Inspection on 28/01/10 for Lakeside House

This inspection was carried out on 28th January 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lakeside House 28/04/10

Lakeside House 23/03/10

Lakeside House 12/05/09

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 11/04/2010.

Key inspection report Care homes for older people Name: Address: Lakeside House Lakeside Lakeside House Darlington County Durham DL1 5TH     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jean Pegg     Date: 0 2 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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: Lakeside House Lakeside Lakeside House Darlington County Durham DL1 5TH 01325286000 01325361253 lakeside.darlington@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Southern Cross OPCO Ltd care home 67 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: the maximum number of users who can be accommodates is 67 The registered person may provide the following category of service only: Care Home with nursing - Code N 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 - Code OP, maximum number of places, 67 Dementia - Code DE, maximum number of places, 67 Physical disability - Code PD, maximum number of places 12 Date of last inspection Brief description of the care home Lakeside House is a purpose built care home which is able to provide both nursing and residential care to people with dementia. The home also has a unit for younger people with physical disabilities. All bedrooms have en-suite facilities and each unit has its own dining room and lounge areas. There is a private car park for visitors to use. Fees Care Homes for Older People Page 4 of 30 67 0 12 Over 65 0 67 0 Brief description of the care home range from £490 - £503.70 for private clients and £428 for clients funded by the Local Authority. 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: This inspection took place on 28 January and 2 February 2010 following a number of adult protection referrals that were made by the home, and concerns expressed by relatives and other professionals. Two inspectors completed this inspection. As part of the inspection we looked at documents held in the home, talked to staff who work at the home, observed practices within the home and we also walked around the building to make sure that it was clean and tidy. During our visit we also gave surveys out to people who live at the home and their relatives and to people who work at the home. At the time of writing this report we have received two surveys back from people who live at the home, three from their relatives and four from staff who work at the home. Some of their comments will be used in this report. Care Homes for Older People Page 6 of 30 What the care home does well: What has improved since the last inspection? What they could do better: Care plans do not show that service users or their representatives have been involved in the development of their care plan. One person we asked said about being involved in their relatives care plan No, I dont know. They dont ask about things. The systems in place for managing medication are not good and need to be improved. We were told I have seen the drugs trolley open and unattended and the dispensary door open and unattended. People do not always have their privacy and dignity respected at all times. Other peoples clothes are sometimes found in the chest of drawers. Complaints are not always responded to appropriately. People are at potential risk of abuse because of a lack of training for staff. This is a modern purpose built home that lacks some attention to detail. This prevents it from promoting a more homely atmosphere for the people who live there. Some parts of the home are not wheelchair friendly. More staff need training in good infection control techniques. Staff training provision is poor and does not equip staff with the skills and knowledge that they need to do their jobs properly. The home has lacked any consistent leadership and has been without a registered manager for over a year. Quality assurance systems have not been implemented Care Homes for Older People Page 7 of 30 resulting in little or no improvements being made. Staff have not received regular supervision. As one person said A place without a manager unsettles staff, and residents feel insecure which is very unsatisfactory. As the saying goes, while the cats away the mice will play. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has information available to inform people about the services provided. This information is in the process of being updated. Written confirmation that the home can meet individual needs is provided as are contracts stating the terms and conditions of residency. Evidence: Lakeside House has a statement of purpose and service users guide that people can read to help them decide if the home is able to meet their needs. Both these documents are in the process of being updated to reflect changes to management in the home. Both documents are also available on audio cassette if needed. The home provides written confirmation to service users stating that they are able to meet their needs. This is done once a pre admission assessment has been completed. We saw examples of letters confirming that the home could meet peoples needs and completed pre admission assessments are on individual files. People living at the home are provided with contracts or statements of terms and Care Homes for Older People Page 10 of 30 Evidence: conditions that apply to them whilst living at the home. These documents explain what is included within the fees paid and how much notice is given or needs to be given should anyone wish to leave the home etc. Care Homes for Older People Page 11 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans do not show that service users or their representatives have been involved in the development of their care plan. The systems in place for managing medication are not good and need to be improved. People do not always have their privacy and dignity respected at all times. Evidence: We looked at five service user care plans. These care plans included people who lived on the residential and nursing units. We found that the care plans followed a strict pro forma produced by Southern Cross that included a range of different assessments and pro formas for monitoring behaviour etc. From looking at the care plans we could see that plans were in place, but that none of the care plans looked at had evidence of service users, families or their representatives being involved in the formulation of those plans. We did see evidence of representatives signing risk assessments but not care plans. We asked one relative if they had been involved in their relatives care plan. They said No, I dont know. They dont ask about things. I communicate with them. Two