Care Home: Bafford House Rest Home

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What the care home does well The home is decorated and furnished to a good standard and provides a homely and comfortable environment. The grounds and gardens are also well maintained. The staff provide a good standard of personal care and people living in the home say they are treated with respect. What has improved since the last inspection? The home has completed risk assessments in the areas where they were required. The majority of staff have undertaken safeguarding training. Some parts of the home have been decorated. What the care home could do better: The homes needs to provide formal supervision for its staff. The home needs to register a management with the appropriate qualifications. The home needs to ensure that management hours are provided to ensure that tasks such as staff supervision are completed. The home needs to ensure that staffing rotas are better organized to ensure that sufficient staff are on duty at all times to meet the needs of the people living in the home. The home needs to improve the quality of activities that are provided. The home needs to provide fire safety training and complete a fire risk assessment by a person qualified to undertake this task. Key inspection report Care homes for older people Name: Address: Bafford House Rest Home Newcourt Road Charlton Kings Cheltenham Glos GL53 8DQ     The quality rating for this care home is:   one star adequate 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: Simon Massey     Date: 0 5 0 2 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 28 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 28 Information about the care home Name of care home: Address: Bafford House Rest Home Newcourt Road Charlton Kings Cheltenham Glos GL53 8DQ 01242523562 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: ramnial@aol.com Mrs Rosa Calvo Ramnial,Mr Manmohun Ramnial care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Bafford House is situated in a quiet residential area of Charlton Kings, approximately two miles from the centre of Cheltenham. It is easily accessible by public transport and car. It is an imposing detached residence with a large entrance hall where a cage of parakeets is situated. The accommodation has been adapted to provide fifteen single bedrooms and two double bedrooms, although in practice these rooms are used as singles unless occupied by a couple. Eight bedrooms have en-suite facilities, and all other rooms have hand washbasins. There are three communal bathrooms, one with a hoist. The accommodation is provided over three floors, accessed by a shaft lift or the stairs. There are two lounge areas on the ground floor, a sitting area on the first floor and a dining room on the lower ground floor. The two offices, kitchen and laundry are also located on the lower ground floor. The home is set in extensive gardens and the home has won several awards for the Cheltenham in Bloom competition for its floral Care Homes for Older People Page 4 of 28 Over 65 19 0 Brief description of the care home displays. To the front and side of the house are parking spaces for several cars for staff and visitors to the home. The fee range for the home at the time of this Inspection was between 381 pounds and 771 pounds per week. Care Homes for Older People Page 5 of 28 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: This inspection took place on the 03/02/10 and 5/02/10. The Inspector met with the Providers, one of whom is also the Registered Manager, the Deputy Manager, members of the care staff and people who live in the home. Records relating to care planning and assessment, medication, health and safety, staff training and recruitment and general administration were examined. An inspection of the environment was also carried out. Prior to the inspection the Commission issues a number of surveys to various stakeholders and the majority of these were returned. Care Homes for Older People Page 6 of 28 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 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 7 of 28 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 8 of 28 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 comprehensive information describing the service and facilities available to individuals living at Bafford House. Individuals needs are usually assessed prior to admission but this is not always the case when the home accepts short term and emergency placements. Each person living at the home has a contract which outlines the terms and conditions of the placement Evidence: The home has a Statement of Purpose and Service User Guide that provides clear information for people living in the home and for prospective residents and their relatives. There is an admission procedure which is followed except when time does not permit, and an assessment is undertaken which forms the basis of the care plan that is then developed and reviewed over time. People have the opportunity to visit and spend some time in the home and there is also a policy on trial periods, which are Care Homes for Older People Page 9 of 28 Evidence: between 4 and 6 weeks. At the time of this inspection a person had been admitted at short notice the previous evening. They explained their circumstances and also how they were trying out the home with a view to moving in permanently if they chose to. The home had begun drawing up a care plan and had done a basic assessment of personal care needs. The person was very positive about how they had been treated so far. Another person spoken to, who was also probably only staying for a temporary period, was very positive about the care and support they had received and felt their personal care needs were being well met by the care staff. Each person living at the home has an agreement which outlines the terms and conditions of the placement. All extra charges are clearly indicated. Care Homes for Older People Page 10 of 28 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. Individuals personal and health care needs are being met. Individuals are protected by the homes medication administration and practice. Evidence: A sample of care plans were seen and these were reasonably detailed and showed that recording was completed regularly by the care staff and that the