Care Home: Beech Court Care Centre

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What the care home does well Care records are of a good standard and generally care is person centred. Routines within the home are flexible and this gives residents choice. Residents have access to a GP, dentist, chiropodist, optician and all other health and social care professionals as necessary. Many of the residents were able to tell us that they were very happy at the home, and that generally staff were very kind and caring. Meals are well presented and nutritious and again residents are given choices. Training is of a good standard and staff retention is good with no use of agency staff. This does give residents the assurance that the staff looking after them are consistent. End of life care is good and this was confirmed when talking to staff and relatives, together with letters of appreciation which had been sent to the home. Medication administration is of a good standard with accurate records being maintained. Safeguarding is given a high priority within the service with no current safeguarding issues, and also complaints are dealt with in a positive manner and in accordance with the home`s policy and procedures. What has improved since the last inspection? Care plans and general recordings have improved since the last inspection, and this was also confirmed in discussions with a visiting healthcare professional who was undertaking nursing assessments. Comments were "The records have really improved and I can always find what I am looking for easily, unlike records in some other homes." What the care home could do better: Whilst training is of a good standard it is essential that the service ensures that all staff implement the training. This will help to improve the interactions between some staff and the residents. We have made a requirement that advice be taken from the local deprivation of liberty safeguards team (DOLS) to ensure that the use of key pads and other locks are in accordance with the new legislation. Key inspection report Care homes for older people Name: Address: Beech Court Care Centre 298-304 South Street Romford Essex RM1 2AJ     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: Sandra Parnell-Hopkinson     Date: 2 7 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 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) 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 28 Information about the care home Name of care home: Address: Beech Court Care Centre 298-304 South Street Romford Essex RM1 2AJ 01708720123 01708720220 beechcourt@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd care home 50 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Beech Court Care Centre is a purpose built care home registered to provide nursing care. The home is registered to care for three different service user groups. People who are over the age of 65 and physically frail or who have a diagnosis of dementia and people between 18 - 65 who have physical disabilities. The home is operated by Southern Cross Limited a company, which operates similar homes across the country. The home is situated just outside Romford and has good access to local facilities and transport links. The home was purpose built in 1999. It is a three-storey building. The home consists of single bedrooms with en-suite facilities. A large passenger lift services all floors. There is a secure landscaped garden. On the day of the inspection the range of fees for the home was between £469. and £950. per week. A copy of the Statement of Purpose and service user guide to the Care Homes for Older People Page 4 of 28 0 0 12 Over 65 20 18 0 Brief description of the care home home is made available to both the resident and the family. There is a copy of the guide in each bedroom, and copies of both these documents are available at the main reception. Copies of the most recent inspection report are available on request. 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: 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: We arrived at the home at 08:15 hours on the 27th July 2009 to undertake an unannounced key inspection. The registered manager was on annual leave but the deputy manager was available throughout the day. We were able to speak with many of the residents, some relatives, staff and a visiting healthcare professional. Other evidence was gathered from checking records and other documentation, together with information contained within the annual quality assurance assessment (AQAA) which had been returned by the home, and notifications received as required under regulation 37 of the Care Homes Regulations 2001. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their families have the information needed to choose a home that will meet their needs. Evidence: All prospective residents and/or their families are encouraged to visit the home prior to making a decision to move in. The homes statement of purpose and service user guide are made accessible to people so that they have as much information as possible to inform their decision. The statement of purpose clearly sets out the objectives and philosophy of the service, and information is included which informs people on the complaints procedure. The service plans to produce a more simplified service user guide for those people who find the current document too difficult to understand. Comprehensive pre-admission assessments are undertaken and from this information care plans are drawn up with the involvement of the resident and his/her family. 6-8 Care Homes for Older People Page 9 of 28 Evidence: weeks after admission a review is undertaken to ensure that the resident has settled and that the care plan is appropriate to the needs. All residents have either a contract or a statement of terms and conditions, and this is dependent upon whether they are privately funding their care or are being supported by a local authority or primary care trust. The service is committed to equality and diversity and the needs and preferences of people from different social, cultural or religious groups can be catered for. 