Inspection on 15/05/09 for Whitehaven Lodge

This inspection was carried out on 15th May 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whitehaven Lodge 15/05/08

Whitehaven Lodge 16/05/07

Whitehaven Lodge 20/11/06

Whitehaven Lodge 18/05/06

Whitehaven Lodge 16/02/06

Whitehaven Lodge 22/09/05

Whitehaven Lodge 03/02/05

Whitehaven Lodge 01/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 21/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Whitehaven Lodge Buttermere Close Maybush Southampton Hampshire SO16 9JR     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: Anita Tengnah     Date: 1 5 0 5 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: Whitehaven Lodge Buttermere Close Maybush Southampton Hampshire SO16 9JR 02380784839 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Southampton City Council Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 55 Number of places (if applicable): Under 65 Over 65 0 55 dementia old age, not falling within any other category Additional conditions: 55 0 The maximum number of service users who can be accommodated is: 55 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: Old age, not falling within any other category (OP) Dementia (DE) Date of last inspection Brief description of the care home Whitehaven Lodge is a large purpose built residential home providing care and support to 55 elderly persons, who have dementia relating to their old age. The home is located in Millbrook, the west of Southampton, approximately 2 miles from the city centre and is managed by Southampton City Council. Care Homes for Older People Page 4 of 30 Brief description of the care home The building is laid out over two floors with a passenger lift access to the first floor. Bedrooms are arranged in 6 separate living units. On the ground floor there is one large dining room and four smaller lounges, one of these is a smoking lounge. The home has a pleasant garden, which incorporates a raised sensory flowerbed and a lawn. Garden furniture and a handrail enable residents to enjoy the garden to the full, particularly during the warmer months. There is an extra charge for items such as chiropody, hairdressing, that are not included in the fee. 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: An unannounced inspection visit was undertaken over one day on 15th May 2009 as part of our inspection process. We sent out the Annual Quality Assurance Assessment AQAA to the registered person at the service. This is one of the means of collecting data from the service. We also sent out service users and staff surveys to the home to seek their views of the service provision. We spoke to a number of the service users, their relatives and the staff on the day of the visit. We looked at the environment, service users records and care plans and some staff records as maintained at the service and we observed care practices. We have used information as supplied by the home in their AQAA and other information that we have received since the last inspection. Care Homes for Older People Page 6 of 30 The service users had positive comments about the care that they are receiving. These will be reflected in the body of the report as appropriate. We received an improvement plan following the last visit to tell us how the home was planning to meet the requirements we raised. The home is working to effect the improvement started and this needs to be sustained and embedded in practice and ensure that the assessed needs of the service users are appropriately met. 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 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 9 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. There is a pre admission process in place, however we have not been able to assess this section due to the lack of new service users. The manager confirmed that the home did not provide intermediate care. Evidence: We looked at the pre admission process that the service has in place as part of this visit. The manager stated that there has been no new admissions to the service since the last inspection. A number of the service users have recently moved out. The manager told us and information received from the AQAA stated that they work with the other agencies including receiving care managers assessment as part of their admission process. The manager stated that any service users would be assessed prior to the home providing care. Information such as the statement of purpose and the Care Homes for Older People Page 10 of 30 Evidence: service users guide would also be provided. We have been unable to fully assess this section as no new service users had been admitted. The manager confirmed that the home did not provide intermediate care Care Homes for Older People Page 11 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. The care plans have been put in place, however all care needs are not identified and plans are not in place to meet them. The service users access to external healthcare team is supported by the staff. The medication management is inadequate to safeguard people living at the service. The service users right to privacy is respected. Evidence: We looked at the care plans of three service users as part of this visit. The care plans had been recently redeveloped and contained assessments and care plans such as personal care, relationship, spiritual and end of life wishes were recorded. The records of care contained detailed information about the care and support given by the carers. The manager had introduced food and fluid balance records .We noted Care Homes for Older People Page 12 of 30 Evidence: that the staff maintained good records of fluids administered. However the records for food that were recorded on a separate chart were not fully completed as required to identify if people were receiving as adequate nutritional intake. This was brought to the attention of the manager and who confirmed that action will be taken. Nutritional assessments should be developed to ensure that the service users nutritional needs are assessed and care plans put in place in particular for people who are at risk. Care plans in relation to thickening agents must be developed for all those requiring this in order to inform practice and ensuring that this is managed safely as this was not available for one of the service users. One of the service users record showed that they were at risk of choking, they were receiving a soft diet and can have some difficulty in swallowing. A record was later