plans were being reviewed every month by the senior staff. The risk assessments in relation to bed rails which were required after the last inspection have been completed and reviewed where necessary. People spoken to were positive about the personal care and the approach of the care staff and said they were treated with respect and that there dignity was maintained. People confirmed that staff knocked before entering rooms, though during the inspection staff were observed knocking and entering some rooms before receiving a reply. The home keeps no records of individual weights for people living in the home and Care Homes for Older People Page 11 of 28 Evidence: only has stand on scales, which are not suitable for the majority of people living in the home. It would be good practice to monitor, with consent, peoples weight. The home does not employ a system of bruise charts for monitoring or recording any injuries or accidents, but rather staff are required to describe the injury in the daily notes. It would be better practice to use the charts as well as the written record. This would also contribute to better adult protection practice. One person living in the home has developed epilepsy and this is not being correctly monitored or recorded and the home needs to seek advice on how to do this. At present staff were simply recording, when a seizure was observed, that the person was shaky. The length of the seizures should be recorded and advice sought as to whether other precautions or monitoring is required. Medication is correctly stored and all records were up to date and there are appropriate auditing systems in place. Staff must complete training before they are permitted to administer medication to the people living in the home. The home has the correct facilities in place to store and administer controlled medication if required. The home have implemented the changes that were recommended as a result of an inspection by the pharmacy inspector for the Commission. There are no formal systems in place to consult the people living in the home about the quality of care and there is no formal process for people to be involved in the reviewing of their care plans The records showed people living at the home are supported with all aspects of their health. People have access to primary care services, such as the general practitioner, dentist and optician as needed and that specialist services such as oncology, physiotherapists, and community psychiatric nurses can be accessed when a need for this has been identified. It was reported that two people are currently receiving input from the community mental health services. Care Homes for Older People Page 12 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to maintain contact with friends and families but improvements in the frequency and variety of activities would improve the quality of daily life for some people. Evidence: There was evidence that people are supported to maintain their links with friends and families and visitors spoken to confirmed they are always made welcome in the home by the staff and the management. The home has a stated objective in its Statement of Purpose and also in its last completed Annual Quality Assurance Audit (AQAA) that the service provided meaningful and varied activities for people living in the home. It was evidenced during this inspection that there are some shortfalls in this area that require addressing. The Inspector was shown a laminated rota of weekly activities and it was explained that it is intended that these are supported by the care staff on duty. These activities listed things such as skittles and craft work, and were a little vague and the programme was not implemented on either days of the inspection. It was explained, and observed, that any activity was often interrupted due to the need to provide Care Homes for Older People Page 13 of 28 Evidence: personal care and support. It was also evident that many people were not necessarily engaged in these activities and that additional options could be provided. This could be done on a more assessed needs basis. The home is registered for 19 and the time of this inspection there were 15 people in residence. The Inspector was informed that a number of these had dementia and mental health needs. At present it cannot be said that a sufficient variety of activities are being consistently supported to provide the appropriate stimulation to meet the needs of the individual people living in the home. This is partly due to lack of staff expertise in organizing and running activities but also due to the staffing levels and the pressures on the staff team to complete the personal care tasks that need to be done. The Deputy Manager has completed a course in activities but is not provided with the administrative hours to develop and monitor an activities programme. Some of the people living in the home appeared not to engage in any activities. Improvements in this area will be linked, in the view of the inspector, to improved organizing of management hours and ensuring there are sufficient care staff on duty to support the people living in the home with their personal care needs as well as coordinating and running activities. There is also potential for the developing of some dementia specific activities and stimulation. Further comment around the staffing rota is made under the Staffing Standards. There is a daily record of activities undertaken by each person that list things such as reading a book or watching TV. However at the time of this inspection many of these records had not been completed for several weeks. People living in the home commented positively about the care provided by staff but some people also stated how little time they had to talk and engage with the care staff. There were also occasional activities or events brought in from outside and the records that there had only been one such event in the last two months, which was some Bollywood dancers. People were generally very positive about the food and the menu, saying the food was well cooked and presented and with a good variety. There was recording in the individual files of personal preferences and it was stated by the staff that that they were aware of the different choices that were required. However two comments were made by residents which expressed