Care Home: Bethany Francis House

Similar services:

• Claremont House
• Oak Ridge
• Sun Court Nursing Home
• Ashville House
• Bilney Hall
• Hill Barn
• Mabbs Hall Nursing Home
• Henrietta House

What the care home does well We found the operations manager open and honest and willing to work with ourselves and the local authority. They showed a commitment to improving the home and had already identified shortfalls in service provision and because of this had taken the decision not to admit any new residents until they had the time to sort out these issues. The staff we meet were polite and helpful. Pre-admission assessments are in place and comprehensive. The operations manager has introduced consent form and is looking at mental capacity assessments and training for staff. Care plans were comprehensive and were being actively reviewed. They were written in a person centred way. The operations manager showed us what further improvements she wishes to make. Requirements in relation to medication had been met. The home has put some photographs up and there are some examples of art work that have been completed. The operations manager has worked in co-operation with the local authority and has reported safeguarding concerns and taken actions against staff. The home is beautifully laid out and has extensive, well maintained grounds. The physical layout of the building promotes choice for residents who can choose to sit in one of three lounges. Staff spoken to had completed their mandatory training and care practices observed were good. What the care home could do better: We were encouraged by the actions taken to date by the operations manager. We identified significant shortfalls in the service again and the service history would indicate that without some continuity of management who are given the tools to manage this service will not improve. There has been an ongoing problem with the high turnover of managers and operational managers in post within this service which has led to a lack of sustained improvement and continuity within the home. Records are not in place, cannot be found or are not up to date. The operations manager has sent out surveys for feedback about the service being provided. There is no overall plan for the service addressing staff training and development and a plan for the routine maintenance and upkeep of the building. Schedules regarding the cleanliness of thebuilding were not seen. We have requested a copy of the accounts for the service, to ascertain the financial viability of the home given the current self imposed embargo. The operational manager does not have any administrative support. Whilst the operational manager is overseeing the management arrangements in Bethany Francis House, this prevents the person from performing the role of operational manager in all of their homes. In one instance a pre-admission assessment was not completed in a timely fashion and this led to a residents needs not being fully understood by staff. We have not made a requirement on this occasion We are not satisfied that residents have their privacy and dignity respected at all times, particularly in relation to care giving. We have had a number of complaints from relatives about poor personal care given. We have spoken to care staff who feel there are insufficient staff on shift. We have spoken to the district nurses who had a recent concern about fluid intake and incontinence pads not being changed sufficiently. A recent investigation against a staff members conduct resulted in dismissal. We saw poor evidence of induction into meeting peoples care needs and this incident of poor care was reported by a relative and not care staff who had observed it. There are insufficient hours devoted to the provision of meaningful activities and we have seen no evidence of residents involved in daily tasks around the home. Care Staff however well intentioned do not have the time to provide activities or spend lots of time with residents because they are expected to complete non care tasks as well. Complaints and SOVA concerns had been investigated but we saw no records recorded in the complaints book. Incidents had not been written up. The home do not have robust staff selection and recruitment procedures which puts people at risk. The home is not being maintained in accordance with a routine programme of maintenance and renewal. Bedrooms do not have locks affording residents privacy. Equipment, furnishing and bedding is basic in some bedrooms. The cleanliness of the kitchen was unacceptable and the laundry room not fit for purpose. We will be making a requirement and liaising with the environmental health department. Staffing We were not able to find evidence that staff are properly recruited, and sufficiently supported through induction, training and supervision. We are not satisfied that staff are employed in sufficient numbers or have the skills, or competence to perform their jobs to a high standard. Random inspection report Care homes for older people Name: Address: Bethany Francis House Bethany Francis House 106 Cambridge Street St Neots Cambridgeshire PE19 1PL one star adequate service 08/03/2010 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Shirley Christopher Date: 1 0 0 8 2 0 1 0 Information about the care home Name of care home: Address: Bethany Francis House Bethany Francis House 106 Cambridge Street St Neots Cambridgeshire PE19 1PL 01480476868 01480473799 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) ADR Care Homes Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 34 Number of places (if applicable): Under 65 Over 65 0 34 dementia old age, not falling within any other category Conditions of registration: 34 0 The maximum number of service users who can be accommodated is 34 The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Date of last inspection 1 5 0 6 2 0 1 0 Care Homes for Older People Page 2 of 18 Brief description of the care home This home is owned by ADR care homes, who own several other homes. Bethany Francis House is a listed building, set back from the main St Neots to Cambridge road. It has large extensive gardens. It is a Victorian property which has been extended and provides spacious accommodation on two floors. The upper floor is accessed by a wide sweeping staircase at each end of the house. There is a lift available. The home can accommodate up to 34 people who fall into the category of older people, with or without dementia. There are three double rooms and 28 single rooms. 