Inspection on 13/07/09 for Shipley Hall Nursing Home

This inspection was carried out on 13th July 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shipley Hall Nursing Home 28/07/08

Shipley Hall Nursing Home 27/04/07

Shipley Hall Nursing Home 27/04/06

Shipley Hall Nursing Home 12/12/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Shipley Hall Nursing Home The Field Shipley Heanor Derbyshire DE75 7JH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Helen Macukiewicz     Date: 1 3 0 7 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Shipley Hall Nursing Home The Field Shipley Heanor Derbyshire DE75 7JH 01773764906 F/P01773764906 shipleyhall123@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Shipley Hall Limited care home 30 Number of places (if applicable): Under 65 Over 65 30 old age, not falling within any other category Additional conditions: 0 One DE(E) place for service user named in notice of proposal letter dated 09 January 2006. One MD place for the service user named in the notice of proposal letter dated 29 November 2005. Registration to include the accommodation of one named service user PH (as specified on the notice of proposal) under the category PD, not transferrable to any other service users. The Responsible Individual must submit a Manager for registration within 3 months of registration. Date of last inspection Brief description of the care home Shipley Hall is a care home with nursing, set in attractive parkland grounds, with a pond and gardens that attract a variety of wildlife. The home is a converted, extended building, dating from the turn of the century, and provides facilities for thirty residents. There are five day/quiet rooms, which include two conservatories overlooking the garden areas. Accommodation is provided on ground and first floors, with passenger Care Homes for Older People Page 4 of 30 Brief description of the care home lift and staircase access to the first floor. An additional stair-lift provides assisted access to one of the first floor bedrooms up a short flight of stairs. There are eighteen single bedrooms and six double bedrooms, all with wash hand basins. No en-suite rooms are provided, but the home has adequate provision of WC and bath/shower facilities throughout, including an assisted bath. All rooms are equipped with a call system. The nurse in charge told us that the current range of fees is from 375.00 GBP to 455.00 GBP per week plus top up for continuing care. A copy of the last Inspection report was seen in the office. 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: 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 focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people using the service and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgments such as notifications from the provider, complaints or concerns. We also use information from an Annual Quality Assurance Assessment (AQAA), referred to throughout this report as the pre-inspection self-assessment, which the provider is Care Homes for Older People Page 6 of 30 required to complete prior to a visit to the service. This provides evidence for us to make informed judgments when assessing the National Minimum Standards (NMS). The primary method of inspection used during the visit to this service was case tracking. This involved selecting three people and tracking the care they receive through review of their records, discussion with them where possible, the care staff and observation of care practices. Time was spent in discussion with the Manager and staff. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. All of the key standards were inspected on this occasion. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 30 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. Lack of available information about the home means that people do not have all the information they need to base their decision to move in. Gaps in assessment of need means that some people may have their care needs overlooked. Evidence: The information about the home found in the Statement of Purpose and Service Users Guide could not be located by staff during this visit, although they told us they had seen a copy, and knew what information it contained. We saw that there was no copy in peoples bedrooms for them to read. This meant that people did not have full access to information about the home at that time. People were receiving pre-admission visits from qualified staff, so that staff could assess whether they could meet the persons needs. This reduced the potential for inappropriate admissions. Once admitted, people had their needs assessed and Care Homes for Older People Page 11 of 30 Evidence: recorded. However, we found that the standard of assessments was inconsistent. Some people had a thorough assessment of need, whilst other peoples care records contained significant gaps in establishing medical and social history and usual routines. However, there was no evidence to suggest that staff were not aware of peoples needs. People told us they were happy with their choice of home. In their completed preinspection surveys, relatives told us the service is very good, great kindness is shown to my mother, my mother is very happy at Shipley Hall. One person living in the home said Im satisfied. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Gaps in the planning of care may lead to care needs being overlooked. Peoples privacy and dignity may be compromised through lack of attention to individualised care practices and outstanding maintenance within the environment. Evidence: We found inconsistencies in the standard of care plans. Some staff had produced detailed plans with clear directions for staff, which had been reviewed within required timescales. Other care plans had review dates that had expired and limited care instructions for staff to follow. One care plan lacked directions for staff in dealing with potentially aggressive behaviour, observations of a recent injury and wound care. Whilst there was no evidence to suggest that people had not received the care they required, gaps in care planning meant there was potential for people to be placed at risk. New problems arising after the initial care plan was written, were not always being updated into the main care plan, but the care given was recorded in daily notes. Whilst this supported that care had been given, it did not support that this was being provided in a planned and consistent way. Care Homes for Older People Page 13 of 30 Evidence: Gaps in care planning is an unmet requirement from our last Inspection of this service. The registered person has been given extra time to make the required improvements. There was some evidence that relatives had been consulted about specific issues. However, records did not support full consultation with people about their care. People were receiving the medical care they required and had regular visits from the Optician, Dentist and Audiologist. In their completed pre-inspection surveys relatives told us that people were well looked after and one wrote the staff always keep a close eye on residents and anytime residents are not well, GPs are contacted immediately. People living in the home told us their care needs were being met. There had been improvements made to the way medications were managed. One of the qualified staff was undertaking regular audits of medications. Evidence suggested that everyone was receiving the medication they needed although there were some gaps in the signing following administration. People who were able to offer an opinion on the standard of care provided told us that staff treated them with dignity and maintained their privacy, one said staff always knock if your door is closed. In their completed pre-inspection survey one relative wrote the dignity of residents is paramount at Shipley Hall, which is evident throughout the home, we are very happy with all aspects on this issue. We observed that staff were respectful in their communication with all people in their care. However, we observed a few matters that had the potential to impact negatively on peoples dignity and privacy. A toilet/shower room used by people living in the home contained a list with peoples names and the continence equipment they required. One bedroom contained a strong urine odour, this was a shared room. A further shared room did not have full privacy screening, the room divider was not adequate for providing full privacy. Two people who were not related shared this room. The privacy lock was broken on toilet 52. Finally, a collection of spare underwear which was not individually labeled or stored was found in one bathroom. Care Homes for Older People Page 14 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. People have their social needs met but care in this area is not always planned and delivered in a person centred way. Evidence: A member of staff had been allocated responsibility for maintaining a general social programme for people living in the home. There was evidence that people were receiving regular group entertainment and organised activities and these were well documented. People told us they could come and go as they pleased, and that there was enough to do, one said we do different things, play dominoes at night. Another confirmed that a mobile library service visited them at the home. Although people were going out individually and had enjoyed what entertainment was on offer, there was less evidence of an individualised approach to promoting lifestyle choices and activity planning. Care records generally contained little information about peoples individual preferences and routines, or preferred activities. A specific care plan as to how staff could meet social needs was only found in one of the care records we saw. People told us they were happy with the food provided and we saw effective systems in place for maintaining peoples diet and kitchen hygiene. Peoples comments included Care Homes for Older People Page 15 of 30 Evidence: food is quite good, fine, sometimes get a choice of two things and we get an alternative. One relative, in their completed pre-inspection survey wrote there is always a choice at each meal time and seconds are available if requested. Care Homes for Older People Page 16 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. Lack of information about the complaints procedure may be a barrier to people raising concerns. Staff are trained to keep people safe, but gaps in recording where restraint is needed may adversely affect wellbeing. Evidence: Staff were unable to locate information about the complaints procedure around the home, either on display or in a Service Users Guide. However, people told us they could raise concerns and knew who to go to. One person mentioned that they had raised a concern recently. This was not recorded in the complaints file, however, the person said this had been resolved to their satisfaction. The complaints file showed that one separate complaint had been received since we last inspected. Records supported that this had been dealt with. We noted that the complaints folder was not stored confidentially, therefore staff had access to potentially confidential information which could be a barrier to people wishing to raise concerns. There was evidence to support that staff had received training in keeping people safe, and safeguarding procedures were easily