Care Home: Crann Mor Nursing Home

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What the care home does well All food provided at the home is freshly cooked and the home uses fresh fruit and vegetables everyday and this was observed during the visit. Policies and procedures are in place at the home on values of privacy and dignity, choice, fulfilment, rights and independence. These values are discussed with new members of staff on induction and during appraisals. There is no restrictions on visiting and family and friends are welcome at any time. during the inspection some relatives were seen during the day and spoke with us. One relative told us that her husbands health had really improved since his stay at the home due to the care and attention he receives. The staff spoken to on the day were knowledgeable about the care needs of the people using the service. They were observed to be interacting and speaking appropriately to the people using the service in a calm manner. Regular training takes place and this includes the NVQ (National Vocational Qualification) which all staff have access to. Other regular training also takes place to include safeguarding adults and fire awareness. Training in specialist areas is also undertaken by some staff and this includes training in dementia to improve staffs awareness of this condition and how to care for people with this problem. Employment folders for the staff that were sampled demonstrated that all necessary checks are carried out prior to staff commencing work at the home which safeguards the people living there. During the visit people using the service were complimentary about the care that they received from the staff at the home. One person told us `the staff are good, very good and caring`. Another told us `the staff look after me very well they are very kind`. What has improved since the last inspection? Two requirements were made following the inspection in September 2007 and these have now been met. The home now has a protocol in place for the provision of medical cover in urgent situations. The home has liaised with the fire officer to ensure compliance with the fire safety regulations. The fire officer has visited the home and the deputy manager told us that the requirements made at the time of the visit have now been met. What the care home could do better: Five requirements were made following this key inspection. The statement of purpose and service guide to be reviewed and updated. Some old information is contained within these documents and should be removed. The revised guides should then be reviewed regularly.Pre-admission assessments should be carried out for all people who wish to use the service. This ensures that the home can meet their needs and that some care plans can be prepared prior to their admission. The writing and updating of care plans to be completed and to ensure that each care plan is kept under regular review. Limited activities take place at the home. Consultation to take place with the people who use the service about their social interests. A programme of activities to then be agreed and organised. To review the home`s internal safeguarding adults policy to ensure that it matches the local authority`s procedures. Key inspection report Care homes for older people Name: Address: Crann Mor Nursing Home 151 Old Woking Road Pyrford Woking Surrey GU22 8PD     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: Lesley Garrett     Date: 2 8 0 5 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: Crann Mor Nursing Home 151 Old Woking Road Pyrford Woking Surrey GU22 8PD 01932344090 F/P01932344090 crannmor@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr A M Emambux,Mrs M Emambux care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 24 The registered person may provide the following category of service : Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category : Dementia (DE) Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Crann Mor is a large two storey detached property, which has been adapted to provide nursing care for up to 24 Older Persons. The home is situated in a residential area not far from the town of Woking. Accommodation is offered mainly in single rooms. There are communal areas consisting of a lounge/dining room and another small sitting area within the home. Care Homes for Older People Page 4 of 28 Over 65 0 24 24 0 Brief description of the care home There are gardens to the front and rear of the property, and there is ample parking space within the grounds. 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: This inspection of the care home was an unannounced Key Inspection. Mrs Lesley Garrett, Regulation Inspector, carried out this visit and the deputy manager represented the service. We were joined, for feed back, by the person who will be registering with CQC to become the registered manager. We arrived at the service at 09:30 and were in the home for five hours. It was a thorough look at how well the home is doing. It took into account information provided by the home and any information that CQC has received about the service. The deputy manager for the service supplied CQC with an AQAA (Annual Quality Assurance Assessment) and this document was used to assist with the inspection. The inspector also spent time talking with some of the people using the service and staff members. We looked at how well the service was meeting the key national minimum standards Care Homes for Older People Page 6 of 28 and complying with the regulations and have, in this report, made judgements about the standard of the service. Documents sampled during the inspection included the homes care plans, daily records and risk assessments, staff files, training records, and the homes safeguarding and complaints policies and procedures. From the evidence seen by us and comments received, we consider that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. 