Inspection on 11/01/10 for Beechwood Hall

This inspection was carried out on 11th January 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 11/04/2010.

Key inspection report Care homes for older people Name: Address: Beechwood Hall 34 Beechwood Gardens Lobley Hill Gateshead Tyne and Wear NE11 0BY     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: Alan Baxter     Date: 1 1 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 34 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 34 Information about the care home Name of care home: Address: Beechwood Hall 34 Beechwood Gardens Lobley Hill Gateshead Tyne and Wear NE11 0BY 01914605899 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Humayun Saleem Name of registered manager (if applicable) Mrs Joan Short Type of registration: Number of places registered: care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The registered person may provide the following category of service only: Care Home Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category(ies): Dementia, not falling within any other category - Code DE, maximum number of places: 17 The maximum number of service users who can be accommodated is: 17 Date of last inspection Brief description of the care home Beechwood Hall is a care home for older people who suffer from Dementia. It is situated in a residential area in Lobley Hill, Gateshead. It is reasonably close to local shops and transport. There are 17 single bedrooms, two assisted bathrooms, a large lounge and a dining area. The weekly fees range from £424 to £430. Care Homes for Older People Page 4 of 34 Over 65 17 0 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 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 is an overview of what the inspector found during this inspection. The quality rating for this service is zero star. This means that service users experience poor quality outcomes. This was the first key inspection of the home since it was newly registered under new ownership in September 2009. Before this inspection, we looked at any information we have received about the home since that date. We looked at how the service has handled any concerns or complaints since then. We looked at the views of the proprietor and the manager as to how well they are Care Homes for Older People Page 5 of 34 caring for the residents, and we also looked at the views of the residents and their relatives. An unannounced visit was made to the home on the 11th January 2010. This took nine hours in total. During the visit we talked with some of the people who live in the home, and also with some of the staff, and with the manager and proprietor. We looked at information about the people who use the service, and how well they are being cared for. We looked at other information that must be kept. We checked that the staff have the knowledge, skills, training and experience to meet the needs of the people they care for. We looked around parts of the building to make sure that it was safe, clean and comfortable. We told the proprietor and the manager what we found. Care Homes for Older People Page 6 of 34 What the care home does well: What has improved since the last inspection? What they could do better: The information given to new and prospective residents needs to be updated. All residents need to be given a contract by the new proprietor. The manager needs to receive a full assessment of needs from social workers who Care Homes for Older People Page 7 of 34 refer new residents to the home. Care plans need to be drawn up for each identified need, and need to be more detailed. Actions taken to meet the health care needs of residents need to be better recorded. Medication records need to be clearer, and problems identified and addressed quickly. All forms of feedback need to be recorded. A clear policy on how residents are to be protected from any possible abuse is needed, and staff need the training necessary to go with this policy. Staff recruitment practices needs to be tightened up. Staff need to be brought up to date with a wide range of training. Clearer management of the home is needed. Proper quality assurance systems need to be introduced. Better accounts must be held in the home. Staff need to be given regular supervision. Fire alarms and extinguishers need to be checked more regularly, and clearer records of staff fire safety training kept. The homes fire risk assessment needs to be updated and acted upon. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 34 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 34 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. The information available to residents and their families is not up to date. Assessments are not being received from the referring social workers, and in-house assessments are not being carried out in a thoughtful way. Evidence: The home is currently updating its statement of purpose and service user guide. It must include the criteria for admission, as currently it does not state that the home is registered to take only elderly persons suffering from Dementia. It must also refer to the current regulator (i.e. the Care Quality Commission), with appropriate address and contact numbers. It must also be checked to make sure that it accurately reflects the current policies and practices of the home. All residents have a written contract (although not all sections have been completed for some people). The registered proprietor is introducing new contracts which will reflect the recent change of ownership of the home. Care Homes for Older People Page 10 of 34 Evidence: The manager said that she is not usually given a full assessment of needs by the referring social worker. Some residents care