Inspection on 22/04/10 for Red Hill Court Care Home

This inspection was carried out on 22nd April 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Maple Lodge

Heathlands

Inspirations

Westmead

Hopwood Court

Coton Hill House

Doddington Lodge

Innage Grange

Extracts from inspection reports are licensed from CQC, this page was updated on 17/07/2010.

Key inspection report Care homes for older people Name: Address: Red Hill Court Care Home 229 London Road Redhill Worcester WR5 2JG     The quality rating for this care home is:   zero star poor 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: Christine Potter     Date: 0 5 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Red Hill Court Care Home 229 London Road Redhill Worcester WR5 2JG 01905354000 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.southerncrosshealthcare.co.uk Trinity Care Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 70 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Redhill Court is a purpose built home consisting of three separate units. They offer accommodation to elderly and younger people. The home provides residents with single bedrooms all with en suite facilities. Accommodation is on two floors with a lift to assist people using the service to access all areas of the home. The home provides a range of aids and equipment to assist them in meeting the needs of people using the service. Communal areas are available with lounges and dining facilities are provided on all units so people have a choice of where they wish to spend their day. The home has a pleasant garden which is accessible for people in wheelchairs. Care Homes for Older People Page 4 of 30 Over 65 0 60 0 8 0 70 Brief description of the care home A range of activities are provided for the people living at the home. The home is owned by Trinity Care part of Southern Cross and the proposed manager is Shirley Houghton. Information regarding the home is available in the Statement of Purpose, The Service Users Guide and Inspection reports. These documents are available on request from the home. Care Homes for Older People Page 5 of 30 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: zero star poor 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: We, the Commission, undertook an unannounced inspection of this service, which means that the home did not know we were coming. This was a key inspection - which is an inspection where we look at a wide range of areas. The home changed its registration details so were assessed as a new service, so this was the first inspection following the change in registration. Before the inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the service for completion. The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Information was gathered from speaking to and observing people who lived at the Care Homes for Older People Page 6 of 30 home. Three people were case tracked from each of the units. Which involved discovering their experiences of living at the home by meeting and observing them, looking at medication and care files, and reviewing areas of the home relevant to these people in order to focus on outcomes. Case tracking helps us understand the experiences of people who use the service. Care Homes for Older People Page 7 of 30 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 on page 4. Care Homes for Older People Page 8 of 30 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 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before they move into the home to enable the home to find out all about them, and the support they will need. Evidence: The home has made changes to their registration with the CQC, which has resulted in the service being classed as a new service. A new certificate has been issued to Red Hill Court which is displayed in the reception area of the home. Red Hill Court went through a difficult period and a number of allegations were raised about the quality of the overall service provision. In response to this the service accepted a voluntary ban to admit people to the home and developed a clear action plan in how they were going to improve their service. They appointed a new manager, and additional support from the registered providers was given. Care Homes for Older People Page 11 of 30 Evidence: The home provides written information in the form of a Service User Guide to help people decide whether they wish to live at Red Hill Court Care Home. Copies of the information is available in the home and also in alternate formats to assist people to understand the information. The Statement of Purpose was available in the reception area of the home. Some information was in need of being updated to reflect the management changes. Generally the majority of people told us that they had received sufficient information about the home prior to moving in. People admitted in an emergency situation informed us that they were not fully informed about the home and the service provision. We looked at the pre admission assessments for three people who had recently moved into the home. The assessments provided sufficient information for the service to decide whether they would be able to meet the persons needs if they chose to move into the home. People using the service and relatives confirmed that the manager had visited and assessed their relative prior to them being admitted to the home. Care Homes for Older People Page 12 of 30 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To ensure that peoples health care needs are not being compromised, the care records should provide clear guidance for staff to follow. The management of medication must ensure that people receive their prescribed medication correctly to avoid errors which places people who use the service at risk of harm. Evidence: Each person living at Redhill Court had a written plan of care in place. This is an individualised plan which should clearly reflect individuals health and psychological needs. Peoples personal preferences should be taken into consideration to assist staff in ensuring that they provide person centred care. During the inspection we looked at three peoples care plans in detail, two of which had been discharged from the home, and allegations reported to us that