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: Five requirements were made following this key inspection. The statement of purpose and service guide to be reviewed and updated. Some old information is contained within these documents and should be removed. The revised guides should then be reviewed regularly. Care Homes for Older People Page 8 of 28 Pre-admission assessments should be carried out for all people who wish to use the service. This ensures that the home can meet their needs and that some care plans can be prepared prior to their admission. The writing and updating of care plans to be completed and to ensure that each care plan is kept under regular review. Limited activities take place at the home. Consultation to take place with the people who use the service about their social interests. A programme of activities to then be agreed and organised. To review the homes internal safeguarding adults policy to ensure that it matches the local authoritys procedures. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to use the service do not benefit from a pre-admission assessment from a suitably trained person from the home to ensure that the home can meet their needs. Some shortfalls were found in the service user guide and statement of purpose and these documents need to be reviewed. Evidence: We looked at the service user guide and statement of purpose. They did not contain all the information that would allow people to make an informed choice about the home. Some of the information contained within the documents was no longer relevant. Both documents should be reviewed and updated, and then kept under regular review. A requirement will be made a the end of the report. The deputy manager told us that people who wish to use the service rarely benefit from a pre-admission assessment from a suitably qualified person from the home. The deputy said that she normally telephones the hospital or care home to get the Care Homes for Older People Page 11 of 28 Evidence: necessary information. Relatives or friends sometimes visit the home and look around prior to admission. The deputy will talk to these people to gain information about that person prior to their admission but again no visit takes place. A requirement will be made a the end of the report for assessments to take place prior to admission to the home to ensure that the home can fully meet the needs of people wishing to use the service. The home does not offer 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. The health and personal care that people using the service receive is based upon their individual needs, which is documented in their care plans. The people using the service also have support from healthcare professionals when it is required. Evidence: Four care plans were sampled and it was observed that the home uses the Standex System. This is a system of care plans, assessments, risk assessments and daily recoding notes purchased from a national organisation specialising in paperwork for care homes. Two care plans were observed to be blank with only basic details about the people using the service available for staff to read. The deputy told us that due to time constraints some paperwork had been taken home to complete. The deputy was reminded that staff and people using the service should have access to the care plans at all times. We then sampled another two care plans and all the necessary care plans and risk assessments were in place to allow staff to care adequately for the people using the service. Following the inspection the deputy and the person who is proposing to be the Care Homes for Older People Page 13 of 28 Evidence: manager confirmed that the care plans were now completed and back in the home. All plans are now reviewed every month and whenever it is necessary, and this is done in consultation with the person using the service and/or their representative. The deputy told us that the service has a local GP that the people using the service are registered with. The GP will visit the home every week and for emergency calls in between. Opticians visit every six months and the chiropodist every six weeks. The deputy told us that the GP is a good support to the home and the district nurse is supportive and willing to give the nurses advice. The home has its medications delivered every month by a large pharmacy chain and this is dispensed in blister packs. We sampled some medication administration records and these were found to have no gaps.Policies and procedures are in place for the nurses that administer the medicines and also protocols for those people using the service that wish to self medicate. The AQAA told us that the home has policies and procedures on values of privacy and dignity, choice, fulfilment, rights and independence. These values are discussed during staff induction and appraisals. During the day staff were observed to knock on doors prior to entering and were using the preferred names of the people using the service as documented in their care plans. During a tour of the building we observed that some people using the service were in the lounge and wearing large tabards. We were told that these were in place as morning coffee was about to be served and were used to protect the clothes. Following the inspection the person who will be the manager told us that consideration would now be given to the purchase of napkins. The use of tabards can be viewed as inappropriate for the age group and does not respect the dignity of the people using the service. Consent will be gained for those people who still wish to use the tabards. 