relatives that completed surveys for us said that they were only sometimes kept up to date with important issues affecting their relative. Care Homes for Older People Page 12 of 30 Evidence: The records held within the care plan showed that other health care professional advice had been sought. For example there were records of telephone conversations with the community psychiatric nurse regarding concerns about some service users behavior. The general practitioner was also called to visit one service user during one of our visits. We checked the medication records for the service users who live on the ground floor of Lakeside House. And we found some problems with the recording of one persons medication, that gave us cause for serious concern. Action was taken by the manager to make this person safe however, we remained concerned that the system in place was not good enough to have allowed these errors to occur. We also noted that an internal Southern Cross audit completed on 18 January 2010 had identified that for medication that the outcomes had not been met and that an audit of the medication systems on both units showed that a poor system was in use. Our inspection visit on the 28 January 2010 showed that no improvements had been made to the system for managing medication since that audit had taken place. In our survey to staff we asked Are you being given training that gives you enough knowledge about health care and medication? All four said No. The quality of signatures used on the medication administration records is poor, however, we can not match two of the signatures used to the list of people who have received training in medication. This means that either the training records have not been updated or people who have not received training in medication, are giving medication. One relative who returned a survey to us told us that I have seen the drugs trolley open and unattended and the dispensary door open and unattended. We told the management of the home to make sure that improvements to the medication systems were made by 28 February 2010 after which time a further inspection would take place. During our visits to the home we have observed care staff interacting positively with the service users living at the home. We have received conflicting information from relatives about how their relatives are treated. For example in our survey we asked What does the home do well? one relative told us Treats them with respect, recognises their dignity and individuality. Whereas another relative said My relative has been in public areas not fully dressed. Another relative told us about how incontinence pads go missing from their relatives room shortly after they have been delivered. The relative thinks that they may be being used for someone who has not been assessed for incontinence pads. Another relative told us that Other peoples clothes are sometimes found in the chest of drawers. We also observed differing practices. For example we saw staff being very attentive to service users however, we also observed two people who were in bed in the upstairs unit. One was lying in bed Care Homes for Older People Page 13 of 30 Evidence: with what looked like the remnants of breakfast thrown on the floor and a drink left on the bedside table. The bedroom door was wide open. Another person was in bed with the curtains closed and the door left wide open. Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides activities for people to take part in. People living at the home are able to receive visitors and they are helped to take part in visits to places outside of the home. Service users are provided with a diet that is nutritionally balanced and they are helped to make choices. Evidence: The home does not have a dedicated activities coordinator at present. We were told that they are planning to recruit someone soon and hope to involve a relative in the appointment process. There is a daily activities plan on the notice boards both upstairs and downstairs and we were told by the manager that staff use this as a guide. We observed care staff engaging in activities with people in the home. For example one lady was taken out for a walk around the local area. Another lady was helping to lay the tables for lunch. One lady was arranging flowers for the dining room tables. A small group of people were playing dominoes and others were having one to one conversations with care staff. When we looked at some of the financial records held we saw receipts for outings that people had taken part in. For example visits to the Railway Museum and Preston Park. We observed relatives and friends visiting the home. One relative told us I visit twice a day. Care Homes for Older People Page 15 of 30 Evidence: On our first visit to the home we looked in the dining room downstairs and saw that the tables were set for lunch. On closer inspection we noticed that one of the tablecloths being used was stained and that there were crumbs on the table from breakfast time. On the wall there was a white board that had the menu for the day written on. The size of the writing was difficult to read and may not have been any use to the service users living at the home. The home has a four week menu in place that has been designed to meet the nutritional needs of the service users who live at the home. One relative told us They offer me lunch if I want it. That is a better menu than I have at home. On our second visit we noticed fresh fruit on the windowsills in the dining rooms. During lunch, each service user was offered the choice of two different meals. They were shown two plates of food and they chose the one that they wanted. People were offered help to enable them to eat as independently as possible. For example we saw food being cut up into small pieces and protective aprons being used to stop food spillages from marking clothes. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are not always responded to appropriately. People are at potential risk of abuse because of a lack of training for staff. Evidence: We looked at the complaints file and saw that there had been five complaints recorded between March 2009 and September 2009. The complaints were concerned about issues to do with laundry, staff attitude and care. There was also one complaint letter on file that had not been recorded on the monthly summary. The operations manager who would usually sign to say that they had checked the monthly summary reports had not signed the report since September 2009. This would indicate that there had been no complaints made since September 2009. An internal audit report recently completed tells us that a complaint had been made to the acting manager, yet there was no record of this in the complaints file. The two relatives that returned surveys to us said that they did not know how to make a formal complaint. The home has made a number of adult protection referrals including one that showed that staff were not fully aware of issues around Deprivation of Liberties. Records show that the majority of staff have received training in the Protection of Vulnerable Adults. We were told that training in the Mental Capacity Act and Deprivation of Liberties was being planned and that they were waiting for dates from the training provider. Care Homes for Older People Page 17 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. This is a modern purpose built home that lacks some attention to detail. This prevents it from promoting a more homely atmosphere for the people who live there. Some parts of the home are not wheelchair friendly. Evidence: We walked around the building to see if it was being cleaned and maintained. Lakeside House is a relatively new building and only half of the home is occupied. Although the standard of fixtures and fittings is good, there are parts of the building that do not look as though they are cared for as well as they should be. For example in one bathroom on the first floor we saw hoists, linen trolleys and items of clothing stored. In one vacant bedroom we found an old magazine left on the windowsill. In parts of the building that are not meant to be used we found evidence of face cloths and towels left in rooms and liquid soap stains on walls. In one disused lounge we found a plastic bag full of rubbish that looked as if it had been left over from a fund raising event. All of the bedrooms we looked at had en- suite facilities and there was evidence of personal items used to decorate and furnish rooms. During our visit we also observed new technology being installed that can be used to alert staff when service users may need assistance during the night. The laundry facilities were all in good working order. In general, the home is clean but we were concerned to see that staff training records show that only twelve staff have received training in Infection Control. We also witnessed poor infection control Care Homes for Older People Page 18 of 30 Evidence: technique when we saw a member of staff place a soiled duvet into a red linen bag without the use of gloves. A relative also pointed out the following The exit doors from the dining room to the patio are a hazard because there is a raised step which the residents with poor eyesight and mobility aids find difficult to negotiate. It is the same problem at the front door where it is difficult to push a wheelchair over the ridge. Another relative said The building is clean and therefore, there is no unpleasant smell. In March 2009 the home was awarded five stars for the Tees Valley Food Hygiene Award. Care Homes for Older People Page 19 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. Current staffing levels are good in the home and the majority of care staff have a National Vocational Qualification in Care. Recruitment practices are good but staff training provision is poor. Evidence: At the time of the inspection visits there were twelve service users in the residential unit and sixteen service users in the nursing unit. For the last few weeks the home has been operating with extra staff to allow care plans to be reviewed and updated. For the nursing unit this means that there are currently two qualified nurses and five care staff on duty from 8am until 8pm and for the residential unit there is one senior care staff and three care staff on duty for the same time period. From 8pm until 8am there is one qualified nurse and three care staff on duty. When we asked staff if they felt that there were enough staff on duty to meet the individual needs of the people who use the service. The responses ranged from usually to never. The training matrix shows that twelve of the sixteen care staff employed at the home have achieved a National Vocational Qualification in Care at level 2 or above. This means that 75 of care staff have a nationally recognised qualification in care. From the staff records that we looked at we found evidence of references and criminal record bureau checks having been completed before the person started working at the Care Homes for Older People Page 20 of 30 Evidence: home. We also found evidence that the home had ensured that where the person was not a British citizen, that they were eligible to work in the United Kingdom The staff training matrix that we were provided with showed that many staff had been without basic training for a long time. For example only one senior care staff had received training in Pressure Care and Care Planning. Not all staff had received training in Challenging Behaviour or Dementia Awareness. No one had received training in Bed Rail Safety. Arrangements for staff to receive this and other training did not take place until January 2010 following concerns raised by the Local Authority. The staff training matrix provided to us during inspection showed that one qualified nurse, two senior care assistants, one care assistant and a member of the kitchen staff received medication training in November 2008. We were also concerned to see that staff training records show that only twelve staff have received training in Infection Control. When we looked at recruitment records we also found that not all staff had completed a proper induction programme. Care Homes for Older People Page 21 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has lacked any consistent leadership and has been without a registered manager for over a year. Quality assurance systems have not been implemented resulting in little or no improvements being made. Staff have not received regular supervision. Service user financial records are managed appropriately and maintenance records are generally well maintained. Evidence: The home has been without a registered manager since November 2008. We know that there has been four people covering the role of manager from November 2008 until the most recent manager appointment. The current manager who assisted us with this inspection only started working at the home on 25 January 2010. The registered provider is required to keep the Care Quality Commission informed of any changes to the management arrangements of the home. They have failed to do this. One relative told us Staff, especially senior management, should be replaced more quickly. A place without a manager unsettles staff, and residents feel insecure which is very unsatisfactory. As the saying goes, while the cats away the mice will play. Care Homes for Older People Page 22 of 30 Evidence: We asked to see copies of the regulation 26 provider visit reports. The file we were shown did not have any reports filed between the dates of September 2009 and the most recent report completed 18 January 2010. We were told by the manager that no other reports could be found. We