Care Home: Birch Heath Lodge Nursing Home

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What the care home does well Care plans provide good information about the person`s needs, so that staff know what to do to make sure each person`s needs are met in the way they prefer. Processes are in place to monitor mobility and falls so that people are kept as safe as possible. The home maintains good links with other health professionals so that people living in the home are supported the best way possible for their health and wellbeing. Meals provided in the home are nicely presented and good quality; one person described the food as "excellent". What has improved since the last inspection? There are processes in place to ensure that Criminal Record Bureau checks are sought and the necessary information received before any new staff start working in the home, so that residents are assured staff are suitable to work in the home. There is an on going refurbishment plan for the home so that people live in comfortable surroundings. What the care home could do better: A clear system of auditing medicines received, administered and or returned should be developed so that records demonstrate there is no mishandling of medication. Sufficient staff should be available to ensure that planned activities go ahead to avoid residents` disappointment about activities being cancelled. All complaints (including verbal complaints) need to be recorded with a record of the action taken to deal with them so that the home can demonstrate they take complaints seriously and residents` concerns are listened to. Staff must received regular training on safeguarding adults to make sure they are working in accordance with good practice, they know what to do to protect people and people`s welfare is safeguarded. Risk assessments must be undertaken about unguarded radiators and action taken to minimise identified risks, such as low surface temperature radiators or radiator covers being fitted, to make sure that people living in the home are safe. Staff must be on duty in sufficient numbers to meet the needs of the people living in the home. Staff must receive regular and refresher training in the following areas; moving and handling, fire, food hygiene, infection control and health and safety. This is to make sure they are competent to fulfil their role, work in line with best practice and safeguard residents` welfare. Staff should receive regular, planned, formal supervision so they are given the opportunity to discuss any areas of concerns, their performance and any training needs. Key inspection report Care homes for older people Name: Address: Birch Heath Lodge Nursing Home Birch Heath Lodge Birch Heath Lane Christleton Chester Cheshire CH3 7AP     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: Julie Porter     Date: 2 9 0 3 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: Birch Heath Lodge Nursing Home Birch Heath Lodge Birch Heath Lane Christleton Chester Cheshire CH3 7AP 01244335503 F/P01244335503 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Birch Heath Lodge Limited care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care home with nursing - Code N 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 The maximum number of service users who can be accommodated is: 38 Date of last inspection Brief description of the care home Birch Heath Lodge is a listed building that has been converted and extended into a nursing home for older people. The home consists of the main house and the Greenwood unit, which is a separate building in the same grounds. Some of the bedrooms have en-suite toilets and wash basins and the home has two shared bedrooms. It is situated in the centre of the village of Christleton, approximately four miles from Chester. Information regarding the current weekly fees are available from the manager. Care Homes for Older People Page 4 of 28 Over 65 38 0 Brief description of the care home 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: The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. We carried out this unannounced visit to Birch Heath Lodge 29 March 2010. The visit lasted a total of 6 hours and was carried out by one inspector. The report says we when referring to what we did, as it is written on behalf of the Commission for Social Care Inspection. The visit was just one part of the inspection. We also looked at other information we had received about the home since our last inspection there. Before the visit the manager was asked to complete a questionnaire to provide up to date information about the service. During the visit we spoke with the manager, some staff members and a number of Care Homes for Older People Page 6 of 28 people living in the home. The records of two people living in the home were looked at to check the care they receive. We looked at records of medication, care plans and training records were also examined to see how the home is run, how care is provided for the people who live there and what training staff have received. The views of the residents and relatives and friends available on the day of the visit were sought; their views are incorporated into the report. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: A clear system of auditing medicines received, administered and or returned should be developed so that records demonstrate there is no mishandling of medication. Sufficient staff should be available to ensure that planned activities go ahead to avoid residents disappointment about activities being cancelled. All complaints (including verbal complaints) need to be recorded with a record of the action taken to deal with them so that the home can demonstrate they take complaints seriously and residents concerns are listened to. Staff must received regular training on safeguarding adults to make sure they are working in accordance with good practice, they know what to do to protect people and peoples welfare is safeguarded. Risk assessments must be undertaken about unguarded radiators and action taken to minimise identified risks, such as low surface temperature radiators or radiator covers being fitted, to make sure that people living in the home are safe. Staff must be on duty in sufficient numbers to meet the needs of the people living in the home. Staff must receive regular and refresher training in the following areas; moving and handling, fire, food hygiene, infection control and health and safety. This is to make sure they are competent to fulfil their role, work in line with best practice and safeguard residents welfare. Staff should receive regular, planned, formal supervision so they are given the Care Homes for Older People Page 8 of 28 opportunity to discuss any areas of concerns, their performance and any training needs. