Inspection on 29/07/09 for Shawe House Nursing Home Ltd

This inspection was carried out on 29th July 2009.

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

Shawe House Nursing Home Ltd 30/01/09

Shawe House Nursing Home Ltd 28/12/07

Shawe House Nursing Home Ltd 22/09/06

Shawe House Nursing Home Ltd 28/02/06

Shawe House Nursing Home Ltd 18/11/05

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for older people Name: Address: Shawe House Nursing Home Ltd Pennybridge Lane Flixton Manchester M41 5DX     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: Adele Berriman     Date: 3 1 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 31 Information about the care home Name of care home: Address: Shawe House Nursing Home Ltd Pennybridge Lane Flixton Manchester M41 5DX 01617487867 01617487920 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.shawehouse.co.uk Shawe House Nursing Home Ltd care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: A maximum of 33 older people requiring nursing care as a result of an organic mental illness can be accommodated. Service users shall not be subject to detention under the terms of the Mental Health Act 1983. Staffing levels as specified in the Section 13 Notice dated 30 December 2002 shall be maintained. Date of last inspection Brief description of the care home Shawe House is a nursing home providing care for 33 older people with dementia. It is a large Victorian house that has been appropriately converted and extended. The home is located in Flixton in an area that is close to Flixton gold course. There are good bus links to nearby towns. There are 27 rooms of which 6 are shared rooms; 12 bedrooms have en suite toilets. The rooms are situated on the ground floor and first floor and a passenger lift is available for the residents to use. Care Homes for Older People Page 4 of 31 Over 65 33 0 3 0 0 1 2 0 0 9 Brief description of the care home Shawe House has two lounges, one of which is used as a lounge/dining area and the other for quieter pursuits. There are 3 bathrooms with toilets, a shower room with toilet and 3 single toilets. There is a large and well-maintained garden that overlooks green open space and a large parking area at the front of the house. Fees charged by the home were £499. 50 per week. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: We visited Shawe House on 30th January 2009 and carried out a random inspection. We visited in response to concerns being raised. During the visit we looked at their compliance in respect of maintaining an odour free environment, the supervision of people living at the home and peoples general appearance. Following our visit five best practice recommendations were made. Following our visit the manager wrote to us to tell us what actions they had taken following our recommendations. Following our random inspection on the 30th January 2009 we decided to visit the home sooner than we had planned to carry out a key inspection. As part of this key inspection we carried out an unannounced visit to the service on Wednesday 29th July 2009 at 11.40am. A further visit was made to the service on the 31st July 2009. During our visits we looked at documents including a selection of care plans, staff files, policies and procedures. We looked at several areas of the home Care Homes for Older People Page 6 of 31 including communal lounges and bathrooms and peoples bedrooms. We spoke to five people who live at Shawe House, four staff and a director of the home. In October 2008 the manager of the service completed an Annual Quality Assurance Assessment (AQAA). This document gave the service the opportunity to tell us what they thought they did well, how they felt they had improved since their last key inspection and their plans for the future. The document told us some of the information we asked for. Five people, some with the assistance of their relatives completed a survey form to tell us their thoughts on life at Shawe House. People told us good things about the staff. These comments included they care, the care and courtesy of the staff is excellent in this home and the nursing staff are very good. They told us that two formal complaints had been made about the service since we last visited, all of which had been managed in line with the homes complaints procedures. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: Risk assessments and care plans relating to nutrition must consider all known information and clear guidance should be recorded of how the persons needs are to be met. This is to help ensure that people receive the care and support they need at all times. All safeguarding concerns must be referred under the local authoritys procedures. This is to help ensure that people are protected from any a further risk of harm. An application must be made to the Commission for the registration of a registered manager. All incidents that occur that are listed in Regulation 37 of the Care Homes Regulations must be reported to the Commission without delay. this will help ensure that the service tells the Commission of the information they need to know. Care Homes for Older People Page 8 of 31 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had their needs assessed before they move into Shawe House to ensure that their care needs can be met. Evidence: Since we last visited we saw that the manager had reviewed and updated the Statement of Purpose to inform people of what they could expect whilst living at Shawe House. The majority of people who completed a survey form told us that they had received enough information to help them decide that the home was the right place for them. We saw that peoples needs were assessed prior to them moving into Shawe House. The purpose of the assessment was to ensure that the home had the facilities to meet all the needs of the individual. They told us that either the manager or the deputy manager would carry out the assessment by visiting the person at their current address and spending time with them and where possible, family members. Care Homes for Older People Page 11 of 31 Evidence: We saw that the pre admission assessment was recorded on a set format that gave the opportunity to record peoples specific needs relating to their day to day living. Information gained during the assessment process contributed to the persons care plan. Shawe House does not provide intermediate care facilities. Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A lack of up to date information recorded in peoples care plans may result in people not receiving the care and support they need. Evidence: We saw that people had their own individual files which contained information relating to health care appointments, individual risk assessments and their care plan. We looked at the care plans of four people. We saw that they contained a mental, physical and social profile of their needs and information based on activities of daily living. The format of the care plans gave the opportunity to records peoples needs in aspects of their day to day life. We saw that the detail of information recorded in peoples care plans differed in detail. For example, under the communication section of one care plan it clearly stated that staff were to speak slowly and clearly ensuring eye contact is maintained and staff to give time for the person to respond to any questions or conversation. Other information was not as informative, for example, one care plan stated bath/shower as Care Homes for Older People Page 13 of 31 Evidence: required and gave no direction on how the person was to be supported when having a bath or shower. We saw that risk assessments for skin integrity, moving and handling and general health and safety formed part of peoples care plans. We saw that they were using the Malnutrition Universal Screening (MUST) tool to assess if people were at risk from weight loss and to highlight dietary requirements. We saw two care plans that contained inconsistent information about peoples dietary needs. For example, one care plan record stated that the person had experienced a weight loss of 8.2kg over a six month period. The nutritional screening tool stated usual weight and steady and usual appetite and did not consider the persons weight loss. We saw information on another persons care plan that demonstrated that a dietitian had visited the person and had given clear dietary advice on how to support the individual with their nutritional intake. None of this information had been transferred to the care plan or considered in other assessments. It is essential that up to date information is considered when reviewing care plans and risk assessments to ensure that people receive the care and support they require. Daily records were maintained for each person. Several of the records that we saw contained little information for example, comments included adequate dietary and fluid intake, settled mood, dignity maintained, safety and comfort maintained and safety ensured. A detailed record of peoples daily experiences, care and support that has been delivered should be maintained to help ensure people are receiving the care and support they require. We saw that the staff team maintained records of visits from health care professionals. Three people who completed a survey told us that the home always makes sure they get the medical care they need and one person said they usually did. Another person told us they sometimes received the medical care they needed. A relative of a person living at Shawe House told us that it is a while before they can get satisfaction about their relatives health when they told them of their concerns. Policies and procedures were available for the safe management and administration of medication. We saw that medication was stored safely in appropriate trolleys, cupboards and fridges. Medication Administration Records (MARs) were in use for staff to record medication administered. We saw information from a GP giving permission for staff to administer medication to a person covertly. This means that it is given without the persons knowledge or Care Homes for Older People Page 14 of 31 Evidence: agreement. Any decision relating to covert medication should be made in the persons best interest. We saw no evidence to demonstrate that people involved in the persons care had been involved in the decision to administer medication covertly. Where decisions are made about the use of covert treatments, appropriate multi-agency assessments should be carried out to show the decision was make in the best interests of the individual. This is in accordance with the Mental Capacity Act 2005 - Deprivation of Liberty Safeguards. At the time of the visit we observed people being supported by staff in a respectful manner. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The daily routines within the home did not always consider or promote peoples choices. Evidence: They told us that in the absence of the activity organiser carers were carrying out activities with people. They told us that the week before we visited several residents had visited Blackpool for the day and that they had recently had a BBQ and garden party. They told us that a music for health session takes place twice a month and day to day activities included talking with residents, painting, reading the newspaper and listening to music. Two people who completed a survey form told us that there were always activities available for them to take part in. Other people said there sometimes and usually were. We saw pieces of multi-sensory equipment were situated in the lounge areas to provide stimulation and relaxation to people. Care Homes for Older People Page 16 of 31 Evidence: They told us that people have the opportunity for a priest or vicar to visit them if they or their family requested this service. They told us that they had an open visiting policy to enable people to visit at any time. They told us that people were encouraged to handle their own money when possible. They gave an example of one person who manages their own money and what procedures have been put in place to support the individual. These procedures involved staff supporting the person on a daily basis with their money and a lockable facility being made available in the