Inspection on 14/04/09 for Kestrel House

This inspection was carried out on 14th April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kestrel House 06/10/09

Kestrel House 15/04/08

Kestrel House 23/05/07

Kestrel House 18/04/06

Kestrel House 17/10/05

Kestrel House 10/05/05

Kestrel House 08/11/04

Kestrel House 25/05/04

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 09/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Kestrel House 220 Willingdon Road Eastbourne East Sussex BN21 1XR     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: Kathy Flynn     Date: 1 4 0 4 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 30 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 30 Information about the care home Name of care home: Address: Kestrel House 220 Willingdon Road Eastbourne East Sussex BN21 1XR 01323-431199 01323649420 potterde@bupa.com 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) : BUPA Care Homes (ANS) Ltd care home 54 Number of places (if applicable): Under 65 Over 65 54 old age, not falling within any other category Additional conditions: 0 The maximum number of service users to be accommodated is 54 The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Kestrel House is owned and managed by BUPA. The accommodation comprises of forty-eight single bedrooms with ensuite facilities and three double rooms. There is ample communal space, which has recently been upgraded. Kestrel house is situated on the A22 and just over a mile from Eastbourne town centre. There is car parking on site at the front of the home and a small garden and patio area is situated to the rear and side of the home. Care Homes for Older People Page 4 of 30 Brief description of the care home Copies of inspection reports and the homes Statement of Purpose are available in the reception area of the home. Fees charged as from 1 April 2009 in accordance with the contract with the Primary Care Trust is 671 pounds. Additional charges are made for hairdressing, toiletries, chiropody, newspapers and outside activities. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection was carried out on the 14th April and the 18th and 19th May. It included a tour of the home, a review of pre admission assessments, care plans, staff records and training, medication records, activities, and menus. There were up to 39 residents at the home during the inspection. 12 residents were spoken with and three visitors to the home were happy to discuss the support provided. The manager and the staff on duty discussed the care and support they provide at the home. Care Homes for Older People Page 6 of 30 Residents and staff surveys were sent of the home prior to the inspection, eight resident and ten staff surveys were completed and returned to the Commission, and the information provided has been used as part of the inspection process and included in this report. The reader should aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the term service user to describe those living in care home settings. However for the purposes of this report those living at Kestrel House will be referred to as residents. The Annual Quality Assurance Assessment (AQAA) was completed by the manager, within the required timescale, and identified areas where improvements have been made and are planned for the benefit of residents. 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 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The statement of purpose and service users guide provide information about the services provided at the home, however it does not identify the range of needs that the home intends to meet. Evidence: The statement of purpose and service users guide provide prospective residents with information about the home, including the qualifications and experience of the manager and staff working at the home, a complaints procedure that the manager confirmed has been updated since the last inspection, and details of the facilities offered. However it does not clearly identify the range of needs the home intends to meet, stating only that older people and persons over 18 years who are assessed as continuing care can be admitted. Clearer information is required so that prospective Care Homes for Older People Page 10 of 30 Evidence: residents or their representatives can be sure the home can meet their individual needs, a requirement has been made regarding this. The PCT has contracted all the beds at Kestrel House with all but six allocated to people assessed as needing continuing care. Feedback from talking to residents and residents surveys was that they are not offered a choice, they do not have a contract, and visiting may be difficult if relatives and friends live some distance away. Residents should be provided with the terms and conditions of residency at the home when they are admitted, which clearly states the room they will occupy, the fees and the services they cover, and what additional services are not included in the fees. The process of discharge from the hospital to Kestrel House appeared rushed with assessments at the hospital and admissions to the home carried out on the same day. On one day six people were assessed at the hospital, one was admitted to Kestrel House that day and five were admitted the next day. Feedback during the inspection was that the discharge and admission process fails to take account of peoples needs and understanding of the move. People have been moved in the early evening when staffing levels are lower than the mornings, one did not understand that he was being moved out of the hospital, some are not kept informed about their transfer, and they have been distressed and upset because of this. Clearly this process puts additional pressure on staff and may offer poor outcomes for residents. The manager and deputy manager advised that in future they will only admit people whose needs they are sure they can meet, and they will ensure that prospective residents are involved in decisions about their move from the hospital to the home. The manager said that pre admission assessments are completed before a place is offered at the home. These are completed using information available at the hospital and a visit to the hospital to assess each person. However the manager advised that some of the hospital discharge assessments are not