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. The health and personal care that people receive is based on their individual needs. Generally the principles of respect, dignity and privacy are put into practice. Evidence: We found that those care plans inspected were generally person centred, and contained clear information about the individuals wishes, choices and decisions as their health deteriorates. A resident with a hearing aid had a care plan in place with clear documentation on the need to keep this clean and with a working battery in situ at all times. A visiting healthcare professional told us that the documentation within the home had greatly improved and all of the information was easy to find, unlike many other homes that she visited. We were also told that the nurses were very knowledgeable as to the needs of the residents that they were caring for, and we were able to confirm this in our discussions with the nurses and residents. We observed that good infection control methods were in use in the home, and that staff were aware of the need to practice good infection control procedures. Care Homes for Older People Page 11 of 28 Evidence: Continence care at the home is good and there were no offensive odours within the home. This was also confirmed in conversations with some residents and relatives. Generally residents receive personal and healthcare support using a person centred approach. However, staff must be more aware of the need to talk to people during the delivery of care. We did observe some staff undertaking tasks such as hoisting and assisting with eating being undertaken in silence. It is essential that staff put into practice their training and ensure that the dignity of people is maintained, and that they are always treated with respect. Some staff must be less task orientated and not forget that the resident is the reason that they are working at the care home. The service is aware that it needs to ensure that dignity is reflected throughout all care processes, as this has been identified in the annual quality assurance assessment (AQAA) sent to the Commission. However, general feedback from residents and relatives with whom we spoke was that staff are very kind and caring. A quote from a letter sent to the home was The care that you and your team provided far exceeded any expectations I had. Mum received all the care and kindness that I had only hoped for. All residents have access to healthcare and social care professionals, and we saw evidence of visits from/to a GP, optician, dentist, chiropodist, nutritionist and physiotherapist. Nutritional screening is undertaken on admission and subsequently on a periodic basis, a record is maintained of nutrition including weight gain or loss and appropriate action taken as necessary. The incidence of pressure sores, treatment and outcome, are recorded in the residents individual care plan and reviewed on a continuing basis. Equipment necessary for the promotion of tissue viability and prevention or treatment of pressure sores is provided. Where necessary risk assessments are in place and these are regularly reviewed. End of life care is provided at the home, and the home has received letters of thanks for the care provided. One relative wrote words are not enough to thank you all for the care you gave my mum during her time with you. The care you gave her was exceptional and all of you were always cheerful and willing when you attended her. Mum always looked well groomed and comfortable, and for that I am extremely grateful. Thank you all for enabling mum to maintain her dignity. You all gave meaning to the word care. We looked at the medication administration records (MAR) on all three units and found Care Homes for Older People Page 12 of 28 Evidence: that the medication administration was good, as was the system for ensuring that controlled drugs were being administered and stored. However, we did find that there were no protocols in place for the administration of PRN (as required) medication, and we discussed this with each of the nurses in charge of each unit, as well as with the deputy manager, and are satisfied that such protocols will be developed for residents as appropriate. Care Homes for Older People Page 13 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their life style, and generally the social, cultural and recreational activities meet the individuals needs. Evidence: The service has a strong commitment to enabling residents to develop or maintain their skills, and are supported to identify their goals. Residents are involved in daytime activities and the two activity co-ordinators work extremely hard in organising fetes, celebration of festivals as well as organising a varied programme of daily activities. Residents who prefer to stay in their bedrooms are not neglected as the activity co-ordinators ensure that 1:1 sessions are organised. However, all staff working at the home have a responsibility to ensure that they are involved in activities to daily living with the residents. Sitting and talking to residents, reading a newspaper with them, walking with them or helping a resident to tidy his/her wardrobe or drawers is essential in helping a person maintain skills for daily living. We did observe some staff just sitting and watching residents instead of engaging with and interacting with them. The service has identified in the annual quality assurance assessment (AQAA) that it could build on the service users strengths and provide more living skills based activities to promote independence where we are able to. Residents are encouraged to personalise their own bedrooms and to have items of furniture of their Care Homes for Older People Page 14 of 28 Evidence: own choice. One resident has two pet budgerigars in her room. Residents have the opportunity to develop and maintain important personal and family relationships. One relative told us I visit everyday and help my husband with his main meal as he seems to eat better when I am here. The staff are very good and always make me feel welcome. Residents are free to go out to the local shops or on other outings, and one resident likes to go out on a daily basis. Routines within the home are flexible to suit the needs of the individual, and when we arrived at the home some residents were up and dressed and having breakfast in the dining rooms, some were still in bed asleep and some were having breakfast in their bedrooms. We spoke to some residents who told us that they can go to bed when they