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Inspection on 06/04/09 for Amberleigh Manor Care Home

Also see our care home review for Amberleigh Manor Care Home for more information

This inspection was carried out on 6th April 2009.

CQC found this care home to be providing an Adequate 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home makes good efforts to provide appropriate social entrainment and activities for the people living there. The appointment of two activities co-ordinator has assisted with this. There are good opportunities for family and friends to visit and maintain contact with their relatives. They is a good rapport between the care staff and people living at the home. The home has a well-qualified and competent staff team who have been working at the home for a long time.

What has improved since the last inspection?

Evidence was in place to demonstrate that the requirements made at the previous site visit have been met. The home continues to improve to the decor and furnishings of the home, creating an environment, which is suitable to the needs of the people living there.

What the care home could do better:

The home needs to have a registered manager in place. A permanent and meaningful management is required to ensure the development of the home, support to staff and to ensure people receive the required level of care.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Pendean Nursing Home Primrose Hill Blackwell Alfreton Derbyshire DE55 5JF     The quality rating for this care home is:   one star adequate 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: Nancy Bradley     Date: 0 6 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Pendean Nursing Home Primrose Hill Blackwell Alfreton Derbyshire DE55 5JF 01773860288 F/P01773860288 sheilagh_kelly@yahoo.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mr Mohinder Singh Kelley care home 40 Number of places (if applicable): Under 65 Over 65 7 33 dementia old age, not falling within any other category Additional conditions: 0 0 No more than 7 DE/E service users can be accommodated, in the designated areas identified for accommodating this category of service user. Staff must receive suitable training in meeting the needs of service users with dementia. There must be a specialist dementia advice and training on an on-going basis, provided by a Registered Mental Nurse (RMN). To allow two named persons DE(E) to be accommodated in an area outside the designated area for the duration of their stay. Date of last inspection Brief description of the care home Pendean nursing home is a converted and extended country house providing nursing and personal care for up to 40 older persons, including up to seven service users with dementia (all aged 65 years and over). Accommodation is provided on two floors, with 28 single bedrooms and 6 shared rooms. One single and one double room have en Care Homes for Older People Page 4 of 29 Brief description of the care home suite facilities. (At the time of the inspection one shared bedroom was being used as single accommodation-measuring less than 16 square metres). There is a passenger lift, handrails to corridors, grab rails provided to toilets and an emergency nurse call system throughout the home. Moving and handling equipment is provided. There is access for service users to a garden and patio area. The homes scale of charges at this site visit are as follows: Residential £365.00 per week. Residential EMI £400.00 per week. EMI Nursing £520 per week. Nursing £500.00 per week. Expenses such as toiletries, chiropody, and hairdressing services were additional to the weekly fee. 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 quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection and took place over a total of eight hours. An Expert by Experience accompanied us and they were present for several hours of the site visit. We spoke with the business manager, care staff and people living at the home. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. Care Homes for Older People Page 6 of 29 We looked at all the information that we received or asked for, since the last key inspection. This included the following: The Annual Quality Assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. At the time of this site visit the home had twenty-eight people in residence. The majority of the people indicated they were happy living at Pendean, and made very positive comments about the staff. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 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 9 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. Arrangements are in place to ensure that peoples potential needs were fully assessed and can be met prior to admission. Evidence: The care records of two people living at the home were looked at in detail, one of which was the most recent admission to the home. The majority of the people admitted to the home have their needs assessed through the care management system. The home currently has several people who are self funding and no care management assessment was available for them, although there was evidence to show the home had undertaken their own assessment. These assessments addressed all areas of health, personal and social care with care plans being developed from the information provided. Care Homes for Older People Page 10 of 29 Evidence: The homes care needs assessments had not always been signed or dated by the person undertaking the assessment. This was highlighted at the previous site visit. The home is now starting to consult more with families about the care their relatives receive. All of the people living at the home have received visits from their Care Managers following concerns raised by the Fire and Rescue Service and the Primary Health Care Trust Continuous Care Team. Care Homes for Older People Page 11 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. Although some work has been undertaken in this area continuing