records contained a social worker care plan, but none had a comprehensive assessment document carried out by the social worker. The manager was advised not to consider any placement without this essential documentation. The manager carries out an assessment of needs of every person who wishes to be admitted to the home. This covers personal care needs, a mental health assessment, moving and handling requirements, and a range of risk assessments, including nutrition and falls. This is normally carried out in the persons own home before admission, but in one example seen it was carried out the same day as the person was admitted. The manager also carries out a post admission assessment, using the same range of assessment documents. However, there was evidence that this is sometimes rushed, and not carried out in a thoughtful way. In the case of the person referred to above, the post admission assessment was carried out on the same day as the pre-admission assessment, which is pointless. Nor was there evidence that assessments are being periodically reviewed. Documentation regarding skin integrity, including the use of body maps, needs to make clear what areas of the body were actually observed, as they are otherwise potentially misleading. Care Homes for Older People Page 11 of 34 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The records of the care being given are not sufficiently detailed, nor are they kept up to date. Although the privacy and dignity of the residents is protected, their medication records do not always give enough information about the administration of medicines, and medication practices do not fully protect residents from harm. Evidence: The format used for care planning allows for only one plan for each area of need assessed, however many needs are identified under each heading. Care plans are not in place for every identified need. A particularly significant omission was the total lack of care plans to meet the mental health and behavioural needs of people suffering from Dementia, which is the sole category of care for which the home is registered. Where care plans are in place, they are not sufficiently detailed, lack clarity, and there was evidence that they had been completed in a hurry. There was also evidence that staff do not always study the care plans (although one recently appointed member of Care Homes for Older People Page 12 of 34 Evidence: staff said that reading the care plans had been a useful introduction to the residents). There was no evidence that care plans are reviewed or updated in line with changing needs or circumstances. General health care needs were being met, although there was poor documentation of this on some files. This is disappointing, when, as one relative commented, The care is first class..... the manager has instigated a lot of improvements for the comfort of the residents. The mental health care needs of residents are not being properly assessed or met, and this reflects an urgent training need for both the manager and the staff in the home. Nutritional screening is carried out. The Medication Administration Record (MAR) showed that the codes to be used when a prescribed medicine is not given are not being used properly, and that the MAR lacked clarity. The MAR also showed that one resident did not receive a range of prescribed medicines between 6/1/10 and 10/1/10, as the medicines had run out; and that in December, the same resident was not administered two prescribed medicines because they were recorded as being missing. The manager was not aware of these discrepancies, and had taken no action regarding them. Handwritten entries in the MAR were not always being signed. Medicines are stored in a suitable drugs trolley, and the manager has arranged for this to be secured to the wall when not in use. Controlled drugs are securely stored and are recorded in a suitable record book. However, there was no mechanism for counting controlled drugs, and staff are signing the book without always having physically counted the remaining drugs. Staff protect the privacy and dignity of the residents. They are given personal care and any health care only in the privacy of their own bedrooms. Where an individual is unable to choose his or her own clothing, staff ensure that they dress the person appropriately, and with colour co-ordination. Care Homes for Older People Page 13 of 34 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. Residents have good contact with their families and enjoy the meals in the home. Social activities for residents are improving. Evidence: There is a daily activities programme. This identifies one activity per day, including weekends. The programme includes reminiscence, board games, cooking, indoor gardening, knitting, armchair exercises, charades, hand ball, skittles and film shows. The activities diary shows that, although the displayed programme is not being slavishly followed, it does form the basis for what happens in the home. The manager reported that the culture of regular social activities is becoming well established, and staff are increasingly joining in. Since the new proprietor took over the home in September last year there has been an improvement in social activities, and visiting entertainers have been introduced. The proprietor has also stated that he will pay for bus hire for trips out. However, the home is hampered by having to fund raise for money for social activities, and it was recommended that the proprietor allows the manager a regular monthly budget to meet the social needs of the residents. Care Homes for Older People Page 14 of 34 Evidence: Although group activities have improved, there is insufficient attention paid to the individual