provided by the discharge team, and therefore they may not have a full picture of prospective residents individual needs. The information available for one resident did not identify mental health problems when the home were carrying out an assessment, the person was inappropriately placed in Kestrel House, the staff were unable to meet specific care needs, and alternative accommodation is now being arranged. The manager confirmed that in future they will be asking to see all relevant information before they decide if a place at Kestrel House can be offered. Six assessments were viewed as part of the care planning system. The assessments cover a wide range of care needs and are used as the basis of the care plans. Of those viewed one did not identify the specific needs of a resident, consequently the care plan Care Homes for Older People Page 11 of 30 Evidence: and support offered did not meet her needs. Refer to Standard 7. The pre admission assessment process may not identify the specific needs of prospective residents, this was highlighted at the last inspection, and continues to be an area of concern for the Commission. The home is required to inform them in writing that their individual needs can be met, before they are admitted to the home. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning system offers staff information about the needs of residents, however some had not been reviewed and updated, which may put residents at risk. Policies and procedures are in place regarding medication to protect residents. Evidence: The care planning system contains a considerable amount of information regarding the nursing and personal care needs of the residents, including assessments for moving and handling, pressure relief, nutrition and falls. In addition there are records of visits from GPs, physiotherapists, the Tissue Viability Nurse, chiropodist and other health professionals as required; as well as opportunities to record the residents life history and evidence that residents are involved in developing and agreeing to the support they receive. Six care plans were examined and it was noted that the falls assessments for those who had fallen were not reviewed, which meant that any potential problems were not identified, the care plans were not updated and therefore the written guidance for staff Care Homes for Older People Page 13 of 30 Evidence: was not appropriate. There was no evidence that three of the residents, or their relatives, were consulted about the support offered, and life histories were not completed for all. The specific needs of one resident had not been identified prior to admission and when the home had been advised of these the care plan was not reviewed, therefore staff were unable to offer the support she needed. Bed barriers were used for one resident even though the care plan stated that he has tried to climb over them, a risk assessment for the use of barriers had not been completed, therefore staff were unable to protect this resident. The expectation is that the home ensures that the care plans reflect the individual needs of residents. Guidance is available in the homes own policies as these clearly indicate that care plans should be based on the individual needs of residents; when risk assessments are identified action to minimise them must be planned and documented, drawn up with the involvement of the residents and agreed by them, or their representatives if the resident agrees. Feedback from staff surveys suggested that more information is required in the care plans so that the staff can understand the needs of the residents. Although staff spoken with during the inspection did not identify this as an issue, and stated that the handover is a good way of finding out the needs of residents. The manager advised that training has been arranged to ensure the nurses complete the care plans appropriately. Nutritional assessments are completed for each resident and records are kept of the amount of food and drinks they consume at each meal if the assessment identifies a need. However it was noted that the food and fluid charts are not completed accurately, for one resident there were no records for one day; for another a drink had been recorded as given in the daily life record but not on the fluid chart; overall the the information recorded gave the impression that those viewed were only given drinks three or four times a day. there was no clear evidence that residents who need assistance or reminding to eat and drink were fully supported, and this places them at risk. At the last inspection residents were registered with a local GP practice. This has now changed and a GP attends the home daily for three hours, with support from the local practice and SEDOC to cover the 24 hour period. Because of this change there are delays in obtaining test results from the hospital, some have taken as long as 10 days, and this may result in poor outcomes for residents. The home is considering a safeguarding referral to the local authority to address this. Care Homes for Older People Page 14 of 30 Evidence: The nurses advised that they are responsible for the ordering, storage and administration of medication at the home and that there are policies in place for them to follow. Medicine Administration Record (MAR) charts for the ground floor were viewed and found to be completed appropriately. Communication between the residents and staff was relaxed and comfortable, residents spoken with said the staff are very good and would do anything, I have no complaints, you cannot fault them, they are very friendly and look after us well. Staff were noted to treat residents with respect and made sure that their privacy was protected. The home uses the Gold Standard Framework and end of life care systems to ensure that staff offer appropriate support if the health of a resident deteriorates. Training is provided and staff spoken with said they have completed this or are attending relevant training. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A programme of activities is provided for residents to take part in if they wish. The food at the home is good, choices are offered and staff assist residents as required. Evidence: An activity group made up of staff, residents and relatives meet monthly to discuss the range of activities that they are planning to offer residents, in addition to the programme provided by BUPA. On the day of the inspection a quiz had been organised in one of the lounges and a number of residents were taking part, with the support of two members of staff and visitors. The AQAA states that a range of additional activities will be developed over the next twelve months and will include knitting and reading clubs. Feedback from residents, who expressed an opinion, and staff was positive and those taking part during the inspection were enjoying themselves. The activity organiser has attended a training course, and works with a colleague to offer group and individual activities from Monday to Friday. Records are kept of the individual activities, usually for 5 to 10 minutes, and their usefulness was discussed with the manager in terms of the amount of time spent with residents who remain in Care Homes for Older People Page 16 of 30 Evidence: their rooms. There are no specific activities arranged for residents who have a dementia type disability, and the feedback was that they are taken to group activities for company. There is no evidence they are consulted and the care plans do not identify this as a specific need, therefore it is not met. Appropriate support should be available to enable the activity organisers to develop activities for all the residents in the home. Links with the local community are encouraged, local churches attend on a regular basis, visitors are welcome at any time, and trips to local pubs and parks are arranged for residents with the support of staff. An open day is arranged for later this month and a sensory garden has been developed for residents to use when the weather permits. Residents are encouraged to make choices about their day to day lives, some prefer to spend time in their rooms, including mealtimes, while others sit in the lounges and use the dining rooms. However residents who have a dementia type disability may not have the opportunity to make choices, appropriate systems should be in place to enable this. The food at the home is good, feedback from residents and staff was very positive, choices are provided and assistance is offered by staff if required. Staff confirmed that residents can have what they wish at any time, as drinks and meals are available throughout the day and night. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes complaints policy, which is included in the statement of purpose, is up to date and gives clear information for residents and relatives. The home has not followed the multi agency guidelines for safeguarding adults, which may put residents at risk. Evidence: Information about the complaints procedure is provided in the statement of purpose and can be clearly seen in the entrance area of the home. The manager confirmed that it has been reviewed and updated with clear details of how complaints can be made, and who they can contact if a complainant is not happy with the homes investigation. Since the last inspection there have been four referrals to the local authority under the safeguarding procedures. One was made by Kestrel House and has been addressed, three have been made by other parties, two have been substantiated and one is still being investigated. The manager confirmed that she is aware of the safeguarding adults procedures, in line with the updated East Sussex and Brighton and Hove protection of adult guidelines, in addition to the policies produced by BUPA. However these have not been followed and investigations have been started, or completed, before the local authority or the Commission have been informed. The guidelines are in place to protect people receiving care and support and no action should be taken before advice has been Care Homes for Older People Page 18 of 30 Evidence: sought from the local authority. A requirement has been made regarding this. Training in protecting vulnerable people is provided for staff, and those spoken with have attended this. They were able to demonstrate an understanding of abuse and any action they would take if they have any concerns. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Kestrel House provides a comfortable and homely environment for residents. Training in the control of infection is provided for staff to protect residents. Evidence: Residents are provided with single rooms with ensuite facilities at Kestrel House, as well as lounges and dining areas on each floor, and attractive gardens to the side and rear that residents use when the weather permits. The home was comfortable and well maintained, the rooms have each been assessed for health and safety of the residents, and the maintenance person stated that there is an ongoing maintenance programme to ensure that any repairs or replacements are carried out as soon as they are identified. Residents are encouraged to personalise their rooms and many or them have done this with ornaments and pictures. The lift ensure that residents and visitors have access to all parts of the home and aids, including hoists, pressure relieving mattresses and cushions, walking aids and wheelchairs are available as required. Care Homes for Older People Page 20 of 30 Evidence: Staff spoken with have attended training in the control of infection and were noted to be using gloves and aprons appropriately during the inspection. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Robust recruitment procedures are used to protect residents. Training is provided for all staff with regard to their roles and responsibilities, however this may not be sufficient and should be reviewed and additional training provided as required. Evidence: The manager advised that there has been an active recruitment procedure over the past year, they have a stable team of nurses and care staff at the moment, and the feedback from staff supported this. However concerns were identified with regard to the needs of residents with a dementia type disability, staff ensuring that residents are supported to eat and drink, and the difficulties with ensuring that the care plans are completed appropriately and reviewed and updated as individual needs change. Appropriate training should be provided for staff to ensure they are aware of their roles and responsibilities, and can offer person centred care which would include activities and support