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 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 10 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. People are provided with information so that they can decide if moving to the home will meet their needs and they have their needs checked before moving in to make sure their needs can be met at the home. Evidence: There is information about what the home offers and what people can expect from living there (the service user guide and statement of purpose). Information we received before our visit told us that the individual needs of people are looked at before they moved to the home so that they know their needs can be met at the home. We looked at care plans and saw that assessments had been carried out before the person had moved to the home. This meant that the home and the staff had the information they needed to make sure that the persons needs could be met as soon as they moved into the home. Care Homes for Older People Page 11 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 of the people living in the home is monitored to make sure they get the support they need to maintain their health and wellbeing. Evidence: We checked one persons care plan in detail and looked at others to see what care they were receiving to meet their needs. We saw that care plans include health reviews and daily recordings about peoples well-being. There are monitoring and review processes in place for falls, peoples mobility, pressure care, nutrition and general well-being. One member of staff has the responsibility for liaising with the continence advisor to ensure that people living in the home get the right advice and the correct products for their needs. On the day of our visit we saw the doctor visiting the home. We were told this is a regular weekly visit to see people would needed a consultation or an opportunity to do a bi-annual health review. We were told that people living in the home could see the doctor at any time in accordance with their needs. We were told that people could retain their own GP if they wished. We looked at medicines on Greenwood unit with the nurse on duty. On arriving there, Care Homes for Older People Page 12 of 28 Evidence: we found the top medicine cabinet was unlocked, which meant that the medicines were not being kept as securely as they should have been. Medicines are given out to people who live in the home from bottles by qualified nursing staff. We looked at the records of two people; we saw that the medication administration record (MAR) had been signed and showed no gaps. However the stock of medicines could not be reconciled with the records. In each case, there was more medication remaining than there should have been according to the records of amounts received and given. Unused medication was collected from the home by a representative from the pharmacy that supplies the home. We asked the nurse if there was a process for recording what medicines, in what amounts, were being returned to the pharmacy in this way. We were told there was no process for this. Throughout our visit we saw and heard staff knocking on bedroom doors before entering. Although one person living in the home said she didnt like staff knocking and preferred them to come in a chat with her, staff knocking on doors showed us that they appreciated the need to respect the privacy of the people who live in the home. In the bathroom in Greenwood unit, we saw a list on the wall that provided information of who had had a bath and confirmation that the bathroom had been left tidy. We asked this to be removed to ensure that peoples privacy and dignity is maintained. 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 living in the home have the opportunity to participate in some activities and enjoy varied, good quality, wholesome food that helps them to stay well and healthy. Evidence: The information we received from the manager before our visit said that the home could do more to improve/develop social activities. We were told that two carers have responsibility to organise activities and one person we spoke with told us they had just completed training to help them plan and organise activities. Two of the five surveys that were returned from people who live in the home said they would like more activities. One person said, the home should make sure that the people keep their minds and bodies active. Another told us, I would much appreciate the occasional outing around the village. One person we spoke with told us that they were supported to go to church each week which is across the road from the home. At our visit we saw information displayed around the home informing the residents and their relatives of forthcoming events. We were told by two people living in the home that they would be finishing Easter bonnets later that day. However, this activity did not take place during our visit; we were told that this was because of staffing levels. The information about the home (the statement of purpose) dated April 2010 said the Care Homes for Older People Page 14 of 28 Evidence: home had a hairdressing salon and we saw that work was in progress to develop a room into a salon. The hairdresser was in the home during our visit and we saw her chatting with residents who appeared to know her well. We saw that people had visitors throughout the day and that they either met them in private in their own bedrooms, or in the lounge area. Relatives told us that they were made to feel welcome and were very often offered a drink. We saw that drinks were available in the entrance of the home and were told they were for visitors and people living int the home. Relatives told us that staff in the home were lovely. We were told by people living in the home that the food is excellent. We looked at the menu plans and saw that they were varied and wholesome. Each person has a individual preference card which has been agreed with them for breakfast and included cereals, toast, fruit, and full cooked English breakfasts. For their main meal, people are offered a choice from two starters, two main courses and two sweets each day and either a hot or cold supper. One person suggested that the portions could be smaller and another that more fresh fruit and vegetables should be served. We discussed with the manager arrangements around supporting people with eating and if this could be managed better within Greenwood where a number of people living there need staff support. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples concerns are listened to and dealt with but the records of this need to be improved and staff need to receive updated safeguarding training to make sure they know what to do to protect the people living at Birch Heath Lodge from harm. Evidence: We looked at the complaint log and saw that two formal complaints had been made to the home. We spoke with people during the visit who told us that they would speak with staff if they were unhappy with any aspect of their care or the home. One person told us that she had spoken with the manager and staff about her room and the concerns she had. Staff we spoke with told us that they believed people living in the home were very able to tell them what they thought. We were told that issues raised with staff either individually or at residents meetings are often recorded in the persons daily notes but not necessarily recorded as a verbal complaint or concern. We therefore felt that the extent of complaints/ issues raised may not be accurate and may not truly reflect the hard work done by staff to meet peoples needs and resolve their concerns. Two of the resident surveys we were sent told us that they did not know how to make a formal complaint. During our visit the manager provided us with a summary of training completed in the home. The day after our visit, she sent us a updated copy of this information and we have used that for this report. The record showed us that 4 of the 11 qualified nursing staff, 12 of the 22 health care staff and 2 of the 6 ancillary staff had not received training on safeguarding adults in the last two years. This training does need to be kept up to date to make sure that staff know Care Homes for Older People Page 16 of 28 Evidence: what to do to protect the people who live at the home from harm and abuse. The home has policies and procedures for safeguarding residents finances and people living in the home can keep valued possessions and a small amount money securely in the home. We saw that residents bedrooms did not lock and they did not have anywhere in their rooms where they could lock away possessions. Care Homes for Older People Page 17 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 generally well maintained so that people living there do so in comfortable surroundings that suit their needs. Evidence: We walked around both of the buildings that make up the home with the manager, who told us of the plans to refurbish the bedrooms. The information we received from the manager in February 2010 says that all radiators in the home will be changed to low surface temperature models but at our visit, she was not sure about the timetable for this work to be completed. We were told the estates manager was visiting the following day and she would raise it with him. During the tour we saw some radiators that were extremely hot and pointed out one in particular that was out of sight of passing traffic that would pose a risk if people fell in that area. A new maintenance person was being employed at the home for 18 hours a week. The manager confirmed that future refurbishments in the home such as decorating would be done by contractors. In the Greenwood unit there wads a small kitchen area where the staff prepared drinks and where meals are served from with a microwave to reheat food when necessary. A cupboard door was missing and the worktop was very badly scratched, in places down to the raw material, so posing a hygiene risk. Care Homes for Older People Page 18 of 28 Evidence: All areas of the home were clean and smelled fresh. Care Homes for Older People Page 19 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. Some staff have up to date training but not all and staff may not be available in sufficient numbers to be able to meet the needs of the people living at the home at all times. Evidence: We checked the records of three new members of staff to see that all the necessary recruitment checks had been carried out when they were appointed. In all cases we found that there were completed application forms, two written references, a record of the interview, a contract of employment and either the Criminal Record Bureau (CRB) disclosure or an internal disclosure record giving the date of the disclosure and the number. During our visit we provided the manager with information in respect of retention of CRB disclosures between inspection visits. During our visit we observed staff working in the Greenwood unit we observed staff during a period in the morning, at the end of lunch, and during the afternoon and up to and including tea. We saw two members of staff available to support the people living there and for a period after lunch only one person was available. Staff told us that five people living in Greenwood were being cared for in bed and required turning every two hours in line with good practice. This would mean that both staff on duty in the unit would be involved with re-positioning residents and unable to respond to call bells from other residents. We observed on more than one occasion people waiting Care Homes for Older People Page 20 of 28 Evidence: more that 5 minutes for the bell to be answered. This would confirm the information received on one of the service user surveys and information told to us on the day. One comment we received was, there is a noticeable increase in stress and tension in staff which passes on to us patients. Its probably due to a shortage of good carers and no replacement when helpers are sick or absent. This means longer waiting for assistance calls to be answered. One person told us, when asked about activities, the staff are too busy to pursue these things and they are badly needed. We discussed staffing