Inspection on 01/07/09 for Willoughby House

This inspection was carried out on 1st July 2009.

CQC found this care home to be providing an Poor 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willoughby House 07/07/08

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

Key inspection report Care homes for older people Name: Address: Willoughby House St Johns Road Cudworth Barnsley South Yorkshire S72 8DE     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Mike ONeil     Date: 0 1 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Willoughby House St Johns Road Cudworth Barnsley South Yorkshire S72 8DE 01226717152 F/P01226717152 wendy.lovely.willoughby.house@googlemail.co m Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Flagswan Two Ltd care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 40 The registered person may provide the following category of service only: Care Home only - Code 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, Code OP - maximum number of places 40 Date of last inspection Brief description of the care home Willoughby House was formerly a vicarage that was adapted and extended to provide accommodation for up to forty service users. The property is in its own grounds and car parking is available. Accommodation is on two levels serviced by a passenger lift. It has 20 single bedrooms and 10 double bedrooms. The home is situated off the main Barnsley to Pontefract road in the village of Cudworth. It is within walking distance of all shops and local amenities in Cudworth. Barnsley town centre is approximately four miles away. No information was avaliable at the time of our visit as to the fee level at Care Homes for Older People Page 4 of 29 Over 65 40 0 Brief description of the care home Willoughby House. However the following statement was recorded on the services Annual Quality Assurance Assessment which was submitted to us. There are no variations in fees and no top up is charged. The fees are the same for all clients whether they are funded by the local authority or self funded. The service users are offered the same care service regardless of financial status. There are no additional charges for laundry or chiropody services and no charge for outings or entertainment. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The inspection process included looking at the information we have received about the home since the last key inspection in July 2008. Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the service was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. The AQAA also included data as to when utilities and equipment at the home were serviced. Information from the AQAA is included in the main body of the report. On this occasion we did not send out surveys to people before our visit. We made an unannounced visit to the home. This was carried out regulation on 1st July 2009 over a period of six hours. We talked to 6 staff about their work and the training they have completed. We checked some of the records, policies and procedures the home has to keep. Tracy Keele, senior care assistant was in charge of Care Homes for Older People Page 6 of 29 the home at the time of our visit. At the close of our visit we also provided feedback via telephone to Mitesh Dhanak, registered provider. Mitesh Dhanak confirmed that a deputy manager is due to start at the service this week with a newly appointed manager starting at the home next week. The community matron from Barnsley Primary Care Trust (PCT) and a care manager from Barnsley Council also visited the home during the day to assess peoples health and welfare within Willoughby House. Concerns had been raised at recent adult safeguarding meetings over the general management of the service and the failure to promptly report an alleged case of abuse. It had therefore been agreed within these meetings that representatives from Barnsley Council, Barnsley PCT and the CQC should carry out a joint visit to Willoughby House. We spent some time watching staff support people and talking with 8 people and 3 visiting relatives. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Peoples care plans need to contain more detailed information so that staff know what support each person needs. All complaints made must be recorded as well as any action taken to address or investigate the complaint. Care Homes for Older People Page 8 of 29 Staff and the management of Willoughby House must follow and adhere to local safeguarding policies. Procedures must be improved to ensure that peoples financial interests are safeguarded. The service must notify us of any event which adversely affects the well-being or safety of any person. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 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 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments were carried out to ensure that the home could meet peoples needs. This home does not provide intermediate care. Evidence: Care plans checked showed that people within the service had been assessed before moving into the home. Risk assessments and a plan of care reflected any specialist interventions. Staff liaised with professionals, the person and their families to find out about peoples needs. This assessment will help to ensure that people have the information needed to make choices about where they live. We were not able to speak with anybody who had recently moved into Willoughby House. Care Homes for Older People Page 11 of 29 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. People were treated with respect and said they were very happy with the care they received. Health needs were generally met and medication procedures ensured that people were protected. Care plans did not fully reflect peoples care needs. Evidence: Five