Care Home: Briarwood

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What the care home does well People feel well supported in the home - they told us that they felt they could not be looked after better. We saw that people had a good rapport with the owner and readily chatted with her. People are assessed before they enter the home to make sure that the home can meet their needs. Peoples health needs are met; people are supported to attend appointments as necessary and health professionals are contacted for assistance. People told us that within reason they are able to do as they please and records showed that people undertake activities. People like the food in the home and are happy with the choices that are offered. People like their rooms, they are comfortable and their rooms can be personalised with items from their own home. What has improved since the last inspection? There is now a fire risk assessment and procedures in place that would assist people to manage the situation in the event of a fire and reduce their risk of harm. The owner and staff are now trained in Safeguarding Vulnerable People from Abuse, which will help people if an allegation of harm occurs. People are now supported though a care planning process which helps in the identifying of their needs so that staff are sure that they are aware of and know how to meet peoples current needs. There are now risk assessments in place to identify peoples needs and to help to keep them safe. What the care home could do better: Peoples care files should contain an up to date photograph of the person, this would assist the emergency services should the person become missing from the home. Risk assessments should be completed for window opening restrictors to identify if restrictors are required to protect people from the risk of falling. Training for staff requires updating to make sure that they have the correct skills to meet peoples needs. This includes , Dementia and moving and handling training. In addition staff should keep their skills up to date and undertake refresher training including medication training. Staffing levels should be reviewed to address the shortfalls on a weekend and evening when only the owner is available to support people with their needs.A risk assessment must be undertaken regarding the walls of the laundry, this is to assess if they are permeable which may compromise the infection control within the home. There should be a quality assurance system in the home that allows the people living there and their representatives the opportunity to comment on how the home meets its objectives and how it might improve on these. Notifications under Regulation 37 of the Care Homes Regulations 2001 must be forwarded to the CQC when an incident occurs in the home. Key inspection report Care homes for older people Name: Address: Briarwood 12 Station Avenue Bridlington East Riding Of Yorks YO16 4LZ     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: Sarah Rodmell     Date: 1 3 1 0 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: Briarwood 12 Station Avenue Bridlington East Riding Of Yorks YO16 4LZ 01262679233 F/P01262679233 jacquiblower@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Jacqueline Vera Blower care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Briarwood is a detached three-storey property located in a residential area of Bridlington. It is conveniently situated for all of the main community facilities including the public transport network. The home provides accommodation and personal care for a maximum of seven (7) older people some of who may have dementia. Nursing care is not provided. Should such care be required on a short-term basis, the community health care team will provide it. The home also provides accommodation and personal care on a respite care basis. Peoples private accommodation is located on the ground and first floors. A stair lift provides access to the first floor. The registered providers private accommodation is on the upper floor. There are three double bedrooms and one single. All of the bedrooms except for one are currently used for single accommodation. The bedrooms have en suite facilities consisting of a toilet and a wash-hand basin. People have the use of a lounge and Care Homes for Older People Page 4 of 28 Over 65 7 7 0 0 3 0 1 0 2 0 0 8 Brief description of the care home dining room on the ground floor. There are some internal steps on the ground floor. The home has a large pleasant garden with an aviary. The garden is accessible to people. If people want to see the Statement of Purpose, service user guide, or the report written by the Commission for Social Care Inspection, they should contact the registered provider direct. 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 star . This means that the people who use the service experience good outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last key inspection on 30 October 2008, including information gathering during a site visit to the home. The unannounced visit was undertaken over one day by one inspector. It began at 9.30 am and finished at 3.00 pm. On the day of the visit the inspector spoke with the people who live in the home, one member of staff and the owner of the home, who is also the manager. Inspection of the premises and close examination of a range of documents, including three care plans, were also undertaken. The owner submitted information about the service prior to the site visit by completing and returning an Annual Quality Assurance Assessment, (AQAA). The AQAA is a self assessment tool that focuses on how well the outcomes are being met for people who use the service. Care Homes for Older People Page 6 of 28 The owner told us that the current fees for residential care is £ 337 to £385 per week. At the end of this visit, feedback was given to the owner on our findings, including requirements or recommendations that may be in the key inspection report. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated it is likely that enforcement actions will be taken. 