Inspection on 12/01/09 for Jeannette Lodge

This inspection was carried out on 12th January 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jeannette Lodge 13/07/09

Jeannette Lodge 16/04/09

Jeannette Lodge 19/02/07

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Jeannette Lodge 15-17 Park Avenue Gillingham Kent ME7 4AS     The quality rating for this care home is:   zero star poor 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: Sue McGrath     Date: 1 2 0 1 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 31 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Jeannette Lodge 15-17 Park Avenue Gillingham Kent ME7 4AS 01634852894 01634851647 richardraj@rosedenerch.freeserve.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Golden Slumbers Limited Name of registered manager (if applicable) Mr Richard Anthony John Raj Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Jeanette Lodge offers residential care to older people. They are registered for 21 service users, 6 of which provide care for service users with dementia. The home is a large detached property situated in a residential area and directly opposite an attractive park. The home is close to local shops, bus stops and local amenities. Chatham and Gillingham town centres are approximately one mile away. Accommodation is provided on three floors, the upper floors are accessible by chairlifts. All bedrooms have a call bell point. The home has a large garden, which is accessible for all residents. Fees are from 323.00 pounds to 408.00 pounds per week. 6 0 Over 65 0 15 care home 21 Care Homes for Older People Page 4 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home 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 was a key unannounced inspection that took place on 12th January 2009 and was conducted by Sue McGrath, Regulation Inspector for the Commission for Social Care Inspection. The key inspections for care home services are part of the methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and further feedback is gained through discussion with service users and relatives on the day of the inspection if possible. The actual date of the site visit is unannounced. Additional information was also obtained through the Annual Assessment Quality Assurance (AQAA) review, which all services registered with the Commission for Social Care Inspection (CSCI) must now complete on a yearly basis. Care Homes for Older People Page 5 of 31 At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Judgments have been made based on records viewed, observations and verbal responses given by those people who were spoken with. These judgments have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORAs and AQAAs. Not all of the requirements made at the last inspection had been complied with. 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 Care Homes for Older People Page 7 of 31 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 31 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 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them 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. People who live in the home and their families are not provided with the information they need to make an informed choice about moving into the home. People who live in the home benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. People who live in the home benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. Evidence: The home could not produce a current statement of purpose or service user guide. Old documentation was offered but was not relevant to the current service. The homes AQAA stated that the home produced a Residents Guide pack and the home did this Care Homes for Older People Page 10 of 31 Evidence: well, but it could not be found. The evidence obtained at the inspection demonstarted that the requirements on the statement of purpose and the service user guide issued on 19 February 2007 has not been complied with. The owner confirmed each resident was given a contract/statement of terms and conditions when they were first admitted to the home. Evidence was seen in individual files of such documentation. The owner stated that all residents undergo a thorough assessment completed by either himself or the senior carer prior to admission. Again evidence was seen of such documentation in individual files. Care management assessments were also gathered if funding was to be provided by Social Services. The admission process was discussed with the owner and it was stated that all prospective residents were invited to visit the home prior to admission with a relative or representative. Trial periods were offered after admission and before the final decision to remain needed to be made. A visitor to the home confirmed she had been fully involved with the admission of her relative. The home does not offer intermediate care. Care Homes for Older People Page 11 of 31 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home benefit from having clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and the people who live in the home benefit from having full access to all professional health care services as required. People who live in the home are protected by the homes policies and procedures for dealing with medicines. Evidence: During the inspection four care plans were reviewed. Each one was detailed and gave clear instructions to staff to enable them to deliver a high level of care. It was seen that individuals were encouraged to maintain their independence where possible and where not possible full assistance was offered. Residents and relatives confirmed they had been involved with drawing up the original plans and were aware that regular Care Homes for Older People Page 12 of 31 Evidence: reviews took place. Evidence was also seen that health care needs were well met and that each resident was registered with a local GP had full access to other health care professionals as required. Records of such visits were recorded in the daily notes and it was advised that these be recorded within the care plans on a separate sheet to enable tracking to take place. This would also enable other health care professionals to get a clear idea of any trends of histories if needed. Staff were able to demonstrate a good understanding of skin integrity and care. The senior carer confirmed that no residents in the home had any pressure areas. Specific equipment for the care of skin integrity and tissue viability was seen throughout the home. Medication was still stored in a dedicated medical cupboard that was chained to the