peoples care plans were checked. The care plans contained details about the persons biography, personality and their preferences and choices. Overall we felt some parts of the plans were good and they did try to focus on the individual person. The care plans were medically based but were concise and mainly clear. Staff said that they had been working hard to improve peoples care plans so they are comprehensive clear and concise. A new care planning format had recently been introduced at the home. This means that at the moment staff have to find information in two separate files. The two file system means that staff may not know well the attention and support each person needs. Some evidence highlighted below supports the difficulties staff have encountered. The new format should be fully implemented as soon as possible. Care Homes for Older People Page 12 of 29 Evidence: Several inadequacies were found in peoples care plans some of which were identified at our last visit to home in July 2008.The following inadequacies were found with the documentation: A person had some small skin damage on their ankle. This damage was not reflected in the persons tissue viability assessment and a care plan had not been formulated. One persons care plan had not been signed or reviewed for over 3 months. Staff were failing to record times they made entries in the plans. Staff must be reminded that peoples care plans are a legal document and must always be signed, dated and timed. Relatives and people said they were aware of care plans and that they were involved in discussions about their care. However there was no evidence recorded to show that people and/or their relatives were involved in drawing up and reviewing the care plans. Staff, when writing peoples daily notes, were not being reflective of the information actually recorded in the persons care plan. An overall statement of hygiene needs met is not sufficient or specific enough information. Risk assessments were included within the documentation and included moving and handling, skin integrity, and other risk factors. The care plans identified that a range of health care professionals visited the home to assist in maintaining peoples health care needs. People said they had regular contact with their GP and other health professionals. We saw that people looked clean, well dressed and had received a good level of personal care. One person said they were unhappy with the attitude of some staff however overall they thought the other staff were excellent. The persons care manager has been contacted about these concerns. The overall feedback from people and their relatives was that the care delivered by staff at Willoughby House was good. Peoples comments included Care Homes for Older People Page 13 of 29 Evidence: The staff are lovely The care is good and Im very happy. Relatives comments included Cant grumble about anything, staff are smashing The staff are approachable and I dont have any concerns. Medication was securely stored in locked cupboards in a locked room Medication Administration Records (MAR) were up to date with no gaps. The Controlled Drugs Register was checked and this had been completed correctly with two signatures and a diminishing total. Staff said they had received medication training. A visiting training assessor told us that they were providing comprehensive medication training to all senior staff at the home. People were treated with respect and dignity and addressed by their preferred name. Staff spoke to people in a friendly and pleasant way. Staff took time to explain what task or support they were about to offer people. Care Homes for Older People Page 14 of 29 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 are able to make some choices about daily living and being involved in social activities. People receive choice of a well balanced diet at times convenient to them. People are able to maintain contact with family and friends and feel part of the local community. Evidence: People said they were able to get up and go to bed when they chose and generally how they spent their day and evenings. They said they often went out with their families. Relatives said they were able to visit at any time and were made to feel very welcome. Throughout the day friends and family were visiting the home and there seemed to be a very friendly and welcoming feel in Willoughby House. There were some activities taking place during the day and people were enjoying the time they were spending with each other and the staff. Some staff were playing Care Homes for Older People Page 15 of 29 Evidence: dominoes with people. One person was helping to set the table for lunch. She said she did this every day and enjoyed keeping herself busy. People said they did join in with some activities that were arranged such as board games and they enjoyed visiting entertainers that came regularly to the home. People who are more physically able can participate in many more activities around the home. However a more individualised activity programme is needed which should encompass the likes and dislikes of people, this information could be discussed with people and their relatives. This would enable all people, including those with more physical frailties, the opportunity to exercise their choice in relation to social and leisure activities. All comments about the food were very positive. People said the quality and choice of food served was very good. At lunchtime we saw that the tables were set nicely with table cloths, condiments and matching crockery. The meals were served in a relaxed unhurried manner by staff and the cooks. People said they were always offered a choice and asked what they wanted for their breakfast, lunch and teatime meals. People said their specialist and cultural diets were well catered for. People said they were offered drinks on a regular basis throughout the day. We saw people being offered drinks frequently. Care Homes for Older People Page 16 of 29 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service cannot fully evidence that peoples complaints are taken seriously and resolved or that people are fully protected from abuse. Evidence: People had been provided with a copy of the homes complaints procedure, which was also on display in the home. