Inspection on 08/07/09 for Culliford House

This inspection was carried out on 8th July 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Culliford House 09/07/07

Culliford House 24/07/06

Culliford House 04/10/05

Culliford House 01/06/05

Culliford House 25/02/05

Culliford House 17/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for older people Name: Address: Culliford House Icen Way Dorchester Dorset DT1 1ET     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: Susan Hale     Date: 0 8 0 7 2 0 0 9 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 30 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 30 Information about the care home Name of care home: Address: Culliford House Icen Way Dorchester Dorset DT1 1ET 01305266054 01305266259 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs R F Moors care home 25 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Culliford House is situated close to the town centre of Dorchester and within easy proximity of shops and other amenities. The property is a large elegant Victorian house retaining many period features. The house has been sympathetically extended and is set in its own attractive landscaped gardens with a large car park to the front of the property. This is a well established family-run home, in the ownership of Mrs R Moors (proprietor) since 1985. Suzanne Jackson is Mrs Moors daughter and the registered manager. Mrs Jackson is assisted by a deputy manager. Culliford House is registered to accommodate a maximum of 25 older people. Accommodation is provided at ground, first and second floor levels of the home. A passenger lift affords level access throughout the home. Fees range from 474 pounds to 750 pounds per week. 0 Over 65 25 Care Homes for Older People Page 4 of 30 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: The inspection took place over the course of one day in July 2009 and was undertaken by one inspector. The inspector was accompanied for part of the visit by an expert by experience. The observations and findings of the expert are incorporated into this report. The purpose of the visit was to look at all the key national minimum standards and focus on outcomes for people who live in the home. The aim was to measure the quality of the service under four headings, excellent, good, adequate and poor in each of the seven outcome group. The results of each outcome group are collated and used to inform an overall rating. The home completed an Annual Quality Assurance Assessment (AQAA) as required under the Care Home Regulations 2001 and information provided in this was used to inform the inspection process and is also included in this report. We spoke to eight residents,four staff and the registered manager, Mrs Jackson. We Care Homes for Older People Page 5 of 30 looked at selected care and staff files and all paperwork relevant to the running of the home. We also undertook a tour of the premises. We sent out surveys to randomly selected professionals who visit the home, staff and residents. Completed surveys were received from one member of staff and two professionals and their responses are incorporated into the report. The manager informed us that all the surveys had been distributed and some members of staff told us they had completed them but they had not been received at the time of writing this report. Care Homes for Older People Page 6 of 30 What the care home does well: What has improved since the last inspection? The quality of care plans has improved significantly and these now provide clear details about individuals needs and how they will be met by staff. A care plan specific to Care Homes for Older People Page 7 of 30 individuals prescribed medication is now in place. References received for prospective members of staff are now dated so that they demonstrate they were received prior to staff starting work. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 30 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 30 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not move into the home unless the home is confident that their needs can be met. Prospective residents are provided with written information about the home so that they can make an informed decision about residency. Evidence: All care plans looked at confirmed that pre admission assessments are undertaken before people move in. There was no written evidence that residents or their relatives were consulted during the pre admission assessment and it was not recorded where the assessment took place. However, Mrs Jackson told us that prospective residents and their families were fully involved in the pre admission process.Two professionals completed a survey both of whom said the home always or usually ensured that accurate information was gathered during the initial assessment. Care Homes for Older People Page 10 of 30 Evidence: Prospective residents and their families are encouraged to visit the home and spend time there before they make a decision about residency.Some people spoken to confirmed that they had been given the opportunity to visit. Prospective residents are given a colour brochure and an information folder about the home that includes a quality assurance questionnaire, the homes aims and objectives, a copy of the statement of purpose and service user guide, a list of room sizes, a sample menu, and a copy of the last report. Interim care plans are put in place to make sure that people receive the care that they need immediately. Care Homes for Older People Page 11 of 30 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. All residents have a very good, detailed, up to date ,clear care plan that records their needs and how these are to be met by staff. Risk assessments in place were of a good standard but not completed routinely in line with good practice. People have access to medical and health care professionals and equipment whenever necessary accordign to need. Residents and their relatives are not involved in care planning or reviews. Medication practice is generally safe but would benefit from minor improvements. People are treated with respect and their right to privacy and dignity maintained. Evidence: We looked at the care plans of four residents in detail. Care plans covered all the Care Homes for Older People Page 12 of 30 Evidence: recommended topics in very good detail and gave clear instructions to staff on how to meet individuals assessed needs. It was very positive to see that all the assessments and care plans were regularly reviewed and updated