the home had failed to fully meet their health care needs. These allegations have been referred to the multi agency safeguarding team, who are in the process of investigation. The outcome of this is not yet concluded but details will be reported in the homes next planned inspection. The care plans we looked at for the three units showed inconsistency, and Care Homes for Older People Page 13 of 30 Evidence: unfortunately the findings particularly on one of the elderly units, reflect the homes overall quality rating. Generally the documentation failed to provide a clear person centred approach for people, and the psychological needs of people going into a care home had not been considered. For example, the initial assessment for one person recorded can be quite withdrawn, but this had not been developed into plan of care, or information recorded how the staff were managing this. The information shows poor communication being passed on and acted upon by staff and individuals changing needs. For example, a person had returned from hospital and the home had failed to update their risk assessments. The persons health care needs had changed including dietary needs and continence management. The risk assessments and plan of care had not been reviewed or updated to reflect these changes. On the 05/02/2010, there was an entry that recorded a problem with the individuals hand. This information appeared not to have been passed on to the next shift to be monitored or request for a medical assessment. On the 06/02/2010, an entry stated noticed that hand was swollen the person was later transferred to hospital. On talking to the nurse they were unsure if the initial information had been passed on. For another person the daily entries recorded that they were taking tablets for pain. No care plan had been developed to identify the cause of pain or if the tablets were being effective. The medication records showed that the person was having more medication when one particular nurse was on duty, and the records failed to show the reason for this. One plan recorded the assessment for skin damage incorrectly, and the actual score was higher than the score recorded. The actual score placed the person at very high risk of developing pressure sores. So the planned care would not be suitable. One other plan of care showed that the individual had developed skin damage, and the care plan directed to redress the wound every two days. However, the evaluation for that period recorded that the skin was intact. For one person admitted to the home with known skin damage, the home had failed to develop risk assessments for potential to pressure sores and moving and handling. The nutritional assessment failed to include a weight measurement or the reason why the weight had not been recorded. This places vulnerable people at risk of their health and personal care needs not being fully met. The care plan stated that, for the person with Diabetes, they should have weekly blood sugar monitoring tests. These could not be found in the care records. We asked the nurse if they were kept separate and was told yes. However these could not be found at the time of the inspection. Care Homes for Older People Page 14 of 30 Evidence: A nurse had recorded that they had dressed a wound, but they had failed to develop a care plan for this, and how it should be managed. We looked at some fluid balance charts for people who were dependant on staff. For one person, the record had not been added up correctly. This person was prescribed for treatment to thicken fluids to assist them with swallowing, yet the records failed to show that this was being used. The nurse was not aware of the reason for this. Comments from people using the home included: lots of things they could do better they do everything well more staff answer the call bell quicker would prefer female staff for bathing and toileting Professionals visiting the home have raised concerns about the poor communication and failure by some of the nurses to monitor peoples changing health care needs. We looked at the management of medication. Some errors were observed, which the manager was aware of and records of their investigation were shared with us at the inspection. This was specifically about one of the units. There were discrepancies and issues including vast overstocking, medication given wrongly, medication not signed for, medication not ordered, medication received for deceased resident not returned, and an error with the number of a controlled medication held in the home. The pharmacist completed checks on 5th Feb 2010. We observed some gaps on the medication administration record where there was no explanation if the medication had been given. We found a discrepancy where the balance was short or over for the amount of medication given. The nurse could not explain the reason for this. Care Homes for Older People Page 15 of 30 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. Improvements have been made and the service is starting to support people to keep up their interests and activities and to be part of their local community. People are able to keep in touch with family, friends and representatives. They have nutritious and attractive meals and snacks, at a time and place to suit them. Evidence: We were told the home employs two activity co ordinators for 28 hours per week. One of the co ordinators spends eight hours a week on dignity training and monitoring for the staff. We spoke to the activities co ordinator who is enthusiastic to develop this area for the residents but is limited due to financial restrictions. It is recommended that this area is reviewed and look at providing activities for the home over a seven day period and, internet access provided for people wishing to use it. There is a list of activities displayed in the units, and rummage boxes for people to look through around the home. We saw a church service being held on the first day of the inspection for people wishing to attend. Other people were observed reading daily newspapers, watching television and sitting in the garden. We were told other activities include walking around the grounds and paintings. They have a room Care Homes for Older People Page 16 of 30 Evidence: specifically