Inspection on 06/11/08 for Moors Park House

This inspection was carried out on 6th November 2008.

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

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

Other inspections for this house

Moors Park House 26/01/10

Moors Park House 04/06/07

Moors Park House 31/05/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Moors Park House Moors Park House Moors Park Bishopsteignton Teignmouth Devon TQ14 9RH     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sue Dewis     Date: 0 6 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Moors Park House Moors Park Moors Park House Bishopsteignton Teignmouth Devon TQ14 9RH 01626775465 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mycare Homes Ltd care home 37 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Moors Park House is registered as a Care Home providing Personal Care for up to thirty-seven elderly physically and mentally frail people. Most people have single rooms (the two double rooms are generally only used as doubles on specific request), and most have en-suite facilities. The home is a large detached property set in its own grounds, it is well kept and managed and is well adapted and equipped to meet the needs of people living there. The manager told us during this inspection that fees for the home are currently between 321 and 490 pounds per week. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading Care Homes for Older People Page 4 of 28 Over 65 37 37 37 37 0 0 0 0 Brief description of the care home web site at www.oft.gov.uk. A copy of the most recent CSCI report is displayed in the hallway. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good 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 unannounced visit took place over 9 hours at the beginning of November 2008. The last Key Inspection of this service took place on 04 June 2007. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the visit 3 people were case tracked. This involves looking at peoples individual plans of care, and, where possible speaking with the person and staff who care for Care Homes for Older People Page 6 of 28 them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to some people living at the home and some staff. At the time of writing the report, responses had been received from 6 people living at the home (some had been completed by their representatives) and 4 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. Although only one inspector undertook this inspection, throughout the report there will be reference to what we found and what we were told. This is because the report is written on behalf of the Commission for Social Care Inspection. During the inspection 4 people living at the home were spoken with individually and 4 others in a group setting. The interaction between the people living at the home and those who care for them was also closely observed. We spoke with 3 staff, the manager and the assistant manager. A tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. An Annual Service Review was completed on the home in June 2008. This review concluded that we needed to do a Key Inspection of the home to ensure a good service was still being provided to people who live at the home. Our main concern was that the AQAA (Annual Quality Assurance Assessment) had not been fully completed and did not provide us with the information we asked for. However, the manager subsequently identified that the wrong copy of the AQAA had been sent to us, and she then forwarded a copy of the fully completed form to us. The Commission received an anonymous complaint relating to cleanliness of the home and low staffing levels. A Random Unannounced visit was made on 25 January 2008 when the complaint was found to be unsubstantiated. A further complaint was made to the Commission about items that had allegedly gone missing while someone was staying at the home, some time ago. The complaint was passed to the provider to investigate using their complaints procedure. Evidence was seen at this visit that showed the home had appropriately investigated the matter when we had asked them to, and that they had also investigated the matter thoroughly when the complaints had first been raised. What the care home does well: What has improved since the last inspection? What they could do better: No major issues were identified, but several areas for improvement were discussed with the manager and these included, Care plans need to show more detail of how staff are to meet the needs of individuals, rather than just what those needs are. This will ensure people receive care in a consistent way. More detailed risk assessments need to be completed, including, nutrition and moving and handling. People should be encouraged to participate in the care planning process. Medications received into the home need to be counted so the home knows the quantity of each medication it holds and would know if any were missing. All handwritten entries on Medication Administration Record (MAR) sheets should be double signed, to ensure the correct information is recorded. A sample list of signatures/initials of staff who administer medication should be kept so that it can be checked who did/did not administer any particular dose. Keeping a complaints log would ensure it was possible to quickly check how issues had been dealt with. The contact details for CSCI need to be amended to show the current details so that people can contact the Commission if they wish to. The home should be kept free from unpleasant odours at all times. Care Homes for Older People Page 8 of 28 The quality assurance system should be formalised by compiling a report to show how people have been consulted with and issues acted on. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission procedure ensures that there is a proper assessment prior to people moving into the home, and therefore people can be assured that their care needs can be met. Evidence: There is a Statement of Purpose, Service User Guide and Brochure available to people thinking of moving into the home. These are given to people and their representatives and discussed with them before they decide whether to move into the home. The files of three people living in the home were looked at. The Manager told us the procedure that is followed when people have been referred for possible admission to the home. We were told that this usually included visiting the person whether they were at home or in hospital to complete a pre-admission assessment. We were told that although people are always invited to visit the home, in general it is their family Care Homes for Older People Page 11 of 28 Evidence: that looks at the home on their behalf. The three files looked at, showed some form of assessment had been completed prior to the person moving into the home. The home does not provide intermediate care. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Everyone who lives at the home has a care plan which provides staff with some information to enable them to meet peoples health and social care needs on a day to day basis. The management of medication is generally good and helps ensure people are protected from the risk of not receiving their prescribed medication. Evidence: The care plans of three people living at the home were looked at. They contained some assessment of peoples health and social care needs. However, they did not contain any details of how staff should meet these needs. It was clear through discussion with staff that they knew what peoples needs were and how they should be met, but there was no written guidance. This means that there is the potential for people to either receive inconsistent care or to not have their needs met at all. There was no evidence that detailed risk assessments have been completed where necessary and in particular there were no risk assessments for nutritional or moving and handling needs. Care Homes for Older People Page 13 of 28 Evidence: Although there was evidence that the care plans had been reviewed regularly there was no evidence that the individual had been included in the care planning process. There were some good daily recordings that gave a good indication of how the individual had spent their day and what care had been given. We discussed with the manager and assistant manager varying ways in which the care planning process could be improved, and the manager and assistant manager were very keen to talk over options with staff and to ensure a system was devised to give staff clear written guidance on peoples identified needs and how they are to be met. There was evidence on file that peoples health care needs were being met, and that a range of health care professionals visited the home, including GPs and District Nurses. One individual told us how the home helped them to manage their diabetes. There is a policy and procedure for the administration of medicines and evidence was seen to show that people are supported to look after their own medicines if they wish to. All medicines were seen to be stored correctly and staff were seen administering them appropriately and signing the MAR (Medication Administration Record) as needed. We were told that medicines are checked and counted when they come into the home, but the quantities are not recorded, so there is no record of actual quantities received and there is no way to check if any medication is missing. Hand written entries onto MAR (Medication Administration Record) sheets are not double signed, which is good practice to ensure the correct information is recorded. Also, there is no list of sample signatures or initials to help identify who has/has not administered a particular dose of medication. All people we saw during this visit looked well cared for and were treated with respect by the staff and their right to privacy was upheld. Personal care was seen to be offered in a discreet manner. Staff told us how they respect peoples privacy when helping them with personal care and we heard staff speaking with people in a kindly, friendly way. There was an obvious affection between staff and the people they care for. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social interaction and activities are available, and there is daily variation and social interaction for people living in the home. Evidence: The home produces a monthly newsletter that contains a list of activities for the forthcoming month and also any news about events, staff and people living at the home. Activities that are available include skittles, bingo and quizzes. There is also regular entertainment and a harpist and guitarist visit regularly. There has also been a recent visit by a small theatre company performing a New Time Music Hall. Some people we spoke with were very happy with the amount of activities and stimulation available, while others said they would like more. There was very little social history recorded on peoples care plans and therefore it is difficult to know what peoples hobbies or interests are. Regular Communion is held every month as well as visits by Catholic and Anglican priests. Several people go out to church with their families each Sunday, and the home is willing to transport anyone else that wishes to go. Care Homes for Older People Page 15 of 28 Evidence: There are no dedicated activities staff employed, but one senior staff member is responsible for co-ordinating most activities. Staff told us that they had time to sit and chat with people and that not all their interaction was centered around care giving. People living at the home told us that their family and friends can visit them at any time and that they are always