social and cultural needs of each resident. The part of the pre-admission assessment that looks at social and cultural needs is not being thoughtfully completed (for one person, the section said, None). Although there is a list of suggested activities for a new resident to tick, this information is not being used to draw up detailed individual social care plans for residents. The manager reported that most residents have good support from their families, and that most get regular visits. Visitors are welcome at all reasonable times, but residents also have the right to refuse to see a particular visitor. The local shops are fairly close, but most residents do not often get out to them. Several residents were refused when they clearly stated that they wished to leave the building. None of the care files seen had a proper assessment of mental capacity under the Mental Capacity Act, as is necessary before they can be legally refused permission to leave the home. Residents are, however, able to choose when they get up and go to bed, what to wear and whether or not to join in activities. Residents have a degree of choice as to their meals, in that there is an alternative offered if they dont want what is on the menu. The chef agreed to make a virtue of this option by putting the alternative meal on the menu, to allow all the residents to make a choice. Residents said that they enjoy their meals, and the food looked well-presented and appetising. Two residents spoken with said that the portions they are given are too large, which they found off-putting. It was advised that residents are given a clearer choice of portion size, and that the manager should consider using tureens for serving vegetables etc. at the table, rather than ready-plated from the kitchen. Residents are offered cereals, porrage and toast for breakfast. Lunch was chicken pie, mashed potatoes , broccoli and carrots, with home made rice pudding. The tea meal was to be homemade vegetable soup and bread roll, with chocolate mousse to follow. Hot drinks were offered with the lunch meal. One residents soft diet was nicely prepared and well-presented. Tables were generally well-set, but the table cloth was too small for the largest table, Care Homes for Older People Page 15 of 34 Evidence: which also lacked salt and pepper condiments. The issue of getting residents closer to the table, so that they can access their food easier and be less likely to drop food on themselves, was discussed with the manager. This is particularly important for people who use wheelchairs at the dining table. Care Homes for Older People Page 16 of 34 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are not being protected by the policies and practices in place regarding complaints and protection. Evidence: The home has a suitably positive complaints policy, which welcomes comments and promises a full, thorough and open discussion of any issues raised. However, it needs to be updated to refer to the current proprietor, and to the current regulator (CQC). The most recent entry in the complaints record was dated 2006, which indicates that the minor complaints or expressions of concern to be expected in all residential establishments are not being recorded. The manager was not able to provide a safeguarding of vulnerable adults policy. She said that the previous owner had removed all the homes policies when he sold the home in September 2009, and that she was still in the process of drawing up new policies. However, she was not able to describe a suitable response to such an allegation, and must ensure that she and her staff receive the appropriate training. The failure of the homes boiler, some days before this inspection, had not been reported to the Commission, and the manager was advised to immediately report any incident that affects the safety or well being of any or all of the residents. Care Homes for Older People Page 17 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable, clean and warm environment for the people who live there. The home is currently being significantly upgraded. Evidence: The new proprietor is in the process of redecorating and refurbishing the home. About one third of bedrooms have been upgraded since September last year, including the replacement of beds, bedding, bedroom furniture and carpets, as part of an ongoing programme. The lounge is pleasantly decorated and reasonably furnished. It has a large screen t.v. The kitchen has been completely re-fitted, and has up to date equipment. Wheelchairs were being stored in one of the bathrooms, causing a risk to safety. Alternative arrangements must be made for such storage. Smoke alarms are fitted throughout the building. The proprietor agreed to submit an annual development plan, to describe the improvements to be carried out over the next 12 months. Care Homes for Older People Page 18 of 34 Evidence: All areas of the home seen were fresh and clean, other than one bedroom which retained a faint odour of incontinence despite daily cleaning. The manager agreed to consult a Continence Advisor for advice. Care Homes for Older People Page 19 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good level of staffing, and staff are well qualified, but recruitment practices are not sufficiently robust, and staff have not been given the necessary training required by law. Evidence: Staff rotas showed that the normal staffing compliment is one senior and two carers between 8 am and 8 pm; and one senior and one carer from 8 pm overnight. The manager felt that this is appropriate for the numbers and dependency of the residents currently in the home. In addition, there is a cook between 9 am and 5 pm each day, and domestic cover each day. The