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: Peoples care files should contain an up to date photograph of the person, this would assist the emergency services should the person become missing from the home. Risk assessments should be completed for window opening restrictors to identify if restrictors are required to protect people from the risk of falling. Training for staff requires updating to make sure that they have the correct skills to meet peoples needs. This includes , Dementia and moving and handling training. In addition staff should keep their skills up to date and undertake refresher training including medication training. Staffing levels should be reviewed to address the shortfalls on a weekend and evening when only the owner is available to support people with their needs. Care Homes for Older People Page 8 of 28 A risk assessment must be undertaken regarding the walls of the laundry, this is to assess if they are permeable which may compromise the infection control within the home. There should be a quality assurance system in the home that allows the people living there and their representatives the opportunity to comment on how the home meets its objectives and how it might improve on these. Notifications under Regulation 37 of the Care Homes Regulations 2001 must be forwarded to the CQC when an incident occurs in the home. 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. We looked at standards 3 & 6. People are assessed and receive information before moving into the home to make sure that the home can meet their needs and that this is an informed choice. Evidence: The owner told us that people are provided with a service brochure as part of the admissions process to the home. They also told us that when possible a care management assessment is undertaken prior to people moving in, and that on other occasions the owner completes an assessment to make sure that the home can meet the persons needs. Copies of assessments were seen in peoples care plans. The owner recorded in the AQAA and told us on the day of the visit that everyone moves in on a trial basis, that is both to find out if the home is acceptable to them and if they are suitable to live in the home. People told us that their relative visited the Care Homes for Older People Page 11 of 28 Evidence: home or that they knew the reputation of the home before they decided to move in. A professional told us that the home had worked well to support someone with the move there and that this had been successful for the person concerned. The owner confirmed to us that they do not provide intermediate care. Care Homes for Older People Page 12 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. We looked at standards 7,8,9 & 10. People are supported to meet their health and medication needs, with their privacy and dignity being maintained. Evidence: We reviewed the care files of three of the people who live in the home. Each of these files had an assessment and plan of care based on the persons individual needs. The plan covered both their health and social needs. However, the plan of care did not include a photograph of each person, which could be used should the person become missing from the home. Where possible people had signed to say that they have agreed to the contents of their care plan - they also acknowledged this to us when we spoke to them. People further told us that they are supported to meet their needs and that this includes visits to health professionals. Peoples records included details of their Care Homes for Older People Page 13 of 28 Evidence: individual health needs, including assessments and their medication details. Their care notes also included details of visits from health professionals with the reason for the visit and the outcome. One professional told us that they felt peoples needs were well met in the home. The owner informed us that she and one member of staff administer the medicines in the home. Discussions with the owner found that although all medicines entering the home are checked, no record of this is kept. She further told us that when medication is disposed of a record is kept, however, none were available on the day of this visit. Records for the administration of medicines are kept and these were correct at the time of the visit. The owner recorded in the AQAA and told us on the day of the visit that there are no controlled drugs in the home. She told us that, although she and the one staff member have attended a general medication training course, this was three years ago and was due for renewal. We observed one person being supported with personal care and that this was completed in a dignified manner, and that peoples appearances reflected their own individuality. The owner recorded in the AQAA that We constantly strive to make sure our residents feel safe, loved, useful and important. Care Homes for Older People Page 14 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. We looked at standards 12,13,14 & 15. People are supported through a care planning process to undertake some activities of their choice. However, lack of staff could restrict opportunities and choices. Evidence: People told us that they are happy with the activities offered in the home. Peoples care plans recorded the interests and hobbies that they have and some of these were then recorded in peoples daily notes when they had been undertaken. These included going for a walk, knitting and watching the TV. The owner recorded in the AQAA that: people enjoy activities by car or a walk, that they enjoy meals, have visitors at anytime and go out when they wish ( with staff if needed). A professional told us that activities take place in the home and that people are supported by the staff to undertake these. The owner told us that the staff shift ends at 6 pm and that there are no staff on duty apart from her on a weekend. This restricts the opportunities for people to socialise on an evening or weekend and the owner should look at this. Care Homes for Older People Page 15 of 28 Evidence: People told us that they are able to do as they wish and go out when they want to. There was information available in the hallway regarding advocacy should people wish to access this. People are supported to manage their own finances and the owner told us that they do not manage anyones monies for them. The owner showed us the menus that they use. She also explained that, due to the small size of the home, she is able to deviate from the menu when there are special offers at the local shops and so offer other choices. She told us that should someone not like the meal that day they would be offered a choice and people told us that they are happy with the food provided and that is it home cooking. Peoples files included a nutritional assessment and records of their weight which help to make sure that their nutritional needs are being met. 