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. People who use the service are offered some options for activities but would benefit from having more resources dedicated to this area. Evidence: It was observed and discussed with the people in charge during this inspection that there are limited activities available for people who use the service. The home does not benefit from an activity organiser but the deputy told us that staff organise entertainment in the afternoons. This includes bingo, jigsaws and balloon games. Music is played in the background and staff offer choices to the people using the service asking them their preferences for that afternoons activity. Then deputy also arranges outside entertainers to sing for the people and the next visit is in June. The home has the services of an occupational therapist who provides exercises and this happens every two weeks. The deputy told us that a favourite with the people using the service is the pets as therapy dog that also visits every two weeks. A requirement will be made at the end of the report for the management of the home to consult with the people using the service for their activity preferences and for staff to help them to then engage in the activity if they choose to. Family and friends are welcome at the home at any time. Visiting is not restricted and Care Homes for Older People Page 15 of 28 Evidence: people using the service can return to their bedrooms if they wish to see their visitors in private. The deputy said that local schools have visited at Christmas to sing Carols but they are not frequent visitors. The deputy told us that the home contacts the vicar at the local Church of England church if requested but they do not hold church services at the home. It was observed during the inspection that people who use the service are offered choices on a variety of different topics. The deputy told us that staff ask when people would like to go to bed and get up in the morning and the time they would like breakfast. The home has a full time cook and for her days off and holidays another member of staff covers who has the necessary qualifications. The cook told us that she prepares all the meals from scratch using fresh fruit and vegetables everyday. The environmental health officer visited in March 2009. The deputy told us the requirement that they made during their visit has now been met. The cook told us that they have a four week menu rota and that she has a good knowledge of the likes and dislikes of the people living at the home. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be confidant that their complaints are listened to and that they should be protected from abuse as the staff team have received training in safeguarding adults. Evidence: The manager said that during the last year they had received one complaint that had now been resolved. The complaints log was seen and the concern had been appropriately investigated with timescales met. Currently the deputy logs all complaints in a book. A discussion took place about this practise as the book was not as clear as it could be as outcomes are not documented these are kept separately in the upstairs office. The deputy stated they will start a new system where all documentation is kept together. One complainant had contacted us prior to our inspection. They were concerned about the environment following a visit to the home. The concerns were discussed with the people in charge during this inspection who explained about some of the environment issues. The environment is documented in the next outcome area. The complaints procedure is available at the home and is also made available to all people who use the service and their representatives. During this inspection people using the service were asked if they knew how to complain and who to complain to and all said yes. Care Homes for Older People Page 17 of 28 Evidence: The deputy manager told us that the home follows the local authoritys procedures for the safeguarding of adults. Staff have access to these procedures and the homes own policy. This policy was observed and it did not match the local authoritys procedures so a requirement will be made for the management to ensure they are in line. Staff spoken to on the day confirmed that they had received training in safeguarding adults and the records also confirmed this.The AQAA told us that staff have also received training in the deprivation of liberty standards. The home has a whistle blowing policy that staff have access to. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides an environment that meets the physical needs of the people using the service but would benefit from the refurbishment when palanning permission is granted. Evidence: Prior to this inspection a complainant had contacted the commission with concerns about the homes environment and offensive odours within the home. The complainant was looking around the home with a view to placing a relative there. During this visit we discussed this complaint with the deputy and the proposed manager. We were told that the home has submitted plans to the local council for the home to be totally refurbished giving larger rooms and en-suite facilitates to benefit the people using the service. The original plans have been rejected and the home has appealed. . On the day of the visit it was observed that the home would benefit from the planned refurbishment. The wood work especially the skirting boards in some areas were in a poor state of repair. The deputy stated this is caused by the wheelchairs knocking into them. The paint on the wall in the corridors need refreshing as these areas had not been fully re-decorated. Some of the bedrooms are small with no en-suites available but this is what the home is intending to improve with the planning permission. One of Care Homes for Older People Page 19 of 28 Evidence: the assisted bathrooms on the ground floor has a door that is split down the middle to gain access which has a small gap therefore not allowing the user complete privacy. One of the ground floor bathrooms