21 have ensuite facilities. The first floor has two bathrooms with hoists and toilets and two individual toilets and one shower room. There are attractive gardens and a number of the residents help with the garden. They have hanging baskets and raised flower beds. The grounds are enclosed and there are suitable seating areas. The home is situated just a few minutes walk from the market town of St Neots where a range of shops and leisure facilities can be accessed. It is close to public transport; the railway station and bus routes. A copy of the homes statement of purpose and service user guide are made available by the home. The current inspection report is available in the hallway. Care Homes for Older People Page 3 of 18 What we found: We, the Care Quality Commission carried out a random inspection to the home on the 10 August 2010 because we had a number of concerns about the home and there were a number of outstanding medication requirements made by the CQC pharmacy inspector at an earlier inspection. The timescales for compliance were the 31 March 2010. The inspection was undertaken by a pharmacy inspector who looked at medication and did some case tracking for ten residents, (3) where there had been a number of known concerns. The other inspector talked to the operations manager about issues in the home and looked at some records, including maintenance, staffing, complaints, and discussed SOVA issues, for which no records were available. We spoke to staff and residents, observed care practices, including lunch and walked round the home. We were notified on the 3 August 2010 by a relative visiting the home that the manager at Bethany Francis House had left her post. We rang the home for clarification and spoke to the Operational Manager, who confirmed this was the case and they would be overseeing the day to day management of the home until a new manager could be appointed. We received two complaints, one written and one verbally on the 2 August 2010 and the 4 August 2010. In both instances, the operational manager, was dealing with them and they had been referred under safeguarding of vulnerable adults, (SOVA)and to the Local authority. As a result of one of the complaints we spoke to the district nursing services for further clarification about incontinence aids and found out that they had conducted an investigation with regards to one resident where there had been some initial concerns. We followed up these and other concerns raised as part of our random inspection. The operations manager has been in post for eight weeks at the time of this inspection. The manager who had been in post since March 2010 left last week. We did a random inspection to the home on the 15 June 2010 and the manager and deputy manager were in post. At this inspection the deputy manager was no longer in post and the operations manager had appointed team leaders. The operations manager said appointments were made to these posts according to staffs training, competence and length of service. We noted in our last report that the home would benefit from a period of stability and better retention of staff. The home was purchased by the providers Mr and Mrs Rudd in October 2008 and had a registered manager in post until July 2009. Since then the home has had three further managers, who were unregistered and left after a short period and two operations managers who have also left. The local authority placed an embargo on this home back in November last year because of a serious safeguarding issue which highlighted significant failings of the service. This was only lifted in March 2010 after agreement from all agencies involved that the home had done enough to meet requirements made by the CQC and satisfied the terms of the contract it had with the Local Authority. They continue to monitor the service. The operations manager made the decision after discussion with the providers not to admit any new residents to the home from the 6 August until they sort things out. This was in light of the manager walking out and a number of safeguarding concerns which have come to light. Care Homes for Older People Page 4 of 18 The home has had three key inspections since October 2008 and six random inspections. The high number of inspections has been a result of changes in management, staffing and various complaints and safeguarding issues. The home has been rated adequate and has met requirements made but has been unable to sustain improvements to the service. The home has had two warning notices and has produced improvement plans for CQC and action plans for the Local Authority. The operations manager stated on the day of inspection that Mrs Rudd was at one of the other registered homes where they were interviewing for a manager. The previous manager, also unregistered left their post the week before. At Bethany Francis house they had interviewed for a manager but had not yet made an appointment. The provider owns three homes in Cambridgeshire and one in Norfolk and one in London. Only one home has a registered manager. The operations manager is currently based at Bethany Francis house and is unable to carry out her other duties in respect of the other services. We asked about the on-call arrangements for the home and were told that she covers the on call for all five homes. The emergency contact details for staff were out of date for Bethany Francis and included details of staff that had left. We saw little evidence of staff competencies. Most mandatory training was up to date, but the home has not carried out staff appraisals. The staff supervision matrix could not be produced on this occasion and the operations manager stated that the manager had supervised all staff once whilst in post and she had managed to supervise two staff since being in her current post. She did state that supervision training was being rolled out across the organization in October 2010 for managers, deputies and team leaders. We asked the operations manager about the statement of purpose and service user guide and when they were