also asked to see a copy of the latest report based on service users views. We were told by the manager and the administrator that a copy was not available. The administrator tried to locate a copy at head office but was unsuccessful. A number of internal quality assurance audits had not been completed since June 2009 and September 2009. No one could offer a reason as to why this was the case. We looked at the system in place for safeguarding the cash that is held on the premises on behalf of service users. We found this sytem to be satisfactory. We asked to see the supervision records held for staff. We looked at the staff supervision planner for April 2009- March 2010. The last entry made on the planner was for two staff on the 11 August 2009. The supervision planner provided for this period did not list any qualified nurse names. Of the thirteen staff named, nine had one supervision planned and three had two supervisions planned. A new list prepared for supervision sessions planned from January 2010 contains forty names. Eleven of these people have received supervision in January 2010. This means that staff will not have received the recommended six supervision sessions a year. Regular supervision is needed to ensure that staff are kept up to date with what is expected of them and that they can discuss any concerns that they may have with practice. Information from staff surveys tells us that staff do not receive regular or frequent supervision. One person we spoke to said that she had received her First and only supervision just after Christmas 2009. We looked at the maintenance records held in the home and found that they were generally up to date. We did notice that two fire system weekly checks had not been completed for 30th December 2009 and 7th January 2010. This information was passed on to the manager. Care Homes for Older People Page 23 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 24 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Service users and or their representatives must be consulted about how their health and welfare needs will be met by the home. The results of this consultation must be reflected in a written care plan. This will ensure that the service user or their representative is happy and in agreement with how their health and welfare needs will be met. 31/03/2010 2 9 13 Arrangements must be in place to ensure that medication is given as prescribed and a record must be made at the time that it is given. This will make sure that people receive their medications correctly and the treatment of their medical condition is not 28/02/2010 Care Homes for Older People Page 25 of 30 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 affected. 3 16 17 A record must be kept of all complaints made in the home. This will ensure that an accurate record of complaints is kept and can be used to identify trends and areas for imporvement. 4 30 18 Training in the 30/04/2010 administration of medication must be provided to all staff who are administering medication. This will ensure that staff giving medication know how to do it safely. 5 30 18 Infection Control training and techniques must be implemented and monitored for all staff. This will ensure that good infection control measures are in place and the risk of cross infection is reduced. 6 30 18 New staff must receive a 30/04/2010 structured induction programme when they commence employment with the home. This will ensure that staff know what is expected of 30/04/2010 31/03/2010 Care Homes for Older People Page 26 of 30 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 them and enable further training needs to be identified without delay. 7 30 18 Regular staff training must 30/04/2010 be provided that equips people with the skills and knowledge that they need to meet the needs of the people they care for. This will ensure that staff skills and knowledge are kept up to date and service users are not put at risk through ignorance or poor practices. 8 31 39 The Care Quality 31/03/2010 Commission must be notified of any changes to the management arrangements of the home. This will ensure that the Care Quality Commission know who is responsible for the day to day management of the home 9 33 26 Provider visit reports must be produced and a copy provided to the manager of the home. This will ensure that the manager of the home is aware of areas that need improvement and that a copy of the report can be 31/03/2010 Care Homes for Older People Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action made readily available for inspection purposes. 10 33 24 The quality of the services provided by the home must be monitored and take into account the views of service users and their representatives. This will ensure that the service provided remains acceptable to the people who use the service and their representatives. It will also highlight areas that may need to be developed to meet peoples expectations about the service provided. 11 36 18 Regular staff supervision sessions must take place and records kept of the outcome. This will ensure that staff receive regular feedback on their performance and are given the opportunity to raise any concerns that they may have. 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 31/03/2010 31/03/2010 1 1 Information about the home should always be kept up to Page 28 of 30 Care Homes for Older People 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 date and reflect any changes made in the home or to the service provided. 2 7 Care plans should be signed by the service user or their representative to show that they are in agreement with the content of the care plan. People requiring incontinence pads should be properly assessed for them and any incontinence pads received by the home should only be used for the person they are prescribed for. Menus should be produced in a variety of different formats that can be understood by the service users who live at the home. This will help them to make choices as part of their daily lives. Staff should be provided with training in the Mental Capacity Act and the Deprivation of Liberties. This will ensure that they are up to date with current legislation and do not make decisions that could place a service user at risk of potential harm or abuse. The home should be audited and adaptations made to ensure that it meets the needs of wheelchair users especially the entrances and exits to the home. The home should be kept tidy and free from unnecessary clutter at all times. Staffing levels should always be kept under review to ensure that service users needs are met at all times. The manager should apply to be registered with the Care Quality Commission as soon as possible. 3 8 4 15 5 18 6 19 7 8 9 19 27 31 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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