wall of the dining room. This was discussed at the last inspection. The home had produced a policy regarding the security of the medication cupboard keys as required from the last inspection. The actual administration of medication was found to be safe and again it is recommended that staff who actually administer the medication undertake an accredited course in the safe administration of medicines. Staff confirmed the current course as watching a video for approximately 1.5 hours. It is again advised the PRN protocols be drawn up, with GPs input, to ensure staff correctly administer these medications. There were no gaps seen in the medication administration records. The home only uses one controlled medication and this was managed well. Correct procedures were in place for the admission and returns of medication in the home. The home was advised to obtain a copy of the Royal Pharmaceutical Society of Great Britains guidelines called The Handling of Medicines in Social Care. Residents commented on the day of the inspection that staff were competent and caring. All said they felt well cared for and comfortable with the staff. All of the residents looked well cared for. The majority of the ladies had manicured nails and were wearing coordinating clothing. Examples of very good interaction between staff and residents was seen throughout the inspection and the atmosphere was relaxed and pleasant. It was evident that staff respected privacy and dignity when delivering personal care. Several relatives were spoken with and all were very complimentary of the staff. One resident commented that there always seems to be enough staff on duty and they did not wait long for them to respond to a call for assistance. She said they never seemed short staffed. There is always something going on and I do not get bored. Another resident commented that she thought this was a lovely home and was glad Care Homes for Older People Page 13 of 31 Evidence: she lived there. She added she goes out on outings sometimes and there are lots of other things to do. We have entertainers come in which is nice. Although the issue of illness and death was discussed on admission there were no details on the care plan as required by NMS 11. It was advised that this information be added to the current care plans. Care Homes for Older People Page 14 of 31 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. People who live in the home have their social and recreational interest and needs well provided for with a wide range of activities organised. People who live in the home are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. People who live in the home receive a wholesome appealing balanced diet in pleasing surroundings Evidence: The residents are offered a wide range of activities and entertainments during the day and these are normally arranged by the staff. The owner is involved with the entertainments and often takes residents out to local Church groups and on outings. Recent outings included a trip to the local theatre to see a version of Oliver. One resident said she enjoyed the show very much. The local Baptist Church came into the home on a regular basis and the owner also takes some residents to the Baptist Church and Rochester Cathedral on a regular basis. Professional entertainers were used very regularly in the home and a picture board of photos in the hallway showed Care Homes for Older People Page 15 of 31 Evidence: how much the residents enjoyed these events. Relatives who were visiting on the day confirmed they could visit at any time and were always made very welcomed by the staff. Staff were seen to offer choices where possible and where not possible full support was seen to be given. Mealtimes were relaxed and not rushed but the dining room only accommodated 18 residents.This meant that two residents had to have their meal at a second sitting and staff confirmed their meals were heated up in a microwave. The home did not have a food temperature probe so could not evidence this was safe practice. The owner is strongly advised to revisit this procedure as soon as possible. The meals seen on the day looked appetising and residents confirmed they were always nice and well presented and that they were normally given a choice. Records seen confirmed what food residents had taken. Fresh fruit and vegetables were seen in the kitchen. Since the last inspection a weekend cook had been employed but the owner had not followed correct recruitment procedures. Care Homes for Older People Page 16 of 31 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. People who live at the home are potentially put at risk from poor management understanding of adult protection procedures. People who live at the home are potentially put at risk from poor recruitment of staff. Evidence: The owner stated the home had a complaints procedure in place and it was seen at the last inspection but on this occasion it could not be found. Relatives visiting said they felt confident the home had a policy but they could not remember seeing it. All felt confident the owner would deal with any issues appropriately. The owner confirmed there had been no major complaints since the last inspection. The owner must produce a procedure and ensure all residents and their families are aware of the procedure. The home had a basic Adult Protection Policy but the owner was unaware of Kent and Medways Adult Protection Policy and Guidelines which is the policy preferred by Medways Commissioning department. All homes had been supplied with a copy. Concerns were raised when the owner was unsure of the correct procedure to follow should any alerts be raised or need to be raised. He is strongly advised to obtain a copy and read the contents. There were no concerns over his understanding about abuse, just the correct procedures to use if identified. Care Homes for Older People Page 17 of 31 Evidence: Staff spoken with had a good understanding of different types of abuse and were clear about what action they would take. Only seven staff had received training on Adult Protection and a requirement will be made to ensure all staff receive training in the staffing section of this report. Major lapses in the recruitment of staff had the potential to put residents at risk. Five staff files were found without POVA first checks or CRB checks. References were not asked for and in some cases identity had not been confirmed. The evidence obtained at the inspection demonstrated that the requirement on recruitment issued on 19th February 2007 has not been complied with. Care Homes