last updated. She stated this was done when the previous manager was in post, so the documents need to be reviewed to reflect the current situation. We received a complaint from a relative. The operations manager has completed an investigation and has given a written response to the relative. Part of this complaint was about medication and we understand that the persons medication was reviewed but information from this review was not passed on by management resulting in some confusion. This person had not had a detailed assessment of their needs at a home which they were later transferred from. Bethany Francis house did ask for information about this persons needs but not in a timely fashion which meant that staff were not initially aware of this persons likes and dislikes. The person was quite able to give staff this information. The home has adequate documentation in place to assess residents needs and this must be completed before their admission and the home must be able to show ongoing monitoring of a person needs. A requirement regarding pre admission assessments was made following the key inspection in March 2010 and was considered met at the random inspection in June 2010. A requirement will not be made on this occasion. Another element of this complaint concerned staff not having specialist knowledge of a particular medical condition. The operations manager confirmed that staff had not had specific training but that training would be provided by linking up with the primary health care teams that support the home and would be willing to provide training for staff. A requirement was made following the key inspection in March 2010 regarding care plans, which did not give sufficient information to care staff about meeting residents Care Homes for Older People Page 5 of 18 needs. A requirement about care plans was made at the first key inspection to this home in January 2009 and on subsequent visits. The Local Authorit have also looked at care plans as part of their ongoing monitoring. At the random inspection we identified considerable improvements with the care plans and pre admission information. We looked at ten care plans during this inspection and found they clearly described peoples needs and these have been actively reviewed every month. Some records which we looked at as part of the last inspection were not up to date, such as the dependency scores which help determine how many care staff should be on duty. Accident records were not up to date and we have not received any notifications from the home required under regulation 37 since June 2010. We were unable to look at records relating to a recent complaint, which was referred under safeguarding. We were not notified directly. There were also concerns expressed by relatives about residents personal care needs not being met fully. Examples given to us were residents not being washed at the end of the day, infrequent toileting and staff not using shaving foam when giving a wet shave. Concerns were expressed by the hairdresser that some residents hair was very dirty. There were also concerns about insufficient continence aids being supplied. We spoke to the District nurses who confirmed that they had carried out continence assessments for a high percentage of residents and had supplied pads. Protective bed covers should be supplied by the provider. They said that pads had sometimes run out and they had no explanation for that other than pads may be used for people who have not been assessed as incontinent. We were told that they have visited the home to look at the well being of one person and had raised concerns about fluid intake and pads not being changed frequently enough. They did not have any major concerns about skin tears. We looked at fluid charts and they were satisfactory. We observed lunch, all but one resident ate in the dining room, which has been re-sited since the last inspection. If the home had full occupancy there would be restrictive space. Residents were offered one of two choices. We looked at the menu and the food being offered did not relate to the menu. When we asked, we were told a new menu had been put together by the previous manager but it was being revised and staff were currently providing daily choices, and not working to a set menu. In the dining room there were a selection of alcoholic beverages and fresh fruit. During the inspection we spoke to staff and established that residents can choose when to have a bath and there is a weekly bath rota. We were concerned when walking around the home that there were only two bathrooms in use, one on each floor the shower was out of action. some rooms have en suite facilities, but in some bedrooms, a small sink is provided. We tried some taps which were very stiff and it is unlikely that an elderly, frail person would be able to turn them on independently. Some taps did not work and some had a slow trickle of water. Some bedrooms have a malodorous odour. At the last random inspection there were three outstanding requirements regarding medication practices. Requirements about medication have been made on more than one occasion. The pharmacist inspectors findings were as follows: We assessed progress to wards meeting the outstanding requirements on medication. We looked at medication, medication records and associated care records for 10 people living in the home. We toured the building and talked to some residents and staff. You were required by 31/03/2010 to ensure medicines are given in accordance with the prescribers instructions. On looking at the medication records we saw that for one person Care Homes for Older People Page 6 of 18 a medicine had been prescribed to be used for 7 days but had been given for longer than this, but for all other people, medication was given in line with the instructions from the prescriber. We therefore consider this requirement has been met. On the last inspection we also made a requirement that the records made when medicines are given to people were accurate and complete. The timescale for action was 31/03/2010. In looking at the medication records being used, we found a few unexplained omissions in the records but in general these were in good order and demonstrate that people receive their medicines as prescribed. But we also