persons bedroom. We saw that several people were sitting in chairs that they would not be able to get out of without assistance. Several of these people were not able to ask for assistance to get out the chairs. We saw no evidence that peoples best interests had been considered in relation to the use of the chairs. In a situation where a person is deemed as not having capacity to make a choice or decision a appropriate multi agency assessment should be carried out to demonstrate that decision to use the chairs have been made in the best interests of the individual. There was little evidence around the home that actions had been taken to orientate people in their daily routines. People with memory issues can often benefit from having access to the time, date and the day being displayed. This information can assist people with their day to day routines. We saw that meals were served in the dining areas of the two lounges. They told us people could also have their meals in their bedrooms if they wished. We observed the lunchtime meal being served in one of the dining areas. We saw a staff member giving people their hot lunchtime meal. The meals were pre plated and had been taken to the dining area uncovered on an open trolley. This practice does not ensure that people receive their meals at an appropriate temperature. We saw that the menu for the day was not displayed. We looked at the menus. They demonstrated that a set meal was served for lunch and dinner. Staff told us that alternatives were available to people if they asked. The menu should be made available to people on a daily basis. To assist some of the people living at the home they should consider introducing several ways of displaying the menu. This would help people with choosing what they wanted to eat. The majority of people who completed a survey form told us that they always liked the Care Homes for Older People Page 17 of 31 Evidence: meals at the home. Care Homes for Older People Page 18 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems were not in place to ensure that people were safeguarded in their home. Evidence: We saw that the service had a complaints policy available at the home. A copy of the policy was also available in the services Statement of Purpose. The policy was clearly written and informed people of how complaints would be investigated. The people who completed a survey form told us that there was always somebody to speak to if they were not happy and that they were aware of the complaints procedure. We saw that the Local Authority safeguarding policy and procedures were available to staff. We saw training records that demonstrated several staff had undertaken safeguarding training. We spoke to two staff about what action needed to be taken in the event of a safeguarding situation arising. Both staff demonstrated little awareness of what actions needed to taken. To ensure that all risks to people are minimised all staff must have an understanding of identifying and responding to potential abusive situations. We looked at a selection of accident records during our visit. We saw three safeguarding incidents had been recorded. None of these incidents had been reported under the Local Authorities safeguarding procedures. All safeguarding incidents must Care Homes for Older People Page 19 of 31 Evidence: be reported under the Local Authorities safeguarding procedures. Failure to report these situations may put people at risk from unnecessary harm. Care Homes for Older People Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clean and comfortable environment is provided. Evidence: Shawe House is set within its own grounds and has a large well maintained secure garden. Outdoor seating was available in the garden area. A part-time maintenance person is employed to carry out general repairs and maintenance around the building. This included regular testing of fire detection equipment. An up to date fire risk assessment was not available to us when we visited. However, following our visit we were informed that an up to date fire risk assessment was available during our visit. We looked at several areas of the home during our visit. These areas included a selection of bedrooms, communal bathrooms, toilets, lounge/dining areas. We saw that peoples bedrooms had been personalised with their own effects which individualised their rooms. We saw the home was clean and tidy. We found two areas of the home had a slight malodour. People who completed a survey form told us that the home was always fresh and clean. Other people told us it was sometimes fresh and clean. Care Homes for Older People Page 21 of 31 Evidence: They demonstrated that they had a refurbishment plan that programmed in what decoration needed to be carried out around the home. Since we last visited several areas of the home had been decorated. On the day that we visited the temperature around the home was high leading to a very warm environment. One person who completed a survey form told us the temperature control of the building is poor and the heat in the conservatory in hot weather was dreadful. A senior representative of the organisation told us that they were considering what changes they needed to make to the air conditioning system around the building as they acknowledged that the current system was not meeting peoples needs. Care Homes for Older People Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Shawe House are supported by a team of staff who know them well. Evidence: During our visit there were seven carers, a registered general nurse and a registered mental nurse on duty to meet the needs of the 32 people living at Shawe House. In addition, a team of kitchen and ancillary staff were on duty to ensure the peoples needs were met. Staff demonstrated a good awareness of individuals needs and were seen to interact with people in a respectful manner. People made positive comments about the staff team. They told us they care, the nursing staff are very good and the care and courtesy of the staff is excellent at this home. The majority of people who completed a survey form told us that staff were usually