Inspection on 30/04/10 for Lyons Court Care Home

This inspection was carried out on 30th April 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lyons Court Care Home 11/08/10

Lyons Court Care Home 13/07/10

Lyons Court Care Home 06/07/10

Lyons Court Care Home 18/03/10

Lyons Court Care Home 30/01/09

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/06/2011.

Key inspection report Care homes for older people Name: Address: Lyons Court Care Home Stones End Evenwood Bishop Auckland County Durham DL14 9RE     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: Sam Doku     Date: 0 6 0 5 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 31 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 31 Information about the care home Name of care home: Address: Lyons Court Care Home Stones End Evenwood Bishop Auckland County Durham DL14 9RE 01388834516 01388832327 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Durham Careline Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 50 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 50 Dementia Code DE, maximum number of places 50 Date of last inspection Brief description of the care home The home is well designed and has pleasantly landscaped surroundings. It shares a site with its sister home, Bowes Court. There is ample parking space and views of the surrounding countryside. The home has three floors and all are accessible Care Homes for Older People Page 4 of 31 Over 65 0 50 50 0 3 0 0 1 2 0 0 9 Brief description of the care home by lift. The home has very generous communal and circulatory space and it has been designed to enhance the experience of the service users and to make operation easier for the staff. There is a generous amount of storage space in the home. This design and build is an example of good practice. There is a good standard of equipment such as mobile and fixed hoists, and specialist beds. A suitable call system has been installed. The scale of charges is between 454.71 and 476.44 Pounds per week depending on whether nursing care is required or not. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 quality rating of this service is 1 Star. This means the people who use the service experience adequate quality outcomes. The inspection was unannounced and commenced on 30 April 2010 and completed on 6 May 2010. Before the visit the inspector looked at: Information we have received since the last inspection. How the home dealt with any complaints and concerns since the last inspection. Any concerns brought to the attention of the Commission about the home by other agencies or individuals. Any changes to how the home is run. During the visit the inspector did the following: Talked to the people who use the Care Homes for Older People Page 6 of 31 service and the staff. Looked at information about the people who use the service and how well their needs are met. Looked at other records which must be kept. Checked that staff have the knowledge, skills and training to meet the needs of the people they care for. Looked around the home to make sure it is safe and secure. Checked what improvements have been made since the last inspection. The inspector told the manager and the provider what he found. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use the services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: The senior care staff, in addition to the nurses have responsibility for administration of medicines. However, there was no evidence in the staff files or the training log to show that the home has provided staff with safe handling of medication training. The training log shows that none of the nurses have had safe handling of medication training. The inspector found a number of incidents where medication was given but not signed for or signed for but not given. There was also one instance where the medication for a resident was available in the home but the staff recorded it as out of stock and the resident went for two and half days without their medication. It was also noticed during the morning medication round that the nurse left the blister pack of medication on the trolley and this was out of sight, thus making the tablets accessible to anyone around. Staff who are responsible for the administration of medicines must ensure that they follow the homes policy on medicines management and also they must manage medication in line with the Royal Pharmaceutical Societys guidelines. Care plans did not always include details of information supplied by social workers and nurse assessors. There were a number of examples where the nurse who was drawing up the homes care plans did not include important information from the social workers assessment and care plans. Where such information is considered out of date or no longer relevant, this should be clearly stated in the care plan review notes. There were a number of care plans that were not dated or signed and therefore it was not possible to know when the care plan was put in place and by whom. There was information in the staff communication book to indicate that on several occasions, residents were not offered a bath or shower because of what the staff members described as staff shortage. The management team stated that this is an unofficial book and therefore should not have been considered by the inspector. The inspector on the other hand considered the information as relevant and cannot be ignored and therefore it was considered as part of the evidence to support the inspectors findings. Care Homes for Older People Page 8 of 31 There is poor training of the staff at all levels. The staff training record showed a number of staff have not received training in dementia care, challenging behavour, infection control, health and safety training, pressure area care, first aid, safe handling of medication, Mental Capacity Act and Deprivation of Liberty Safeguards training. During the inspection, an officer of the local authority social service department shared information with the inspector regarding two incidents of restraints, which were being dealt with under the local authoritys safeguarding adults procedure. Risk assessments do not always reflect the actual needs of the residents. For example, in one case the risk assessment stated that the resident mobilises independently but the same resident was assessed on the same day by the same nurse as requiring assistance with two carers to mobilise. The staff are not following infection control procedures. There are two residents in the home with MRSA but the staff did not follow proper infection control procedures when dressing the wounds of the residents concerned. Regulation 26 visit reports are a repetition of the same report month after month. There was no evidence that the recommendations have been followed up in subsequent reports. 