levels and the layout of the home with the manager in respect of meeting peoples needs in two separate buildings. Training information we saw showed that 13 health care assistants and 2 ancillary staff had a National Vocational Qualification (NVQ) at level 2 and 2 had an NVQ at level 3. The manager told us that the home had employed a training provider and a timetable of training had been left in the staff room for staff to nominate themselves. Training information we saw showed some significant gaps in the staff training. We suggested that the manager should nominate staff for training to make sure that mandatory training is undertaken regularly by all staff. Care Homes for Older People Page 21 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 home is well managed in some areas but gaps in staff training may mean that it is not always being run in the best interests of the people living there. Evidence: We looked at the accident records and found that clear accurate information had been recorded. We saw that the manager had a process in place to monitor all injuries in the home on a monthly basis. The manager told us that the quality assurance surveys for the year had been sent out just before our visit to people living in the home and other interested parties so they could say what they thought about how the home was being run. We saw records of meetings held with residents to seek their views about living in the home. We spoke with the manager and the deputy about the supervision of staff in the home; they both told us that they see staff everyday and either work alongside them or there is an open door policy if they want to raise issues. We found that was no plan Care Homes for Older People Page 22 of 28 Evidence: in place to have formal supervision or appraisal with staff. One staff file we saw had only one recorded supervision session dated 09/11/09 although they had been employed in 2008. A file was shown to us of templates for supervision but the manager agreed that staff were not formally supervised or appraised as a minimum 6 times per year. We inspected the records kept for two residents where the home holds money for safekeeping on their behalf. A regular balance was maintained for all transactions and records were clear and well recorded. We saw a sample of service contracts that showed that checks of fire safety equipment, emergency lighting, bath seats and portable hoists had all been carried out. We were told that the lift had been serviced the week before our visit but the certificate was not available then. The last service before then was 14 September 2009. We looked at training records, in particular for mandatory training. These showed that some staff had not attended refresher training or in some cases attended any training and and the shortfalls were as follows: seven of the eleven qualified nurses, six of the twenty two health care assistant and three of the six ancillary did not have up to date moving and handling training. The chef and head chef had not since 2000 and 2002 respectively received training in food hygiene and six of the twenty two health care assistants did not have current food hygiene training. One qualified nurse had not received fire safety training since 1997; four other staff not since 2009; one not since 2007, and 2 had not received any fire safety training. Twenty of the total thirty nine staff had not received any health and safety training. Six of the eleven qualified nurses and twelve of the twenty eight health care and ancillary staff did not have up to date infection control training. Care Homes for Older People Page 23 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 24 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 9 13 Detailed records must be kept of the medications returned to the supplying pharmacy, including the amount being returned. This is to make sure there is a full audit trail to show that the people living at the home have received their medicines safely, as prescribed by their GPs, without any errors occurring. 06/05/2010 2 16 22 Records must be kept of any 07/05/2010 complaints or concerns raised about the home, including information about what action has been taken to investigate and resolve them. This is so to make sure there is evidence of how concerns are dealt with to show that the people who live at the home are listened 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 to and their concerns acted upon. 3 18 13 Staff must receive up to date training on safeguarding adults from abuse. This is to make sure that they have up to date guidance so they know what to do to make sure that the people living at the home are protected. 4 25 13 Assessments must be undertaken on the uncovered radiators to establish the risk posed to residents from hot surface temperatures. This is to make sure that possible risks are identified and action taken to minimise those risk and ensure that people living in the home are safe. 5 27 18 Enough staff should be on 30/04/2010 duty at all times in the home to make sure that the needs of the residents are met. This is to make sure that people who live in the home receive care to meet their needs as they require it. 6 38 18 Those staff who have not undertaken updates of 28/07/2010 07/06/2010 07/06/2010 Care Homes for Older People Page 26 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 mandatory training must do so. This must include health and safety, fire safety, moving and handling, food hygiene and infection control. This is to make sure that staff have the knowledge and up to date guidance to provide safe care for the people living at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 10 12 Personal information should kept confidential so that peoples privacy and dignity is assured. Staffing levels should be sufficient to ensure planned activities go ahead to avoid residents disappointment when planned activities are cancelled. The kitchenette work tops in Greenwood unit should be replaced as part of the refurbishment plan so that hygiene standards are maintained. Staff should receive formal supervision at least six times per year to provide them with the support and guidance they need to develop and maintain their skills. 3 26 4 36 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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