to make sure that they reflected peoples current circumstances. However, there was no formal evidence that residents or their relatives were involved in care planning or its review and were asked their opinion about how care was delivered. There was no record on care plans looked at of peoples life histories so that this could inform the delivery of person centred care but we were told that this was currently being undertaken with individual residents and their families and would be completed shortly. Not all the care records had been dated and signed by the person completing them. Daily records were well kept with entries made on each shift, records also showed residents contact with family and friends. Risk assessments relating to moving and handling and pressure sores were in place for some but not all residents. Risk assessments are not routinely undertaken at admission but completed when a need has been identified. Risk assessments in relation to individuals for example moving around the home and using aids and adaptations ,were in place and contained very good detail and clearly encouraged peoples independence. It was clear from looking at records that people have access to medical and health care professionals whenever necessary including opticians, dentists and chiropodists. People are provided with aids and adaptations including pressure mattresses and pressure cushions with detailed records kept of what each person needed on an individual basis. Two professionals completed our survey and they said that the home always or usually sought advice and acted upon it to meet residents healthcare needs. Both said that the home always monitored and reviewed individuals healthcare needs. We looked at the way that medication was managed. One member of staff takes responsibility for ordering, checking it on delivery to the home and undertakes regular audits. A sample list of staff signatures was in place and patient information leaflets were retained so that any adverse effects from medication could be checked. Risk assessments were in place for residents who choose and are able to manage their own medication and these were robust and designed to support peoples independence for as long as possible.All residents had a care plan relating to medication which was detailed and gave staff clear guidance.Medication practice was generally safe however there was no rationale for the administration of medication prescribed as required ( P.R.N.), the opening and expiry date of creams and ointments had not been recorded and photographs of each resident was not kept with the Medication Administration Care Homes for Older People Page 13 of 30 Evidence: Record (MAR). The home does not undertake nutritional risk assessments although care plans relating to nutrition were detailed and identified and addressed any risks. The pressure sore risk assessment tool used was incomplete and did not give staff for information on any action needed to be taken if risks were identified. This information was obtained by the home during the visit and Mrs Jackson told us would be implemented immediately. We observed that staff knocked on residents rooms before entering their room and that people were treated with courtesy and their right to privacy respected. Two professionals who completed our survey said that they thought the home always respected peoples privacy and dignity. Care Homes for Older People Page 14 of 30 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The routines of the home are generally flexible to suit the preferences and needs of residents. A varied activity programme that meets the expectations of residents is in place. Residents supported in maintaining contact with their friends, family and the community and visitors are made welcome to the home at any time. A varied, wholesome diet that meets individuals dietary requirements is provided and people who live in the home are satisfied with the standard and variety of meals. Evidence: Residents spoken to generally told us that they chose how to spend their time and that they could go to bed and get up at times to suit themselves. However, one person told us that they were shaken awake at 7 a.m. Residents preferences in relation to getting up and going to bed were not recorded on their care plans. Two professionals completed our survey and they said they thought that the home usually or always supported residents to live the life they chose whenever possible. Care Homes for Older People Page 15 of 30 Evidence: An activity programme was in place that included films, quizzes, word games and arts and crafts. The home has an in house fully equipped hairdressing room which residents told us they enjoyed visiting. An individual record of when residents take part in activities including when they have visits from their families was in place. All residents are asked their interests when they moved into the home and these are recorded. Records are also kept of when residents are offered activities but choose to decline. Activities were available all day on the day of the inspection with support provided for people to join in if necessary. People are able to continue with their religious worship if they want and church services are held at the home on a regular basis. Residents told us that their visitors and always made welcome and offered refreshments. The home also offers to accommodate relatives from outside the area in the separate apartment on the top floor of the home. This is also available to relatives if a resident is seriously ill or at the end stages of their life. When residents move into the home they are asked what they would like for breakfast and this is recorded on their care file, they are able to change this to suit themselves. Everyone has breakfast in their rooms at a time of their choosing, and they had a choice of cereal, toast and a choice of cooked items including scrambled egg. The menu shown that the food provided was varied and nutritious offering a choice of two main meals every day. Home-made cakes are always available and birthday cakes are purchased for each resident.We noted that there were sufficient stocks of fresh, tinned and dried food which were all of good quality. Residents spoken to confirmed that the cook and staff were aware of their likes and dislikes and always responded to any individual requests for food and drink. