medication only included a brief description about residents self administering medicines. This did not include a procedure to enable staff to confirm they were undertaking this task safely. Records kept by the staff which charts the progress and protection of people are held securely in the home. Some residents require to have periodic monitoring performed, this however is not appropriately reflected in the documents that were seen. Comments collected from surveys sent prior to, and those made on the day included. What the staff think the home does well Good management and team working Care Homes for Adults (18-65 years) Page 23 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 20 13 Secure storage must be put in place for controlled drugs To meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody Amendment) Regulations 2007 Original timescale of 31/03/02009 not met. 30/04/2009 2 24 23 The registered person must ensure that appropriate fire warning systems are fitted throughout the home. To comply with the requirements made by the fire authority on 09/01/2009 and ensure the ongoing safety of people living in the home. 30/04/2009 3 24 23 The registered provider must 30/04/2009 ensure that all fire doors fit and close correctly. To comply with the requirements made by the fire authority and to ensure the ongoing safety of people living in the home. 4 31 23 The registered provider must 15/05/2009 ensure that all fire doors fit and close correctly. To comply with the Care Homes for Adults (18-65 years) Page 24 of 31 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 requirements made by the fire authority and to ensure the ongoing safety of people living in the home. 5 42 13 The registered provider must 31/05/2009 ensure that the fire risk assessment is updated. This is to meet the requirements of the local fire authority and to ensure the ongoing safety of people living in the home. Care Homes for Adults (18-65 years) Page 25 of 31 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 9 13 The registered person shall ensure that any activities which service users participate are so far as reasonably practicable free from avoidable risks. This is to ensure people are aware how to keep people safe. 07/05/2010 2 20 13 The registered person shall 07/05/2010 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This is to ensure staff have the appropriate medication to give to people. 3 22 22 The registered person shall establish a procedure for considering complaints made to the registered person by a service user or 07/05/2010 Care Homes for Adults (18-65 years) Page 26 of 31 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 person acting on the service users behalf. The complaints information has the correct contact details of CQC. 4 26 23 The registered person shall 30/04/2010 having regard to the number and needs of the service user ensure that equipment provided at the care home for use by services users or persons who work at the care home is maintained in good working order. This is to ensure the privacy and dignity of people in the home. 5 39 24 At the request of the Commission, the registered person shall supply to it a report, based upon the system referred to in paragraph (1), which describes the extent to which, in the reasonable opinion of the registered person, the care home. This is to ensure the AQAA document is completed comprehensively with all the information required. 6 40 18 The registered person shall, having regard to the size of the care home, the 07/05/2010 07/05/2010 Care Homes for Adults (18-65 years) Page 27 of 31 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 statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users This is to ensure policies and procedures are up to date and comprehensive to enable staff to follow them and ensure residents safety. 7 41 17 The registered person shall ensure that the records referred to in paragraphs 1 and 2 are kept up to date. Where records need to be kept for monitoring purposes that they are periodically checked to ensure the recording is in place and up to date 8 42 23 Subject to regulation 4, 3, the registered person shall not use premises for the purposes of a care home unless they take adequate precautions against the risk of fire, including the provision of 16/04/2010 07/05/2010 Care Homes for Adults (18-65 years) Page 28 of 31 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 suitable fire equipment and provide adequate means of escape. This is to ensure the safety of those in the home 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 1 The contact details in the Statement of Purpose and Service User Guide, could be updated to allow people the accurate information and enable them to complain to the appropriate authorities. It would be advantageous to draw up individual contracts for any restrictions placed on people. This would enable individuals to ensure they were being fairly treated. Where monitoring of people is requested, staff could write in the daily report about this on a regular basis. Further information could be sought to assist staff to offer a wider range of suitable activities, linked to peoples past experiences and preferences. A tablet splitter could be obtained, this would enable staff the appropriate means of dividing tablets. Residents photographs could be displayed on the medication records and main files, this would aid in ensuring medication was administered to the appropriate person. Regular audits of the medication system would ensure errors and omissions were found promptly. The complaints information could also include details of social services, voluntary bodies and advocates which would assist people wishing to make or register a complaint. The quality of staff records could be enhanced where Page 29 of 31 2 3 3 4 6 14 5 6 20 20 7 8 20 22 9 34 Care Homes for Adults (18-65 years) 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 records could include an information sheet detailing dates of received documents through the recruitment process. 10 11 36 39 The quality and frequency of supervision could be increased to enable staff to develop in their role. When the people visit the staff group out of hours, to observe practice, it would be useful to record the time date and content of the visits for quality purposes. Care Homes for Adults (18-65 years) Page 30 of 31 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. 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