Inspection on 12/01/10 for Piper Court

This inspection was carried out on 12th January 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Piper Court 19/03/09

Piper Court 28/03/08

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 28/03/2010.

Key inspection report Care homes for older people Name: Address: Piper Court Sycamore Way Stockton-on-Tees TS19 8FR     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: Jacqueline Herring     Date: 1 2 0 1 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 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Piper Court Sycamore Way Stockton-on-Tees TS19 8FR 01642606512 01642605503 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 60 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 60 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 60 Mental Disorder excluding learning disability or dementia, Code MD, maximum number of places 10 Date of last inspection Brief description of the care home Piper Court is a modern, purpose built facility that is registered to provide personal and nursing care to sixty older people. The home is divided into three units. On the ground floor of the home there is a twenty-eight bedded unit that accommodates Care Homes for Older People Page 4 of 27 Over 65 0 60 10 0 1 9 0 3 2 0 0 9 Brief description of the care home people requiring personal care. On the first floor of the home there is a twenty-two bedded unit that accommodates people requiring nursing and personal care and also a ten bedded mental health unit. Each unit has separate lounge areas, a dining room, toilets and bathing facilities. Bedrooms are single in nature and meet the required amount of space, all have ensuite facilities, which comprise of a toilet and hand wash facilities. The home is situated close to North Tees Hospital and other local amenities. The fees range from four hundred and twenty pounds per week to five hundred and forty two pounds and sixty-two pence per week depending on the type of care being delivered and depending on whether people are paying privately or being supported with their funding. Care Homes for Older People Page 5 of 27 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 one star. This means the people who use this service experience adequate quality outcomes. This Key Inspection was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. This inspection was conducted by one inspector in one inspection day. During the inspection, a number of records were looked at, including records of people who use the service, along with staff recruitment and training records. The medication systems was also looked at and discussed with key staff. Discussions also took place with people living at Piper Court as well as a number of staff and the manager. Care Homes for Older People Page 6 of 27 An Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards had also been completed prior to the last Key Inspection. Information was also used from it for this inspection. We have reviewed our practice when making requirement to improve national consistency. Some regulations 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 risk or 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 27 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 Care Homes for Older People Page 8 of 27 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 27 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 27 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. People are provided with the information they need about the service. People have their needs assessed prior to admission, which ensures they can be met. Evidence: The AQAA detailed that people had comprehensive information about the home available to them. Service user guide and brochure are available within the home reception area. The AQAA also detailed the process for people being admitted to the home. It was stated, We carry out a full and comprehensive pre-admission assessment to ensure we are able to meet all needs and we include relatives in this process. In addition, we obtain assessments from Social Services and Health Care Services where applicable, so we have a complete picture of individual needs. The care files of three people living at Piper Court were looked at, one from each of Care Homes for Older People Page 11 of 27 Evidence: the units. Pre admission assessments were in place along with information obtained from other health and social care professionals. People spoken to confirmed where appropriate, they or their families had the opportunity to look around the home and receive information prior to moving in. On the day of the inspection people were observed to arrive unannounced with a view to looking around the home, they were welcomed and taken around the home and given information as requested. In the three care files looked at there was also evidence of ongoing reviews of care and information to confirm that peoples needs are being met and that they are satisfied with services provided at Piper Court. Care Homes for Older People Page 12 of 27 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. People receiving the service are happy with the way in which care is delivered by staff. Care records detailing how health and personal care is to be delivered and associated risk are well written and give staff the information they need to meet peoples needs. The way in which medication is managed is good, with clear systems and records in place ensuring people receive the medication they should. Evidence: The care files of three people living at Piper Court were looked at in detail, one persons file from each of the three units. The documentation was comprehensive both in format and in the way it had been completed by staff. A range of care