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has not followed its own complaints policy and procedure and record keeping was poor. Policies and procedures are in place in relation to keeping people who live in the home safe. Evidence: The home has a complaints policy and procedure that makes clear that complainants are able to contact the Commission at any stage. However, it did not contain the current contact details and was not visibly displayed (under the hall table). The home had received five complaints since the last inspection. Records showed that four were substantiated and one was unresolved. Recording of complaints was poor with no written acknowledgment of receipt of the complaint, poor investigation records and no written acknowledgment to complainants of the outcome of the investigation.Two professionals completed our survey both of whom said that the home had responded appropriately if any concerns had been raised. A member of staff who completed our survey said that they knew what to do if any concerns were raised about the home. All the staff spoken to on the day of the inspection were clear about how to report any concerns or complaints. Clear, appropriate policies and procedures are in place relating to the protection of people who live in the home. All staff have received training in adult protection and Care Homes for Older People Page 17 of 30 Evidence: those spoken to during the inspection were very clear about what constituted abuse and their duty to report it. A whistle blowing policy was in place for staff but this did not include the contact details of external agencies. Very clear policies and procedures were in place in relation to managing aggression by residents and restraint. These were person centred and gave clear guidance to staff on how to defuse situations and manage them safely. Care Homes for Older People Page 18 of 30 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 excellent 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 high standard of accommodation that is homely, safe and well maintained. Signage in the home could be improved to promote peoples independence. Infection control measures are in place to reduce the risk of cross infection to people who live and work in the home. Evidence: The home was clean, tidy and free from unpleasant odours on the day of the visit. The home is bright and spacious and offers a range of communal areas decorated and furnished to a high standard. All rooms have en suite facilities and are redecorated and refurbished every time they become vacant. Residents are able to bring in personal belongings and items of furniture within the space constraints of their room so they can personalise it to reflect their own tastes and preferences. Some communal bathrooms and toilets did not have any signage on to tell residents where they were. We noted that personal toiletries including bars of soap were in communal bathrooms which could present a risk of cross infection. These were removed during the inspection. Care Homes for Older People Page 19 of 30 Evidence: Policies and procedures are in place in relation to infection control and the management of laundry. Appropriate laundry equipment and facilities provided with detailed information to staff on good practice. It was positive to see that the home provided vinyl and latex gloves to reduce the risk of allergies to staff and residents. Protective clothing and liquid hand wash was provided in the laundry but there were no paper towels. Care Homes for Older People Page 20 of 30 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. The home employs enough staff to meet the needs of residents, ensure their safety and comfort in a good condition of the environment. Procedures for the recruitment of staff are robust and designed to minimise the risk of unsuitable staff being employed. An extensive training programme gives staff support and opportunities to gain relevant knowledge and skills. Evidence: A staff rota was in place that showed that there were always enough staff to meet residents needs and who was in charge of each shift.However, the rota does not show the individual staffs designation i.e. carer. and did not include the hours worked by the manager, Mrs Jackson. One member of staff who completed our survey said that they thought there was usually enough staff to meet individual residents needs. They also said that they usually had the right support, experience and knowledge to meet peoples needs. We looked at the staff files of three people whove started working at home since the last inspection. People do not start work at the home until a satisfactory POVA first check has been received and there were very good records of the supervision of staff Care Homes for Older People Page 21 of 30 Evidence: until a satisfactory Criminal Records Bureau check has been received. Whilst all the necessary records were on file two people had not fully completed the application form and two people had not put down their last employer as a reference, and this had not been explored by the home at interview. All staff are given terms and conditions of employment and their own copy of the General Social Care Council code of conduct. All new members of staff complete an in house induction the day before they start work and then undertake structured formal induction using Skills for Care common induction standards. A comprehensive training programme is in place and it was very positive to see that training in infection control, and the protection of vulnerable adults is seen by the home as necessary for all staff. All staff spoken to said they were encouraged, supported and paid to attend training. The home employs eighteen care staff, eleven of whom are qualified to at least NVQ level 2( 61 ). One member of staff completed our survey and they told us that they considered their induction had covered all aspects of the job and that they received up to date relevant training. Residents mostly praised the care received from staff saying that help was given as required in relation to personal care. However, three residents said that a couple of (younger) staff can be quite sharp and a little bit rough. residents told us that call bells were usually responded to quite quickly. Two professionals completed our survey both of whom said that staff are usually have the right skills and experience to support residents social and health care needs. Care Homes for Older People Page 22 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally very well managed by Mrs Jackson and an effective staff team. Quality assurance systems are in place to make sure that the quality of the service is regularly reviewed