uncertainty about how to get an alternative to the planned menu. Feedback in two of the surveys also commented upon the need for a more personalized approach to the menu planning. Care Homes for Older People Page 14 of 28 Evidence: On the first day of the inspection one of the Providers had to take responsibility for the supervising of the midday meal and it was also observed that the Deputy Manager had responsibility for preparing the evening tea. In view of the large number of delegated management tasks the Deputy has, this seemed inappropriate. Further reference to the organizing of staff and the rota is made under the staffing standards. Care Homes for Older People Page 15 of 28 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 are systems and protocols in place to protect those who live at the home from abuse and there is a complaints policy in place. The majority of staff have undertaken training in adult protection. Evidence: Information on how to make a complaint is given in the homes Statement of Purpose. The service has received no formal complaints since the previous inspection. There is however no formal complaints book or compliments book and it would be good practice to have one. Some people said they would be happy to raise a concern with the staff but some also were not sure how they would go about raising a concern. The establishing of appropriate quality assurance processes would be of benefit in ensuring that the opinions of people living in the home are fully sought and listened to. This issue is also referred to under the management standards. People spoken with said they felt safe within the home and that staff treated them with respect. The majority of the staff have undertaken adult safeguarding training. Care Homes for Older People Page 16 of 28 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 well maintained, clean and tidy but some needs would be better me with improved bathroom facilities. Evidence: The home was well decorated and clean and hygienic throughout. Many of the rooms had been personalized and people spoken with said they were happy with their rooms and that repairs, when required, where carried out promptly. The garden is also well maintained and provides a comfortable and attractive area for people to enjoy. The home has three bathrooms but only one of these is regularly used, as it is the only one which has hoisting equipment. Of the other two bathrooms, one is situated in the basement and is used mainly by the staff and the other has a very small bath that is not suitable for the majority of the people living in the home. Care Homes for Older People Page 17 of 28 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 in the home are caring and have good relationships with the people living there but low staffing due to poor organization compromises the quality of care and the provision of activities. Evidence: On the day of the inspection visit there were two carers on the morning shift. One of these was the deputy and the other carer was a night care assistant who was doing an extra shift. The Manager explained that they had been unable to cover a staff absence and that normally there were three carers on the early shift. The Manager and her husband, who are also the Providers, are also at the home every day and said they were able to offer assistance if required. On the days of the inspection the Providers were observed helping with meal preparation and supporting the staff in the dining area. The rota also showed there were other days when there was only two carers down to work. There were 15 people living in the home at the tome of the visit and all but one of these required help with personal care and the Inspector was also told that there were two people who required two staff to complete their personal care. The care staff are also required to complete activities and undertake recording. Whilst staff were having their handover meetings between shifts in the basement office the Inspector was told that the cleaner upstairs would fetch a carer if there was a problem. One carer was left to provide support and care for a period of time at lunch time. They were observed coming downstairs and quickly writing notes before quickly Care Homes for Older People Page 18 of 28 Evidence: returning upstairs to the main communal areas. The manager stated that she and her husband were available if required. People living in the home made several comments about the care staff and their approach. Staff were described as caring and friendly. There is a need for the staff levels to be maintained to an appropriate level and for the rotas to be properly organized and planned in advance to ensure that the correct level of staffing is in place to meet the needs of the people living in the home. If the Providers are part of the rota red staff providing support for a particular shift this should be recorded on the rota and staff should be aware that they are part of the team of staff for that shift. Improving the numbers of staff and the organizing of the rotas should also enable for better activities to be run and organized, and without interruption. The home is not registered for dementia care or mental health needs but the inspector was informed that a number of people living in the home have care and support needs from these conditions. The home needs to ensure that sufficient staff are on duty to provide the stimulation and interaction that these people require. A sample of staff recruitment records was seen and these contained all the required information. The necessary pre employment check were being completed and recorded. Care Homes for Older People Page 19 of 28 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. Some parts of the home are effectively managed but there is a need for designated management hours for a variety of tasks. The health and safety of the people living in the home is being potentially comprised by the lack of fire safety training and the absence of a professionally completed fire risk assessment. Evidence: Requirements were made at the previous inspections about the registered manager completing further training. This has not happened but the Inspector was informed at this visit that the service is putting forward the Deputy Manager to be registered and take over as the manager of the service. The deputy