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People and relatives said that they felt comfortable in going to a senior member of staff or the provider as they felt that any concerns they may have would be addressed. Other than the ongoing safeguarding issues we have not received any direct complaints or concerns about the service since our last visit in July 2008. Complaints procedures were not sufficient to fully protect people however as there were no records available of any concerns /complaints that have been made and /or the action taken to resolve these complaints. There have been two recent safeguarding issues involving the service. The management and staff have been cooperative and fully involved within the local safeguarding procedures however, during both strategies and case conferences staff and the management of Willoughby House have failed to provide all the information required or requested within agreed timescales. We have also found that there was a Care Homes for Older People Page 17 of 29 Evidence: delay by staff when reporting one instance of alleged abuse. Adult safeguarding policies and procedures are available to the staff. Staff said they had undertaken safeguarding adults training within the last 18 months and the training records of this training were seen. Care Homes for Older People Page 18 of 29 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 home is clean, pleasant and hygienic although some areas of the home are in need of redecorating and refurbishing. Evidence: The home is clean and tidy and no unpleasant odours were noticeable. People and relatives said the home is always kept very clean. Areas of the home are steadily being refurbished which people who live at Willoughby House were pleased to point out to us. People and staff felt that more money was now being spent to refurbish the home. Some parts of the home however are still tired and these areas are in need of refurbishment and redecoration. This refurbishment should continue so that people can live in pleasant safe surroundings. Bedrooms checked were comfortable and homely. People said their beds were comfortable and bed linen was clean and in a good condition. Care Homes for Older People Page 19 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are employed in sufficient numbers and recruitment procedures promoted the protection of people. The service cannot fully evidence that staff have received all the training required to meet peoples needs. Evidence: People generally spoke highly of the staff team and said staff listened and acted on what they said. People and relatives said that staff were available when needed. Staff all said that staffing levels were adequate for the current number of people at Willoughby House. We saw that staff were available to attend to peoples needs when needed. Three staff files were checked at this visit. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. Staff said that they really enjoyed working at the home and got a lot of job Care Homes for Older People Page 20 of 29 Evidence: satisfaction. We found that the staff were very enthusiastic and keen to improve the service further. They were very optimistic about the future of the home and were looking forward to the new management team starting. The AQAA provided the evidence that the staff have all of the training needed to make sure that they can care for people. This included all of the mandatory health and safety training specific to the needs of people at Willoughby House. Staff were able to talk about the various training courses that they had attended. Staff said training opportunities were generally good. Staff said they were undertaking or had completed their NVQ qualifications in care. However the service was not able to evidence all the training that staff had undertaken because the training records were not up to date with many of the records held by staff at their own homes. These records need to be collated and stored at the home so that the management of the home are aware of all staff training and development needs. Care Homes for Older People Page 21 of 29 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes procedures do not fully promote the health, safety and welfare of people who use the service. Peoples financial interests are not fully safeguarded. Evidence: There has been no permanent/registered manager at Willoughby House for over 18 months. This has had a negative effect on the running and management of the home. The majority of the requirements and recommendations we have made permeate from poor record keeping and an inconsistent approach synonymous with constant change in the organisation. Mitesh Dhanak, registered provider, has confirmed that a permanent experienced care manager will be appointed by 13th July 2009 and an experienced deputy manager will be in post by 7th July 2009. These managers must be supported by the owners of Willoughby House to ensure that all the requirements and recommendations made Care Homes for Older People Page 22 of 29 Evidence: following this CQC visit are addressed. People, relatives and staff said they are really looking forward to the new manager starting and they are very optimistic about the future of Willoughby House. The providers have systems to check out