made welcome. One representative keeps in contact with staff via email as well as regular visits to their relative. Staff were able to tell us how they offered choices to people though out the day, including what time they get up and what they wear. We saw people being offered choices at tea time. People told us that the food was generally very good at the home and that there was always an alternative if they didnt want what was on the menu. One person commented on their survey form that the food is all home cooked another commented that too much food is put on the plate. We sat with people in the dining room while lunch was being served. The meal was well presented and nutritious and people said that they enjoyed it. Tea was served in the lounge or peoples rooms if they chose. They was a wide variety of things on offer including crumpets, muffins, fresh fruit and yoghurt. There was also much friendly banter between staff and people living at the home. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good complaints procedure and people can be confident that their concerns will be listened to. Adequate procedures are in place to ensure that people are protected from abuse. Evidence: There is a clear and simple complaints procedure in place to help people who wish to, to raise concerns. The contact details for CSCI need to be updated to ensure people can contact the Commission if they wish. there is a copy of the procedure contained in the Residents Handbook and displayed in the hallway. A Complaints Book is also kept in the hallway and people are encouraged to write any concerns in this. No complaints file is kept so there is no easy read record of how any complaints have been dealt with. Although details of any complaints that have been dealt with are kept on the individuals file. Some people living at the home who were spoken with during this visit were unable to tell us whether they knew about the homes complaint procedure or whether they would feel comfortable making a complaint. However, those who were spoken with were able to tell us who they would speak with if they were unhappy about anything. One person commented on their survey form I have always found the staff at Moors Park more than willing to help. Care Homes for Older People Page 17 of 28 Evidence: The Commission received an anonymous complaint relating to cleanliness of the home and low staffing levels. A Random Unannounced visit was made on 25 January 2008 when the complaint was found to be unsubstantiated. A further complaint was made to the Commission about items that had allegedly gone missing while someone was staying at the home, some time ago. The complaint was passed to the provider to investigate using their complaints procedure. Evidence was seen at this visit that showed the home had appropriately investigated the matter when we had asked them to, and that they had also investigated the matter thoroughly when the complaint had first been raised. Records show, and staff told us that they had received training in Protection Of Vulnerable Adults (POVA) issues. All staff were able to discuss different forms of abuse and said that they would report any suspicions they had to the manager. They were also clear about who they would report any concerns to, outside of the home. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a pleasant, comfortable and safe environment for those living in, working at and visiting the home. Evidence: A full tour of the communal areas of the home was made and some of the bedrooms were looked at. The communal areas of the home were light and airy with a comfortable homely feel. They are nicely decorated and comfortably furnished in a domestic style. Peoples bedrooms contained many individual items and reflected the personality of the occupant. People told us that they had been able to bring things from their home when they had first moved in. Locks have been fitted to bedroom doors where people have requested them. The house was clean and generally free from unpleasant smells. One bedroom did have a slightly unpleasant smell and the carpet was badly stained. The manager said that the carpet was stained due to a vase of flowers having been knocked over and was due to be professionally cleaned that evening. Radiators throughout the home are covered or have a low surface temperature which helps reduce the risk of people suffering burns from falling against them. Windows above ground floor level are fitted with restrictors which minimises the risk that people Care Homes for Older People Page 19 of 28 Evidence: may fall from them. Thermostatic valves are fitted to the hot water system to ensure people are protected from burns from water that may be too hot. There is a range of aids and adaptations around the home to help staff meet the needs of people who have limited mobility. Staff also said they had received training in moving and handling. Staff said that they had received training in infection control matters and were seen following good infection control procedures. Disposable gloves and aprons were readily available around the home. The laundry area was clean and tidy and has an impervious floor covering to help prevent cross contamination from soiled articles. Washing machines have the ability to meet disinfection standards. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A wide range of training is provided and the numbers and skill mix of staff on duty are generally sufficient to meet the needs of people currently living at the home. People are generally protected by recruitment procedures that ensure people who may be unsuitable to work with vulnerable people are not employed at the home. Evidence: On the morning of the visit there were 5 care staff on duty plus the manager, assistant manager and 5 ancillary staff. People that were spoken with felt that there was enough staff at the home to meet their needs. However, some people commented on their survey forms that they sometimes felt there were not enough staff available. Staff told us that they felt there were enough staff and that they did not feel rushed at any time. However, there were comments on staff survey forms that some shifts were difficult to cover when staff are sick and ring in late. There was also one comment received (via a survey form) from someone living at the home, that sometimes they are short of staff. We received a complaint about low staffing levels at the home and we made a Random Unannounced visit on 25 January 2008 when the complaint was found to be unsubstantiated. Care Homes for Older People Page 21 of 28 Evidence: Four staff files were looked at. Three files contained all the required information including satisfactory CRB (Criminal Records Bureau) checks, two written references and proof of identity. However, the file of a recently employed staff member did not show evidence of any references being obtained. The manager showed us a checklist showing that references had been received and she felt they must have been misfiled. She assured us that they had been obtained. Training has a high priority at the home with the manager providing much of the training themselves and obtaining other training from outside sources. Records show and staff confirmed, that they receive a wide variety of training including a comprehensive induction for all new staff. Other training includes Fire procedures, Moving and Handling, Food Hygiene, First Aid and Infection Control. Staff are also encouraged to work for NVQs (National Vocational Qualifications) and currently 50 of staff have or are working for NVQ level 2 or above. Staff have recently received comprehensive training on meeting the sexuality needs of older people. Staff were praised by people living at the home when we spoke with them and also via surveys we received, some of which were completed by relatives. Comments included we have been pleased with the cheerfulness of the staff and I have nothing but praise for them. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed resulting in practices that promote and safeguard the health, safety and welfare of people who live and work in the home. Evidence: The Registered Manager is experienced and well qualified and has obtained the Advanced Managers Certificate. She has worked at the home for many years and works hard to ensure there is an open and transparent atmosphere within the home. There is a very low staff turnover at the home and staff that we spoke with during the visit told us that they felt supported by the manager to do a good job. Comments received via survey forms included am always able to discuss problems with manager. However, one staff member commented via their survey form that I really have no support from care manager or assistant manager. This was discussed with the manager and assistant manager who said that they would ensure through supervision, that all staff felt supported. Care Homes for Older People Page 23 of 28 Evidence: There is an informal quality assurance system in place at the home. Questionnaires are sent out to everyone connected with the home and any suggestions implemented. For example, following a suggestion received through this process, staff now wear name badges. The system needs to be formalised and the information collated into a report, which should be made available to everyone at the home with a copy being sent to CSCI. The Responsible Individual for the company that owns the home, regularly visits and prepares a report on their findings. This ensures that they are aware of and deal with any issues of concern at the home. No monies are managed on behalf of people living at the home. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Moors Park House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, fire precautions, health and safety checks and risk assessments. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. So that the risk of burning from hot surfaces is minimised, radiators within the home have either cool wall surfaces or are covered and so that the risk of burning from hot water is minimised temperature controls are fitted to taps. Restrictors are fitted to windows above ground floor level to minimise the risk of anyone falling from these windows. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 You are recommended to ensure care plans contain sufficient information to enable staff to meet the needs of people living at the home in a consistent manner. More detailed risk assessments should be completed and people should be encouraged to participate in the care planning process. You are recommended to ensure the quantity of medication received into the home is recorded, to ensure all handwritten entries are double signed and a sample of signatures and initials of staff administering medications is kept. This is to ensure people have enough medication. that they receive the correct medication and it is possible to see who has administered any particular dose. You are recommended to maintain a log of all complaints and the outcome of the investigation. This is so that people can easily see that the complaint has been dealt with. The details of CSCI should be updated on the complaints procedure so that people can contact us at any time. You are recommended to ensure that the home is kept free from unpleasant smells at all times. You are recommended to formalise the Quality Assurance system of the home, producing a report so that all interested parties can see that the home consults with Page 26 of 28 2 9 3 16 4 5 6 16 19 33 Care Homes for Older People people and acts on their suggestions. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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