saw that when medicines are given in variable doses e.g. one or two tablets, the actual dose given is not recorded. This could result in people receiving too much or too little medication. We looked at the records for 4 people prescribed such medicines and, with one exception, there was clear guidance in care plans, and held with the medication records, on the use of these medicines. Staff we talked to were aware of, and followed this guidance. We therefore consider the requirement has been met. At the first key inspection to this service in January 2009 we made a requirement about activities because did not feel the home were meeting peoples social needs. This requirement was repeated again In December 2009 and January 2010. The home have had several activities persons in post who have left. At the last random inspection in June 2010, activities were being provided by two care staff who had additional hours. They said they would be doing a course in the provision of activities. At this inspection nine hours a week were being allocated to activities which took place in the afternoon. On the day we were there the only observed activity was a visit from the hairdresser who comes twice a week. There is a volunteer to the home who does a quiz twice a week but he was on holiday. We observed residents sitting in the lounges. A number of activities and events were displayed, such as beauty therapy but when we asked about this we were informed that this did not take place anymore. We asked staff about routines and were told residents had the choice of when they got up and went to bed. Some residents choosing to go to bed after tea. Staff were busy throughout the morning and the only time we saw staff spending time with residents was whilst assisting them with tasks. Before the inspection we received two complaints, both of which the home were aware of. They have both been reported to the Local authority, but we had not been informed of the complaints or their outcomes by the home. One had been referred to SOVA by the home. There were no records relating to these. The complaints and their outcome had not been recorded, although one complaint had been responded to formally by the home. We also learnt of a safeguarding concern investigated by the district nurses. Records were not at the home. We learnt about a further concern which had not been recorded or investigated. We flagged this up with the local authority. We have not received any notification since June 2010 and records are incomplete. We were concerned that staffing records were incomplete putting people at risk from ongoing poor employment practices. A requirement was made regarding the environment at the first key inspection and at the key inspection in March 2010, (different issues were identified. A requirement was made about cleanliness and infection control in December 2009. At the time the home only employed one domestic, whose hours had not been covered when they were off. The home then employed a second domestic. The home was reasonable clean during this inspection but we did identify a number of issues relating to cleanliness and maintenance. The home employ a maintenance person but they work 20 hours per week and this is spread between two homes. There is no routine plan of maintenance and repairs are done Care Homes for Older People Page 7 of 18 as and when required. Initially the providers made improvements to the environment, furniture was replaced, rooms were painted and new pictures were purchased. On this occasion we noted floo coverings had been replaced and bathrooms re-tiled. Vacant bedrooms were being refurbished. We walked into a dozen bedrooms, which were occupied and noted that almost all doors banged shut, some did not have running water, or had merely a trickle, taps were not fit for purpose, some windows did not open, some bedrooms had a malodorous smell. Bedding in one room was soiled and in a number of bedrooms, sheets were crumpled and bedding was thin. The communal areas were satisfactory, although the carpet was ripped near the main entrance. We were told this was going to be replaced. The shower room is out of action and this is the noyl shower. The cleaning materials stored on a trolley were left unattended near residents bedrooms, potentially putting residents at risk. We bought this to the operational managers attention. The laundry rooms door did not shut. We did not see any chemicals stored in here. We felt the laundry room is not fit for purpose because there is no space to sort out clothes and clothes were communally placed in a trolley. We were informed that the environmental health officers had been out in March 2010 and had made a number of requirements regarding the kitchen. We requested the report but this could not be found. The operations manager confirmed that some of the requirements had been completed. We found the kitchen unoccupied and walked straight in. The back door was open and full of rubbish outside, not all in designated containers. The kitchen itself was poorly equipped with very few utensils . The kitchen cupboards were grimy. The cooker was dirty but had just been used. There is a sterilizer, which staff told us had not worked for some time. The home does not have a dishwasher and staff wash up by hand. We asked the operations manager about COSSH sheets and she told us these were in place, but there were no risk assessments or cleaning schedules. There was food in the fridge which was not dated including a lasagne. At the last key inspection in March 2010 we made a requirement about staff recruitment checks. Staff files were acceptable when checked as a part of the random inspection in June 2010. We made a requirement about staff recruitment at the first key inspection in January 2009. We made a further staff requirement in August 2009 specifically about POVA checks now known as ISA checks. Further requirements have been made around staff records and staff rotas. At this inspection we identified further breaches of staff recruitment practices. An issue was reported to SOVA in June 2010. A member of staff had been appointed despite unsatisfactory checks being received. At this inspection occupancy levels was down to 23 residents. There were no up to date records looking at the dependency