Inspection on 03/08/09 for Landemere Residential Care Home

This inspection was carried out on 3rd August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Landemere Residential Care Home 02/10/07

Landemere Residential Care Home 06/09/06

Landemere Residential Care Home 09/06/05

Landemere Residential Care Home 25/02/05

Landemere Residential Care Home 26/07/04

Landemere Residential Care Home 07/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Landemere Residential Care Home Inverary Close Off Grampian Way Sinfin Derby Derbyshire DE24 3JX     The quality rating for this care home is:   one star adequate 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: Helen Macukiewicz     Date: 0 3 0 8 2 0 0 9 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 29 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) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Landemere Residential Care Home Inverary Close Off Grampian Way Sinfin Derby Derbyshire DE24 3JX 01332272007 01332271224 maxine.smith@anchor.org.uk www.anchor.org.uk Anchor Trust care home 40 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) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Landemere is a purpose built care home for Older People, was built in 1991, and provides accommodation for up to 40 Older People. It is situated close to local amenities and to bus routes serving Derby city centre. The accommodation is on two floors, with access to the first floor via staircases or via a shaft lift. All rooms are single occupancy, with en-suite facilities. Each room has the benefit of refreshment facilities and is fitted with a small refrigerator. Services include personal laundry, meals, and personal care designed to meet individual needs. The charges made for a room at Landemere Care Home were 444.00 GBP per week. Care Homes for Older People Page 4 of 29 Over 65 40 0 Brief description of the care home Extras included some toiletries, private chiropody, private dentistry and hairdressing, a list of charges was on display in the hairdressing room. The manager provided this information. A copy of the last inspection report is available from within the Home and on display in corridor areas. Further copies can be found by visiting www.cqc.org.uk Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people using the service and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgments such as notifications from the provider, complaints or concerns. We also use information from an Annual Quality Assurance Assessment (AQAA), referred to throughout this report as the pre-inspection self-assessment, which the provider is required to complete prior to a visit to the service. This provides evidence for us to make informed judgments when assessing the National Minimum Standards (NMS). Care Homes for Older People Page 6 of 29 The primary method of inspection used during the visit to this service was case tracking. This involved selecting four people and tracking the care they received through review of their records, discussion with them where possible, the care staff and observation of care practices. Time was spent in discussion with the Manager and staff. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. All of the key standards were inspected on this occasion. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Staff need to assess and plan peoples care in a much more consistent way. They need to ensure that all potential risks to people and all care needs are identified, and that a plan of care to meet all needs is in place. People also needed to become more involved in the planning of their care and this needed to be recorded in care files. The recording of medicines to be given needs to be improved so records are clearer about what medicines are being brought into the home and what medicines people Care Homes for Older People Page 8 of 29 receive. There needs to be greater priority given to meeting peoples social care needs, both in terms of staffing resources and the way activities are individually planned. There will need to be greater consistency in the quality of food that people receive. People perceive there are times during the day when staffing is not sufficient to ensure people are adequately supervised and the planning of staffing needs to change to ensure people are kept safe. Internal quality assurance needs to provide clearer action plans so that the service is more reactive to areas that need improving. This will ensure people receive better quality and safer care. 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 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Comprehensive information about the home and pre-admission procedures ensures that people have the information they need to choose a home that is right for them. Gaps in assessing needs post-admission leave the potential for care needs to be overlooked. Evidence: In her completed pre-inspection self-assessment the manager told us there was a full and comprehensive pre-admission process completed for each person prior to admission. Enquiry brochure, simple but robust including DVD. Capturing all aspects of our service with visual aids, pictures/photographs and the views/experiences of people using our service. Also that we have introduced a welcome pack, a personal feel of what you may wish to experience during your stay at landemere. Our corporate service users guide is being translated into a selection of other languages. In their completed pre-inspection surveys people told us they had enough information Care Homes for Older People Page 11 of 29 Evidence: about the home, and a contract stating terms and conditions of their stay. One relative wrote it was an excellent home. We saw that information in the form of a Service Users Guide was provided in each persons flat and was up to date. We also saw that there were systems in place to make sure people had a thorough assessment of need prior to being admitted to ensure people were not admitted inappropriately. However, the quality of their assessment once they had arrived at the home was variable. Some peoples care records showed that they had received a comprehensive baseline assessment of need, but other files lacked basic information leaving the potential for care needs to be overlooked. The Manager had already identified that care records needed improvements in a recent self-audit of the service and intended to provide further staff training in this area. Once they had been admitted to the home, people told us they were very happy there. Comments included I think its lovely here and Im not moving, we are happy here and I wouldnt go anywhere else, you couldnt find anywhere better, its nearly like home. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care in a private and dignified way. Gaps in care planning, risk assessment and recording of medications has the potential to adversely affect well being. Evidence: The standard of peoples risk assessments and care planning was variable. Some files were comprehensively completed and others contained significant gaps that could adversely affect care, such as failure to identify risk of falls, and to update the care plans with changes to care that had arisen since admission to the home. There was also a delay in writing a plan of care for one person, following admission. Only one of the care files we saw demonstrated that the person had been fully involved in the planning of their care. The lack of involvement was also evident when we spoke to people, as although they knew staff held documentation about them, they told us they had not seen their plan of care. The manager told us that some of staff had been on care plan workshops but acknowledged that it was relatively new documentation to staff and work still needed to be done to make the necessary Care Homes for Older People Page 13 of 29 Evidence: improvements. Care files and discussion with people using the service did support that people were receiving health services within the community such as District Nurse, Dentist and G.P. visits. One said you get to see the doctor as you would in your own home. People told us they received good care. In their completed pre-inspection surveys one person wrote that staff look after our welfare, and another said care for us was one of the things that the home does well. One visiting professional wrote provides good quality care. People also confirmed that the staff respected their dignity and privacy, one said they either knock on the door or ring the bell. In her completed pre-inspection self-assessment the manager wrote that All staff who administer medication have attended accredited training and we have in house competency frameworks for appointed staff. Also that they had medication audits and policy to ensure processes to lessen the likelihood of incident both internally and externally. We were able to confirm that staff had received training on handling medicines at regular intervals. We saw the systems in place to maintain regular internal audits of this area, and this had led to general improvements since we last visited. However, the following areas still needed improving: Some medication was locked in the treatment room, but not stored in approved medication cupboards. A hand written entry on a medication administration record (MAR) for directions on where to put a cream were not dated and signed. Staff had only signed that this had been applied three times, but the prescription stated it was required twice daily. Staff had only ticked that this should be applied at bedtime. One hand written entry on a MAR chart for a drug stated own supply on trolley, no further information was given in terms of dose, amount and amount coming in to the home. The medication itself was not correctly labeled. There were further hand written entires to MAR charts that had not been dated or signed and the amount of medication coming into the home was not always recorded although a check of records and stock supported that all had been given and numbers tallied. Most of these issues had been picked up by the manager in a recent medication audit and an action plan written for staff. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples lifestyle choices are restricted at times. People do not always receive the standard of food they expect. Evidence: One person in their completed survey told us that games and outings was an area that the home does well. On the day of the visit we spoke to the activity co-ordinator who described ways in which she was encouraging people to engage in activity such as gardening projects, individual manicures and shopping to the local supermarket for small items and clothing. She kept records of what people did, although this was not fully integrated within the individualised care plan to form part of an overall plan of care to meet individual social needs. We observed that people with a higher level of physical needs received less occupation of their time than those who could participate in group activities. On the day, people told us we have just had a summer fayre about 2 weeks ago and did a barbecue outside and said they went on a trip to Staunton Harold, but trips have been planned much less than they used to. They told us that the amount of activity offered was dependent on the availability of staff, and was very limited during the times that the activity co-ordinator was not on duty, one said not enough to do and Care Homes for Older People Page 15 of 29 Evidence: no encouragement to do anything (when activity lady not present). People said they would like to go out more in their community but they cant spare the staff and staff are too hard pressed. In her completed pre-inspection self-assessment the manager told us their aims for the next twelve months were to continue to make improvements to our social/recreational programme. Introduce additional hours to enhance our person led activities and social diversity. She also said that social/recreational pursuits, hobbies and interests are evolving with our service; lifestyle preferences are supported and encouraged. People told us their spiritual needs were being met, peoples individual needs were identified through their baseline assessment. People received leaflets informing them of visits by local Churches. One person said Church come and give a lovely service once a month and a vicar comes every Thursday. People told us they could come and go as