Inspection on 22/01/09 for Kay-sera-sera

This inspection was carried out on 22nd January 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kay-sera-sera 08/01/07

Kay-sera-sera 16/01/06

Kay-sera-sera 24/08/05

Kay-sera-sera 03/02/05

Kay-sera-sera 08/09/04

Kay-sera-sera 10/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Kay-sera-sera 7 Willowbrook Derrington Stafford Staffordshire ST18 9NN     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: Pam Grace     Date: 2 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 28 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 28 Information about the care home Name of care home: Address: Kay-sera-sera 7 Willowbrook Derrington Stafford Staffordshire ST18 9NN 01785244684 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : kayserasera@sagainternet.co.uk Mr Michael Patrick Lucas,Mrs Jennifer Elizabeth Lucas care home 4 Number of places (if applicable): Under 65 Over 65 0 4 dementia old age, not falling within any other category Additional conditions: 4 0 The maximum number of service users who can be accommodated is: 4 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 4 Dementia (DE) 4 Date of last inspection Brief description of the care home Located on the periphery of the town of Stafford, and in the village of Derrington, Kay Sera Sera can be accessed by a public transport route. The home is registered to provide accommodation for four older people, two of whom have a mental frailty. Kay Sera Sera is located near to a shop and post office, and is also the family home of the providers Mr & Mrs Lucas. The home provides an extremely comfortable, and well maintained environment. Each person using the service has been provided with exceptional personal space for their daily life style. There are two large lounges, Care Homes for Older People Page 4 of 28 Brief description of the care home additionally, one lounge has been converted into a ground floor bedroom. An area at the head of the stairs is where one person prefers to sit. Each person has been provided with a bathing facility off their bedroom, or, can easily access the shower room on the ground floor. Access to the home is via a short flight of steps, or via the ramp, which is fitted with a substantial hand rail for peoples safety. There is a well maintained garden and patio area at the rear of the home for people to enjoy. Care Homes for Older People Page 5 of 28 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 last inspection for this service was 08 January 2007. This inspection visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over eight hours by one inspector who used the National Minimum Standards for Older Persons as the basis for the inspection. Prior to the inspection, the care manager completed an Annual Quality Assurance Assessment for us. Three surveys were also received from people using the service. On the day of the inspection, the home was accommodating four people, and one person was attending the service for day care. Care Homes for Older People Page 6 of 28 We spoke with staff and the people using the service. We also examined records, carried out indirect observation of the four people who use the service, and the two staff on duty. two plans of care and two staff records were examined, we also directly observed daily events. We looked at one persons bedroom, two communal lounge areas, the dining area, kitchen, toilet and bathing facilities. We inspected the system of medication administration and storage. The fees charged for the service at Kay Sera Sera, are from 386.90 pounds per week. The fee information included in this report applied at the time of inspection, the reader may wish to obtain more up to date information from the care service. What the care home does well: What has improved since the last inspection? What they could do better: The homes statement of purpose should include all of the items listed in the National Minimum Standards Schedule 1. This ensures that people wishing to use the service have the information they need to make an informed choice. The individuals care plan and risk assessment should set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met. Thus ensuring the safety of the people using the service. The use of signed Medication Administration Records (MAR) will ensure an auditable trail, and the safe administration of medication for individuals. Staff should receive formal supervision, annual appraisals, update and refresher Care Homes for Older People Page 8 of 28 training according to their role and responsibilities. Existing quality assurance systems should be expanded to include other professionals for example the General Practitioner, District Nurse, Pharmacist. Feedback should then be documented and given to people using the service and staff. Policies and Procedures should be reviewed and updated to reflect changes in working practice and legislation. 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.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 9 of 28 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 28 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 may use the service and their representatives should have up to date information, in order to choose a home that will meet their needs. Evidence: The Annual Quality Assurance Assessment (AQAA), which was completed by the registered care manager told us: If not referred by Social Services who assess themselves, the proprietor will go and visit each individual in their home setting, and assess their individual needs. Each person has their own care plan developed by the proprietor. All falls are now recorded, and we are looking into the purchase of a stair lift. We have changed facilities to accommodate a blind service user, who is doing fine now. Service users all have call buttons for instant assistance. Surveys received from the people using the service confirmed that they had received enough information, and had a contract. Comments received included the following, Care Homes for Older People Page 11 of 28 Evidence: we were shown around by the owner, and liked the house, its really lovely