Inspection on 09/02/09 for Ferngrove House Care Centre

This inspection was carried out on 9th February 2009.

CSCI found this care home to be providing an Adequate 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferngrove House Care Centre 25/02/08

Ferngrove House Care Centre 14/12/06

Ferngrove House Care Centre 06/05/05

Ferngrove House Care Centre 22/09/04

Ferngrove House Care Centre 08/06/04

Similar services:

Chirnside House

Emmaus House

East Croft Grange

Craignair

Croston Park Nursing Home

Conifers Nursing Home

Cloisters

Elmsdene Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ferngrove House Care Centre Blackstone Edge Old Road Littleborough Lancashire OL15 0JG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Steve Chick     Date: 0 9 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Ferngrove House Care Centre Blackstone Edge Old Road Littleborough Lancashire OL15 0JG 01706378938 01706375356 f.house@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ashbourne Homes Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 36 Number of places (if applicable): Under 65 Over 65 36 dementia Additional conditions: 0 A revised Statement of Purpose and Service User Guide, in a format suitable for intended service users, must be provided to the CSCI by 1st September 2006. Rooms numbered, as 30, 31, and 32 must not be used as personal accommodation. The Registered Person must ensure that all staff working in the home have dementia care training, which equips them to meet the assessed needs of the services users accommodated, as defined in the individual plan of care. The home is registered for a maxinum of 36 service users in the category of DE(E) Dementia over 65 years of age. The service should at all times employ suitably and experienced members of staff, in sufficient numbers, to meet the assessed needs of the service users with dementia. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The newly appointed Manager must make application to register with CSCI by 28th August 2006. Work on the interior of home, to assist residents with audio and visual clues must be completed by 30th September 2006. Care Homes for Older People Page 4 of 29 Date of last inspection Brief description of the care home Ferngrove House, part of the Southern Cross Group, is a care home providing accommodation and personal care for up to 36 residents suffering from dementia on both a permanent and respite basis. The home is a conversion of two period semi detached houses that have been extended and modernised during 2006 to provide a home on three levels. Local shops and amenities are a short drive away from the home. There is ramped access to the front of the home with adequate parking. Safe enclosed garden areas are available at the rear of the home. The rooms and facilities of the home are spread over three floors with a passenger lift available to all levels. Two of the three floors were in use at the time of this inspection visit. All rooms are single and vary in size they all have ensuite toilets. There are four lounge/dining areas: two lounges on the ground floor, one of which has a bar area, and two smaller lounges on the second and third floors. The toilets and bathrooms on all floors have aids to assist residents. The weekly fees charged for this service range from 385 pounds to 498 pounds. Additional charges are made for hairdressing and chiropody. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. We (the Commission for Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. This meant that no one at Ferngrove knew that the visit was going to take place. Two inspectors visited the home. One was a specialist pharmacy inspector who undertook a thorough examination of the way in which medicines were managed and administered by the staff. For the purpose of this inspection two service users were interviewed in private, as were three relatives of service users and three staff members. Additionally discussions Care Homes for Older People Page 6 of 29 took place with the operations manager. The acting manager was not at work at the time of this visit. All the key inspection standards were assessed at the visit. We also looked at information we have about how the service has managed any complaints, what the service has told us about things that have happened in the service, these are called notifications and any relevant information from other organisations. Before the visit, we asked for surveys to be sent out to some service users and staff, asking what they thought about the care at the home. We received completed surveys from three staff but no service users. Some of the information from these surveys is included in the report. We also asked the management of the home to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA). This is a legal requirement. The AQAA told us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, some of these comments have been included in the report. We undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. At the time of this visit a safeguarding investigation was being undertaken by the Local Authority. The operations manager told us the company was cooperating fully with this investigation. What the care home does well: What has improved since the last inspection? 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 set out 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 29 Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users needs are appropriately assessed and they, or their representatives, are able to visit before a decision is made that the home is appropriate for them. Evidence: The management of the home had told us in the AQAA (annual quality assurance assessment) that all service users had a comprehensive preadmission assessment so that individual needs could be identified to assist with implementing appropriate action to ensure that needs were met. A selection of service user files was looked at. All had written evidence that contact and an assessment had been undertaken before the service user moved to the home. Not all of these records were as thorough as they needed to be to demonstrate that a comprehensive range of potential needs had been assessed. The organisation has its own preprinted preadmission assessment format which in one example seen did not Care Homes for Older People Page 11 of 29 Evidence: appear to have been fully completed. In another service user file the preadmission assessment had not been dated. These omissions do not necessarily indicate a failure to fully assess the needs of a prospective service user. However, they do make it more difficult to demonstrate that a reasonable judgement had been made that the staff and facilities at Ferngrove could meet the prospective service users needs. Ferngrove does not offer intermediate care. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are not always updated to reflect current physical needs. Policies and procedures in connection with medication are not always consistently implemented for the benefit of service users. Evidence: The management of the home had told us in the AQAA that each service user had a care plan which was regularly reviewed and updated when necessary. The care plan is important as it provides basic information to ensure that staff are aware of the up-todate needs of each individual service user. A selection of service users files was looked at. All had a written care plan and there was evidence that these plans were periodically reviewed. However there was not consistent evidence that care plans were always updated following a change in circumstances. Examples of this included weight loss being noted in connection with one service user but the corresponding nutritional risk assessment and care plans did not appear to reflect that observation. Another example was seen where records Care Homes for Older People Page 13 of 29 Evidence: indicated that a service users behaviour towards other people had deteriorated but the care plans did not appear to address how this should be monitored or managed. Daily records were maintained. However, examples were seen where they were not in a chronological order. This would make it difficult to use the daily records as part of the process of reviewing and identifying any changing needs of service users. Staff who returned surveys to us told us that up-to-date information regarding service users was passed on either usually (2) or sometimes (1). Staff who we asked said that up-to-date information was passed on verbally at each shift handover. We had heard from some local authority social workers that they were not always confident that staff had up-to-date knowledge of the circumstances of individual service users. Relatives who we spoke to were generally positive about the care offered by the staff at Ferngrove. They all felt there was good communication from the staff and were confident that medical advice would be sought if necessary. One visitor cited as among the best things of the home that their relative was well looked after and was treated as a real person. Visitors who were asked confirmed that they had been involved in discussion about care planning. There was evidence on service users files that they had access to community based medical staff. All service users, visitors and staff who we asked, expressed confidence that medical advice and support is sought in a timely manner. Service users who were asked also spoke positively about the care they received. One person said I love it and another said they treat me well. Observation and discussion with visitors, service users and staff all indicated that service users were treated with respect and that their dignity was maintained. As part of the visit a pharmacist inspector checked how medicines were being handled. We looked at medicines records, medicines stock, peoples care plans and observed part of the morning medicines round. We found medicines stock to be secure and the records to be generally well-organised. Records of medicines received and given to people were usually complete and accurate and there was a clear system in place for controlling medicines stock that made it simple to fully account for them. We saw an example of poor practice when no night medicines were given to some people because a qualified member of staff was not available to do them at the right time, this was clearly due to poor organisation by staff. The area manager was unaware of this and agreed that it should not have happened. Care Homes for Older People Page 14 of 29 Evidence: We checked a sample of medicines and found they usually added up showing they had been given to people correctly. However, we found several examples of recording mistakes that showed staff were not always checking the records carefully enough when completing them. One medicine that is only taken weekly was signed for on six consecutive days even though it had not been given. Several short courses of treatment did not add up because more medicines was signed for than supplied, which showed staff had signed the record but not given the medicine. Poor records of medicines handling can lead to serious mistakes that can seriously affect a persons health and wellbeing. We looked at the times medicines were given and found the records did not always state the correct time to take them. A carer confirmed that at least two people were being given a medicine with food instead of before. Giving medicines at the wrong time can stop them working properly. We looked at a sample of care plans and records to check if medicines and peoples health care needs were properly reflected in them. We saw some detailed care plans about how to handle some medicines used for angina and anxiety but when we checked the records and talked to staff it was clear that these plans were not being used properly, which had resulted in some medicines being given too often and others not often enough. The area manager agreed that these plans with not being used by care staff and that other care plans did not have enough information to give medicines correctly. We saw an example of good practice when we looked at a care plan for a person that did not want to take their medicines. We found a good assessment of their mental capacity that was well recorded and had taken into account their health and wellbeing. All relevant health professionals and family were included when making any decisions and this was reviewed on a regular basis. This is important so that any decisions that are made for people are made with their best interests in mind. We looked at how medicines were checked and how care staff were trained to give medicines safely. All carers had attended formal medicines handling training on a regular basis and they were supervised by senior staff until they were deemed competent. Audits were carried out on a regular basis and the most recent ones had found mistakes that had been acted upon to help prevent them happening again. As a result of recent mistakes a new medicines stock count sheet had been started to help improve record keeping and to help make sure medicines were being given correctly. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate social contact and activities facilitated within the home to give service users the opportunity to social fulfilment. The provision of food to maintain service users health and well-being is good. Evidence: The management had told us in the AQAA that visitors were actively encouraged and there was an activity coordinator who had a remit to engage residents in person centred activities. Service users who were asked confirmed that they had freedom of choice around how they spent their day. For example they could get up and go to bed when they wanted to and were free to spend their time in communal areas or their private rooms. Service users and visitors who were asked confirmed that a range of social activities was available to participate in if they wished. These included outings and involvement with local churches. Service users and visitors who were asked also confirmed that there were no unreasonable restrictions on visiting. One visitor also commented that they could stop for a meal if they wished, and said that staff make you feel Care Homes for Older People Page 16 of 29 Evidence: comfortable and are welcoming. The provision of food at Ferngrove is guided by the companies corporate menu which is intended to be nutritionally balanced and varied. Service users and visitors who were asked described the provision of food as good and confirmed the availability of choice. One meal was sampled during the visit which was nicely cooked but was visually unappealing as it consisted of too much food of the same colour, namely cottage pie, boiled potatoes, white cabbage and carrots. One visitor commented that they were impressed by the provision of a proper Sunday roast. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are protected from abuse or exploitation by the homes policies and practices and are confident that any complaints they may have would be dealt with appropriately. Evidence: The management told us before the visit that the complaints procedure was available and given to each resident on admission and that policies and procedures relating to complaints and protection were available for all staff. All staff who returned a survey to us said that they knew what to do if a service user or visitor had concerns about the home. All staff who we asked were confident that service users or their representatives could complain and that those complaints would be listened to. All service users and visitors to the home who we asked, said that they were confident that they knew how to complain and that they would be listened to. One service user spoken to was very clear that if things werent going my way Id tell the manager. One visitor expressed some frustration that although they believed that the staff meant well matters were not always totally resolved. They gave as an example clothing been returned to their relative not always ironed. Care Homes for Older People Page 18 of 29 Evidence: The complaints log was looked at and presented as being an appropriately maintained record of written complaints. All service users and visitors spoken to believed that the service users at Ferngrove were safe. One service user who was asked if she felt safe replied absolutely, I go to bed and then dont wake up until they wake me. Not all staff had received specific training in connection with the protection of vulnerable adults. However, all staff we spoke to recognised the need to be vigilant about adult protection issues and were confident that they knew what to do if they had any concerns about the safety or well-being of any service user. This included a willingness to whistle blow if necessary. We were aware of one safeguarding concern regarding the administration of medication which was still subject to investigation by the local authority at the time of this visit. The operations manager told us that they were co-operating with the investigation. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is appropriately maintained, decorated and cleaned to enable service users live in a pleasant, safe and hygienic environment. Evidence: The management told us before this visit that the home was well maintained, that all rooms were single with ensuite facilities and that service users could personalise their rooms. During this visit we undertook a tour of the building which included communal areas and a selection of service users bedrooms. There were several communal areas where service users could go. Service users were also able to access their own rooms whenever they chose. Observation confirmed that service users were able to personalise their rooms. One service user said it is my own furniture and feels like home. The building presented as well maintained with no significant remedial issues identified at this visit. Some bedrooms doors had key operated bolts which looked as though they had been disabled as they are not permitted as they have the potential to be misused. There was no suggestion that any of these bolts could be used, but it was strongly recommended that they should be completely removed to prevent any Care Homes for Older People Page 20 of 29 Evidence: ambiguity. And at the time of this unannounced visit the home presented as clean and tidy and predominantly odour free. All staff, service users and visitors who were asked said that this was the usual state of the building. One visitor described the home as being lovely and confirmed that their relatives room was always clean. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skills mix of staff on duty did not promote consistently the independence and well-being of service users. Evidence: The operations manager told us that staffing levels are generally maintained at four or five care staff between 08:00 - 14:00; four care staff between 14:00 - 20:00 and three care staff between 20:00 - 08:00. A copy of the staff Rota for the fortnight beginning the 12th of January 2009 was provided as evidence of this. All staff who returned questionnaires, as well as some staff spoken to, queried if these staffing levels were sufficient given the layout of the building and dependency levels of some service users. For example if two members of staff were required to assist one service user to have a bath on the ground floor this could leave one member of staff on their own on the first floor. A structured and comprehensive training routine appeared to have been weakened, possibly by temporary management arrangements in the home. A relatively low number of staff had completed NVQ (National vocational qualification) level 2, which is a nationally recognised qualification intended to help staff provide good quality care. We were told by the operations manager that more training was now planed and that nine staff were undertaking NVQ II and two staff were undertaking NVQ III. Care Homes for Older People Page 22 of 29 Evidence: Information from staff who completed surveys and whom we spoke to indicated a lack of consistency in in the provision of both induction and training. The operations manager informed us that this had been identified as an area which needed to be addressed. A selection of files relating to the recruitment of staff was looked at. These provided good evidence that the required checks were undertaken before any applicant started work at Ferngrove. However, examples were seen where further information should have been sought but there was no record that this had been done. Specifically this related to gaps in some applicants employment history which did not appear to have been explored and apparently conflicting information between an applicants statement and a reference received. Observation indicated that appropriate relationships were maintained between staff and service users. Visitors who were spoken to were positive about the staff who were described as good caring people who always make you feel comfortable. One service user said that the staff treat you well and [I have] never been as comfortable or happy . Another service user said that the staff are very good and I like them and they love me. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users do not benefit from strong management in the home although their health and safety and financial interests are protected. Evidence: Service users at Ferngrove have not benefited from a manager, who has been registered with us, for a significant length of time. Management arrangements which had been put in place did not present as being as effective as is necessary to guarantee the well-being of service users. This was particularly noticeable in several areas of administration. Some staff who returned surveys to us commented on the need for more support and better running of the home from management. The operations manager, who had not been working for the company for long, was present throughout this unannounced visit. They presented as having an understanding of the weaknessess in the management structure and had plans to address them. Care Homes for Older People Page 24 of 29 Evidence: A range of quality assurance systems were reported as being in place. Evidence identified in connection with written care plans and medication records suggested that these were not routinely or rigorously implemented. Visitors who were spoken to confirmed that there were residents and relatives meetings although they were poorly attended by relatives. A small selection of records relating to money held on behalf the service users by Ferngrove was looked at. These presented as being well maintained to protect the interests of service users, with receipts kept for items purchased on behalf of service users. We were told in the AQAA that equipment was serviced or tested at appropriate intervals. A small selection of records relating to the maintenance of fire equipment and the lift was seen to substantiate this. We were told by the management that personal protective equipment (e.g. disposable gloves and aprons) were provided for staff so that the risk of cross infection was minimise. Staff who we are asked confirmed the availability of this equipment. Care Homes for Older People Page 25 of 29 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 31 8 The manager must submit an 10/03/2008 application to become the registered manager of this home. Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Medicines must always be given to people correctly as prescribed. This is important because receiving medicines at the wrong dose, wrong time or not at all can seriously affect a persons health and wellbeing. 03/04/2009 2 9 13 Care plans must have enough information in them about how when required medicines should be used. This will help make sure they are given to people correctly. 03/04/2009 3 31 8 The responsible individual must ensure that an application is made to the commission for registration of a manager at Ferngrove. Service users benefit from effective consistent and accountable management. 22/05/2009 Care Homes for Older People Page 27 of 29 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 Care should be taken to complete fully the record of information obtained to establish that the staff and facilities at Ferngrove can meet the needs of any prospective service user. This is to demonstrate that the risk of not being able to fully meet the service users needs is minimised. The manager should ensure that the service user files are periodically audited so that any failure in the recording systems can be quickly identified. Changing needs or circumstances must be reflected in the written care plans and daily records should be maintained in a way where information can be easily obtained from them. This is to ensure that the staff and management can demonstrate their accountability for the well-being of service users. The manager should ensure that any remnants of the key operated bolts on bedroom doors should be completely removed to exclude any possibility of service users being accidentally locked in their rooms. The manager should ensure that staffing levels are kept under review and take into account both the dependency of service users and layout of the building. The manager should ensure that records relating to staff recruitment can demonstrate that all reasonable steps had been taken to minimise the risk of employing staff who are unsuitable to work with vulnerable adults. The manager should ensure that there is a structured induction and training programme in place so that service users benefit from well-trained and supported staff. The manager should ensure that information gathered through the quality audit processes are used in a report which includes an annual development plan to indicate how the services for people living in the home are to be improved. 2 7 3 19 4 27 5 29 6 30 7 33 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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