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. We looked at standards 16 & 18. People are able to raise concerns and complaints. However, the lack of formal systems could mean that complaints are not dealt with fully and to peoples satisfaction. Evidence: The owner recorded in the AQAA and told us on the day of the visit that no complaints have been made to the home for several years. She felt that this was due to the fact that, as she supported people and was available every day, any concerns were dealt with immediately. She does not have systems in place should a formal complaint be made, and told us that she refers to a management system for advice and sample policies. She also recorded in the AQAA and informed us on the day of the visit that she had attended a safeguarding vulnerable adults from abuse training session. Following this she had trained staff herself, in this subject. She did not have a copy of the Local Authoritys policy on the safeguarding of adults, although in discussion she was clear on how to refer any allegations to the Local Authority. She recorded in the AQAA that she had a policy on the Protection of Vulnerable Adults in the home. In discussion with the people in the home, they told us that they felt safe in the home. 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. We looked at standards 19 & 26. People live in a clean and comfortable home. However, the lack of risk assessments means that their safety needs are not fully met. Evidence: We completed a tour of the premises, which was warm and comfortable throughout. On the ground floor there is a communal lounge and dining area. One persons bedroom is also on the ground floor with the remainder being on the first floor. There is no CCTV in the home and we saw that there are gardens that people can access. The owner told us that these have recently been improved with the removal of some large trees that previously blocked some of the light. When asked people were happy for us to view their rooms, and also told us that they were happy with their rooms. We found that people were able to personalise their rooms, bringing items from home. The owner recorded in the AQAA that refurbishment of the home is ongoing, that the requirements of the fire service are met and that she holds certificate for training in the control of infection. Care Homes for Older People Page 18 of 28 Evidence: We saw that the windows do not have opening restrictors and the owner was advised to complete a risk assessment for this, with consultation from the Local Environmental Health Officer. She should also consider the requirements of the Local Fire Authority. The laundry room is situated on the first floor of the home and is wallpapered. The owner should complete an assessment to ensure that the walls are not permeable and so do not compromise the control of infection in the home. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at standards 27, 28, 29 & 30. People are supported by inadequate numbers of staff, who are adequately recruited. Although well skilled, staff require additional training to ensure that they can continue to meet peoples needs. Evidence: The owner told us that there are 2 staff employed in the home, one who works 40 hrs per week and one who is part time. Both work shifts Monday to Friday starting at 8 am and finishing either at 1 or 6 pm. This means that there are no waking night staff and there are no staff except the owner after 6 pm or on a weekend. The owner told us that her son (who is the handyman) is also available on an evening and weekend, for emergency assistance.As there are no domestic or catering staff employed in the home, the owner also completes these tasks on a weekend. The Residential Forum, care staffing tool identifies that for 5 service users there should be a minimum of 124 hours staffing provided per week, with 97 of these being purely for care. There is one full time staff member who works 40 hours per week and one part time member of staff who works 20 hours per week. As the owner also works in the home and completes all of the administration, this would mean that they individually would work in excess of 60 hours per week. This is in addition to them Care Homes for Older People Page 20 of 28 Evidence: being on call overnight as the only person available. This is not good practice and must be addressed.The lack of staff at these times restricts peoples choices in the home. Some of the people who live in the home require a higher level of support than others and the lack of enough staff prevents these needs from being fully met. The owner both recorded in the AQAA and informed us on the day of the visit that one staff member has worked in the home for 20 years and the other for 2 years. We looked at the recruitment documents for the member of staff who had worked in the home for 2 years. There was no application form and the owner confirmed that they had not received one. At the time of employment the owner had accepted a Criminal Record Bureau check (CRB) from another organsiation and following advice at the last inspection had undertaken another CRB for this person. A CRB check assists the owner in ensuring that the person does not have any criminal convictions that may prevent them from working with vulnerable people.Two references were received as part of the persons recruitment. However, these were addressed To whom it may concern and the owner was advised as to the necessity of receiving references specific to the person and the current role they are applying for. The owner recorded in the AQAA that all staff have either a National Vocational Qualification (NVQ) level 3 in care or are qualified nurses. On the day of the visit she confirmed that one member of staff holds the NVQ level 3 and that one staff is a nurse. The owner also recorded in the AQAA and told us on the day of the visit that there is no staff development plan as she is aware of the training needs of the staff. Staff have completed several courses this year, including in-house training on safeguarding provided by the owner. In addition, they are to attend a formal safeguarding training