for Older People Page 18 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, 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. People who live in the home benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. People who live in the home are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. Evidence: The home was decorated to a good standard and since the current owner purchased the home he had invested 50,000 pounds on the internal environment. New carpets have been fitted throughout the home and new chairs provided in the lounge. All of the bedrooms have had new carpets and furniture and were individually decorated with the residents choosing the colours where possible. All had access to a lockable drawer and could have a key to their rooms of they wished. All had new beds and matching bed linen. A new fire panel had been fitted along with a new call system in every room. Several residents said how much the home had improved recently and several said they enjoyed the new specialist bath. Care Homes for Older People Page 19 of 31 Evidence: Several of the bedrooms were viewed and all were well personalised and decorated. Evidence was seen that residents were able to bring in small personal items. Evidence was seen that some specialist equipment was provided such as specialist mattresses and cushions but the home does not have a hoist. The home was very clean and fresh and visitors confirmed this was always the case. The kitchen was viewed and is was disappointing to find that a cleaning schedule was not being used as discussed at the last inspection. The owner said he had prepared one but it was not in use. Fridge and freezer temperatures were not recorded and the food temperature probe was broken. The owner must ensures these concerns are dealt with in the immediate future. Care Homes for Older People Page 20 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent 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. People who live in the home benefit from being cared for by staff who have a good understanding of their needs. People who live at the home are put at risk from poor recruitment procedures. People who live at the home are put at risk from poor staff induction and training. Evidence: Rotas seen on the day of the inspection indicated that sufficient staff were employed to meet the needs of the current residents. Residents also confirmed the home never appeared to be short staff and that all staff were supportive and caring and gave personal care in a private and dignified manner. Visitors also spoke highly of the staff and owner and one said they felt confident to leave their relatives in their care. During the inspection staff were seen to be caring and considerate to residents and spoke to them in a sensitive and thoughtful way. Major concerns were raised of the procedures used for the recruitment of new staff. Five staff did not to have POVA first or CRB checks in place, which is an offence under the Care Standards Act 2001. Other staff files did not contain proof of identity or Care Homes for Older People Page 21 of 31 Evidence: photographs of staff. Several application forms were incomplete and not all references had been taken up. Two staff files were completely empty on the day of the inspection. One files contents were found at a later date but insufficient information was found in this file. The registered owner must contact the Border and Immigration Agency for advise on recruiting staff from overseas. The evidence obtained at this inspection demonstrated that the requirement on CRB checks issued on 19th February 2007 has not been complied with. Other serious lapses in the recruitment procedures have also been identified. CSCI will now follow their enforcement pathway and further action is likely to be taken. Staff training was also an issue. The owner had compiled a list of training that had been undertaken and this indicated that not all of the mandatory training had been undertaken by all staff. There were gaps in Safe Guarding Vulnerable Adults, Moving and Handling, First Aid, Infection Control and Fire Awareness. NVQ was now over the fifty percent required by regulation with nine of the fifteen staff having completed level two. One member had recently completed level three. Induction training did not meet with TOPPS standards and must be improved to meet with the Common Induction Standards. Care Homes for Older People Page 22 of 31 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. People who live in the home are put at risk from poor management of the service. People who live in the home do not benefit from having staff who receive regular supervision. Sound financial procedures protect people who live in the home Current arrangements do not protect the health, safety and welfare of the people who live in the home and the staff. Care Homes for Older People Page 23 of 31 Evidence: The registered person is also the registered manager but has failed to manage the home appropriately. It is commendable that he continues to improve the environment and to be fully involved with the daily activities and outings but is clearly not demonstrating his understanding of his responsibility of being the registered manager. There was little evidence that the manager had undertaken periodic training to update his knowledge, skills and competences, whilst managing the home. His understanding of the National Minimum Standards was poor. There was no management structure apart from Mr Raj in the home. Quality assurance had only just been started in December 2008 and then only residents views had been sought. The results had not been collated or acted upon. This had been a requirement from the last inspection in February 2007. Again the registered manager had little understanding of what was required under NMS 33. The evidence gathered at this inspection demonstrated that the requirement on quality assurance issued on 19th February 2007 has not been complied with. A robust system was in place to ensure residents financial interests were safeguarded. The home only manages small amounts of personal monies on behalf of some of the residents. Staff supervision was not happening on a regular basis and again the registered manager was unaware that NMS 36 states staff should received formal supervision at least six times a year. It was also noted that the homes Policies and Procedures had not been updated since 21/08/07. These should be updated and amended as necessary on a yearly basis. Some policies were missing from the policy file. Areas of concern were also raised in the