levels of the current residents which is used to determine the numbers of care staff required on duty. We had received two complaints prior to the inspection, one relative referred to inadequate staffing levels. We discussed this with the operations manager who stated that staffing numbers were not the issue but it was around staff lacking sufficient skills and competencies to meet the needs of the Care Homes for Older People Page 8 of 18 people living in the home. And in addtion clear clarity around job roles. ( This is something we have identified at an earlier inspection.) At this inspection there were four care staff in the morning and three in the afternoon. We spoke to two staff who said that four staff in the morning is not always sufficient and in the afternoon three staff are responsible for care and doing the laundry and assisting with meal preparation. The operations manager stated there are some times four staff on duty in the afternoon. The home has a budget for laundry which was not being utilized. They only have one cook on duty from 9.00 am to 3.00 pm so care staff are responsible for preparing tea and washing up afterwards. The home does not have a dishwasher so this is done by hand. One staff member said this could take up to an hour. There are two domestics. Only nine hours a week are allocated to social activities. The home has a maintenance person but their hours 18/20 hours a week are spread between two homes. The physical layout of the building enables residents to have a choice of lounges, but makes it more difficult to supervise residents adequately. The operations manager told us a post had been created for one team leader and five senior posts, but she had not had the opportunity to clarify their roles and responsibilities formally. We asked, but were not provided with evidence of staff supervision. The operations manager stated that all staff had received supervision this year and she had supervised two staff. There was no evidence of staff appraisals. We saw some evidence of staff training. Some staff had undertaken a lot of training, but outstanding mandatory training included: infection control, health and safety and the mental capacity Act. The operations manager was in the process of sorting out dates and was able to produce a training matrix for training planned across the year for all the homes in this group. We looked at two staff files. One was for someone appointed quite recently. We were unable to find a start date for this person so it made it impossible for us to check if all the pre-employment checks were in place before this person started, although we had reassurances from the operations manager that they were. We were told that the person had been initially inducted for three days before working unsupervised, but there were no written induction records to support this. We were told that the person would be working through skills for care induction workbook with a mentor, but we had no direct evidence of this. The person would take the record home and work through it when on shift. We saw evidence of basic training in the induction period but the main method of teaching was through watching videos and then question and answer sessions, which when we looked at the multi-choice questions some were incorrectly answered and the answers had not been scored or marked with pass or fail so did not show the person was sufficiently competent. On this first file there were two references, the first was unsatisfactory, and comments raised by the referee had not been followed up by the people interviewing. It was good to see the interview was conducted by two people and notes of the interview were taken, (previous management.) But gaps in employment history had not been followed up either. This person had obtained some certificates relevant to the work before this employment but the home had not retained a copy. The second staff file was satisfactory but we did not see a work permit. We did not see evidence of their induction other than subjects covered by video and question and answer sessions. We asked to see a third staff file for a member of staff that had been dismissed. This could not be produced at the time of the inspection but was later found in archived records. The person had been employed with no references on file. Two of the three staff Care Homes for Older People Page 9 of 18 files had criminal records checks but in one file this could not be produced although had been applied for. What the care home does well: What they could do better: We were encouraged by the actions taken to date by the operations manager. We identified significant shortfalls in the service again and the service history would indicate that without some continuity of management who are given the tools to manage this service will not improve. There has been an ongoing problem with the high turnover of managers and operational managers in post within this service which has led to a lack of sustained improvement and continuity within the home. Records are not in place, cannot be found or are not up to date. The operations manager has sent out surveys for feedback about the service being provided. There is no overall plan for the service addressing staff training and development and a plan for the routine maintenance and upkeep of the building. Schedules regarding the cleanliness of the Care Homes for Older People Page 10 of 18 building were not seen. We have requested a copy of the accounts for the service, to ascertain the financial viability of the home given the current self imposed embargo. The operational manager does not have any administrative support. Whilst the operational manager is overseeing the management arrangements in Bethany Francis House, this prevents the person from performing the role of operational manager in all of their homes. In one instance a pre-admission assessment was not completed in a timely fashion and this led to a residents needs not being fully understood by staff. We have not made a requirement on this occasion We are not satisfied that residents have their privacy and dignity respected at all times, particularly in relation to care giving. We have had a number of complaints from relatives about poor personal care given. We have spoken to care staff who