found relating to assessment from a speech and language therapist (SALT) to show that they were able to have normal diet. The care plans had not been updated to reflect this. We noted that the continence assessments were available for some of the service users but this needed to be developed further as some care plans lacked details of how the service users incontinence needs would be met. The care plans should include details of the type of incontinence pads, frequency of changes and evidence of regular review by the assessment team and the homes staff. One of the service users in particular needed more support with their continence management, however no assessment and care plan were available to inform the staff practice and ensuring that their needs are appropriately met. Other area of development needed is risk assessments and care plans for fall management. A service users record from their care management assessment showed that they had a history of falls, assessments and care plans were not available how this risk will be managed to ensure that this persons needs are met. The AQAA states that all care plans have been reviewed and regular updating is now monitored to ensure that the residents current needs are correctly documented and appropriate support and care is in place. We found that there was some evidence of reviews and assessments would benefit from at least monthly reviews to ensure that any changes are captured and appropriate actions are then put in place. The manager reported that all the service users are registered with the local doctors practice and they felt well supported by the local healthcare team. The care records seen showed that the staff maintained recorded any changes following doctors visits in order to inform practice. Care Homes for Older People Page 13 of 30 Evidence: We looked at the medication management that the home undertook on behalf of the service users. The manager reported that the service has been using registered nurses from an agency who were responsible for all the service users medicines management. All medications were maintained safely including controlled medication when we visited the home. A random sample of creams and ointments found in the service users bedrooms indicated that these were dispensed to the named service users. A record of creams applied by carers was maintained. One of the service users medication administration record (MAR) record showed that they were receiving a controlled medication and the staff maintained accurate record of this. A sample of MAR records showed that staff recorded medication received and discarded. The last inspection report highlighted the large amount of stock medication that were kept. Although action had been taken we found that the home still had large amounts of medications that were due to be returned to the pharmacy. A review of the current large quantity of fortified drinks must be undertaken and action taken for these to be returned as we were told that the service user had moved to another home. We found that two of the service users were receiving nebulisers. One of them had three types of nebulisers in their bedroom. The staff reported that this person was self medicating on these. The medicines were not being stored safely at the time of the visit . There was no self medication assessment and record in place to ensure that the service user was receiving their medicines safely. This was brought to the attention of the manager and must be put in place, as the staff could not confirm that this service user was receiving their medication as prescribed. The manager has put in place a process that when medications are changed a record is maintained that included confirmation form the doctor who had authorised the change. We undertook a random audit of the medication stock as maintained at the service. One MAR record showed that there was one tablet extra that would indicate that the person had not received their medicine although this had been signed for. The staff did not record the stock balance when medicines were carried forward from the previous months and it was not possible to audit medicines received into the service and audit to ensure that people were receiving their prescribed medicines. Assessments and clear procedures for as required medications, risk assessments for Care Homes for Older People Page 14 of 30 Evidence: self medication and pain assessments were not available. The service users that we spoke to said that they were treated well and the staff respected their wishes. We observed that staff knocked prior to entering peoples bedrooms. We also spoke to a visitor who said that they visited regularly and at different times and were made welcome. Comments were that the carers treat people as individual. When we looked round the service we noted that one of the bedrooms had extremely offensive smell and this did not respect the dignity of people. The manager reported that this is a continuous problem that the home was trying to manage. A staff member stated that they were in the process of moving the service user to a different bedroom. We later checked and the service user was accommodated in another room. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some planned activities for the service users. Records of activities including one-to-one support are not in place to ensure and demonstrate that the service users receive regular stimulation and opportunities to participate in activities. The service users are supported to maintain links with heir family and friends. The meals at the home are satisfactory and meets with the satisfaction of the service users. Evidence: We looked at the activities that were available to the service users. The staff told us that they spent time mainly in the afternoons and played games with them. One staff was seen playing dominoes with a service user in the dining room after lunch. The manager has put in place a newsletter that included the activity programme for the week. This included two evening bingo sessions that the service users friends and families could attend. Other planned activities were a sherry and coffee morning and a cream tea on the 30th of May in the afternoon. Care Homes for Older People Page 16 of 30 Evidence: One of the service users we spoke to said that she spent her time watching morning television that she enjoyed. Another service user said that they delivered the morning newspapers for the service users. Two of them said that they attended lunch and spent most