here. We looked at two pre admission assessments. Both of these had been undertaken by the local authority. The service is considering developing a pro forma which will be used as their own pre admission assessment. The Philosophy of Care was readily available, this had been updated to include the change of address for the Commission for Social Care Inspection, and the details in regard to the current fees charged. However the information provided in the document was very brief, did not include day care provision, and details of how the service would respond to a complaint. This did not meet the National Minimum Standard, and was subsequently highlighted and discussed with the care manager. We were assured by the care manager that Contract Terms and Conditions had been reviewed and updated for each individual by the local authority each year. Intermediate care is not provided in this home. Care Homes for Older People Page 12 of 28 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. The lack of care plans and risk assessments, failed to evidence whether peoples needs were being met appropriately. Shortfalls in the administration of medication compromised the health and welfare of people living in the home. Evidence: The Annual Quality Assurance Assessment document (AQAA), which was completed by the registered care manager told us: Each individual service user brings their service log of care with them, we continue to use their own doctor, chiropodist etc Each service users medication is delivered in seperate cassettes, for care staff to give. One service user used to be self administering but not now. Each service user has their own room with en-suite facilities, there are also 3 living rooms available for family or friends when visiting. All appointments are entered into a daily diary. We examined two local authority social work care plans, these were provided upon admission of the individual, by the local authority and were reviewed once yearly. There were no care plans provided by the service to enable staff to care for Care Homes for Older People Page 13 of 28 Evidence: individuals. For example, an explanation of how staff should assist and carry out personal hygiene. Both local authority social work care plans contained evidence of pre admission assessments. The daily diary showed evidence of health professionals involvement, for example District Nurse and General Practitioner visits, and health appointments for individuals. We spoke with staff and people who use the service. Staff spoken with could tell us exactly how each of these people were to be cared for. Surveys received said that people using the service do receive the support and care they need, this was also confirmed during our visit whilst speaking with staff and people using the service. They also said that staff listen and act upon what they say, and that they receive the medical support they need. People we spoke to told us I like it here , we get lovely food , we go for walks with the staff around the village, and go for a cup of tea in the church hall, the food is marvellous.One person described how comfortable and welcoming the home was, he said his relatives could visit anytime, and the staff were really helpful. He also described how his room had been adapted to suit his needs, for example, a recliner chair and a pressure cushion had been purchased, and furnishings had been arranged to enable him to freely and safely mobilise. We discussed the care needs of one person using the service, and the need for their risk assessment to be put in place, it had been stated that no falls had taken place, and that there was no need to have a risk assessment. It is recommended that where appropriate, individual risk assessments should be put in place for all individuals using the service, with a record of the measures taken to minimise the risk. Risk assessments should also include any issues affecting an individuals sensory impairment, and freedom of liberty. We examined the homes administration of medication, which is provided by the pharmacist in a monitored dosage system. There were no Medication Administration Sheets (MAR) to evidence who had given the medication, and there was no system in place for the return of medication, which should be witnessed and signed as received by the pharmacist, thus ensuring an auditable trail. This was discussed with the care manager at the time, and a recommendation made that systems need to be put into place as soon as possible, to ensure the safety and welfare of people using the service. Care Homes for Older People Page 14 of 28 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 are satisfied with their chosen lifestyles, meals and activities in the home. Individual social, recreational and religious needs are met. Contacts with family and friends are encouraged and maintained. Evidence: The Annual Quality Assurance Assessment (AQAA) which was completed by the registered care manager told us: We provide weekly local information, any of the service users can take part in. Transport is provided to service users to any social activity or contact. Service users given a choice of menu for daily menus. Service users can receive visitors any day at any time without notice. We regularly evaluate and assess the social activities that we offer and the lifestyle of our service users experience. We have updated our visitors policy and ensure that all visitors sign in. The main meal of the day was served during our visit, this comprised soup, and a casserole with a pudding for the sweet course. People spoken with said the meals are lovely, sometimes theres too much to eat. The care manager and people spoken with confirmed that there is always a choice of main meal for people. Care Homes for Older People Page 15 of 28 Evidence: Surveys received from people using the service confirmed that there are activities arranged by the home that they can take part in. People spoken with confirmed that activities mostly centre around the village, local church club, games and crafts, such as tapestry and knitting. Comments received included the following: I go to church