is used as a staff locker room and storage area. The remaining bathrooms are not a welcoming environment. A handrail along the corridor in the right wing had fallen off the wall. A hole was noticed on the linen room door. The AQAA told us a number of bedrooms have been decorated during the past year. New carpets have also been laid in the hallway and some bedrooms. We were told that they hoped for all these issues to be resolved when planning permission is granted. The deputy and manger have assured us they will keep us informed of the planned refurbishment. A requirement will be made at the end of the report. The home employs a domestic who is responsible for the cleaning and laundry. The member of staff works five days a week and at weekends staff on duty are responsible for the washing and the emptying of the waste bins. On the day of inspection there was no offensive odours in the home. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are trained and skilled and in sufficient numbers to support the people using the service. Recruitment practises are robust which protect the individuals living at the home. Evidence: The home had a relaxed atmosphere and staff were observed to undertake their tasks in a quiet and orderly manner. We observed staff interactions with people using the service all of which were professional and supportive. The staff in the home during the day were relaxed and calm with the residents. The deputy told us that the provider does all the staff rotas. A nurse is always on for each shift supported by carers. Comments received on the day were all positive about the staff in the home. One person said the staff are good, very good and caring. Another said since I arrived at the home my condition has really improved.A relative spoken to on the day said that they were happy about the care that their relative received and the staff were always welcoming. The deputy said that most staff have now achieved the National Vocational Qualification (NVQ) at level 2 and one staff member has achieved level 3. Records sampled confirmed this and confirmed that this training is on going. Care Homes for Older People Page 21 of 28 Evidence: Three employment folders for staff were sampled. These folders confirmed that the home had in place all the necessary documentation to allow them to employ new members of staff safely. The training records for the home were observed and confirmed that mandatory training takes place. Staff confirmed that they receive regular training and this included safeguarding adults, health and safety, manual handling and fire awareness. Specialist training is also available which included Dementia training. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements at the home ensures the staff team is adequately supported and there are clear lines of managerial accountability. An effective quality assurance system has been developed. Evidence: The deputy manager is in day to day charge of the home and responsible for all clinical decisions. She ensures that the staff are properly supervised and supported. We also had the opportunity to meet the providers son who is to be the person who will be registered with the commission as the manager. There are clear lines of accountability and the providers are always available for advice and support and are regular visitors to the home. The deputy is about the complete her RMA (registered managers award) and the person who will be manager has already completed his award. Care Homes for Older People Page 23 of 28 Evidence: The deputy told us that the home has a quality assurance system in place where the views of the people using the service and their representatives are sought every year. All responses are kept by the home and negative comments can then be acted upon. This survey was completed in February this year. The deputy told us that the home does not hold resident meeting as they were not popular. She told us that people raise their comments or concerns as they occur and the home then acts upon the information. The home does not keep personal allowance money for people using the service. All representatives or people using the service are invoiced directly. The deputy told us that the requirements made by the fire authority have now been met and no further health and safety issues were identified during this inspection. Health and safety certificates required by the home were identified in the AQAA to be current. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 6 To ensure the service user guide and statement of purpose is is regularly reviewed and updated. This ensures that people who wish to use the service have the current information available to them about the home. 15/07/2009 2 3 14 Assessments for all people wishing to use the service should take place by a suitably qualified individual. This ensures that home can be confident that they can meet their assessed needs. 15/07/2009 3 12 16 Consult with people using 15/07/2009 the service about their social interests To ensure that the activities that take place in the home meets their expectations and needs. 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 4 18 13 The homes safeguarding adults policy and procedure to be reviewed to ensure that it matches the procedures of the local authority. To ensure staff follow the procedures of one policy and are clear as to their responsibilities. 15/07/2009 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 9 Photographs for each person using the service should be obtained, with consent, for identification purposes for the medication rounds and placed in front of the medication administration record for each person. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. Care Homes for Older People Page 28 of 28 - 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. 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