feel there are insufficient staff on shift. We have spoken to the district nurses who had a recent concern about fluid intake and incontinence pads not being changed sufficiently. A recent investigation against a staff members conduct resulted in dismissal. We saw poor evidence of induction into meeting peoples care needs and this incident of poor care was reported by a relative and not care staff who had observed it. There are insufficient hours devoted to the provision of meaningful activities and we have seen no evidence of residents involved in daily tasks around the home. Care Staff however well intentioned do not have the time to provide activities or spend lots of time with residents because they are expected to complete non care tasks as well. Complaints and SOVA concerns had been investigated but we saw no records recorded in the complaints book. Incidents had not been written up. The home do not have robust staff selection and recruitment procedures which puts people at risk. The home is not being maintained in accordance with a routine programme of maintenance and renewal. Bedrooms do not have locks affording residents privacy. Equipment, furnishing and bedding is basic in some bedrooms. The cleanliness of the kitchen was unacceptable and the laundry room not fit for purpose. We will be making a requirement and liaising with the environmental health department. Staffing We were not able to find evidence that staff are properly recruited, and sufficiently supported through induction, training and supervision. We are not satisfied that staff are employed in sufficient numbers or have the skills, or competence to perform their jobs to a high standard. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 11 of 18 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 12 of 18 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, 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 10 12 The home must ensure it 30/09/2010 makes proper provision for the health and welfare of residents. They must do this in a manner which respects the privacy and dignity of residents This is to ensure their needs are met in an acceptable way 2 12 15 The lifestyle experienced in 30/09/2010 the home must reflect the life experiences, expectations, preferences and capabilities of the residents living in the home. This is to ensure residents social and emotional needs are met as well as their physical needs 3 15 22 A record of all complaints and their subsequent investigation and outcome must be kept in the home. This also refers to SOVA concerns This is to ensure that the 30/09/2010 Care Homes for Older People Page 13 of 18 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 home are able to demonstrate how effectively they deal with complaints and avoid a reoccurrence where possible 4 19 16 The home must ensure that 30/09/2010 they have adequate facilities and services with particular attention to 16, (2) (c) provide adequate bedding, (f) make arrangements for their clothes to be sorted and kept separately, (g) Provide sufficient and suitable equipment (j) After consultation with the environmental health authority make suitable arrangements for maintaining satisfactory hygiene standards. (k) Keep the care home free from offensive odours and make satisfactory arrangements for the disposal of general and clinical waste. This is to ensure residents are kept safe and comfrtable and hazards to their health from infection are kept at a minimum. 5 19 23 The home must be kept in a 30/09/2010 good state of repair externally and internally and cleaned to a reasonable standard. ( Lighting must be appropriate and work in all areas of the home. Care Homes for Older People Page 14 of 18 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 This is to ensure residents are comfortable and safe and the risk of cross infection is kept at a minimum 6 27 18 The home must ensure that 30/09/2010 it has sufficient staff on duty, day and night to meet the assessed needs of its residents and the home must ensure that staffs roles and responsibilities are clearly clarified This is to ensure the home has the capability to meet assessed needs. 7 29 19 The home must have proper recruitment checks in place before staff are employed. This is to ensure residents are protected 8 30 19 Staff training must be 30/09/2010 adequate and up to date. Training must be shown to increase staffs competence and give them the knowledge they need to fufil their role. This is to ensure residents needs are met. 9 34 25 The registered provider must 30/09/2010 provide evidence to the Commission that they are financially viable and the purpose of running their business in the interest of the service users. The Commission is requesting a copy of the annual accounts for the home. Page 15 of 18 30/09/2010 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 This is to ensure that the home are able to continue to meet the health and welfare of the people in their home 10 38 37 Any event affecting the well 19/08/2010 being, and or safety of a resident must be reported to the CQC without delay, records must be available in the home This to ensure people are safe 11 38 23 The health and welfare of 30/09/2010 people must be protected. Staff must have an up to date food hygiene and health and safety certificate and the home must be able to demonstrate that they store food correctly and have risk assessments in place for food hygiene and infection control and COSSH This is to ensure people are safe 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 3 The home should ensure that a full assessment of a prospective residents needs are completed before admission and kept under review. Where a resident has an identified specialist need the manager must ensure that the staff have the experience and skills to meet this need. Care Homes for Older People Page 16 of 18 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 2 36 Staff supervision should be offered regularly and there should be an annual appraisal of staffs performance Care Homes for Older People Page 17 of 18 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial 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. Care Homes for Older People Page 18 of 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!