every week, and to a fellowship meeting, I go to the local village hall for coffee mornings, I like doing puzzles and quizzes, I stay in my room sometimes I go for walks around the village. Trips out to other venues are organised in the summer months. The home operates very much on a family unit basis, and activities take into account peoples age, and abilities. The care manager confirmed that staff would provide support and transport as needed by individuals, in order to access community facilities. Two people living elsewhere receive day service provision at the home, this provides social opportunities, stimulation and a change of surroundings for those people. The home has three lounge areas, and a dining area, which are well used by the people using the service, their visitors and friends. Visitors can also be seen in private if people so wish. Bedrooms seen evidenced that people can bring in their own furnishings and personal effects. We were told that visitors and relatives can visit at any reasonable time. Care Homes for Older People Page 16 of 28 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. People are listened to and can feel assured that the home will act in their best interests and protect them from harm. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the registered care manager told us: We display the number for social services. All carers are CRB checked. Policies and Practices regarding protection of service users are updated and addressed. Any allegations or incidents are followed up promptly. We have a complaints, comments and compliments policy. We have a complaints log which is confidential. We carry out annual appraisals. All records are available for inspection. We will keep on monitoring service users and staff. The care manager told us that the service had received no complaints since our last visit. We saw from responses to our surveys that people are aware of whom to make a complaint to. Comments received included, I have no complaints, but if I did, I could always speak to any of the staff, I tell my daughter. We discussed a concern which was received by us some time ago. The care manager could not recall any issues raised at that time, and had not been aware of any concerns made by any relatives. We discussed the need to include the homes complaints procedure with appropriate timescales in the Philosophy of Care. Care Homes for Older People Page 17 of 28 Evidence: We spoke with the care manager about safeguarding, and their role in keeping people safe from harm. They said that they and their staff understand their role, and their responsibilities in relation to this. At present there is no restraint needing to being used in the home. We recommended that the home obtains an up to date copy of the Staffordshire Safeguarding Policy and Procedure. We looked at two staff records. We did this to see if the home is fulfilling its obligation in completing safety checks against the Protection of Vulnerable Adults (POVA) list and Criminal Records Bureau disclosures. The service must do this to prevent unsuitable people from working with vulnerable adults. We found that appropriate security checks had been undertaken prior to their employment at the home. The care manager confirmed that people using the service manage their own finances. The service does not hold monies for individuals. Care Homes for Older People Page 18 of 28 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 physical design and layout of the home enables people who use the service to live in a safe, well maintained and comfortable environment, which encourages independence. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the care manager told us: We have a CCTV camera for front door security. We have a programme for routine maintenance and general upkeep of the building and internal areas. Policies Procedures and staff training ensures a clean hygienic home is run. Laundry and handwashing facilities are seperate to the kitchen. We have all relevant, fire, environmental, health PAT records and health and safety records. All records are available on request. The building and grounds were maintained to a very high level, and were safe for people to use. Communal areas were clean and comfortably furnished to a very high standard. These were well used by people using the service, their visitors and relatives. Bedrooms seen had been personalised and adapted to suit the individual. Aids and Care Homes for Older People Page 19 of 28 Evidence: equipment were in place for one person who had a visual impairment. Furnishings and fittings were to a very high standard. The kitchen and laundry areas were clean and tidy. All equipment was in good working order. Infection control measures were in place, ensuring the health and safety of the people using the service. The AQAA did not list the maintenance checks of equipment made since the previous inspection. This was highlighted and discussed during our visit, and the care manager subsequently forwarded this information to us by post. Care Homes for Older People Page 20 of 28 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. Staff are in sufficient numbers to meet peoples needs, however, there are shortfalls in the lack of update and refresher training for staff, according to their role and responsibility. Evidence: The Annual Quality Assurance Assessment told us: We are a small home and the proprietors and carers work to ensure that each service user has the staff for their daily needs. Qualified staff are employed to ensure quality care. We do not use students or trainees. Staff have a probationery period before employment references are required. All staff are CRB checked. All records are available. Keep evaluating policies for recruitment and staff training records. Updated staff recruitment policies. The service has an adequate recruitment procedure that meets statutory requirements and the National Minimum Standards (NMS). However, records were not uniformly kept, and old documentation had not been archived, making it difficult to evidence the training undertaken by staff. It is recommended that staff