manager is supernumerary to the rota. Agency staff are used when necessary, to cover sickness and absences. All established staff hold National Vocational Qualification (NVQ) level 2 in care (2 new staff have been enrolled to do this course). Two carers also hold NVQ level 3, and one holds NVQ level 4. Staff recruitment records indicated that there is a need for a more rigorous approach to the employment of new staff. Application forms are not always being fully Care Homes for Older People Page 20 of 34 Evidence: completed, and employment histories often lack the necessary start and finish dates of previous employments. The reference form used does not ask for the name, designation or signature of the referee, nor the date of the reference. One newly appointed carer had only one reference on file. Criminal Record Bureau (CRB) checks are carried out on behalf of the home by the North East Regional Employment Office, but no copies of checks are kept, and there is no written record of any sort held regarding such checks. Staff training records showed that none of the staff were fully up to date with all the areas of training that they are required to have been given by law; most were not up to date in any of the areas required. Care Homes for Older People Page 21 of 34 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager oversees good care practices within the home, but systems covering quality assurance, staff supervision, residents money, record keeping and safe working practices are not of an acceptable standard. Evidence: The homes manager, Mrs Joan Short, holds the Registered Manager Award, and has achieved NVQ level 4 in Care and Management. She has managed the home for three years. No quality assurance systems are currently in place. The manager is aware of her obligation to send out a survey to all residents and their families/representatives annually, but has yet to undertake such a survey since the home was sold to the new proprietor, Mr H. Saleem, last September. As noted in outcome area Health and Social Care, above, the manager had not carried out adequate assessments under the Mental Capacity Act on the people living Care Homes for Older People Page 22 of 34 Evidence: in the home, and had not drawn up care plans to meet their mental health care needs, both essential elements of the overall management of a home for people suffering from Dementia. As noted in the outcome area The Premises, above, the proprietor is to submit an annual development plan for the home. This should include addressing any issues identified in the annual survey. Money is held on behalf of those residents who request this service. Study of the accounts showed that some inaccuracies had not been picked up by the managers internal audit, and that a full audit was required. Group receipts (such as when the hairdresser attends a number of residents on one day) must include a breakdown of residents names and the individual costs. Staff supervision is not taking place at the required frequency (which is at least six times per year for all care staff). The fire log booked showed that fire alarms and fire extinguishers were not being checked at the frequencies laid down by the fire service in the log book; and that no record is kept of the names of those staff who have been given in-house fire training. The homes most recent fire risk assessment was dated January 2008. It identified the need for new seals to be fitted on doors, and for ceiling tiles to be replaced. These had not been actioned. Care Homes for Older People Page 23 of 34 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 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 6 The homes statement of purpose and its service user guide must be kept up to date. This is so that prospective residents and their families are given accurate information about the home on which to base their decisions. 31/03/2010 2 3 14 New service users must only 05/02/2010 be admitted on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives and relevant professionals have been party. This is to include a summary of the Care Management assessment and a copy of the Care Plan produced for care Care Homes for Older People Page 25 of 34 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 management purposes. This is to make sure that the fullest possible picture of the persons needs can be established, and the manager can decide if the home can meet those needs. 3 7 15 People with Dementia must 28/02/2010 have a thorough assessment of their mental health needs carried out, and a detailed plan drawn up of how those needs are to be met, with advice taken from appropriate health care professionals. This to make sure that staff are given the necessary guidance to enable them to give the proper care to the residents. 4 7 15 Each separate need 28/02/2010 identified in the assessment process must be addressed in appropriate detail in a separate care plan. Care plans must clearly describe the problem or need identified; must state the desired outcome of the plan; must give clear and detailed instructions to the care staff as to how to achieve the Care Homes for Older People Page 26 of 34 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 desired outcome; and must be regularly and thoroughly reviewed as to its effectiveness. This is to make sure that staff are given the necessary guidance to enable them to give the proper care to the residents. 5 8 17 Clear records of must be kept of all referals to and inputs from health professionals. This is to demonstrate that every resident is receiving the necessary health care. 6 8 18 All staff must be given 31/03/2010 training, appropriate to their role and responsibilities, in the care of people with Dementia. This is to make sure staff have the skills to meet the needs of such residents. 