has an NVQ in care but not the award in Leadership and Management, though it was stated that this would be started soon. The Registered Manager has also not completed or updated their training in other areas such as first aid, food handling, or health and safety and as the requirement has been made at the last two inspections it is recommended that this application is submitted without delay. Care Homes for Older People Page 20 of 28 Evidence: A considerable number of responsibilities have already been delegated to the Deputy but they as of yet have not got any designated admin hours and are currently working fully on the rota as a carer. The negative impact of this arrangement is also mentioned elsewhere in the report with regards to the effect this arrangement has on the quality of care and outcomes for people living in the home. There is a need for areas such as staff training, supervision and development, health and safety, medication audits, care planning and reviews and quality assurance to be given designated management hours. None of the staff receive any formal recorded supervision. The Deputy Manager has attended training in the Mental Capacity Act and Deprivation of Liberty safeguards. Requirements have been made in previous reports about quality assurance and there is yet to be a system implemented within the home. There is no development plan or plan for the manager to work from or towards. The Deputy Manager despite having a range of responsibilities also does not receive formal supervision, though they do have regular contact with the manager and Provider. The home has no planned or structured approach to monitoring health and safety. For example there is no formal inspection of the building which is undertaken and recorded. One of the domestic staff has some responsibility for checking fire alarm points and call bells. The Registered Manager stated they monitored the home on an ongoing basis. Records were seen of the testing of the lift and the servicing of the fire alarm system. However this aspect of the administration and organization of the home seemed to be somewhat disorganized with some records being hard to locate, a lack of clarity over whose designated responsibility was what and no regular environmental health and safety inspection checks being completed. The fire risk assessment in place was neither signed or dated and had been completed by the Deputy Manager who has not been provided with training in this area. It was also stated that fire safety training had not been undertaken by several staff members. This training was then organized during the inspection visit and confirmation subsequently received by the Commission that this was being undertaken. The Provider also informed the Inspector that the firm supplying the training would be completing a fire risk assessment for the home. A fire inspection was undertaken of the premises by the Fire Department in February 2008 and a number of recommendations were made in relation to building alterations and also the Care Homes for Older People Page 21 of 28 Evidence: completion of a fire risk assessment. It is recommended that all points from the fire departments report are actioned without delay by the home. Care Homes for Older People Page 22 of 28 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 31 9(2)(b)(i) The Home must have a 30/10/2009 Registered Manager that has completed NVQ level 4 in management. Care Homes for Older People Page 23 of 28 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 12 12 The home must ensure that sufficient activities and stimulation are provided to meet the needs of the people living in the home Appropriate and organized activities should be provided to promote and make proper provision for the health and welfare of the people living in the home. 25/04/2010 2 27 18 The home must ensure that staffing levels are maintained that ensure the needs of the people living in the home are met at all times. staffing rota and cover arrangement must be in place that provide the correct staffing numbers to provide the care and support that is required and also ensure that admin tasks can 25/03/2010 Care Homes for Older People Page 24 of 28 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 also be completed without compromising care 3 31 12 Sufficient designated management hours must be allocated to ensure the effective completion of management tasks and the supervision of staff Staff designated to undertake management tasks should be provided with the time to complete these tasks. 4 31 6 The Home must register a Manager that is suitably qualified The home needs to put in place and register a manager who is appropriately qualified and has the administrative hours to fulfill the full range of responsibilities and tasks involved in managing the service 5 33 27 The home must implement a 25/05/2010 system of Quality Assurance The home should establish a system for reviewing, and where appropriate, improving care and support 6 36 18 All staff should receive regular formal recorded supervision 25/04/2010 25/04/2010 25/03/2010 Care Homes for Older People Page 25 of 28 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 Care staff should receive formal supervision to promote professional development and good practice 7 38 23 The home must ensure that fire risk assessment is in place and that this is completed by a an appropriately qualified person. All home must have a comprehensive fire risk assessment in place to ensure that people living in the home are properly protected 8 38 17 All staff must receive fire safety training All staff must be trained in fire safety procedures to ensure people living in the home are properly protected 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 25/03/2010 25/03/2010 1 2 8 8 The home should incorporate the use bruise charts in their recording systems The home should get further advice and guidance on the managing of epilepsy Care Homes for Older People Page 26 of 28 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 3 4 5 8 16 38 The home should record and monitor peoples weight The home should complete complaints record book The home should action all the points raised in the fire departments report of February 2008 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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