located by staff on duty. Some staff had received training on the Mental Capacity Act and there were information booklets about the Deprivation of Liberty in the office for staff to read. There had been two safeguarding incidents since we last Inspected. The registered provider had worked closely with Social Services to resolve the issues. Care Homes for Older People Page 17 of 30 Evidence: People who needed mechanical forms of restraint to keep them safe, such as bed rails had consent forms in their care files. These had been signed by the person or their representative to agree to their use. However, some details had not been deleted on one form, so it did not show whether the person had consented or not. When equipment was in use there were no records seen that indicated regular checks and risk assessments of the equipment to check it was in safe working order. In care plans there was no rationale to support how the person had been assessed as needing mechanical restraint and no subsequent reviews of whether this was still needed. Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment of the home generally enhances the quality of life for people living there although cleanliness in general areas detracts from this. Evidence: In her completed pre-inspection self-assessment the registered provider had identified that she needs to undertake quicker refurbishment. We saw that new carpets had been fitted to many areas and a sensory area had been completed. New bedrooms furniture had also been provided. In their completed pre-inspection surveys relatives told us that the home was always clean and tidy. People we spoke to on the day also confirmed this was the case. We also saw that a weekly cleaning schedule had been put in place to maintain cleanliness of bedrooms. However, although we saw that peoples bedrooms were kept clean, some of the chairs in the main lounge and conservatory area needed cleaning as there had been spillages. The new conservatory had food debris and the carpet in the small lounge was stained. People told us they were happy with the laundry service. One relatives pre-inspection survey recorded laundry is done on site and care taken to ensure that residents clothing is changed as necessary during the day by care staff. Care Homes for Older People Page 19 of 30 Evidence: There was plenty of information about infection control around the home for staff to read, and many areas contained hand wash, hand rub, gloves and aprons to promote control of infection. One of the staff was an infection control link nurse and was very active in this role. Care Homes for Older People Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by sufficient numbers of trained and competent staff. Gaps in recruitment have the potential to expose people to unsuitable workers. Evidence: Staffing rotas showed there were sufficient staff to care for people. People told us they got on well with staff. In their completed pre-inspection survey one relative wrote Shipley Hall staff do their best at all times. Staff either had, or were working towards National Vocational Qualifications (NVQs) in care to levels 2 or 3. The cook had just completed NVQ 2 in food preparation. Care staff had access to programmes of training and a rolling programme of mandatory training ensured that staff had knowledge in all required subjects such as Health and Safety and Moving and Handling. Staff told us they had also been able to undertake a dementia awareness course, which they had found helpful. Three care staff were undertaking a team leader course. Ancillary staff had received less training in required subjects. Due to the absence of the registered provider (owner) on the day, we could not access full information relating to the pre-employment checks made on staff. However, this information was provided separately and showed that the required pre-employment Care Homes for Older People Page 21 of 30 Evidence: checks were in place to keep people safe from unsuitable workers. Records showed that all but two of the most recent new starters had a documented formal induction when they started employment, and were given opportunity to work some supernumerary shifts. The induction folders that had not been commenced was a result of both the registered provider and deputy manager being away from work during the persons first shifts. However, the nurse in charge confirmed they were working supernumerary shifts and gaining verbal instruction from staff. Care Homes for Older People Page 22 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. Management ensures that staff feel supported and that people who use the service are consulted. Gaps in quality assurance and record keeping means people may be exposed to preventable risk. Evidence: There has been no registered manager at the home since we last Inspected. The registered provider had been acting as manager. It was a requirement of our last Inspection that the manager was registered with us, this had not been met in the timescales given. In her completed pre-inspection self-assessment, the registered provider told us she had appointed a deputy and aimed for her to apply to become manager by October 2009. We have extended the original timescale to account for this change. There had been some internal quality assurance undertaken, we saw that satisfaction questionnaires were sent out to relatives in July 2008 and January 2009. The newly Care Homes for Older People Page 23 of 30 Evidence: appointed deputy manager had made entries in a communication book to record that she had set up a infection control and kitchen audit file and that she was auditing care plans. We had seen improvements to the management of medicines since