they pleased around the home and that there was no restriction of movement around the building, they told us you can do what you like. One person, in their completed survey wrote good dining rooms and food and a relative said in their survey that the meals were an area that the home does well. On the day, people told us that the standard of food was variable. People told us that the food was less satisfactory when agency catering staff were used. Their comments included some days the food is awful and some days its excellent, a menu is up there telling you what it is, but sometimes they (staff) will say its not on and the meals have changed, agency staff are not always very good. People said there was enough food but that sometimes food is badly cooked, sometimes the agency people are rubbish. One person told us they could have drinks and snacks at any time and there was a water dispenser in the corridor, and they confirmed that you could help yourself to a cold drink at any time. The minutes of a residents meeting were on display from April 2009. These recorded that people discussed their concerns regarding food and an action plan was put in place to address the issues. However, some people remained concerned about the standard of food. The cook told us she had raised concerns with the Company about the quality of meat supplied to the home, but this issue had not been resolved at the time of our visit. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are kept safe in the home and have their rights to complain upheld. Evidence: In their completed pre-inspection surveys people living at the home and their relatives told us they knew how to make a complaint to the service. The managers preinspection self-assessment recorded that they had received 15 complaints in the past 12 months, but that they had started to identify and record minor niggles, as part of their quality assurance. She also said that the displayed procedure has been worded in larger print to make it easier to read. We saw the complaints records for the home, these supported that action had been taken to resolve issues. Complaints procedures were well communicated throughout the home and people told us they were able to raise concerns. There had been one potential safeguarding incident in the past 12 months. The manager had worked closely with the relevant external agencies to resolve the issue. Safeguarding procedures were available to staff and staff had received training in this area so they could keep people safe. A programme to educate all staff in the Mental Capacity Act and Deprivation of Liberty had been commenced and some senior staff had attended. One person had bed rails in place to keep them safe. However their risk sheet with action plan in the care file did not identify this, and although a care plan was in place there was no written consent. Care Homes for Older People Page 17 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment enhances peoples lifestyle and is sufficient for meeting the stated aims of the service. Evidence: All the bedrooms we saw were personalised with peoples own belongings, many had a telephone and all those seen had a fridge and a lockable facility or safe inside. All areas were tidy and one person confirmed that staff clean every day and said they had a very nice room. In her completed pre-inspection self-assessment the manager wrote there is a robust maintenance programme in place effectively managed by our surveyor ensuring we have good quality facilities that are adaptable to individual requirements. We have made several improvements to the home with customer consultation enhancing a homely feel that is welcoming and user friendly. In their completed surveys people told us the home was clean and tidy and one wrote that the gardens are a pleasure. On the day people told us they were happy with the standard of their environment. Comments included youve got a little safe and you can lock your door inside and out and we have got a wonderful garden. We noted that one area of the home contained a urine odour, we brought this to the attention of the manager on the day. Care Homes for Older People Page 18 of 29 Evidence: There were facilities for the laundering of clothes and to maintain infection control. People described the laundry service as top class, marvelous and very good. Care Homes for Older People Page 19 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by well trained and suitable staff. Gaps in care had arisen due to staffing shortfalls. Evidence: We saw that there were consistent planned numbers of staff, although staff rotas showed there had been times in the last month where staff sickness levels had been high. In their completed surveys people told us that staff were usually available when needed, one wrote help when needed and were never lonely. However, one relative stated in the what the home could do better section, employment of minimum staff required, number does not provide cover for staff absences nor does it allow for staff to provide activities for service users. On the day, people perceived there had been staffing shortfalls, comments included not enough staff, cant keep the staff and cant spare the staff (for activities). They said this had affected the following outcomes for them they (staff) are very rushed, you dont get the service you expect, nobody came with a cup of tea this morning, breakfast is late and nobody about after lunch and after tea, you get people falling and calling for help, if you can pull the buzzer you are OK, but not all can. The manager told us that she was recruiting staff and in her completed pre-inspection selfassessment she told us that the aims for next 12 months included invite residents to be involved in the recruitment of staff, be part of the decision making processes, to Care Homes for Older People Page 20 of 29 Evidence: build a dedicated care team. People told us that they got on well with staff, one said staff are lovely. In one completed relatives survey they wrote that staff always ready to talk and joke with (x) and said that friendly, caring of residents was one of the areas the home did well. In her completed pre-inspection self-assessment the manager told