for activities, where we saw one person being assisted with craft work. It was nice to see the planted containers which the residents have made for the grounds. The home also has a regular hairdresser and comments from people using the service were complimentary about them and willingness to come into the home. The manager told us that they are looking to convert a room into a sensory room for everyone in the home to use. There is an open visiting policy, which means that people can see their visitors as they choose and maintain relationships that are important to them. We saw visitors coming and going throughout the day. There is provision for them to make drinks whilst visiting the home. The home has a four week rolling menu. Lunch is the main meal of the day and two choices are offered for the main course. The evening meal also consists of two choices, sandwiches or a hot choice. The home is able to provide specialist meals for people with medical or cultural reasons. The chef has received an award for the introduction of a system for producing a soft diet which appears as a normal plated meal. This helps to reduce people feeling different to others. We were told that the home is looking to develop a pictorial menu to assist people when choosing their meals. The home provides snacks with the mid morning and afternoon drinks to assist in ensuring people have the right amount of food and assist in fruit intake. The meals looked appetising and generally the majority of people were complimentary about the choice and quality of the food provided for them. Care Homes for Older People Page 17 of 30 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. People are not always confident that their views are listened to and acted upon. Evidence: Over the last six months the home has gone through a difficult period. The home was referred to the safeguarding team which is the multi agency group whose role is to protect vulnerable people, and accepted a voluntary ban on admissions whilst they reviewed the issues. The proposed manager was appointed and is aware of the shortfalls and feels that they have move forward in the last six months. Prior to the inspection concerns were reported to us by the Primary Care Trust. In addition two relatives have raised concerns about the quality of care. The findings of these complaints are not yet known, the issues are being investigated by the safeguarding team. The outcomes shall be included in the next inspection report. Some of the concerns raised were about the cleanliness in areas of the home, and bedrooms not being tidied when a person leaves the home. This was the same on the first day of the inspection. We looked at the homes complaints records and these showed two complaints about nurses talking in their own language in front of residents. From the records it was unclear about the outcome of the investigation. The proposed manager told us that this had been addressed and the nurses in question had been disciplined. The records were unclear and it is recommended that the home review their complaints procedure Care Homes for Older People Page 18 of 30 Evidence: and ensure all staff working at the home and people living in the home are aware of the procedure to follow. One relative told us during the inspection that they had raised concerns about the standard of cleanliness in xs bedroom, the call bell being positioned out of reach for x, and x not being able to reach a drink. This information was not in the homes complaints register. The home should ensure that all staff follow the homes complaints procedure so that people feel that they are being listened to. The complaints policy is displayed in the reception area of the home. A copy is in the Service Users guide and the Statement of Purpose. We discussed safeguarding scenarios with some staff on duty, and they responded appropriately, all confirming that they would have no hesitation if they had any concerns regarding care practise issues. Staff also confirmed that they received safeguarding awareness as part of their induction training when they commenced at the home. We looked at the staff training matrix which confirmed that staff had received safeguarding training, and new staff confirmed that the induction training covered this topic. Care Homes for Older People Page 19 of 30 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. People live in a well maintained home and plans are in hand to provide a better environment for people with short term memory problems. Evidence: Redhill Court is a purpose built two storey care home set near to Worcester town centre, and is easily accessible for people using public transport. There are parking facilities outside the home for visitors. The home provides accommodation on three units for 70 people in single bedrooms with en suite toilets. There are lounges, dining rooms, and specialist bathrooms and showers on all units. A lift is provided to assist people with mobility problems to access all areas of the home. A pleasant garden area is provided for people to use and can be accessed by people using wheelchairs. The corridors are wide and spacious and allow people at the home freedom to move around with any equipment they are assessed as needing. The home has several hoists to assist people to change their position and have special mattresses for people who are at risk of developing sore skin. We looked at the bedrooms of the people being case tracked and found theses were personalised with items that reflected the individuals personal preferences. The proposed manager told us that plans are being made to redecorate the units to a Care Homes for Older People Page 20 of 30 Evidence: more appropriate colour scheme and taking into account people who suffer with short term memory problems. Some areas of the home were untidy and we saw a soiled bath. Vacant bedrooms were not being cleared properly when people left the home. By the second day of the inspection the proposed manager had changed the housekeeping routine, to ensure staff were aware of these issues. She had also ordered new towels for the home which were badly frayed. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To ensure that peoples health and welfare needs are being met, the skill mix of the staff should be proportionate to the numbers and needs of the people being cared for. Evidence: We looked at three staff files which showed that the home were following their recruitment procedure, and appropriate safety checks had been completed prior to the person commencing. All grades of staff confirmed that they had been through a thorough recruitment process, and received induction training on commencement at the home. At the time of the inspection, the home had 10 vacant bedrooms. We looked at the duty rotas and these showed that the home provides staff to the three units separately. A trained nurse is rostered on all three units for the 24 hour period, and the proposed manager said this was always maintained. The home is currently trying to recruit a deputy manager, and nurses to reduce the need for agency staff to cover at the home. Given some of the comments received from people using the service, and staff, it is recommended that the staffing levels are calculated using a tool based on the dependency levels of the people living in the home. In addition to the nursing and care staff the home employs administration staff, Care Homes for Older People Page 22 of 30 Evidence: activities, laundry, catering and maintenance staff to meet all the needs of the people who live in the home. We looked at the staff training matrix for the home. This training assists staff to meet the needs of people using the service. All staff have regular mandatory training which includes moving and handling, fire, infection control and first aid. It is recommended that the service develop a system for assessing the nurses competencies and skills to ensure they have the appropriate skills to meet the needs of the residents. The home is aiming to have met the requirement for having at least 50 of staff with a NVQ level two or above in care when the carers have completed the course. Care Homes for Older People Page 23 of 30 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. Improvement in some areas is required to ensure that the home is operated in peoples best interests. Evidence: The homes registration changed in December 2009 to Trinity Care which is part of the Southern Cross Group. The registration certificate was displayed in the entrance to the home. The home appointed a manager, Shirley Houghton, who is in the process of going through registration with the Care Quality Commission. Shirley is a registered nurse with many years experience managing a care home. She has completed the management qualification. She told us of the various training courses she has attended since joining Redhill Court and planned training for the next 12 months. Shirley told us that she feels the moral in the home has improved recently. All staff spoken to told us that she was always approachable and supportive. Care Homes for Older People Page 24 of 30 Evidence: A senior manager from the organisation visits the home and provides support as required. The service has a number of audits in place to monitor the service provision. We spoke to the administrator who is well organised, and all records requested were available and up to date. The home does not take responsibility for peoples monies but has a system in place for some people to keep small amounts of money for hairdressing etc. Staff receive fire drills and training to ensure that they have the knowledge to safeguard people in the event of a fire. The records were available and up to date on the day of the inspection. The home employs a maintenance operative who assists in ensuring that equipment is serviced, tested and maintenance, appliances and equipment such as electricity, fire, emergency lighting and hoists are well maintained and this should ensure they are safe to use. The Annual Quality Assurance Assessment received from the home, required additional information to clearly demonstrate how the home was meeting the standards. It was brief in parts, which was discussed with the manager at the inspection. Care Homes for Older People Page 25 of 30 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 26 of 30 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 7 12 Reg 12 1 a The home should ensure that the care plans for people using the service are person centred to reflect personal preferences. They should provide clear guidance for staff to follow, and record changing health and psychological needs for individuals. To ensure that peoples care needs are fully met. 24/09/2010 2 8 12 Reg 12 1 a 12/08/2010 The home should ensure that risk assessments are calculated correctly and the correct equipment is provided for the individual to minimise the potential risk. To assist in ensuring people health care needs are being met. Care Homes for Older People Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 9 13 Reg 13 2 The service must make arrangements that medication administration records are accurately maintained, and that the reasons for non administration are recorded by the timely entry. To ensure people receive their prescribed medication correctly. 30/07/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 1 10 To review the procedure to assist people and their relatives who are admitted to the home in an emergency situation. Peoples preferences for care being delivered by male or female staff is clearly recorded and staff are aware of individuals preferences. That the activities are reviewed to provide people with cover for the seven days. To ensure that people are provided with suitable activities and assist in them not being bored. The home reviews their complaints procedure to ensure that all complaints are investigated and people feel that they are being listened to. To ensure that the peoples health and care needs are met. The skill mix should be reviewed, taking into account the assessed dependency needs of the people being cared for. The home should aim to provide at least 50 of staff with a National Vocational Qualification in care to ensure that 3 12 4 16 5 27 6 28 Care Homes for Older People Page 28 of 30 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 they have the knowledge and skills to care for people. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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