want, and one lady told us I like to spend some time in the lounge but I also like to spend time in my room because I enjoy reading. The home has purchased new flat screen televisions for all of the lounges. During the inspection we were able to observe both breakfast and lunch times on the three units, and were satisfied that residents have a choice, and that meals are very well balanced and highly nutritional and cater for varying cultural and dietary needs of the residents. Generally for those individuals who need support during mealtimes, staff give assistance in a discrete and sensitive way. The service uses the Nutmeg system which shows the dietary and nutritional needs of residents. For people living with dementia the home has developed pictorial menus to help people make a choice of meals. However, the service must look at enabling residents living with dementia to make a more informed choice on the day. Currently, residents have to choose the day before and because of the short term memory loss of people with dementia, they will not remember what they have chosen. This often means that it is the staff who are making the actual choice of meal. This was discussed with a nurse who agreed that this was generally the case. Improvements have been made to the environment on Primrose unit which is for people living with dementia, and this has included bedroom doors which look like a front door, corridors named after roads/streets of the local area which would be familiar to many of the residents, and bathrooms/toilets which are less clinical. In discussions with some of the staff they told us that this had made a difference to some of the residents. For example some of the residents were less stressed when using the toilet as it was now more familiar to one that they remembered. Both residents and relatives meetings are held on a regular basis, and on the day of the inspection a residents meeting was being held. Care Homes for Older People Page 15 of 28 Evidence: Care Homes for Older People Page 16 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are generally able to express their concerns, and have access to a robust, effective complaints procedure and are protected from abuse and have their rights protected. Evidence: The home has a clear complaints procedure which is displayed around the home. However, this should be provided in a more simpler format, or other formats such as audio or video for those residents who have difficulty in understanding the current format. The home has an open culture that allows many of the residents to express their views and concerns in a safe and understanding environment. However, residents living with dementia may only be able to express their dissatisfaction with something by exhibiting behaviours that may challenge. It is essential that all staff understand this and why it is essential that staff actively interact with residents and do not ignore them. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. Complaints are viewed in a positive manner and outcomes are used to improve the service to residents. Care Homes for Older People Page 17 of 28 Evidence: All residents and staff have been issued with information cards on the independent Action on Elder Abuse support line. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. We spoke to staff who were able to demonstrate a clear knowledge and understanding of safeguarding issues, and were clear who to refer an incident to. There is a clear system for staff to report concerns about colleagues and managers, and that staff that blow the whistle on bad practice are supported by the service. Currently there are no safeguarding issues at this home. Training of staff in safeguarding is regularly arranged by the service, as is training in dealing with physical and verbal aggression. Staff spoke to demonstrated a good understanding of what restraint is and alternatives to its use in any form would always be looked for. Equipment that may be used to restrain individuals such as bed rails, key pads, recliner chairs and wheelchair belts are only used when necessary. Individual assessments regarding bed rails, recliner chairs and wheelchair belts are completed with the involvement of the individual where possible, their families and any other professionals. Because of the introduction of the deprivation of liberty safeguards (DOLS) under the Mental Capacity Act 2005, we are requiring the manager to seek advice from the local DOLS team on the general use of key pads/locked doors within the home, to ensure that the home is compliant with the new legislation. Care Homes for Older People Page 18 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 physical design and layout of the home enables residents to live in a safe, wellmaintained and comfortable environment. Evidence: On arrival at the home we understood a tour of the building and found it to be clean and free from offensive odours. The management has a good infection control policy and when necessary advice is sought from external specialists. The home provides a physical environment that is appropriate to the specific needs of the residents. The well-maintained environment provides specialist aids and equipment to meet the needs of the people living there. The communal bathrooms and toilets are homely and have the aids and adaptations to meet the needs of the residents. All bedrooms are single with en suite facilities. Residents are encouraged to personalise their bedrooms and the environment promotes the privacy, dignity and autonomy of the residents. We spoke to several residents who invited us to see their bedrooms, and these rooms were personal to the individual. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. Signage and decor on Primrose unit is also appropriate Care Homes for Older People Page 19 of 28 Evidence: to the needs of people living with dementia. The external area were well maintained and residents are encouraged to access the garden. We were told that whenever possible activities take place in the garden and the addition of a marquee would be beneficial especially in inclement weather conditions. Care Homes for Older People Page 20 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 good 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 generally trained, skilled and in sufficient numbers to support the people who use the service. Evidence: The home operates an effective and robust recruitment procedure and all staff complete an application form, attend an interview and undergo all of the necessary checks and references prior to employment being confirmed. All new staff undertake an induction period, followed by shadowing an experienced member of staff for the first few days on the floor of the home. This is followed by an interview with the home manager after the initial 12 week probation period. We spoke to residents and relatives who confirmed that generally they have confidence in the staff who care for them. On the day of the inspection we were satisfied that there were sufficient numbers of staff on duty to meet the assessed needs of the residents. The home has a good record of staff retention and there is no use of agency staff. Training is given a high profile within the organisation and recent training has included manual handling, first aid, infection control, nutrition, dementia awareness, safeguarding and health and safety. More than 50 of the care staff have achieved NVQ level 2 and a number of care staff have also achieved the NVQ level 3. Nurses Care Homes for Older People Page 21 of 28 Evidence: have registered for the NVQ level 3 in palliative care. The home now has a home trainer with additional supernumerary hours to support training of staff in the home. Staff members undertake external qualifications, and the management encourage and enable this and recognise the benefits of a skilled, trained workforce. Staff training is focused on delivering improved outcomes for residents, and it is essential that all staff ensure that the training that they have received is implemented in the daily care given to all of the residents. The workforce is diverse whereas the majority of the residents were white British, and it is essential that all staff are made aware of the social and cultural needs of the residents, which may be different to their own. Additional training in this area may improve the quality of the interaction between some of the staff and the residents. In discussions with staff they were knowledgeable around safeguarding issues and confirmed that they had undertaken training in this important area. We saw evidence that staff receive regular supervision, and this was also confirmed to us in discussions with some staff. Care Homes for Older People Page 22 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect. There are effective quality assurance systems to ensure a good service for the residents at the home. Evidence: The registered manager was on annual leave on the day of the unannounced inspection, but the deputy manager was on duty to give assistance and answer any questions. The annual quality assurance assessment (AQAA) informs us that the registered manager is a registered nurse and has achieved the registered managers award. The organisation has strategic and financial planning systems, and supported by these systems the management of the home is competent in delivering effective financial planning and budgetary control. This is in the light of reduced funding levels being provided by some local authorities. Care Homes for Older People Page 23 of 28 Evidence: We are confident that the management of the home works continuously to improve services. An improved quality of life is being provided for the residents, but there could be some improvement on equality and diversity issues in the interactions between some staff and residents. The management has a strong focus on person centred thinking and an ethos of being open and transparent in all areas of running of the home. Although the manager leads and supports a strong team of nurses, this strength must be reflected within all parts of the care staff. The service has sound policies and procedures which are reviewed and updated in line with current thinking and practice. Through regular supervision the management ensures that staff adhere to these policies and procedures. The home works to a clear health and safety policy and all staff are made aware of the policy and are trained to put theory into practice. The home has a consistent record of meeting relevant health and safety requirements and legislation and closely monitors its own practice. Maintenance and other records are of a good standard and necessary risk assessments are in place. The home has effective financial systems for the management of residents monies. There are effective quality control/assurance systems in place with regular audits and surveys being undertaken. Through this and visits in accordance with regulation 26 of the Care Homes Regulations 2001, the organisation constantly monitors the performance and practice of the home. Notifications required under regulation 37 of the Care Homes Regulations 2001 are also sent to the Commission as necessary. The annual quality assurance assessment was returned as requested and was comprehensive. The parent organisation appropriately supports the manager in the running of the service. Currently there are no safeguarding issues at the home, and there have not been any referrals under the deprivation of liberty safeguards (DOLS). However, elsewhere in this report we have made a requirement that advice is sought from the local deprivation of liberty safeguards team (DOLS) regarding the use of key pads and other locks within the home to ensure compliance with the new legislation. Care Homes for Older People Page 24 of 28 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 25 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 18 13 The registered persons shall ensure that no service user is subject to physical restraint unless restraint of the kind employed is the only practical means of securing the welfare of that or any other service user and there are exceptional circumstances. Advice to be sought from the local DOLS team to ensure that no resident is being deprived of their liberty through the use of key pads/locks as determined by the deprivation of liberty safeguards Mental Capacity Act 2005. 30/09/2009 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 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. 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). 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