us that we are an organisation accredited with investors in people, demonstrating a commitment to helping people realise their career aspirations, feel supported and valued through training, development, mentoring and supervision. There was a programme in place for regular staff training and induction of new staff. Numbers of staff with National Vocational Qualifications to levels 2 and 3 were lower than minimum standards recommend but again, there was a planned programme in place for staff to pursue these. Staff recruitment systems were well developed and ensured staff were subject to the necessary recruitment checks. Care Homes for Older People Page 21 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is managed in peoples best interests although quality assurance is not always effective in bringing about improvements to the service in a timely way. Evidence: The manager had managed the home for four years and had been deputy manager before then, she had completed a Registered Managers Award and had undertaken further training relevant to her role. In her completed pre-inspection self-assessment the manager wrote that they undertook bi- monthly residents meetings, 6 monthly customer consultation surveys how are we doing. Also that they had introduced an excellence audit, internal selfassessment mechanisms which will be reviewed by our management team. We saw the completed excellence audit, this was very comprehensive and the manager had identified areas of need well. Her findings were consistent with the outcomes of this report demonstrating that she had good insight into where improvements within the service were needed. Care Homes for Older People Page 22 of 29 Evidence: Monthly monitoring visits made by the Company were also undertaken. These were less comprehensive and reports did not always identify main areas for improvements or provide clear directives such as stating who was responsible for pursuing actions and what timescales were needed. We found that some areas of need such as improvements to care documentation and food, which impacted on peoples care, had been requiring action for some time, but had not been highlighted for closer monitoring in the reports. People confirmed they had a say in the running of the home. There was lots of information around the home to keep people informed about matters affecting them. One person said they keep you well informed. The system for handling peoples personal allowances was safe, invoices and receipts were kept and balance sheets were accurate. Money was stored securely and people were given a monthly statement. Staff were being regularly supervised and said they felt supported by management. There were sound systems in place to ensure regular maintenance of equipment and to keep the environment people lived in safe and free from hazards. Care Homes for Older People Page 23 of 29 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 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 2) Every person living in the home must have a comprehensive assessment of their needs upon admission to the home which is fully recorded in their care records. This is to ensure that care needs are not overlooked. 30/09/2009 2 7 15 people must have a plan of care written as soon as practicable following baseline assessment of their needs. Care plans must identify all care needs arising following admission and be updated as care needs change. This is to ensure no care needs are overlooked and to provide staff with clear directions about the care needs of people who live in the home. 30/09/2009 Care Homes for Older People Page 25 of 29 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 3 7 15 1) People must be consulted 30/09/2009 about their plan of care and this must be evidenced within care plan records. This is to support that people have their rights to make informed decisions about their lives upheld. 4 8 13 4c) People must have a thorough risk assessment in all areas of need as soon as practicable following their admission to the home. This is to ensure people are kept safe and have their care needs met. 30/09/2009 5 9 13 2) All medication must be correctly stored in a medicines cupboard. The amount of medications coming into the home must be recorded. Staff must be provided with clear and accurate instructions, which are consistent with the prescribers instructions, when making hand written entries on to the medication administration record. 30/09/2009 Care Homes for Older People Page 26 of 29 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 This is to ensure medications are stored and administered correctly. 6 12 16 2m)n) People must be 31/10/2009 consulted about and have an individualised assessment and care plan in place to meet their social needs. This is to ensure people are supported to lead a fulfilling lifestyle of their choosing. 7 18 13 7) People must have a full risk assessment before mechanical restraint in the form of bed rails are used. Consent for their use must be recorded, as evidence this has been obtained. This is to ensure people are not subject to inappropriate use of mechanical restraint. 8 27 18 1a) The organisation of staffing must ensure that people receive the care they require and that they are supervised. This is to ensure people have their care needs met and that they are kept safe. 30/09/2009 30/09/2009 Care Homes for Older People Page 27 of 29 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 9 33 24 Internal quality assurance 31/10/2009 systems must be effective in bringing about improvements to the service in a timely way. This is to ensure people receive the best quality service and are kept safe in the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 9 15 Hand written entries on the medication administration record should be signed and dated. Measures should be put into place to ensure that the quality of food that people receive is consistent with their needs and that the supply of catering staff and food enables quality to be maintained. All areas of the home should be kept free from unpleasant odours to maintain peoples dignity. 3 26 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. 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