Inspection on 30/09/09 for Westdene

This inspection was carried out on 30th September 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westdene 28/09/07

Westdene 02/10/06

Westdene 27/02/06

Westdene 20/06/05

Westdene 17/01/05

Westdene 07/09/04

Westdene 22/01/04

Westdene 10/10/03

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

Key inspection report Care homes for adults (18-65 years) Name: Address: Westdene 26 London Road Sittingbourne Kent ME10 1NA one star adequate service The quality rating for this care home is: 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: Jo Griffiths Date: 3 0 0 9 2 0 0 9 This report is a review of the 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 stars – excellent  2 stars – good  1 star – adequate  0 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. They reflect the things that people have said are important to them: 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 Adults (18-65 years) 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 Information about the care home Name of care home: Address: Westdene 26 London Road Sittingbourne Kent ME10 1NA 01795472464 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): northwood.house@Ilg.co.uk Kent Assessment & Training Services Ltd Name of registered manager (if applicable) Mrs Linda Ann Tebb Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 10 0 care home 10 learning disability Additional conditions: The maximum number of service users to be accommodated is 10. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection A bit about the care home The home is a detached property with accommodation for service users on two floors and a staff room on the third floor. The home is situated on the outskirts of Sittingbourne approximately 1 mile from the town centre providing access to shopping and all public amenities. The Home provides accomodation and support to people with learning disabilities who may have challenging needs. The Home is registered for ten service users. The Manager is registered in respect of Westdene and Northwood House, which is situated next door to Westdene. Fees are charged according to individuals assessed needs. Current fees range between £1200 to £2000 per week. 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This was a key inspection of Westdene that took place on 30th September 2009. The inspection was carried out jointly across Westdene and the sister home Northwood, that is located next door and is managed by the same manager. The inspection of both services was carried out between 10.30am and 4.30pm. Prior to the inspection visit the manager completed and returned the Annual Quality Assurance Assessment (AQAA). This was received within the required timescales and provided useful information for planning the inspection. The manager was present for part of the inspection and a number of staff were spoken with throughout the visit. Three service users were involved in the inspection. Some of the records and care plans were seen as part of the inspection and the inspector had a look around the home. What the care home does well The service provides people with plenty of opportunities to go out into the local community for activities. The house is located near to the town and community facilities. Everyone living in the home is supported with household tasks and cooking. They choose the meals they would like on the menu each week and have a daily choice of foods and what activities they wish to do. Service users have access to all areas of the home and can use the garden when they wish. The people that use the service are involved in decision making in the home through one to one meetings with their keyworkers and through monthly house meetings. The staff work closely with service users to provide emotional support as well as support with daily living skills. Most of the staff team have completed the NVQ award. What has got better from the last inspection Some areas of the home have been redecorated and refurbished. What the care home could do better The service does not always provide person centred support, for example, recording charts have been implemented for all service users based on the needs of just one person. The care plans contain lots of repeated information and this makes the files inaccessible for service users. Risk assessments are not being followed for one service user and need to be reviewed. The systems in place for monitoring service users well being and for monitoring the quality of the service are not effective as records are made, but often no action is taken or recorded as a result. The recruitment procedures for new staff do not currently safeguard people using the service. Staff do not have the training they need to safely support people before they are required to work unsupervised with service users. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Jo Griffiths CQC Southeast Citygate Gallowgate Newcastle Upon Tyne NE1 4PA Email: Southeast@cqc.org.uk 03000 616161 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 http:/www.cqc.org.uk/. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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. People using the service are provided with some information they need about the services in the home, but some information is not accurate. People have an assessment of their needs before they move to the home and are assured these needs can be met. Evidence: The home has a Statement of Purpose and Service User Guide that gives people information about the services provided in the care home. Both documents were reviewed in August 2008. The Service User Guide has been given to all people living in the home and is presented in a written format, but with some supporting pictures to help people with communication difficulties. The Statement of Purpose correctly reflects the registration category of the home, but the Service User Guide states the home is for people with Mental Health needs rather than Learning Disability. The manager agreed to change this. The Service User Guide states people have a right to have a key to their own bedroom, but people in the home have not been issued with keys to their bedroom doors. Staff said that they can ask a staff member to lock their room for them if they wish. People have an assessment of their needs before they move to the home. The assessments seen had been kept under review. Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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. Service users have a care plan that ensures their day to day needs are met. The plans do not appropriately support people with any challenging behaviours they may display. The records that relate to the care plan do not allow for effective monitoring of the individuals needs. The care plans are not user friendly for staff or service users as they contain too much repeated information. Service users are involved in the running of the home and are supported to make decisions in their day to day lives. Risks to service users have been assessed, but the agreed actions have not always been followed and risk assessments have not always been updated. Evidence: Two care plans were seen as part of the inspection. Essential lifestyle planning documents have been used to give staff information about the needs of the person and the way they prefer to be supported. This has been written clearly and in detail, particularly in relation to personal care. Individuals have been supported to plan their goals and these have been included in the care plan. These have been reviewed and recorded as ongoing, but do not reflect achievements made toward the goal. Evidence: Some of the documentation in the care plan files is repeated, for example in one file there were three different versions of a likes and dislikes form. This can be confusing for staff and does not make the plans user friendly for service users. Another example was seen where there were four risk assessments that all related to the same area of need and each of these risk assessments had been photocopied three times within the file, leading to twelve versions of a similar risk assessment. Some of the risk assessments seen were not being followed and staff said that the actions to be followed in the risk assessment were not realistic. For example one risk assessment states the person should wear a panic alarm, but they have stated they do not want to. The risk assessment has not been updated to reflect this individual choice. The manager said that all risk assessments are being reviewed at present and this will be looked at. Some of the language used in the care plan is not clear. There are frequent references to service users displaying behaviours with no clear detail of what this means. Staff spoken with said that it refers to behaviours that may be considered challenging or aggressive. The records show that staff adopt these terms without really giving consideration to the function of individualised behaviour. There were also a number of examples seen where it had been recorded in care plan notes that the person had displayed behaviours, but that it did not state what these behaviours were or what action was taken in relation to this. There is no effective system for monitoring or following up on incidents of aggressive or challenging behaviour. Mood assessments charts were seen in some peoples files. These are designed for staff to make an assessment of a persons mood and record this every hour. The majority of staff have not received any training in this process. Staff said they usually complete these charts retrospectively at the end of each shift. The charts showed, for one person, that there were no incidents of aggression and staff were not sure why they were completing these charts. The manager said she felt it was invasive for the person. The charts had also been amended by staff and now include activities that the person may be requesting to do each day. This is not an assessment of the persons state of well being. A further chart was seen in a number of files. This was for staff to record that they prompt the service user to get up in the morning. The chart seen for one person showed that they get up independently every day. Staff said that the charts are in place because one person requires prompting to get up, but they were not sure why other service users had a chart. This is not a person centred approach to supporting service users. Documents in the files show that service users are supported to manage their own money as far as they can. They have their own bank accounts and any money they hold in the home is securely stored and accurate records are kept. Service users have the opportunity to participate in the monthly house meeting and have a monthly 1-1 session with their keyworker. They are involved in the weekly menu planning for the home. Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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 supported to participate in activities that meet their social needs and which they enjoy. They are supported to access community facilities. Some of the routines and practices in the home are not person centred. People using the service enjoy their meals and have a balanced diet. Evidence: Individuals are supported to take part in a range of activities within and outside of the home. This includes going shopping, swimming, going to college, eating out, going to the nightclub and visiting family and friends. When at home people are supported to help prepare meals and do their laundry. They can relax and watch TV in the lounge or spend time in their own room. There is a garden to the rear of the home that is safe for them to use. The records of activities show that people are generally busy and have lots of opportunities to go out into the local community. On the day of the inspection a number of people were being supported to go out and one person was decorating their room for Halloween with a staff member. None of the service users are currently in employment and the manager said this is not being explored with them at present. Evidence: The menu is planned by service users with staff support on a weekly basis. The menu provides a guide to meals in the home, but is flexible to allow individual choice on a daily basis. The planned menus provide variety and a balanced diet. A record is kept of the meals people have, but this has not always been completed. This means the manager is not able to effectively monitor individuals nutritional intake and needs. Some institutional practices were noted in the home. For example, one person has plastic cups, plates and cutlery. Staff said that there have been occasions where the service user has thrown crockery in the past, but that this has not happened for some time. The records did not show any incidents of thrown crockery. Staff said that the person now chooses to have these items and the manager said that alternatives have been offered. As reported under the previous section of this report there are a number of charts and records kept for service users without staff or the manager having any clear understanding of the purpose of these or the need for them. Some records have been introduced for everyone in the home rather than based on individual needs. The home is therefore not always being run in a person centred way. People using the service said they are happy with the meals and said they enjoy the activities they do. They confirmed that they have lots of opportunities for going out. The manager said that none of the people using the service had been on holiday yet this year as it had not been agreed where to go. Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have their health and personal care needs met. People using the service have their medication managed safely, but would benefit from being supported to self medicate where possible. Evidence: Everyone using the service has a health action plan. These were seen in two care plan files and are kept up to date by the keyworker. This could be further improved by encouraging service users to take control of their own health action plan and book their own health appointments. Records show that people have their health needs met in a timely manner. The support that individuals require with their personal care is outlined in their care plan. Staff said that they encourage people to be as self managing as possible. All personal care is provided in private. Service users medication is administered by trained staff in the home. The storage of medication is secure and the records were seen to be completed accurately. None of the service users are currently managing their own medication or working toward this. People using the service should have the opportunity to develop their skills in this area through their person centred plan. Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. People using the service are not fully safeguarded due to a lack of robust systems for recruiting new staff to the home. People using the service know how to make a complaint if they need to. Evidence: The home has a safeguarding adults policy and a whistle blowing procedure for staff to follow in the event of allegations of abuse in the home. Staff spoken with knew how to report allegations of abuse. There has been one safeguarding allegation made since the last inspection and this is currently under investigation. The procedures for recruiting new staff do not fully safeguard service users at present. This has been reported under the staffing section of this report and a requirement made in relation to robust recruitment procedures. The home has a complaints procedure and all service users have been issued with a copy in a picture format. There has been one complaint made since the last inspection. The manager said this had been resolved and that she had written to the complainant following the investigation, but the actions taken have not been recorded in the complaints log. Service users have regular opportunities to share any concerns they may have, through the monthly house meetings or one to one sessions with their keyworker. 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is maintained to an adequate standard and meets the needs of those that live there. Service users would benefit from an annual programme for decoration of the home. The home requires attention to the management of unpleasant odours. Service users have bedrooms suitable for their needs and access to sufficient shared space and bathroom facilities. Evidence: The home is maintained to an adequate standard. There is no maintenance plan for the ongoing decoration and refurbishment of the home, but a handyman is employed to undertake any work identified by the manager. Some areas of the home had an offensive odour, which the manager said she was addressing with carpet cleaning, but generally the home was kept clean. There are sufficient numbers of bathrooms and shower rooms for service users to use near to their bedrooms and some people have ensuite facilities. The home is registered for more people than there are bedrooms and the manager said that this was a historical issue. The manager said that there are no shared bedrooms and that the home can only accommodate seven people. The manager said that one bedroom had been reduced in size since the last inspection and was now below the recommended minimum size. The registered provider must ensure that a variation to the registration of the home is applied for in respect of the change to the numbers that can be accommodated in the home. Service users do not have a key to their bedroom door or a front door key. There is a Evidence: coded keypad to the front door. The manager said that if a person was assessed as safe to go out independently they would be issued with a front door key and the keypad code. There is a large lounge, accessible kitchen and a laundry room for service users to use. The rear garden is well maintained and safe for service users to use. 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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. Service users are not fully safeguarded by the homes procedures for recruiting new staff. Staff do not receive the training they need to safely support service users before they are required to work without supervision. Service users benefit from staff that have completed the NVQ award. Evidence: Service users spoken with said they feel there are enough staff on duty to meet their needs. At the time of the inspection there were four staff on duty and staff were available to support people out to activities when they requested this. The staff files for three new employees were seen. These showed that staff do not always have a full CRB check in place before they start working unsupervised with service users. Two staff were working with service users unsupervised on the day of the inspection with only a POVA first check. The manager said she was aware that staff were required to work under supervision if they did not have a full CRB in place. The manager had failed to ensure this happened with regard to the two staff members who only had a POVA first check. Not all the files seen had appropriate references. The application forms for two people did not give dates of previous employment and therefore the manager had not made