7 9 13 The Medication Administration Record must show that the proper codes are used to explain the nonadministration of any prescribed medicines; and must clearly describe what 05/02/2010 28/02/2010 Care Homes for Older People Page 27 of 34 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 actions are taken by the staff or manager when a shortfall of medicine has occured. This is to make sure that residents health is protected. 8 9 13 A system for counting the 28/02/2010 numbers of Controlled Drugs held must be introduced. This is to make sure that any discrepancies in the numbers of Controlled Drugs held are picked up immediately. 9 12 15 Each resident must have their individual social, cultural and recreational care needs properly assessed and met, using a detailed care plan. This is to make sure that the social care given is as individual as possible, and that residents are not just treated as a single group, all with the same needs. 10 14 18 Appropriate training must be 31/03/2010 given to all staff regarding the implications of the Mental Capacity Act, and individual assessments of 28/02/2010 Care Homes for Older People Page 28 of 34 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 capacity must be drawn up for each resident. This is to make sure that, whilst residents are being protected, no-one is unfairly or illegally detained in the home against their wishes. 11 16 22 The homes complaints 31/03/2010 policy must be updated to reflect the current ownership of the home and the current Regulator (the Care Quality Commission). This is so that it is clear who has responsibility to respond to any complaints made to the home. 12 18 13 Suitable safeguarding training must be given to all staff. This is to make sure that all staff know how to recognise abuse, and how to respond to it appropriately. 13 18 13 The home must have a clear 28/02/2010 policy on how it will respond to any allegation or suspicion of abuse. This policy must be in line with that of the local authority 28/02/2010 Care Homes for Older People Page 29 of 34 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 safeguarding team. This is so that it is clear who has the responsibility to respond to such allegations, and what the process will be. 14 19 23 Suitable storage 28/02/2010 arrangements must be made for wheelchairs, when not in use. This is to make sure that bathing facilities can be easily and safely accessed. 15 29 19 Written records must be 28/02/2010 kept of checks made with the Criminal Records Bureau (CRB) regarding applicants for employment. This is to make sure that residents are protected from abuse. 16 29 19 Employment application 05/02/2010 forms must be fully completed, and include the full dates of previous periods of employment. At least two written references must be provided, and the reference request format amended to include the name, Care Homes for Older People Page 30 of 34 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 designation and signature of the referee, as well as the date completed. This is to make sure that any potentially suspicious gaps in employment histories are challenged, and that references can be carefully checked. 17 30 18 All staff must receive the 28/02/2010 training required by law, and must be given refresher training as and when necessary. This is to make sure that staff have the training needed to do their jobs properly. 18 35 17 A thorough audit of all money held for residents must be undertaken on a regular basis. This is to make sure that the accounts accurately reflect the monies being held at all times. 19 36 18 Care staff must receive formal supervision at least six times each year. This is to make sure that any issues are dealt with in 31/03/2010 05/02/2010 Care Homes for Older People Page 31 of 34 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 good time, and that staff are given regular feedback on their performance, and that any issues are dealt with promptly. 20 38 18 A clear record must be kept 28/02/2010 of which staff members have received in-house fire safety training. This is to make sure that all staff receive this training at the required frequency. Fire alarms and fire extinguishers must be checked at the frequencies set down in the front of the fire log book. This is to make sure that service users are kept safe. 05/02/2010 21 38 18 22 38 13 A fire risk assessment of the 05/02/2010 home must be carried out and any deficiencies identified must be speedily addressed. This is to keep residents as safe as possible from the risk of fire. Care Homes for Older People Page 32 of 34 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 12 15 A regular monthly budget should be made available for resources for residents social activities. The manager should review the dining arrangements to make sure that they meet the needs of the residents and make mealtimes as pleasurable as possible. All feedback, both positive and negative, should be included in the homes complaints records, to allow the manager to demonstrate how such feedback is responded to. An annual development plan for the home should be submitted to the Commission. A survey should be sent to all residents and their relatives or representatives to ask their degree of satisfaction with the service being offered by the home. The results of this survey should be collated and published annually in the homes Service User guide. An effective quality assurance system must be introduced. 3 16 4 5 19 33 6 33 Care Homes for Older People Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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