Care Home: Agape House

What the care home does well Agape House provides an environment suitable for the needs of the people who live there. There is a good range of communal space. Care staff receive training to ensure that they are able to meet the needs of the service users. Visitors and relatives are welcomed into the home at all reasonable times and are able to meet in private. The healthcare needs of the service users are addressed and any issues are referred appropriately to healthcare professionals. The home has a clear complaints process in place and there is evidence that concerns and complaints are addressed in a timely manner. Staff recruitment issues are well managed and all required checks are completed prior to employment. Records relating to health and safety issues are well managed and kept up to date. What has improved since the last inspection? Since the last inspection a new manager has been appointed and has subsequently become registered with the Care Quality Commission. She has facilitated many improvements within the service and has plans to develop aspects of service provision further. An assessment process has been instituted that ensures an improved level of information is gathered prior to someone moving into the service. The manager has completed significant work in improving the care planning process, which now adopts a person-centred approach and involves service users and their representatives. The on-going health care and risk assessed needs of service users are more closely monitored. Many aspects of the environment have improved. This includes a new sluice room, redecoration of communal areas and bedrooms throughout the house amongst other things. The processes for control of infection have improved and environmental risk assessments have been completed and kept up to date. The management of medication has significantly improved and is now maintained in an organised fashion and monitored on a weekly basis. What the care home could do better: 2 requirements and 7 recommendations have been made as a result of this inspection process. Staff receive the training they need to meet service users needs, although it was identified that not all staff have received training in dementia care and senior staff should complete advanced training in this regard. Quality monitoring processes are in place, but these need to be further improved by recorded monthly monitoring visits by the registered provider ensuring effective, ongoing monitoring of the service. Amongst the recommendations made were a need to focus on the assessment and outcomes for service users with dementia care needs. The continued development of a varied and individualised activity programme. Some equipment in the kitchen was identified as benefiting from replacement including a dishwasher suitable for purpose. The responsible individual is advised to review the contract for service users ensuring clarity. The number of domestic staff has increased, but this should be extended to cover every day of the week. The appointment of an activities co-ordinator would also be of benefit. Staff should receive instruction covering the Mental Capacity Act and the Deprivation of Liberty Safeguards. Key inspection report Care homes for older people Name: Address: Agape House 45 Maidstone Road Chatham Kent ME4 6DG     The quality rating for this care home is:   two star good 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: Joseph Harris     Date: 1 9 0 5 2 0 1 0 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 26 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Agape House 45 Maidstone Road Chatham Kent ME4 6DG 01634841002 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Thiyagarajah Paramasivam,Mrs Nanthini Paramasivam Name of registered manager (if applicable) Mrs Beverley Ann Keith Type of registration: Number of places registered: care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 20. 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 Agape House is a detached Victorian home providing accommodation on two floors, there is a passenger lift to the first floor. Agape provides care for 20 older persons. It currently uses four beds for service users with a diagnosis of dementia. There are a variety of aids and adaptations around the home, which enable more independence for Care Homes for Older People Page 4 of 26 Over 65 0 20 20 0 Brief description of the care home the residents. The home has 16 bedrooms. The home is situated in a residential area less than a mile from Chatham railway station and town centre. The home is located on a main bus route and within walking distance of shops and a Post Office. The home has front and rear gardens with seating. Further information about the service and current fees are included in the service user guide and are available on request from the service. Care Homes for Older People Page 5 of 26 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: two star good 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: This unannounced inspection process culminated in a site visit to the home on 19th May 2010. The site visit commenced at 10:00 hours and lasted for approximately 7 hours. Prior to the site visit a range of information was reviewed relating to the service. This included the Annual Quality Assurance Assessment completed by the home. This is a document that focuses on the outcomes for service users and is a self-assessment tool. it also provides us with some statistical information. We also looked at notifications received from the home, information about how the service has managed any concerns or complaints and information from other people with an interest in the service. During the site visit discussion were held with numerous service users, visitors, staff and the registered manager. A tour of the premises was undertaken and documentation was examined relating to service users, medication, staff, health and safety and other records required in the day-to-day running of the home. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: 2 requirements and 7 recommendations have been made as a result of this inspection process. Staff receive the training they need to meet service users needs, although it was identified that not all staff have received training in dementia care and senior staff should complete advanced training in this regard. Quality monitoring processes are in place, but these need to be further improved by recorded monthly monitoring visits by the registered provider ensuring effective, ongoing monitoring of the service. Amongst the recommendations made were a need to focus on the assessment and outcomes for service users with dementia care needs. The continued development of a varied and individualised activity programme. Some equipment in the kitchen was identified as benefiting from replacement including a dishwasher suitable for purpose. Care Homes for Older People Page 7 of 26 The responsible individual is advised to review the contract for service users ensuring clarity. The number of domestic staff has increased, but this should be extended to cover every day of the week. The appointment of an activities co-ordinator would also be of benefit. Staff should receive instruction covering the Mental Capacity Act and the Deprivation of Liberty Safeguards. 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 8 of 26 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 26 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. Service users and their representatives are able to make an informed choice about the home and their needs are assessed. Evidence: The home has developed a Statement of Purpose and a Service User Guide that are on display in the foyer of the service and are provided to all new and prospective service users and their representatives. The information contained within these documents is in accordance with the Care Home Regulations 2001 and the National Minimum Standards for older people. Some minor amendments were advised to ensure that full information is available relating to the Care Quality Commission. A discussion was held with the manager regarding the presentation of the Service User Guide. She stated that the quality of this document would be reviewed and that a brochure has recently been developed and is due to be available in the coming weeks. The manager has developed an assessment process ensuring that needs of prospective service users are identified and assessed prior to moving into the home. Care Homes for Older People Page 10 of 26 Evidence: The pre-admission information was examined for two recently admitted service users. Following an initial referral the home requests full information from the care manager including the Joint Assessment. In both cases these assessments had been completed to a very good level of detail. The manager stated that she aims to visit all prospective service users in their current accommodation and completes the homes own assessment pro-forma. The assessment forms examined were suitably detailed and covered the full range of needs for residential clients. However, additional information should be included to ensure that the assessed needs of service users with dementia care needs are fully addressed. This issue was discussed with the manager. Refer to recommendation 1. Service users, where possible, are offered trial visits to the home and the initial 6 weeks of residency are considered a trial period to ensure that needs can be met and that the service user is satisfied with the service received. One resident and the family members of another person who has recently moved into the home stated that they received full and detailed information about the service. One family member said, We were due to visit a number of home, but the welcome was so warm that we had no doubts that Agape House was the right place for our mother. We have been very happy with the care. A contract covering the terms and conditions of residency is in place. Copies of the signed contract are kept on file. It was noted that the contract does not state the rooms to be occupied and it is recommended that the document is reviewed to ensure that the rights and responsibilities of service users and the home are clearly defined. Refer to recommendation 2. The home does not provide intermediate care. Care Homes for Older People Page 11 of 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of service users are met. Evidence: Two individual service user plans were examined. In both cases the care plans contained good levels of detail clearly addressing the care needs of service users. The plans are written in an accessible manner and provide good guidance to ensure needs can be met consistently. The plans show evidence of monthly review and service users or their representatives have been involved in the planning process. A range of assessments are completed including manual handling, nutritional screening, dependency and pressure area care. Further work could be completed to develop specific risk assessments based on the needs and perceived risks of individuals. There is evidence that healthcare needs are addressed through on-going assessments and the involvement of health care professionals. Healthcare records show that issues of concern are referred appropriately and the outcomes of any consultations are recorded. Complimentary healthcare needs are addressed including visits from a chiropodist every 6 weeks and referrals to opticians and dentists, etc as required. All service users and relatives spoken to were positive about the attitude of care staff Care Homes for Older People Page 12 of 26 Evidence: stating that they feel that they are treated in a dignified and respectful manner. This was further evidenced through observation of practice. Staff were seen to talk in a relaxed and friendly manner with residents. Issues surrounding privacy and dignity are addressed within the induction programme and the manager stated of her high expectations in this regard. Issues surrounding medication were examined and reviewed. There is a dedicated storage room for medication that is maintained at a suitable temperature. There are policies and procedures in place relating to all aspects of medication management and staff administering medication have received appropriate training. Medication Administration records were examined and kept up to date. Records of received, returned and destroyed medication are also maintained. The medication room and storage facilities are kept in good order and are well organised. The manager conducts a weekly audit of all issues relating to medication management. All service users and/or their representatives have been asked about preferences in relation to death and dying. These preferences are recorded in each individual file and signed by the service