the quality of the service that they are providing. Staff meetings are arranged. The responsible individual visits the home on a regular basis, a report is written following the visits and any identified actions taken. There is evidence of internal auditing of the homes environment, services and records. We would recommend however that more structured events are organised so that the homes management can meet with people and their relatives on a more frequent basis. Current financial procedures at the service do not adequately safeguard peoples personal finances. Records of peoples monies were recorded, two staff signed when money was withdrawn and numbered receipts were kept. A sample of monies was checked and money tallied with the records. However we found the following inadequacies in the services financial systems that need addressing. A statement sheet of one persons accounts was missing which covered a period over 10 months. There was no evidence that the peoples personal accounts had been audited in the last year. Only 1 check was made that the money held in envelopes tallied with the account sheets, this was carried out last week .In view of the missing statements the check last week was clearly insufficient. Bank cards were stored in the safe, one was held with the persons PIN number. No financial records were available for the people to whom the bank cards belonged. We were informed that the keys for the safe were passed to the next person in charge of the shift. This is an unsafe practice and only appointed staff must have access to peoples monies. A referral to the adult safeguarding team has been made over the inadequacies found relating to peoples personal monies. The homes procedures do not fully promote the health, safety and welfare of people who use the service or the staff. The service, over the last 4 months, has failed to Care Homes for Older People Page 23 of 29 Evidence: notify the CQC of any event which adversely affects the well-being or safety of any person. Evidence was found in peoples notes which the CQC should have been informed of. This is a legal requirement. There were some concerns with regard to moving and handling of people. We saw several people being transferred from chairs into wheelchairs by staff who pulled people up by their arms. This can cause injury to the person and the staff. A safer method of moving people, risk assessment permitting, would be to use a lifting belt. The AQAA provided information of the dates that equipment and systems within the home had been serviced and maintained. A fire risk assessment was in place at the home. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving fire training and drills. We were unable to check other records (see standard 30). At the time of the visit fire exits were clear and hazardous products were safely stored in the home. This will promote the safety and welfare of people. Care Homes for Older People Page 24 of 29 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 7 15 The care plan must set out in 01/10/2008 detail the action, which staff need to take to meet all aspects of the health and personal needs of the person. Care Homes for Older People Page 25 of 29 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 15 The care plan must set out in detail the action, which staff need to take to meet all aspects of the health and personal needs of the person. Previous timescale of 01/10/2008 not met. To ensure peoples health and personal care needs are met. 15/09/2009 2 16 22 Records must be kept of any 15/09/2009 complaints received by the service.Action taken to resolve complaints must also be recorded. This will help to make sure people are protected. 3 18 13 Local safeguarding policies must be followed and adhered to. This will make sure people are protected. 15/09/2009 Care Homes for Older People Page 26 of 29 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 4 18 13 Staff must undertake further 15/09/2009 safeguarding training. This will make sure staff adhere to local safeguarding policies and so people are protected. 5 30 17 Staff training records must be stored at the home. So that records are avaliable for inspection at all tiimes. 15/09/2009 6 35 16 Procedures must be improved to ensure that peoples financial interests are safeguarded. This will make sure people are protected. 15/09/2009 7 38 37 The service must notify the CQC of any event which adversely affects the wellbeing or safety of any person. This will make sure people are protected. 15/09/2009 8 38 13 Staff must use appropriate equipment and employ safe techniques for moving and handling people. So that peoples safety is maintained. 15/09/2009 Care Homes for Older People Page 27 of 29 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 7 7 Staff should ensure that all written entries they make in peoples care plans are dated, timed and signed. Peoples care plans should be reviewed monthly unless there is a recorded reason as to why they do not need to be reviewed at this frequency. Documentation should show that people and/or their relatives have been involved in drawing up and reviewing the care plans. The persons daily notes should reflect the information actually recorded in the persons care plan. The new care plan format should be fully implemented as soon as possible. People should have the opportunity to exercise their choice in relation to social and leisure activities. The programme of renewal of the fabric and decoration to improve the environment should continue. More structured events should be organised so that the homes management can meet with people and their relatives on a more frequent basis. 3 7 4 5 6 7 8 7 7 12 19 33 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - 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!