available when they needed them. We looked at a sample of staff files. We saw that the appropriate information had been obtained for newly recruited staff. This information included written references, completed application forms and evidence that appropriate Criminal Record Bureau disclosure checks had been carried out. Care Homes for Older People Page 23 of 31 Evidence: We saw the services training matrix. It demonstrated that the majority of staff had undertaken training in moving and handling, infection control, food hygiene and safety since we last visited. We saw that some staff had received training in other areas including continence care, vene puncture, basic first aid and tissue viability. The training matrix demonstrated that none of the staff team had received general health and safety training. The service should review staffs training needs in this area to ensure that staff have an up to date knowledge of health and safety legislation. We saw information that told us that 18 staff had either completed or were studying for their NVQ (National Vocational Award) award. A further 10 staff were planned to start to study for their award in 2009. Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current management systems do not always ensure that information about safeguarding situations and notifiable incidents are shared in order to protect people. Evidence: At the time that we visited the manager of the service was on leave. The manager had been in post for several months. The home did not have a registered manager. An application should be made for a person to be registered with us as the registered manager. We saw several records of incidents that had occurred within the home that had not been reported to us. All incidents and occurrences listed in Regulation 37 of the Care Homes Regulations 2001 must be reported to us without delay. We saw that they had a system in place for measuring the quality assurance of the service provided at Shawe House. This involved a questionnaire survey being circulated. We saw the results of the most recent survey that had been carried out in Care Homes for Older People Page 25 of 31 Evidence: March 2009. The information demonstrated that 92.5 of people thought that the home had lived up to their expectations. They told us that the feedback from the surveys was helpful in planning for the future. Systems were in place to safeguard peoples monies. We saw that policies and procedures were in place to protect the health and welfare of people. We saw that the handy person carried out regular checks on the nurse call system and monthly checks on the hot water facilities available to people living at the home. We recommend that the hot water temperatures are carried out on a weekly basis so that any variation in the temperatures can be corrected. Care Homes for Older People Page 26 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 Risk assessments and care plans relating to nutrition must consider all know information about the person and clear guidelines recorded of how the persons needs are to be met. This is to ensure that people receive the care and support they require at all times 14/09/2009 2 18 13 All safeguarding situations must be referred under the local authorities safeguarding procedures. This is to help ensure people are protected from further risk of harm 18/09/2009 3 31 9 An application must be made to the Commission for the registration of a registered manager. 30/10/2009 Care Homes for Older People Page 28 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This will help ensure the continuity of care within the home. 4 31 37 All incidents that occur that 18/09/2009 are listed in Regulation 37 of the Care Homes Regulations 2001 must be reported to the Commission without delay. This will ensure that the service tells the Commission of things they need to be informed about. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Daily records should contain detailed information about what the individual has experienced throughout the day and what care and support has been delivered or offered to the person. Clear detailed information should be recorded as to how peoples identified needs are to be met. 2 9 Appropriate multi-agency assessments should be carried out to determine that the use of covert treatments are used in the best interests of the individual involved. This is in accordance with the Mental Capacity Act 2005, Deprivation of Liberty Safeguards. All nursing staff should follow the guidance issued by the Nursing and Midwifery Council with regard to covert medication administration. 3 12 To encourage and support people and their daily routines the service should consider ways in assisting individuals Page 29 of 31 Care Homes for Older People 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 with their orientation around the home. 4 14 Appropriate multi-agency assessments should be carried out to determine that the use of chairs that could possibly restrict people are used in the best interests of the individual involved. This is in accordance with the Mental Capacity Act 2005, Deprivation of Liberty Safeguards. To help ensuree that people receive hot meals at an appropraite temperature a review of how hot meals and transported to the dining areas should take place. It is strongly recommended that all staff working within the home undertake awareness training on safeguarding procedures. The service should ensure that an up to date fire risk assessment is available at all times. To help ensure that the temperature of the building is appropriate for people living at Shawe House a full review of the home air conditioning system should take place. A review of staff training needs in relation to health and safety should take place to help ensure that all staff have up to date knowledge of current health and safety legislation. Hot water temperatures should be checked on a weekly basis to ensure that any variation in the temperature can be addressed appropriately. 5 15 6 18 7 8 19 19 9 30 10 38 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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