inconsistencies in the care planning system and recording may compromise the service people living at the home receive. Evidence: The care records of the two people seen indicate that improvements had been made to the care planning documentation and other associated records. The information contained within the care plans and risk assessments provided instructions to the staff team of how the peoples needs were to be met. Care plans are continuing to improve. Senior care staff are now being included in the care planning process supervised by the nursing staff. Staff confirmed that the care plans were in place and provided sufficient detail for them to follow, and to enable them to meet peoples needs. However the care plan for one person case tracked did not commence until several weeks after they had been Care Homes for Older People Page 12 of 29 Evidence: admitted. There were significant gaps in the care plan. The nurse on duty agreed to address this issue with the staff member concerned. Care plans addressed all identified areas of health, personal and social care needs and assessments were in place, which included, nutrition, mobility, falls, moving and handling and tissue viability. Each care plan is cross-referenced to a risk assessment. This demonstrated that all areas of support that had been identified and assessed. Risk assessments identified any areas of potential risk and show the appropriate actions required to reducing risk. Care plans and risk assessments seen had been completed and were reviewed on a monthly basis. However the level of recording did differ and in one instance changes to the personal care had not been fully recorded nor had there been consultations with other professionals about the changes in their care. All monthly reviews are completed by a named nurse this includes both nursing and residential placements. Care records seen indicate the home is trying to obtain peoples or their relatives signatures on care plans. A record of peoples weight was maintained according to their assessed need. However there were gaps in some peoples weight records. As records were to monitor increase or loss of weight this error was brought to the attention of the business manager. This was an issue at previous site visits. Records were kept of doctors visits, opticians, dentists podiatry and hospital appointments. The nursing staff completed daily information sheets on all people living in the home. As with the reviews the level of information recorded did differ. However information was not always recorded correctly. People spoken with confirmed they had a good rapport with the staff working at the home. People spoken with stated they liked living there, one person stated they had not been told what to expect, except what other people told them -nothing favourable. Other people stated that they could more or less decide when they go to bed and get up, their rooms were ok, the food was not bad and they could have visitors whenever they want. The medication administration practices of the home were assessed, with the medication administration records (MAR) for the two people case tracked verified. Care Homes for Older People Page 13 of 29 Evidence: Several photographs were not in place as part of confirming peoples identity when administrating medication. The controlled drugs register was examined and this had been completed correctly. The storage of medication was looked at and was found to be satisfactory, this included medication stored in the clinical fridge, where fridge temperatures had been recorded to ensure this medication was stored at the required temperature. At the time of this site visit only the nursing staff administers medication. Staff authorisation signatures for the administration of medication were available; however the list is out of date. Boots the Chemist carried out an audit six weeks ago. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The planned activities and contact with families and friends enables people living at the home to have choice and control in their lives, and maintains their wellbeing. Evidence: The home has engaged two members of staff to arrange activities for the people living there. Discussions with the staff member highlighted difficulties with motivating some people to take part. One member of staff works for sixteen hours per week and the second member of staff works weekends. We discussed with the business manager further training for the activities coordinators to be looked in to. Activities offered include table skittles, dominoes, soft netball, target games, snakes and ladders and card games and craft work. Some of the craft and artwork undertaken by the people was on display in the home. However the people at the home are experiencing difficulties and due to their mental frailty are reluctant to take part. The home had organised various activities for Easter. The home has two DVD players and most of the people have a TV in their rooms. The activities coordinator stated that musicals were a favourite with many of the people living at the home. The Expert by Experience noted the radio and CD player were on for most of the time along with the Care Homes for Older People Page 15 of 29 Evidence: TV, which, no one watched. External entertainment is organised throughout the year. Church services are conducted at the home once a month, as none of the people living at the home is able to attend local church or religious services in the community. From observation and discussion with people at the home it is clear the home makes every effort to meet peoples social needs. The activities co co-ordinator is responsible for recording the daily activities on peoples care records. Visiting hours at Pendean were flexible and people living at the home are able to receive their visitors within the communal areas of the home or within their privacy of their own room which ever they preferred. People spoken with confirmed that their visitors were made welcome