of the time in their rooms. Two other service users that we spoke to said that nothing much happened. The AQAA states that activity programmes have been increased and 1:1 activities to meet residents needs are in place with additional staff. During the visit we observed that the home had some staff that attended the home to assist the service users with their meals. The staff we spoke to said that they had been attending to this person for a couple of weeks and it was evident that they had developed a good relationship with the service users. The home should maintains a record of activities that the service users participated in and also the 1:1 support that the service users were receiving to demonstrate how the social needs of people are being met. The home has an open visiting policy and records of visitors to the service as maintained at the home supported this. A visitor told us that she came in a few times a week and other members of the family came in at other times and this was not a problem. We observed the lunchtime meal on the day of the visit. Meals appeared well presented and choices were offered including soft/ pureed diets. We saw that the staff were available to offer support with meals in a sensitive manner. Two of the service users said that the meals were very nice and always plenty to eat. We noted that hot and cold drinks were also available to the service users throughout the day. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a satisfactory process in place and people say that they can raise concerns. There are some records, however this must be further developed to demonstrate that people are safeguarded at all times. Evidence: We looked at the complaint management process and spoke to the service users as part of the visit. The manager reported that the home had not received any complaints since the last visit. We did not see the complaint log as this was not accessible. The service users we spoke to said that they would talk to the manager if they were unhappy. The AQAA states that the service has an advocacy service that is available to the service users if needed. A visitor we spoke to told us that they were aware of where to go if they wanted to raise any concerns. Comments were the residents are well cared for and I think the staff are doing their best. Since the last visit we received information that raised concerns about care practices and Social Services investigated these as safeguarding.The investigation has been completed and recommendations made to the home. Care Homes for Older People Page 18 of 30 Evidence: The manager stated that the home continues to be supported by the local trust and Social Services undertaking regular reviews and has put in extra support for the service users. They are continuing to work closely with external agencies. We looked for records of the recent safeguarding that must be maintained and the action plan. There were some records on the computer and this related to the ongoing reviews with social services. The registered person must ensure that a record of all allegation of abuse is kept and any action taken in order to safeguard people using the service. This was not available at the time of the visit and was brought to the managers attention. The manager reported that the home was using a group of agency staff to support the staff and the service users. Although records of checks such as criminal record bureau (CRB) were available for some staff, these did not include all the agency staff that the home was employing. This was brought to the attention of the manager at the time of the visit and action required. Staff we spoke to were aware of their responsibility to report any suspicion of abuse and they said they would go to the person in charge. Two of the service users we spoke to said that they felt safe and that the staff were all kind. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users are accommodated in a warm and homely environment that meets their needs. There is an infection control procedure in place and practices observed supported this. Evidence: We looked at a number of the service users bedrooms, communal lounge, bathrooms, dining room, kitchen and the laundry as part of this visit . The home was warm and clean and in good decorative order and furnishing appropriate to the service users needs. The service users reported that they spent as much time in their bedrooms as they preferred and others were found in different lounges and in the dining room. We found that the bedrooms that we looked at were personalised and it was evident that people are supported to bring with them items of personal belongings on admission. One of the service users showed us his bedroom that also consisted a small fridge that his family had bought The AQAA states that within the constraints of a possible closure, the home continues to make necessary repairs and maintenance to ensure an appropriate safe environment. Care Homes for Older People Page 20 of 30 Evidence: We found that one of the bedrooms had an offensive odour and the manager reported that this was an ongoing issue. This did not promote the dignity of this person and was not satisfactory.The service user was moved to another bedroom during the visit as staff reported that they had planned this move. The home has a laundry and the staff reported that all the service users laundry was undertaken internally. The staff reported that there is regular review of the service users laundry to ensure that they are replaced as required. Hand washing facility and flooring in the laundry room were satisfactory. The laundry was well equipped with industrial washers and driers that the staff we spoke to stated worked well. We noted that the laundry was unattended and accessed via two separate doors. Consideration should be given to restricted access to this area to ensure that this is managed safely for the safety of the service users. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has adequate staff to meet the current needs of the service users accommodated. Recruitment checks and evidence of training in moving and handling were inadequate to protect the service users. Evidence: The AQAA states that staffing levels have been increased to ensure appropriate cover. Although recruitment is currently frozen, longer term arrangements with known agency staff are in place to cover many of the vacancies. We looked at the duty rosters as maintained at the service. This showed that there is a roster for the carers and a separate hours for the ancillary staff. This ensured that the care hours are not eroded by domestic tasks. The duty roster showed that there were five carers on the morning shifts, four on the afternoon/ evening shifts and two carers at night. This is in addition to a senior staff that provided cover during the day and sleep in cover for the night carers. The service users and the staff we spoke to said that they felt that there was adequate Care Homes for Older People Page 22 of 30 Evidence: staff to meet their needs. One service user said that they had never used their call bells. Another said there is usually someone around if you need something. Comment was that the place is too big but you can go to the office. The staff we spoke to said that they came in for one to two hours and supported the service users with their meals and they enjoyed the work. Comment was I would like to get a job here. Interaction we observed showed that the service users were supported in a respectful manner. The manager stated that the home has not recruited any new staff and they were trying to use agency carers and that although they are unable to recruit to permanent posts, the home is working with agencies to put in place temporary contracts to ensure a better consistency of care. We looked at the records of agency staff as maintained at the service. This showed that three of the staff records seen had a CRB that included the disclosure number as required. Staff also received a basic induction to the service. Two staff record list seen and who are employed to provide extra support through an agency did not have evidence of CRB checks such as disclosure number. There were previous concerns about recruitment processes at the last inspection. The registered person must ensure that the people living at the home are fully protected by all aspects of their recruitment procedures. Other areas that must be addressed is evidence that all carers who are employed have up to date moving and handling training / update to ensure the service users are not put at risk of harm. This was not available in the records that we looked at and we noted that agency carers worked independently on night duty. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does not have a registered manager. There has been no arrangement in place to provide a a stable management structure. The manager now intends to apply to register with the commission. There is a satisfactory audit system, however not all records are maintained and available. There is an ongoing process to ensure that equipments are in good order and safe. There is a lack of evidence relating to necessary checks and training in health and safety to protect people from risk of harm. Evidence: The home does not currently have a registered manager since the last manager left last year. The city council has put in place a manager from another of their services Care Homes for Older People Page 24 of 30 Evidence: who was overseeing the management functions at the home. During the visit a senior representative of the company stated that the city council would be writing to us regarding management arrangement and an application will be submitted to register the manager. We have since the visit in May 09 written to the responsible individual and sought clarification relating to the management arrangement and the registration of a manager as required. The manager reported that monthly service users and staff meetings were held to keep them updated with the current changes planned for the service. The staff reported that a designated person undertook monthly unannounced visits to the service as part of the regulation and feedback sent to the responsible individual. These were not seen during the last visit. Records of these visits must be maintained at the service and accessible as required. We looked at the process that the home has in place for the management of the service users personal allowances. The manager stated that all monies are maintained in individual bank accounts and invoices are raised for items such as hairdressing, chiropody that are not covered by the fees. The service users received monthly bank statements and records were kept. The AQAA states that there is an ongoing programme in place for the servicing of equipment. This is to ensure that the premises are safe and safeguard people using the service. We noted that in two areas of the home substances that are hazardous to health (COSHH) were not maintained safely. This was brought to the attention of the manager and action was required to ensure that these are kept safely to protect the welfare of people using the service. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 The registered person must ensure that care plans and risk assessments are developed to meet the needs of the service users. So that you can ensure that peoples needs are appropriately met. 15/07/2009 2 9 13 The registered person must ensure that arrangements are in place for the safe administration of medicines into the care home. This must include as required medicines, risk assessments for self medication and audit of medications. So that people are not put at risk of harm and they receive their medication as prescribed. 15/07/2009 Care Homes for Older People Page 27 of 30 3 18 17 The registered person must 15/07/2009 ensure that records of all reports of allegations and action taken are maintained. So that you can ensure that people using the service and welfare are promoted and protected. 4 28 18 The registered person must 30/06/2009 ensure that any staff employed are suitably qualified and have training appropriate to the work they are to perform. To ensure that people are not put at risk of poor practice and endanger their safety. 5 29 19 The registered person must ensure that all appropriate checks are completed for all staff employed at the service. To ensure that service users are not put at risk of poor practice and abuse. 30/06/2009 6 38 13 The registered person must ensure that the service is conducted to promote and make provision for the health and safety of people of the service users. So that they are not at risk of harm and poor practice. 15/07/2009 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 Care Homes for Older People Page 28 of 30 improving their service. No. Refer to Standard Good Practice Recommendations 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. 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. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!