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 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service user guide needs to reflect the service that is provided so that residents and their relatives know what service to expect. The homes pre-admission assessments are inadequate in a lot of cases. This compromises the welfare of the residents. Evidence: The home has a service user guide but this will need updating to provide up to date information about the home. The guide stated which client group will be accommodated on each floor but this is currently not the case as the client groups are mixed on each floor. The information about the Commission should be changed to reflect the new name of the organisation which is Care Quality Commission. The home offers the opportunity for prospective residents to visit and to assess the home for themselves before admission is arranged. One resident described the Care Homes for Older People Page 11 of 31 Evidence: arrangements that were made for her to visit the home with her family before she decided to come and live at Lyons Court. One visiting relative also said that she and her family came to look at the home on behalf of her mother as her mother was not in a position to make the decision for herself. Residents files show that social worker and nurse assessor assessments are received before admission is arranged. The home also carries out a pre-admission assessment for each prospective resident. The inspector advised the home that where information supplied by the social worker or nurse assessor in their care plans are considered by the home as no longer relevant to include in the homes care plans, this should be stated in the review of care notes. Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of the residents are not fully met. This compromises their health and welfare. Evidence: Six residents care plans were examined. In some cases the care plans only cover limited aspects of the residents care and did not reflect peoples entire care needs including religious and recreational needs. For example, the care plans that the home prepared for one resident did not include important information in the social workers assessment about the risk of choking. The social workers assessment and care plan advised that the resident is at risk of choking and therefore requires supervision at meal times and prompts to eat more slowly. The home did not consider this information when the staff drew up the care plans for the resident. During the inspection, an officer of the local authority social service department shared information with the inspector concerning two incidents of restraints, which are being dealt with under the local authoritys safeguarding adults procedures. Care Homes for Older People Page 13 of 31 Evidence: The inspector looked at one specific care plan to see how staff manage challenging behavour and the care plan which was written by a nurse said try and improve on Xs unreasonable behavour. The care plans did not specify what these unreasonable behaviours were and how best staff should manage these. The inspector also noted the care plan of another resident regarding their nutrition. The assessment and care plans received from Durham County Council said, food to be cut up in manageable pieces. The homes care plan did not make reference to this information provided by the social worker. Another residents assessment and care plan from Durham County Council said that the resident has good appetite and fluid intake. The care plan then stated that the resident requires a special diet due to sugar intolerance and cannot eat sweets, biscuits, fruits and such like. There was nothing in the care plans to indicate what this special diet was and whether this is being provided. However, later on the home provided further information to the inspector to indicate that the resident in question is able to make informed choice about what she eats and that she is awareness of her condition. A number of these care plans were not signed or dated and therefore it was not possible to determine which staff member was responsible for drawing up the care plans. The inspector looked at the staff communication book and this shows that basic hygiene care needs for some of the residents were not being met. Between 2/1/2010 and 28/3/2010 there were 8 recordings in which people who were due for a bath or shower did not receive these and the reason given in the communication book by the person making the entry was that there were not enough staff on duty to allow people to receive their baths. However, the management team later provided further information to the Commission to show that there had always been adequate staffing on duty to meet the needs of the residents. Two residents have MRSA but there are no infection control measures in place for managing their wounds. There are no care plans or risk management plans for dealing with the MRSA. Dressings to wounds are done without any of the precautions necessary in dealing with MRSA. The acting manager stated that she would ensure that the porper procedures are followed and she said she had ordered the necessary items necessary to allow this to happen. The medication system was examined and there were a number of concerns in the day Care Homes for Older People Page 14 of 31 Evidence: to day management of the medication system. For example, one resident, on 27/4/10 received his medication at tea time instead of receiving them in the morning. No reason was given in the daily report book why this was the case. One resident was prescribed a long term Sulfasalazine to take twice a day. These were recorded as out of stock and the resident did not receive their medication for two and a half days. Meanwhile, there were two bottles of the tablets in stock. There were two examples of tablets that were not given but were signed for as given. There was one example where the tablets in stock did not tally with the recording sheet. The home is holding Oramorph medication but this is not being considered as a Controlled drug by the nurses. The RGN explained that because it is such a low dose and therefore lower strength (10 mg in 5 ml), it need not be treated as a Controlled drug, hence it is not recorded in the Controlled Drugs book. However the inspector recommended that the medication should be treated as a Controlled Drug. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents social and recreational needs are not fully met, and this could be better enhanced with improved care plans and the appointment of an activities coordinator. Evidence: The staff have tried to maintain peoples lifestyles as much as possible but the lack of an activities coordinator had slowed down this effort to allow people to experience appropriate social, recreational and therapeutic activities in the home. Staff said that they try to get the residents involved in recreational activities but they dont always have time to do this consistently. Two visitors commented that the residents with dementia could do with being occupied with activities. There is a four week menu in the home and this offers choice of meals for the residents. Residents who were spoken with said that they enjoy the meals provided and a number of them commented that there is always plenty to eat and the meals are always nice. The inspector examined the four week menu and this showed a balanced diet for the residents. The residents were offered the opportunity to have their breakfast in their rooms. The breakfast arrangement is good and residents are able to have their meals at times Care Homes for Older People Page 16 of 31 Evidence: that are convenient for them. However, the inspector noticed that staff did not carry the breakfast to residents on a tray. In one instance, the carer did not provide the resident with a tray and the resident had to place the bowl of cereal on her lap. She also had to put her cup of coffee on her bedside cabinet as she did not have a bedside table to us. Service users confirmed that they do receive regular pastoral visits from the local vicar. One resident was able to name the local vicar and showed the inspector the local church information sheet which was given to her and other residents by the vicar. The acting manager confirmed that representatives from other religious denominations also visit the home regularly to provide pastoral care to those who want it. Care Homes for Older People Page 17 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of training and proper understanding of dementia care and deprivation of liberty safeguards have contributed to practices which deprive residents of their rights. Evidence: The home has a complaints policy and procedure in place. Residents and relatives indicated that they are aware of the policy and would know what to do if they have any concerns or complaints. The inspector examined the staff training record and noticed that only 13 of the staff team had received POVA training. None had received Mental Capacity Act and Deprivation of Liberty Safeguards training. In discussions with staff members, it was obvious that they had very little or no understanding of deprivation of liberty safeguards and how that applies to people who have dementia. The inspector was made aware of two incidents of inappropriate restraint methods which were dealt with under safeguarding procedures. Care Homes for Older People Page 18 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is safe and secure and meets the needs of the residents. However, environmental adaptations need to be considered to assist residents who have dementia orientate better. Evidence: The home is well designed and has pleasantly landscaped surroundings. There is ample parking space and views of the surrounding countryside. There is good access to and within the home. There are sufficient communal areas on all the floors and residents and relatives have private spaces available to them. All bedrooms are single occupancy and offer privacy for the residents. There are no features, adaptations or artifacts in the home to help residents with dementia to orientate more easily. The acting manager indicated that this is being looked at and it is intended that the dementia units will be managed in a way that would be in line with dementia care practices. The corridors are wide and have grab rails along the corridors to make it easier for people with walking aids and those with limited mobility to move round the home. Care Homes for Older People Page 19 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides adequate levels of staffing but the lack of effective management overview and suitable training compromise the welfare of the residents. Evidence: The inspector examined the staff training matrix. The record shows that 13 of the staff have not received fire safety training. Only 14 of the care staff have received training in food hygiene. Only one of the 4 kitchen staff have received food hygiene training, and only 8 care staff have received food hygiene training. Only 2 carers have received COSHH training, however all 4 domestics/laundry assistants have all received COSHH training. Only 2 carers have received Health and Safety training. Only 6 carers and one kitchen staff have received training in Infection Control. Only 1 senior carer and three carers have received Safe Handling of Medication training. All staff except 5 have recieved moving and handling training. Only 9 care staff have received training in First Aid. No staff member has received training in challenging behavour. No member of staff have received training in pressure area care and only 5 carers have received training in Dementia Awareness. None of the staff have received training in Mental Capacity Act and Deprivation of Liberty Safeguards training. Overall there were adequate staffing levels and further information provided to the Care Homes for Older People Page 20 of 31 Evidence: Commission on the 24 September 2010 showed that the home maintains adequate levels of staffing. This latest information is contradictory to the information that was in the staff communication book. Care Homes for Older People Page 21 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been inadequate management oversight of the home in recent months which has compromised the welfare of the residents. Evidence: The home has been without a registered manager since October 2009. A few days before the inspection visit, the registered manager for a sister home took over the responsibility for overseeing the day to day management of the home. The deputy manager has previously been acting as manager since the registered manager left. The staff files examined did not contain any information about staff supervision. Staff confirmed that they have not received formal suprvision for some time now. Water temperatures are regularly checked and the readings were within the recommended range. A fire risk assessment is in place. Fire inspection report in June 2009 had made some recommendations on fire safety but there has been no indication that the recommendations have been addressed. According to the staff Care Homes for Older People Page 22 of 31 Evidence: training log, one nurse in charge on night shift has not had fire safety training. The inspector raised his concerns about this with the current acting manager. All the servicing records are up to date and this includes lift serving, gas servicing, servicing of bath and mobile hoists and servicing of electrical appliances. Regulation 26 reports were a