by the home. Any restriction on contact is clearly recorded in peoples care records. The people spoken with during the site visit were positive about living at the home. The daily routine is flexible and they were able to make decisions about how they spend their time during the day. People were seen moving freely around the home and engaged in whatever activity they choose to do. People confirmed they went to bed and got up when they wanted and that the staff supported them with this. Several people confirmed the home was fine,-its alright- have no complaints. Information regarding local advocacy services and their contact details is available. The Expert by Experience spoke with the cook, observed part of lunch time and noted the following. The care staff encouraged people to help set the meal tables. A variety of menu was available which included a main course and sweet. Fresh fruit and vegetarian option is offered. The cook was only aware of one person on a special diet; however records and discussions with health care professionals indicated this might be higher. Records seen indicated that although the home has a record of the daily meals they are not always maintaining a record of peoples individual food and fluid intake. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are in place to safeguard peoples welfare and ensure that their concerns are listened to and acted upon. However current practice may leave people vulnerable and at risk. Evidence: The home has its complaints procedure on display throughout giving information to both people living at the home their families and friends. The procedure contains the current contact details of the Care Quality Commission. The procedure informs the complainants that they are able to contact the Commission at any stage of the complaint if they wish to do so. Discussions with the care staff and minutes of residents meetings, confirmed that they are fully informed about the complaints procedure and would have no hesitation in putting their concerns to the acting manager. The Commission has received two formal complaints about the home since the last site visit. These have been investigated under Derbyshire County Councils Adult Social Services department Safeguarding Venerable Adults procedures. In both cases these were substantiated and the home has been required to take action and to review its practice. The homes complaint record was not available at this site visit. Information in the AQAA indicated the home has not received any complaints from people living at the home since the previous site visit. One person spoken with during the site visit indicated they would speak with the Care Homes for Older People Page 17 of 29 Evidence: acting manager about their concerns. The majority of the staff had completed training on protection of vulnerable adults however they are aware that further training on safeguarding is required. The home has referred two incidents of safeguarding since the previous site visit. These were investigated under Derbyshire County Councils Social Services Adult Safeguarding Vulnerable Adults procedures. Care Homes for Older People Page 18 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 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 a comfortable environment which suits the people who live there and their needs However the full implementation of the refurbishment programme will further enhance the standard of the home. Evidence: We carried out a full tour of the home accompanied by the business manager. All communal areas were viewed together with staff facilities. Peoples bedrooms were viewed with their agreement and all rooms were being decorated and furnished to their personal choice. However several areas still require attention and the business manager confirmed that there was an on going refurbishment programme. The home is fitting new self closing fire door following a resent visit by the Derbyshire Fire and Rescue Service Peoples clothing appeared well laundered and they were happy with the laundry services provided. At the previous site visit the state of the sluice on the first floor was brought to the attention of the home. This was due for removal; however the sluice is still in situate. Care Homes for Older People Page 19 of 29 Evidence: The home has effective Infection Control Procedures in place and information in the AQAA showed that twenty- three here staff had received training in this area. Care Homes for Older People Page 20 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. The skill mix and numbers of staff on duty enabled peoples needs to be met. Staff receive the appropriate training to ensure the safety and welfare is maintained, of the people living at the home. Recruitment procedures ensure further protection. Evidence: During the visit a sample of staff rotas was examined that indicated the home was staffed according to the assessed needs of the people who live there. On the day we visited one registered general nurse, four senior carers, and two assistant carers were staffing the home. In addition ancillary staff were present. The AQAA indicated a good skills mix and a good percentage of staff holding either a NVQ level 3 who work alongside qualified nursing staff. The home has a robust recruitment and section procedures are in place to protecting people residents. Staff recruitment is in line with Schedules 2 and 6 of the National Minimum Standard, Care Homes for Older People. applicant were not always providing a full employment history . As discussed with the acting manager when gaps in employment are investigated this should be fully explored and be formally recorded on interview minutes. The records of one person indicated that full references had not been requested at the point of employment. This was brought to the attention of the Care Homes for Older People Page 21 of 29 Evidence: business manager who stated it was the responsibility of the previous acting manager. The business manager agreed to address this shortfall. The AQAA indicated a staff-training matrix was in place, which demonstrated training that had taken place recently, this showed that all mandatory training was kept up to date. Information in the AQAA indicated that staff had attended various course relevant to the people they are caring for. Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well managed; however the lack of meaningful and permanent management may comprise service delivery. Evidence: At the time of inspection there was no registered manager in post at the home, interim management arrangements were in place. There has been no registered manager since 2003. Although the home has had acting managers in place none of them have fully completed the registration process. Current management arrangements are a Clinical Lead and a management consultant. Information received at the time of this report indicated the management consultant has yet to complete a Criminal Records Bureau check. The home has informed us of the management structure in a Regulation 37 notification. The business manager also visits the home. Discussions with the business manager indicated they are working hard to improve the service for people living at the home following the recent safeguarding referrals. Care Homes for Older People Page 23 of 29 Evidence: Staff spoken with confirmed that they felt supported in their role and indicated that they had clear guidance in their day-to-day responsibilities. The business manager stated that the home has robust quality assurance procedures in place. We requested that details of the quality assurance procedures and findings, and by the time of writing this report we have not received these. Regulation 26 visit are conducted by the Responsible Individual. We requested details of these visits as yet we have not received those. Records of personal monies for people living at the home are kept on computer. These were checked and verified. As discussed with the business manager financial procedures require further strengthening. Information in the AQAA indicates that all staff receive formal supervision. The Clinical Lead supervises the qualified nurses and then the staff are supervised by the acting manager. However with the acting manager being on long term sick temporary supervising arrangements were not in place for the several care staff. The AQAA indicated that that safe working practices were in place at the home. Records showed that portable electrical appliance tests, waste disposal contract, bacteriology and legionnaires tests, service certificates for moving and handling equipment and electrical wiring certificates were in place. The gas-heating certificate was seen confirming that all gas appliances have been serviced. However following the visit by the Derbyshire Fire and Rescue Service the home has been required to have fire risk assessments in place, fire evacuation plans, fire training for all the staff and the removal of combustible material from staircase and corridors. Action was taken during the visit to remove door wedges. We did find that a door wedge was still being used on the office door. Care Homes for Older People Page 24 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 25 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 1 7 17 There must not be any gaps in the information recorded in peoples records This is to ensure the continuity of care. 30/06/2009 2 7 15 Care plans must fully reflect 30/06/2009 peoples assessed care requirements and all changes to that care must be fully recorded. This is to ensure the continuity of care and to ensure people receive the care they were assessed as requiring. 3 7 15 Care plans and risk 30/06/2009 assessments must be in place following an admission This is to ensure the continuity of care 4 8 13 The home must maintain accurate records of peoples weight. This is to ensure the home has record of peoples weight and approprate action is taken following a loss or gain in weight. 29/05/2009 5 9 13 The home must have an up to dated list of staff who are authorised to administer medication. This is to ensure only authorised people administer 29/05/2009 Care Homes for Older People Page 26 of 29 medication. 6 15 13 The home must maintain a full record of peoples individual food and fluid in take. This is to ensure people receive a balanced diet and is assessed to their needs. 7 16 22 The home must ensure the 30/06/2009 complaints record is available at all times. This is to ensure details of all complaints investigations and outcomes are recorded. 8 26 16 The home must remove any 30/06/2009 equipment which is no longer required,or of use . This is to ensure the safety of people living at the home. 9 27 19 .All applicants must provide two references. This is to ensure the safety of the people who live at the home . 10 28 19 All applicants must comply with the homes policy and procedures on staff recruitment as outlined in Schedule 2 of the National Minimum Standards. 30/06/2009 30/06/2009 30/06/2009 This is to ensure the safety of the people who live at the home. 11 31 9 The acting manager must 30/06/2009 submit an application the Care Quality Commission for registered manager . This is to ensure the effective running of the home. Care Homes for Older People Page 27 of 29 12 31 19 The registered provider must 30/06/2009 ensure that all people who work at the home have a Criminal Records Bureau check. This is to ensure the safety of people who live at the home. 13 38 23 The home must comply with current fire legislation. This is to ensure the health and safety of people living at the home. 31/07/2009 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 2 2 7 All assessments should be undertaken by staff with the required knowledge and qualified skills to do so. Care staff should have training on how to record information in peoples care records. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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