user or their representative. Care Homes for Older People Page 13 of 26 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. The home offers a lifestyle that suits the needs of the service users. Evidence: The home offers a variety of activities on a regular basis. This includes music and movement every week conducted by a visiting therapist, sing-a-longs, craft sessions and bingo. An entertainer visits every month and residents are able to maintain their hobbies and interests. A local vicar visits the home on a weekly basis to conduct a non-denominational service. A number of service users were asked about the level of activities in the home and the feedback was generally positive. Some people did have suggestions on where the home could improve in this area however. One person said that they would like the home to organise some trips out and that there could be more activities arranged in the evenings. This was discussed with the manager who stated that the level of activities in the home is an area that she is keen to improve. There are plans to appoint a new activities co-ordinator following the departure of the last person in this role. Refer to recommendation 3. The lunchtime service was observed and discussions held with service users and the cook. Residents were offered a choice of meals and feedback about the quality of the food in the home was good. One person did say that they would like more spicy food, but acknowledged that this may not be to everyones taste. Another person said, The Care Homes for Older People Page 14 of 26 Evidence: food is always nice. Meals are quite a social event. Service users can choose to eat in the dining room or in their bedrooms if they wish. Staff appeared relaxed and unhurried during the service and were able to support people appropriately. Menus demonstrated that a balanced and varied diet is offered with choices at each mealtime. Fresh fruit is available and drinks and snacks are served throughout the day. A reasonable range of fresh food was in stock as well as frozen and noncomestible foods. At the present time the menus and food ordering is managed by the owner of the home, but it was identified that this role would be better suited to the head cook for the home who is better placed to identify shortfalls in stock, specific preferences and special diets amongst other things. Refer to recommendation 4. Three visitors were spoken to during the course of the site visit. Two people stated that they are made to feel very welcome in the home. They said It is always a pleasure to come here. The staff are lovely and we always get offered drinks and refreshments. Another person said that there have been difficulties in the past, but things have improved over the past year. There is a good range of space available for people to meet in private should they wish to do so. Care Homes for Older People Page 15 of 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The views of service users are listened to and acted upon. Evidence: The home has a clear complaints process in place. This procedure is on display within the home and included in the Service User Guide. A record of complaints is maintained demonstrating that complaints received are investigated and any actions or outcomes recorded. The service has been able to provide evidence that they have managed concerns and complaints effectively. Service users and visitors stated, when asked, that they feel that the home takes any concerns they have seriously and that they feel their views are listened to. One visitor said that they have raised a number of issues in the past and that the current manager has been responsive to concerns. Policies and procedures are in place relating to issues of abuse. Staff have undertaken training in this topic. There is information available in the foyer of the home relating to the Mental Capacity Act and the Deprivation of Liberty Safeguards. It is recommended that staff also receive training and instruction covering these topics. Refer to recommendation 5. Care Homes for Older People Page 16 of 26 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 premises are suitable for the needs of the service users. Evidence: A tour of the premises was undertaken. The home is located on a main road leading into Chatham. There is parking available to the rear of the service. The building is set out over two floors. On the ground floor there are three lounges. The main lounge has an adjoining conservatory that acts as a dining/activities room. Bedrooms are located on both floors. The majority of rooms have en-suite facilities and there are two double rooms. One is currently shared by a married couple and the other is presently used as a single room. Throughout the tour of the premises the home has been well-cared for and is clean and hygienic. There were no unpleasant odours. The manager stated that redecoration in the service has been on-going and has included new carpets and furniture and a new sluice room. Bedrooms are being redecorated and furniture replaced as vacancies occur minimising the disruption to service users. Residents spoken to stated that they are happy with their bedrooms and find the communal space comfortable and homely. One person said that she has some minor concerns about her room, this was addressed with the manager who stated that these issues are in the process of being rectified. There is a reasonably sized garden to the rear of the home and a small courtyard off the conservatory. It was noted that the home would benefit from some new garden Care Homes for Older People Page 17 of 26 Evidence: furniture. There are two bathrooms, both in working order, one of which has been recently refurbished. Toilets are conveniently located throughout the building. The kitchen is suitable for purpose, but would benefit from a deep clean. Additionally it was noted that a more suitable dishwasher could be provided and the cook stated that new pots, pans and weighing scales would be beneficial to promote improved health and safety. Further issues were noted including new floor covering in a downstairs toilet. There is a large laundry room in the basement of the home that would benefit from additional work top space. It was stated that all equipment is in good working order. Refer to recommendation 6. It was reported that the home meets the regulations of the environmental health and fire departments and works in accordance with relevant environmental legislation. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient numbers of suitably trained staff on duty at all times. Recruitment processes are followed appropriately. Evidence: The home operates with a minimum of three staff in the morning, two staff in the afternoon and two waking night staff. Due to lower numbers of residents at the present time the staffing hours in the afternoon have been reduced from three staff on duty. A housekeeper works from 8am-1pm Monday to Saturday, care staff stated that they are responsible for cleaning duties on Sundays which is something that should be rectified. additional housekeeping hours would also be of benefit to aid the management and organisation of laundry duties. It is also advised that an activities co-ordinator be employed to develop and facilitate an improved activities programme. Refer to recommendation 7. Service users stated that staff are available to respond to their needs when requested. Care staff appeared unhurried in the course of their duties and stated that they feel enough people are on duty in a caring capacity. A cook is also on duty daily. The staff training matrix and some training certificates were examined that demonstrate staff received suitable induction training and mandatory training to ensure that the needs of the service users are met. New staff attend a general induction course provided by Medway Council and the home uses the Common Induction Standards to supplement this for all new staff. The majority of staff are fully Care Homes for Older People Page 19 of 26 Evidence: up to date with mandatory training and refresher courses although a number of gaps in this were identified, but courses have been booked to address this. A large number of care staff have received dementia care training, but this needs to be provided to all staff. It is also advisable for senior staff at least to undertake an advanced dementia care course. Refer to requirement 1. Over 50 of the staff team have gained at least an NVQ at level 2 and it is an expectation of the home that all new staff work towards this qualification. In discussion staff were knowledgeable about the care needs of service users and interacted positively with residents. Service users stated that the care staff are friendly and approachable and that they support them in a manner that suits their needs. Three staff personnel files were examined and all required checks were in place including CRB/POVA checks, two written references, proof of identity and application forms. It was noted that in one case there were a gap in the employment history. This issue was discussed with the manager. Care Homes for Older People Page 20 of 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is managed in the best interests of the service users and their health and safety is maintained. Evidence: The manager has worked in the home for approximately 12 years and has recently been promoted to the position of manager. She has registered with the Care Quality Commission. Prior to taking over the role as manager she had been employed as a Senior Carer. She has completed her NVQ level 4 and is currently completing her diploma in leadership and management skills. Feedback from staff, service users and visitors was positive about the impact she has had on the service and there is evidence to show that she has facilitated many improvements in the service provision. The home has a quality assurance process in place, but this needs to be further developed to ensure effective on-going monitoring of the service. Staff and relatives surveys have recently been completed and the results of these collated in the form of an action plan. the manager stated that service user surveys are due to completed in Care Homes for Older People Page 21 of 26 Evidence: the near future. The responsible individual visits the service approximately twice a week and monitors improvements and developments in the home. However, at the present time there is no formal monthly monitoring system completed by the responsible individual, which needs to be implemented. Refer to requirement 2. The manager undertakes a range of weekly and monthly audits covering the key areas of the service provision. A range of documentation was examined relating to health and safety issues. All records, service checks and environmental risk assessments were seen to be up to date and subject to regular review. Care Homes for Older People Page 22 of 26 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 23 of 26 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 30 18 (1) The registered person 21/07/2010 shall(a) ensure that at all times suitably qualified, competent and experienced persons are working in the care home in such numbers as are appropriate for the health and welfare of service users. To provide dementia care training for all staff and advanced dementia care training for senior staff working in the home. 2 33 24 (1) The registered person shall establish and maintain a system for (a) reviewing at appropriate intervals; and (b) improving, the quality of care provided at the care home. The responsible individual needs to establish a formal monthly monitoring process 21/06/2010 Care Homes for Older People Page 24 of 26 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 and produce written reports and action plans in this regard. 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 To ensure that the pre-admission assessment process fully addresses the the needs and preferences of people with dementia care issues. To ensure that the contract covering the terms and conditions of residency is reviewed and updated clearly identifying rights and responsibilities. To continue to develop the programme of activities ensuring that individual needs and preferences of service users are met. To review the system of ordering food and managing menus. To provide training and instruction for staff relating to the Mental Capacity Act and the Deprivation of Liberty Safeguards. To ensure that all maintenance issues are addressed in timely fashion and kitchen equipment is suitable for purpose. To ensure domestic staff are employed in sufficient numbers to meet the needs of the service. 2 5 3 12 4 5 13 18 6 19 7 27 Care Homes for Older People Page 25 of 26 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. 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