audits of this area had been started. However, reviews of the care plans had not been effective in identifying gaps in care planning and the assessment of peoples needs, although absence of records and managers made it difficult to assess how long such audits had been taking place and whether or not all care plans had been checked. There were safe systems in place for the storage and handling of money held on behalf of people. Staff were receiving regular supervisions and told us they felt supported in their role. An environmental risk assessment had taken place and we saw evidence that some equipment was subject to regular servicing to keep people safe. However, some service records were not located by the nurse in charge such as hoists and passenger lift. Some service dates were also missing from the pre-inspection self-assessment completed by the registered provider. Therefore we were unable to confirm whether all equipment was subject to routine checks. Care Homes for Older People Page 24 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 8 15(1)(2)(b) People must have a plan of care that clearly details all care needs, including social care needs and provides direction for staff as to what actions they need to take. This must be subject to regular review and updated as peoples care needs change. A new timescale of 31/08/2009 is given for compliance. We may consider taking legal action if there is a failure to comply with the new timescale. This is to ensure care needs are not overlooked and people are kept safe. 30/09/2008 2 31 8 The manager must apply for registration with us. A new timescale of 30/09/2009 is given for compliance. We may consider taking legal action if there is a failure to comply with the new timescale. 31/08/2008 Care Homes for Older People Page 25 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 19 and Schedule 2) All staff must have evidence of a rehabilitation of offenders and medical declaration before they commence work. Written verification from former care homes where people had worked, as to reasons why they had left that employment, must be obtained prior to employment. This is to ensure people are not exposed to unsuitable workers. 31/08/2009 2 18 1)c)i) Ancillary staff must all 31/10/2009 undertake the mandatory training. This is to ensure they have the required skills to keep people and themselves protected. 3 1 4 2) The registered person 31/08/2009 must make the Statement of purpose available for Inspection at all times. Page 26 of 30 Care Homes for Older People This is to ensure that people have full information about the home at all times. 4 3 14 All people admitted to the 31/08/2009 home must have a comprehensive assessment of needs on admission. This must include identification of any social care needs, usual routines and lifestyle choices. This is to ensure that no care need is overlooked and to promote individualised care. 5 7 15 1) Care records must be 30/09/2009 able to support that people or their representatives have been fully consulted about their care. This is to ensure people have their rights upheld. 6 9 13 6) All medication given must 31/08/2009 be signed for on the medication Administration record. This is to support that people are getting the medication they require. 7 10 12 4)a) Toilet 52 must be provided with a functional privacy lock. Spare underwear must be individually labeled and stored. All shared bedrooms must be provided with full privacy screening. All bedrooms must be kept free from offensive odours. Lists 30/09/2009 Care Homes for Older People Page 27 of 30 detailing individual continence needs must be removed from public display. This is to promote the privacy and dignity of all people using the service. 8 18 13 7) Forms of restraint must only be used following appropriate consent and a fully recorded risk assessment process. This must be included in the persons care plan so it can be subject to ongoing review. There must be ongoing recorded safety checks of bed rails. This is to ensure people have their rights upheld and are kept safe. 9 26 23 2)d) All parts of the home 31/08/2009 must be kept clean and tidy. Cleaning of the main parts of the home must include chairs and regular floor cleaning to prevent build up of stains and food debris. This is to enhance peoples quality of life and to reduce potential for infection control. 10 33 24 Reviews of the quality of care people receive must be effective in identifying gaps in care planning and assessment of need. 30/09/2009 31/08/2009 Care Homes for Older People Page 28 of 30 This is to ensure people receive good quality care and that deficits in the service are promptly identified and resolved. 11 37 23 2)c) There must be up to date service records kept at the home, and available for inspection, to support that all equipment is regularly checked for safety. This is to ensure people are kept free from hazards to their safety. 31/08/2009 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 12 People should be have their social needs fully assessed and a plan of care put in place as to how those needs will be met by staff in the home, to ensure an individualised approach to meeting care needs. The complaints procedure should be widely communicated to people and should be on display so peoples rights to complain are fully supported. Complaints received should be stored securely, so people can have more confidence that their concerns will be treated confidentially. All complaints, both formal and informal should be recorded to support peoples rights are being upheld and to promote internal quality assurance. 2 16 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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