records should be uniformly kept and training updated. The staff rota evidenced that staffing levels had been maintained. The care managers also live on site, and are able to be on call at all times. Care Homes for Older People Page 21 of 28 Evidence: The care manager confirmed that they had not undertaken any update and or refresher training since the previous inspection. They confirmed that staff in their employ had undertaken the necessary mandatory training, however, there was no evidence to support this. For example up to date individual training records and Certificates. The care manager confirmed that supervision was undertaken informally with staff, on a daily basis. They confirmed their system of handover, and instructions and support given to staff to enable the smooth day to day running of the service. We saw that this was reflected in the qood quality of care that people receive. However, there was no evidence that supervision, appraisals and staff meetings were taking place. Surveys received from people using the service confirmed that staff listen and act on what they say. Comments included Staff are available when you need them, they do as much as they can, I really like it here. Care Homes for Older People Page 22 of 28 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 management of the home is based on openness and respect. Quality assurance systems should include stakeholders views of the service. The administration and record keeping of the home should be reviewed and improved. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the care manager told us: Since 1996 we still have the orginal proprietors. Feedback is actively sought from service users through anonymous questionnaires. Actions are implemented within an agreed timescale. The proprietors ensure that all safe working practices are adhered to. All service users are responsible for their own money. The Annual Quality Assurance Assessment (AQAA) was poorly completed and returned to us on time by the registered care manager/provider. Some information in sections of the AQAA were not completed. The AQAA gives us some limited detail about the areas where they still need to improve. The ways that they are planning to achieve Care Homes for Older People Page 23 of 28 Evidence: this are briefly explained. The data section of the AQAA was completed, although there were some inconsistencies. We are kept informed via Regulation 37 Notifications of incidents in the home which affect the people using the service. This helps to ensure the safety of individuals using the service. There had been no complaints and or Safeguarding referrals made to us since the previous inspection. Both care managers were unaware of a concern made some time ago in regard to the care of a person on respite. This was highlighted and discussed, but was inconclusive. Staff records did not evidence that up to date training, formal supervision, and appraisals had taken place. Recruitment files were not uniformly kept, making it difficult to see evidence that individuals had been safely recruited, inducted and trained. The environment is safe for people and staff because appropriate health and safety practices are in place. Care plans and risk assessments, in regard to how staff are to safely care for individuals, were not in place. Individual risk assessments should be kept up to date, and should include the measures taken to minimise the risk. Thus ensuring the safety of the people using the service. However, we noted that the quality of the care received is good, and people were very complimentary about this, I like it here, We go for walks around the village, but I can go to my room, or just watch the television if I want to. I sometimes need to ask for help, and I have no problem getting it. The staff are marvellous. We looked at the homes medication systems. Medication Administration Records (MAR), storage and disposal of medication, revealed that there was a shortfall in regard to lack of use of MAR sheets, and therefore missing signatures from MAR records. This was highlighted and discussed with the care manager at the time, and will be rectified. We were told in the AQAA that the registered manager/provider had reviewed records, policies and procedures in the light of new legislation and current good practice. However, we were unable to evidence this during our visit. The home does not hold monies for people using the service. Care Homes for Older People Page 24 of 28 Evidence: People using the service were complimentary of the staff and management, and positive comments were received in regard to the commitment, care and support that they received. Comment cards and letters received by the service since our previous inspection confirmed this. Care Homes for Older People Page 25 of 28 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 26 of 28 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 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 The homes statement of purpose should include all of the items listed in the National Minimum Standards Schedule 1. This ensures that people wishing to use the service have the information they need to make an informed choice. The individuals care plan and risk assessment should set out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs are met. Thus ensuring the safety of the people using the service. The use of signed Medication Administration Records (MAR) will ensure an auditable trail, and the safe administration of medication for individuals. Staff should receive update and refresher training according to their role and responsibilities. Existing quality assurance systems should be expanded to include other professionals for example the General Practitioner, District Nurse, Pharmacist. Feedback should then be documented and given to people using the service and staff. Policies and Procedures should be reviewed and updated to reflect changes in working practice and legislation. Page 27 of 28 2 7 3 9 4 5 30 33 6 38 Care Homes for Older People 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. 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