and improved. Systems are in place to safeguard residents financial interests, these would benefit from minor improvements to make them more robust. Management practices, records and policies and procedures are in place to promote and safeguard the health, safety and welfare the people who live and work in the home. Evidence: The staff team is led by an experienced and competent manager, Mrs Jackson who is supported by a deputy manager and head of care. Mrs Jackson, has extensive experience in running a care home and has achieved NVQ level IV in management in Care Homes for Older People Page 23 of 30 Evidence: care. Mrs Jackson completed and returned the AQAA to us within the timescale required and in enough detail for us to use the information to inform the inspection process. The rating in this outcome group reflects the concerns relating to the poor management of complaints and improvements needed in the involvement of residents in care planning. Relevant policies and procedures are in place to promote and safeguard the health, safety and welfare of people who live and work in the home. these include policies relating to equality and diversity that make clear that the homes is aware that people will come from different backgrounds, cultures and lifestyle and that that this will be accepted and supported according to individual needs. These policies make clear to staff that this is part of the value system of the home. A quality assurance project which looks the views of residents and staff is undertaken twice yearly by the use of questionnaires and views of staff and residents are also sought at regular meetings. There have been three residents meetings since August 2008 with all residents encouraged to attend. Minutes were taken at the meeting and everybodys views and opinions recorded. There have been four staff and management meetings since July 2008 with minutes taken and available for staff. The home manages and supports some residents with their personal allowance. All records checked were correct, records were kept and safely locked away. However, the records are not audited, transactions are not signed by two members of staff and receipts not always available. We observed that some wheelchairs did not have foot plates fitted. There is a formal handover system between each shift and written information kept in a folder in the dining room. This was not kept securely and contains personal information about all the residents that should be kept on their individual care file. The home meets the requirements of Dorset Fire and Rescue Service and the Environmental Health Department. Environmental Health has awarded the home an excellent rating. Care Homes for Older People Page 24 of 30 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 25 of 30 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 7 15 The registered person shall ensure that service users are consulted as much as possible in care planning and reviews. To make sure that people have as much control as possible over what happens to them. 30/09/2009 2 8 13 The registered person shall 30/08/2009 ensure that moving and handling risk assessments are in place for all residents. To make sure that peoples needs are assessed and they are moved safely if necessary. 3 16 22 The registered person shall 30/08/2009 ensure that any complaint made under the complaints procedure is fully investigated. The registered person shall, within 28 days after the date on which the complaint is Page 26 of 30 Care Homes for Older People 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 made, or such short period as may be reasonable in the circumstances, inform the person who made the complaint of the action (if any) that is to be taken. To make sure that complaints are acknowledged, fully investigated and complainants informed of the outcome. 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 3 Pre admission assessments should record who is present and involved in the assessment and where they take place (for example at the persons home or hospital). Records of when residents receive personal care (bathing) should be kept on their individual files in line with the requirements of the Data Protection Act. All assessments should be fully completed, dated and signed. Whenever possible residents should be asked to sign their agreement with the care plan and review. 2 7 3 7 4 7 Information should be obtained on the Mental Capacity Act and the Deprivation of Liberties and used as part of the assessment and care planning process. All creams and ointments should have an opening and expiry date. A photograph of each resident should be kept with the medication administration record (MAR). 5 9 Care Homes for Older People Page 27 of 30 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 A rationale for medication prescribed as required( P.R.N.) should be clearly recorded and clear instructions and guidance to staff available. 6 7 16 18 The complaints procedure should be clearly displayed and contain the current contact details of the Commission. The whistle blowing policy should include the contact details of Public Concern at Work, Care Quality Commission and Social Services. Signage on communal bathrooms and toilets should be improved to promote service users independence. Residents toiletries should be stored in their private room not communal bathrooms to reduce the risk of cross infection. Bars of soap should not be left in communal bathrooms. All razors should be capped and kept in individuals private room. 10 11 26 27 Paper towels should be available in the laundry. The hours worked by the manager should be recorded on the staff rota. All application forms should be fully completed. The home should check and record the response if applicants have not put down their current employer as a reference. 13 35 Two signatures should be in place on residents financial records. Financial records should be audited on a regular basis by the manager. Receipts must be obtained for all residents transactions and incoming monies from relatives should be receipted. 14 37 Handover sheets should be stored securely and be maintained in line with the requirements of the Data Protection Act 1998. 8 9 21 26 12 29 Care Homes for Older People Page 28 of 30 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 15 38 Wheelchair should not be used without footplates being in place. Care Homes for Older People Page 29 of 30 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). 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