needs assessments, specific assessment tools for areas such as skin integrity, moving and handling and nutrition and a number of associated risk assessment were completed and contained a good level of information about the individual person. Care plans had been developed for those areas of need identified through the Care Homes for Older People Page 13 of 27 Evidence: assessment process. The care plan were very well written, with clear actions about how to deliver care in place. They were very much individualised and incorporated peoples lifestyle preferences. Monthly evaluations of care are taking place. Some of these could be enhanced further a clearer, more valued based evaluation, as some read more like a care intervention rather than determining whether the care being delivered is effective or not. In all files looked at there was evidence of the involvement of other health and social care professionals, including GP, Community Psychiatric Nurse, District Nurse, Optician and Consultant Psychiatrists. People have specialist involvement by other professionals should the need arise and was detailed within care files looked at. People who live at Piper Court were very satisfied with the care and service provided. They said, I am settled here and quite happy, the staff are really, really nice. Staff spoke knowledgeable about the care provided to the people living at Piper Court and spoke positively about the relationships that had been developed. One person living at Piper Court also confirmed that their gender preferences in terms of care staff were always respected and that they were supported with their more intimate personal care needs by a male care worker. The medication systems were looked at. Medication Administration Records are well written, in the ones looked at, there were no gaps and all handwritten entries had been signed by two people. The system for ordering and receiving medication was discussed with key staff and very good systems are in place for this with supporting records in place. Appropriate storage is also in place, with each unit having their own dedicated medication room. Audits take place on a monthly basis and daily in respect of controlled drugs. Checks to ensure safety and storage of medication also take place. Care Homes for Older People Page 14 of 27 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. People have a lifestyle that suits them and have opportunities to be involved in social and recreational activities. Individuals have choice and control over their lives and people are able to keep in touch with families and friends. The home provides a varied and balanced diet for people who use the service. Evidence: In the three care files looked at a social assessment has also been completed along with lifestyle likes, dislikes and preferences. An activities co-ordinator has been appointed since the last inspection, who staff spoke extremely highly of and thought that they did a very good job. Care staff also carry out activities with people living at the home as a routine aspect of daily care delivery. A programme of activities is in place and details a range of activities taking place on a daily basis through the week. These included, bingo, arts and crafts, pamper times one to one time amongst others. Care staff also confirmed that they also had ready access to all of the activity equipment. Care Homes for Older People Page 15 of 27 Evidence: People living at the home are able to keep in contact with friends and family, visitors were observed during the inspection of the service and said that they were free to visit at any time. One relative said that they visit everyday as they like to assist their loved one with their lunch. Other people have private telephones in their rooms so they are able to have regular conversations with significant others. People spoken to said they were able to make their own day to day decision, one person said, I do my own thing. The menu was looked at, which is a four week rotational menu. The menus are developed to ensure that they provide healthy and nutritious meals for people. There is clear choice on the menu, which incorporates a vegetarian option. During the inspection staff were observed having discussions with people about their menu choices for the following day. People said that they enjoyed their meals very much. One person said, I am not a big eater, I always enjoy the meals and I have a choice. The dining rooms are nicely presented with linen table cloths and napkins and condiments also available on all of the tables. On the mental health unit peoples independence is promoted and a number of people were observed to be making their own choices directly from the meal trolley rather than having it served to them at the table. There is a small kitchen area available on this particular unit and some people have been encouraged to make snacks and light meals, this is being further developed as a means of further promoting life skills and independence. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that their concerns and complaints will be taken seriously and acted upon and appropriate procedures are in place in regard to protection of people. Evidence: The AQAA detailed that there have been six complaints within the past twelve months, all of which have been investigated and two upheld. Since the completed on the AQAA a further two complaints have been received, one of which is still under investigation. People spoken to said they had no worries or concerns. They said if they did, they would either speak to any member of staff on duty or directly to the manager. They were confident that their concerns would be taken seriously and acted upon. One person said, I am not unhappy with anything, if I was I would speak to the carers. Another person said, If I was unhappy I would go to Jacqueline, the manager. In the event of any incidents that effect the welfare and wellbeing of people living at Piper Court, the appropriate procedures are available and have been followed when the need has occurred. Staff spoken to confirmed they had received training in respect of report abuse and training records looked at also confirmed this. Care Homes for Older People Page 17 of 27 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. People live in a clean, comfortable and safe environment, adapted to meet their needs and match their lifestyles. Evidence: Piper Court is a purpose built care home providing both nursing and personal care for up to sixty people. It has three units, providing three different categories of care. The ground floor unit provide personal care for up to twenty-five people. On the first floor there is a twenty bedded general nursing unit and an ten bedded mental health unit. Piper Court provides a bright and spacious environment for people. Individual bedrooms are extremely personalised, people have their own TVs, music systems, ornaments and photographs. Areas of Piper Court are beginning to look a little tired and there is the need to freshen up some of the communal areas. The bathrooms and toilets also need to have some repair work to the welded skirting as well as some redecoration. There is a dedicated smoke lounge on the ground floor, the carpet needs to be replaced as there are a large number of cigarette burns. Care is also needed in respect of the ventilation as the smell of smoke was evident in the corridor leading to the lounge. Care Homes for Older People Page 18 of 27 Evidence: Following a recent inspection by the fire service, self closures have been fitted to bedroom doors. They type that had been chosen by the organisation were not of a variable setting and not linked to the fire alarm system, as such the room doors had to remain shut at all times. One person living at the home complained to the inspector about these as they were now having difficulty opening their bedroom door. This was tested and found to be difficult to open. It was agreed with the manager that they would adjust the mechanism to allow better access. This also led to discussions with the person concerned and staff about people who had mobility problems and used aids such as walking frames and wheelchairs. It was said that some of these people now feel trapped or locked in their rooms, and that their freedom and Independence was suffering as a result. It was confirmed that the door closure were still new to everyone and that some further adjustment was needed. It was agreed that there would be further discussion would take place with a view to potentially looking at ways to improve. It was noted in one of the bedrooms that the furniture was broken and needed to be repaired or replaced. The manager said that this was the original furniture and a number of pieces of furniture needed to be replaced. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People needs are met by staff who have the knowledge and experience to do so and is sufficient numbers. Recruitment of new staff is generally good, although some additional measures would enhance this further. Evidence: A number of staff files were looked at during this inspection, two of which were for most recently appointed staff. In the main the recruitment process is good, with an application form being completed, records in place detailing the interview, two references, POVA First Checks and Criminal Bureau Checks. Care is however needed, as in one of the files looked at there were two gaps of employment and no evidence to show that these had been explored. The manager said that they would usually record this on the interview form but on this occasion had not. Discussion took place regarding obtaining references as copy letters were not kept on the individual staff members files. In one of the files neither reference was on the standard reference form and one of the references was not dated. The system within the home does not date stamp incoming post so it was not clear when the reference was obtained and there was nothing else recorded on the file to show this. The staffing structure was discussed with the manager who outlined the following. The manager is supported by a deputy manager who is the lead nurse on the general Care Homes for Older People Page 20 of 27 Evidence: nursing unit. The Mental Health Unit has a unit co-odinator and the older persons unit has senior care assistants. The general nursing unit always has a qualified general nurse on duty, during the day there are usually three care assistants and two at night. The mental health unit always has either the unit co-ordinator or senior care assistant on duty and two care staff during the day and one at night. The older persons unit always has a senior care assistant on duty and usually two care assistants during the day and one at night. The day duty cover on the older persons unit is currently under review with a view to increasing the care staff numbers. People spoken to generally thought there was sufficient staff available to support them and to help meet their needs. Staff also thought that the staffing levels were acceptable but one person did say in respect of improvements to the service, Reliability of staff. One member of staff said of the staff team, There is a good staff team and everyone tries their hardest. The residents receive good care and life for them is flexible and they have choices. A training matrix was made available which showed that not all staff are up to date with mandatory training. An action plan for training was made available, which