in addition to personal care. Person Best Programme has been introduced at the home to encourage a person centred approach to care. This involves staff experiencing situations that the residents Care Homes for Older People Page 22 of 30 Evidence: find themselves in when they are dependent on staff, this includes being transported in a wheelchair, being fed and being moved using a hoist. The expectation is that staff will develop an understanding of the affect their actions can have on the residents, although the staff spoken with did not mention this when asked what training they have attended. Recruitment procedures are followed and the staff files viewed included the relevant information including Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks, completed application forms, two references and terms and conditions of employment at the home. The manager advised that all this information is required before new staff are employed at the home. Induction training in line with Skills for Care is provided for all new employees, those spoken with said they have completed this and have continued on to do National Vocational Qualification (NVQ) courses. The home does not yet meet the requirement of 50 percent of care staff with NVQ level 2 or equivalent but there are opportunities for staff to work towards these and they are encouraged to do this. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management approach encourages residents, their representatives and staff to be involved in decisions about the development of services offered. Evidence: The manager is a registered nurse and has been managing Kestrel House for over two years. There are lines of accountability within the home, and staff spoken with are aware of their roles. However a number of concerns were identified during the inspection and should be addressed as a matter of urgency. The staff said they feel well supported by the management, and they are able to take advantage of opportunities to improve their practice through further training. Residents were equally positive about the support and care they receive, they felt the staff are very good and they support them to be independent. Care Homes for Older People Page 24 of 30 Evidence: The home arranges resident and staff meetings, as well as annual quality assurance questionnaires and daily feedback to provide opportunities for participation in decisions about the services offered at the home. The manager said that this is a part of the management process. The AQAA states that a number of changes have been made as a result of listening to the residents and their representatives, these include focus on the residents day; regular communications and newsletters to keep them informed about developments; residents views have influenced menu choices as well as improvements and adjustments to meal times, and staff are encouraged to listen to what residents say and respond accordingly to deal with issues when they arise. However Kestrel House is a care home with nursing that is part of the BUPA group, a national company which as the AQAA states offers considerable support for their homes. This includes regional and national experts that are available within the company for advice and guidance if required, and Quality and Compliance Officers whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. It is not clear if these systems are in place why some of the concerns raised at the last inspection were not fully addressed and continue to be of concern following this inspection. A requirement has been made for the quality assurance system to be reviewed and updated to ensure that it identifies areas for improvement. The home does not take responsibility for residents finances, and those that choose to do so are supported to control their own finances. Health and safety systems are in place and risk assessments are completed for the residents own rooms. Mandatory training is provided for staff and includes fire training, first aid, infection control and food hygiene. However the training programme should be reviewed and updated to ensure that the staff have the skills to meet the residents needs, and ongoing supervision should be used to recognise the training needs of staff. Refer to Standard 30. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 4 The statement of purpose and service users guide to be updated to include clear information about the range of needs the home can meet, as listed in Schedule 1. To ensure prospective residents and their representatives are aware of the services offered by the home. 28/05/2009 2 3 14 The home is to assess prospective residents and inform them in writing that they can meet their individual needs before they are admitted to the home. To ensure the home only admits individuals whose needs they can meet. 28/05/2009 3 7 15 Care planning system to be reviewed and updated to include all relevant information regarding residents assessed needs 28/05/2009 Care Homes for Older People Page 27 of 30 and the action staff are to take to meet them. To ensure the residents receive appropriate care and support. 4 8 15 Nutritional assessments to identify residents needs to be completed with details of action staff are to take to support residents. To ensure residents receive appropriate nutritional support. 5 12 16 Activities provided at the home are to reflect the preferences of all residents living there. To ensure the all residents are consulted about how they spend their time. 6 14 12 Residents to be encouraged to make choices about their day to day lives. To ensure residents can make choices about all aspects of the support and care they receive. 7 18 37 The multi agency guidelines to safeguard adults to be followed by the home at all times. To ensure residents are protected. 8 34 24 The quality assurance system to be reviewed and updated to ensure that it identifies areas for improvement with regard to 31/07/2009 28/05/2009 28/05/2009 28/05/2009 28/05/2009 Care Homes for Older People Page 28 of 30 the care and services offered at the home. To ensure the home care meet the assessed needs of the residents. 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 Care Homes for Older People Page 29 of 30 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). 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