checks of any gaps in employment history. One staff member has not had any previous employment, but the application form does not ask for education history in order to take appropriate references in this instance. One person had two references from the same employer, but neither were from the most recent employer. One person had two character references and no employment Evidence: references. New staff complete an in house induction. This was seen for two new employees and these had been fully completed in one day. The manager was asked whether it would be possible to fully cover the topics in the induction in detail in one day and she said this would not be possible. The manager said that the new staff would be registered for the Learning Disability Qualification. Staff attend a one week training programme when they join the organisation. This covers all core training courses they need to undertake including safeguarding adults, first aid, moving and handling, infection control, food hygiene and fire safety. The three new staff in the home had not yet been booked for this training and the manager said it can take up to three months before they complete the courses. This means that some staff are working in the home without having received the training they need to safely support service users. Staff without the training were seen to be working without adequate supervision with service users. The majority of staff employed in the home have completed the NVQ award in care. Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by a person that has achieved some of the qualifications necessary to undertake the role, however the service is not currently being managed in a person centred way. The systems for monitoring the quality of the service and for monitoring service users well being are not effective. The health and welfare of service users is generally promoted and protected, but some attention is required to risk assessment processes to ensure they are person centred. Evidence: The manager of the home has completed the Registered Managers Award and is working toward completion of the NVQ level 4 in care. The manager has not yet completed any training in person centred planning, but said that this was being arranged. This will assist the manager in developing the service in a person centred way as currently some of the practices in the home could be considered institutional and are not based on individuals needs. The manager must develop effective systems for monitoring the wellbeing of service users and ensure that any records maintained in the home serve a purpose and that action is taken to address any changes in need. The manager must ensure that the service is run in a person centred way and that the quality of the service is monitored and developed. The manager must ensure that the systems for recruiting new staff safeguard people Evidence: using the service. New staff must be appropriately supervised until all the required pre employment checks have been made and they have received the training they need to carry out their roles safely and effectively. Risk assessments must be reviewed, as planned by the manager, to ensure that actions are being followed by staff and that the risk assessments are person centred, relevant and up to date. Are there any outstanding requirements from the last inspection? Yes  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 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 Description 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 Description Timescale for action 1 1 5 The Service User Guide must 31/12/2009 accurately reflect the registered category for the home. To ensure people looking to use the service know the range of needs the home can meet. 2 6 12 The registered manager must ensure that effective monitoring systems are in place to monitor individuals wellbeing, but that this is done in a person centred way. 30/12/2009 To ensure service users needs are met in a person centred way. 3 6 15 Care plans must be in a format that is accessible to service users. 31/12/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action To ensure they can take ownership of their own plan. 4 9 13 Risk assessments must be 31/12/2009 kept under review and updated as individuals needs change. To ensure that individuals are safeguarded from harm. 5 15 12 The registered person must 30/12/2009 ensure that service users are offered a key to their bedroom door. To ensure their privacy and security of personal belongings. 6 16 12 The registered provider must 31/12/2009 ensure that routines in the home are person centred. To ensure people are supported in the way they prefer and need. 7 17 17 The registered provider must 31/12/2009 ensure that accurate records are maintained to allow monitoring of service users nutritional needs. To ensure service users nutritional needs are met. 8 22 22 A record of the action taken in respect of any complaint must be maintained. 31/12/2009 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action This will demonstrate that the manager responds effectively to complaints. 9 24 23 The registered provider must 31/12/2009 ensure there is an ongoing programme of redecoration for the home. To ensure a pleasant environment for service users. 10 29 16 The home must be kept free from offensive odours. 31/12/2009 To ensure a pleasant environment for service users. 11 34 18 The registered provider must 31/12/2009 ensure that staff receive the training they need to support service users before they work unsupervised. To safeguard service users. 12 34 19 The registered provider must 31/12/2009 ensure that the required checks are made of new employees before they work unsupervised in the home. To safeguard service users. 13 39 24 The registered person must 31/12/2009 ensure that effective systems 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 Description Timescale for action are in place for monitoring the quality of the home and developing the service in a person centred way. To ensure service users receive a high quality service. 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 20 It is recommended that service users be supported to develop their skills with regard to managing their own medication. Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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. - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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