detailed that this range of training would be updated within the next three months. A small number of staff have received training in regard to pressure care, staff working within the mental health unit had received challenging behaviour training. The AQAA detailed that 48 of staff have completed NVQ 2 in direct care. Care Homes for Older People Page 21 of 27 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. Whilst people are happy at Piper Court, there is the need for a manager to be appointed and to be registered with CQC. This will ensure that the home is run in the best interest of people living there, with continuity of management systems. There is also the need to ensure that staff receive regular supervision and training ensuring safety and wellbeing of people living at the home. Evidence: The current manager has been in post for some time and is still to register with CQC. She did confirm that the registration process was underway and was now waiting for her Criminal Records Bureau check to be returned before being able to progress further. The need for this process to be completed was discussed with agreement that this would be completed as soon as possible. The manager is a qualified nurse and has the required experience to manager Piper Court. Following the site visit, the manager was moved to another care home within the organisation, as such, Piper Court currently does not have a manager. CQC did not Care Homes for Older People Page 22 of 27 Evidence: receive the required regulation 39 notification to inform us of this change or to notify us of the interim management arrangements. Discussion did take place with the provider who confirmed that the regulation 39 had recently been sent and that interim management arrangements were in place. Of what the service does well, one member of staff said, Tries hard to give the best care. Southern Cross have a range of auditing and quality assurance systems in place, which look at key outcomes. The only audits that had taken place since July 2009 were in relation to medication. Other audits had not taken place. This was discussed with the manager, who had been managing both Piper Court and another care home for several months. Again, CQC had not received notification of this. There was evidence of regulation 26 visits taking place by the providers nominated person, copies of these reports are available within the service, although there were no reports for two of the months. The AQAA detailed the suitable arrangement were in place for looking after peoples personal allowances should the need arise. It was confirmed at last inspection that these arrangements were good. The staff supervision systems was looked at and discussed with the manager. Supervisions had not been taking place at the required intervals, however the manager said that these would take place now that she was working at the home on a full time basis. The actual supervision system is a standard format for everyone, with the same matters covered and the sheets photocopied, it is not currently a personalise, individualised system. A sample of maintenance and servicing records were looked at, including water temperatures and fire equipment tests. These were all in order and it be identified that there are good systems in place to ensure safety of the environment and equipment used. A training matrix was made available along with an action plan for training. A number of staff had received fire training since the last inspection and there was further training planned over the next three months, which would ensure that all staff are up to date with this training. Other mandatory training had also taken place with more training planned over the next month to bring staff up to date with this training. Care Homes for Older People Page 23 of 27 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 27 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 19 23 Bedroom furniture that is broken must be repaired or replaced. This will ensure that rooms occupied by people are safe and they have equipment that is suitable for use. 31/03/2010 2 31 39 Where there are changes to the management arrangements within the service, CQC must be notified immediately. This will ensure compliance with the regulations and also that appropriate arrangements are in place for the management of the service. 12/02/2010 3 31 9 A manager must be 03/05/2010 appointed who must register with CQC. This will ensure compliance with the regulation and that the home has an appropriate Care Homes for Older People Page 25 of 27 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 manager and that the home is managed to ensure health, safety and wellbeing of people. 4 33 24 The quality assurance systems must be fully implemented. This will ensure that the home is being run in the best interest of people living there. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 31/03/2010 1 2 19 19 Ongoing adjustment and monitoring of the self closure on bedroom doors for fire purposes should continue. The carpet in the smoking lounge should be replaced and the ventilation to this area should also be monitored to ensure that it is effective. A refurbishment programme should be commenced and include communal areas and repair/replacement of hard flooring in the toilets/showers/bathrooms. There is the need to explore gaps in employment history and to ensure that references are dated. All staff should receive supervision at the required intervals. The planned programme of mandatory training should continue, which will ensure that all staff are up to date with this required training. 3 19 4 5 6 28 36 38 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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