repetition of the same report on a monthly basis. More significantly, the person carrying out the visit reported under Fire Org and Risk Assessment with the following, need to be organised. Need to review risk assessment regularly. This statement has been repeated continuously from 31/7/09 to date. No action has been taken to address this. There was no name or signature of the person who carried out the visit and writter of the report. This applied to all the reports that were seen. The inspector examined the systems used for handling the residents personal allowances. A spreadsheet is available, which shows details of each residents finances. Receipts are kept for all purchases done on the residents behalf. The accounts are regularly audited to make sure that the residents monies are properly accounted for. Care Homes for Older People Page 23 of 31 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 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 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 Ensure that information provided in the nurse assessor/care manager assessments is taken into consideration when care plans are being devised so that all aspects of the residents care needs are provided for in the plans. Care plans did not always reflect all of the residents care needs. 30/07/2010 2 7 15 Ensure that all service users 01/07/2010 care plans clearly identify all of their individual care needs and how their health and welfare needs are to be met. This is to make sure that staff plan and review how they work with people so that everyone works in the same way to ensure service users needs are being met. 3 7 14 Ensure that individual service user risk 25/06/2010 Care Homes for Older People Page 25 of 31 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 assessments are in place and are reviewed and updated to reflect their changing health needs. This is to ensure service users are protected from risk of harm. 4 8 12 Ensure that the personal hygiene needs of individual service users are met. Put in place effective arrangements to ensure that guidance and instruction provided by the multidisciplinary professionals about care and treatment of service users is relayed to all staff and followed at all times. Put in place effective arrangements to ensure that all staff, including those who prepare food, are aware of individual service users nutritional needs and to ensure that food provided to service users meets their individual nutritional needs. 25/06/2010 This is to make adequate, proper and prompt provision for the care and treatment of service users generally Care Homes for Older People Page 26 of 31 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 and in accordance with specific requirements. 5 9 13 Ensure that all medication is administered as directed by the prescriber to the service user it was prescribed, labelled and supplied for. This is to make sure that residents healthcare needs are met. 6 9 13 Ensure that there is regular and frequent audits of medicines and records must be undertaken to promptly identify and resolve any medication discrepancies and to confirm that staff are closely following the providers medicines policy, and are assessed as competent to administer medicines before undertaking this task. This is to make sure that any discrepancies are detected in time and addressed. 7 9 13 Ensure that medication 25/06/2010 administration records are accurately maintained; that the reasons for nonadministration of medication are recorded by the timely entry of an appropriate code or entry on the medication 01/07/2010 01/07/2010 Care Homes for Older People Page 27 of 31 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 administration record; that the meaning of any such codes are clearly explained on each record; and that the person administering the medication completes the medication administration record in respect of each individual service user at the time of administration. This is to make sure that there are arrangements in place to ensure the recording and safe administration of medication. 8 30 18 Undertake a comprehensive review of the training provided to current staff at the home and produce an accurate record of all training provided to individual staff members. All staff must receive training in safeguarding adults, mental capacity act and deprivation of liberties safeguards. This is to ensure that the residents legal rights and welfare are protected at all times. Produce an assessment of training needs for each member of staff to identify 30/07/2010 Care Homes for Older People Page 28 of 31 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 the training needed to enable each member of staff to meet service users health and welfare needs. Ensure that as a minimum each member of staff receives training in Understanding Dementia Managing challenging behaviour , Infection Control Health and safety Food Hygiene Ensure that all staff with responsibility for administering medication are trained to do so. Ensure there are sufficient staff employed at the home that are trained in first aid so that there is at all times a minimum of one person on duty who has received first aid training. This is to ensure that the staff receive training appropriate to their work in order to meet the health and welfare needs of the service users accommodated at the home. Care Homes for Older People Page 29 of 31 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 26 Carry out and provide 25/06/2010 adequate evidence of appropriate monthly visits to the home on behalf of the registered provider. This is to ensure that the home is being operated in the best interests of service users and that they are receiving good quality care. 10 36 18 Ensure that the staff receive formal and appropriate supervision. This will ensure that staff are appropriately supervised and supported in their work. 30/07/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 The service user guide should be updated to ensure that information contained about the home is correct and reflects acurately the existing service. Lower stength Oramorph medication should be treated as a Controlled Drug. An activities organiser with good knowledge and understanding of dementia care should be appointed to assist with engaging the residents in meaningful activities. Ensure that care staff follow safe food hygiene practices, and also staff to give due regards to how meals are carried to and presented to residents in their rooms. 2 3 9 12 4 15 Care Homes for Older People Page 30 of 31 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. © 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. Care Homes for Older People Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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