course. Staff training completed included: visual impairment, deprivation of liberty and challenging behaviour courses. Staff have not received training in dementia care, or updated moving and handling or the handling of medicines training. It would be advised that a staff development plan is completed to help ensure that staff receive all of the necessary training 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. We looked at standards 31,33,35 & 38. People live in a home that is comfortable, warm and safe with a stable staff team, who are well meaning. However shortages in staff compromise the ability to meet all of peoples assessed needs. Evidence: The service first received an adequate rating at the inspection visit of 30 October 2008. Were requirements were made regarding care plans, risk assessments, training, recruitment and fire procedures. Although these requirements were overall met, a number of new requirements have been found at this inspection visit. The owner of the service must take action to ensure that the home meets all of the regulations of the Care Homes Regulations 2001. The owner recorded in the AQAA that they have managed the service for a number of years. They told us that they have completed recent training, including safeguarding Care Homes for Older People Page 22 of 28 Evidence: training, and are undertaking a management course. Overall people appeared comfortable in their environment. People were observed during the visit and were seen to be left without staff interactions, whilst staff were busy in other areas cleaning and cooking. This means that there are inadequate staffing levels in the home and this must be addressed. The information recorded in the AQAA under the views of people who use our service was that a questionnaire has been introduced that asks friends, family and professionals to complete giving their views on their work and attitude. On the day of the visit the owner told us that they did not have a Quality Assurance system so there were no documents available to view. However, the day after the site visit they contacted the CQC and confirmed that they did have the questionnaires and would forward a copy to the CQC. These have not been received. They told us that they do not handle any monies for the people who live in the home and consequently the standard relating to this has not been assessed. Information recorded in the AQAA included further information as to the polices and procedures and the maintenance checks in the home, confirming that these were up to date. We examined some of these on the day of these site visit and found evidence that the Gas Safety, Electrical Wiring, Portable Appliances, the Fire Alarm system and chair lift had all been serviced and passed as safe. these are in addition to the work required regarding the window restrictors and the laundry. There are no records for any accidents that occur in the home and the owner told us that there is a book for recording incidents but that none have occurred in years. The owner also told us about one of the people who live in the home, that when they first moved into the home, they had often got lost when they went out for a walk and had to be returned to the home by the police. However, no notifications of this were sent to the CQC and the owner must ensure that we are notified of any future incidents. 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 18 Staff who administer medicines must receive up to date training in the safe handling of medicines. This will help to make sure that people receive their medicines correctly and that their health needs continue to be met. 29/01/2010 2 12 18 There should be adequate staff available throughout the week and weekend so that people are provided with the opportunity for activities that meet all of their diverse needs. This would enable people to make choices on a daily basis and not be restricted to going out only when there are staff on duty. 15/01/2010 3 19 13 An assessment of the need for window opening restrictors must be completed, including any 13/11/2009 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 advice from both Environmental Health and the Fire Authority. With any necessary actions being taken including the installation of window opening restrictors. This will help to make sure that people are protected from the risk of harm, and from falling from an open window. 4 27 18 The number of staff must be 16/11/2009 increased so that staff can meet all of the assessed needs of the people who live their. This will help to make sure that peoples needs are safely and fully met. 5 30 18 Staff must be up to date with their knowledge and training. This will help to make sure that they continue to meet peoples changing needs. 6 38 37 Incidents as listed under regulation 37 of the Care Homes Regulations 2001, must be report to the CQC. 27/11/2009 15/01/2010 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 This will assist in ensuring that a full picture is known on how peoples needs are being met. 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 7 There should be a photograph of each person, held in their individual care plan which could be used to assist the emergency services should this person become missing from the home. A record should be kept of all medicines received into and disposed of in the home. There should be a formal system for the recording of complaints, how they are dealt with and the outcome. This would support people in making sure that their concerns were fully dealt with and that they were happy with the outcome. There should be a copy of the Local Authoritys policy on safeguarding adults available in the home. An assessment should be undertaken to ensure that the walls in the laundry room are not permeable . With any highlighted actions being taken There should be a staff training plan to help make sure that staff receive all necessary training. There must be sufficient management time for the manager to undertake management tasks. This time must be clearly shown on the duty rota and in addition to any care hours that they work. There should be a system of quality assurance that seeks the views of the people in the home and their representatives. 2 3 9 16 4 5 18 26 6 7 30 31 8 35 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. 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