way the health, safety and welfare of the residents and staff were managed. The home had no current gas safety certificate. There was no evidence that the central heating had been maintained. The certificate for the maintenance of bath hoists, fire equipment, emergency lighting, stair lift and nurse call system could not be found. At a later date invoices for the work was found. Mr Raj said the bill had been paid but he had not obtained the final Care Homes for Older People Page 24 of 31 Evidence: certificate. There was no evidence of any PAT(portable appliance testing). The homes AQAA stated that the provider considered that risk assessments and maintenance was done well and that it complied with health and safety regulations. Little evidence was seen if this during this inspection. The registered manager confirmed that regular fire drills were not happening and two staff spoken with confirmed this. Some also confirmed they were unsure of the procedure. A fire risk assessment could not be found. This is needed to comply with the statutory fire safety obligations and legislation. NMS 38. It was advised that a risk assessment be carried out on the upper windows based around the individuals that use the service. This will need to identify how the windows are safe. NMS 38 This is to comply with the requirements from the Health and Safety Executive. There was no procedure in place for the monitoring of hot water to ensure the safety of residents and staff. The level of first aid training was poor with only the provider holding a first aid certificate approved by the Health and Safety Executive. The provider is again advised to look at NMS 38 and in the Guidance Logs on CSCI website. A risk assessment is required. All risk assessments must be carried out by people trained to do so. This includes the risk assessments contained in the care plans. Care Homes for Older People Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 1 4 The registered person must 30/04/2007 produce a service user guide as defined in part one section five of the Care Home Regulations 2001. A copy to be forwarded to the commission on completion. 2 29 19 All staff must hold a satisfactory police check (CRB) 31/03/2007 3 33 24 An effective quality 31/08/2007 assurance and quality monitoring systems, based on seeking the views of service users, needs to be in place to measure success in meeting the aims, objectives and the statement of purpose of the home. It is recognised that the owner has only been at Jeanette Lodge for five months and is waiting for a suitable length of time so the judgements can be made on the change of ownership. Care Homes for Older People Page 26 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 38 23 The registered person ensures that safe working practices include fire safety: understanding and implementations of appropriate fire procedures. All staff must be aware of the fire precautions and drills 24/01/2009 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 16 22 The registered person must ensure that there is a simple, clear and accessible complaints procedure which includes the stages and timescales for the process, and that complaints are dealt with promptly and effectively. The homes complaint procedure must be made available to all residents and their relatives to ensure they are fully aware of the procedure of required. 27/02/2009 2 30 18 The registered person shall ensure that all staff are appropriately trained 31/03/2009 Care Homes for Older People Page 27 of 31 In that all staff undergo structured induction training that meets with the Common Induction Standards Framework. 3 30 18 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed by the registered person to work at the care home are trained appropriately to the work they are to perform. All staff must undertake mandatory training on Moving and Handling, First Aid, Fire Awareness Training and Safe Guarding Vulnerable Adults. The level of First Aid training must reflect the requirements of the Health and Safety Executive. 4 36 18 The registered person shall 27/02/2009 ensure that persons working at the home are appropriately supervised. In that all staff receive formal supervision at least six times a year. 5 37 17 The registered person shall 28/02/2009 ensure that records are kept up to date. 31/03/2009 Care Homes for Older People Page 28 of 31 In that policies and procedures are reviewed and amended as required on an annual basis 6 38 23 The registered person shall after consultation with the fire and rescue authority make adequate arrangements for people working in the care home to receive suitable training in fire prevention and ensure regular fire drills are undertaken. In that staff have receive instruction regarding fire drills and are aware of the procedure to be followed in case of fire. 7 38 12 The registered provider shall 23/02/2009 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of the service users and staff. In that all necessary maintenance and safety checks are carried out on a regular basis. 28/02/2009 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 9 9 It is recommended the PRN protocols be drawn up in consultation with the GP for PRN medications. It is recommended that staff who administer medication undergo in depth training in the safe administration of Page 29 of 31 Care Homes for Older People medication. It is also recommended that the home obtains a copy of the Royal Pharmaceutical Society of Great Britains guidelines called The Handling of Medicines in Social Care. 3 11 It is recommended that details of wishes of the people who live in the home for the way the home manages for illness and death are added to the care plans. It is recommended that the registered person investigates the need to purchase a hoist to enable staff to lift residents from the floor after any falls. A full assessment should be undertaken to ascertain what type of hoist to purchase and professional advise should be sought. It is recommended that a cleaning schedule be used in the kitchen and that a food temperature probe be purchased and used. Fridge and freezer temperatures must be recorded. It is recommended that the provider considers employing a Registered Manager to take day to day responsibility for managing the home. It is strongly recommended that the registered manager makes himself more familiar with the National Minimum Standards. 4 22 5 26 6 31 7 31 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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. 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