Care Home: Featherbed Lane Care Home

What the care home does well Service users are included through choice in the daily routines of the home. There are a good range of activities made available to people who live in Featherbed Lane. Some of the service users attend day centres and everyone has an annual holiday at least once a year. The service makes sure people are given enough information about the home and what they can provide so that they can make a choice of whether they want to live there. Service users bedrooms are very personal and both the furniture and the colour scheme are chosen by service users with support from the key workers. The dining arrangements are pleasant and service users are part of the process when writing menu choices so that their likes and dislikes are included as part of the menu. Healthcare needs records are available within the care plans and shows that all healthcare needs are addressed with specialist healthcare professionals brought into the home when necessary. What has improved since the last inspection? This inspection was the first inspection to be carried out since the home was reregistered with another provider in September 2009. What the care home could do better: Every person living in the home has a personal plan of care that staff can follow to make sure the needs of people are met but the care plans in place are not fully completed with enough detail that will tell staff what they need to do to meet those needs. There is no monitoring and evaluation of the care plans and therefore the home cannot be confident that all of the care needs are being met on a daily basis. Pre admission assessments were not available at the time of the visit and new care plans are being introduced without this information. Service users in Featherbed Lane have complex difficulties and little communication, therefore, these records need to be in place. A complaints policy and procedure is made available to service users and their families should they not be happy about the service they receive but records showed they are not fully completed and therefore the home do not know if complainants are satisfied their complaint or concern has been dealt with to their expectations. A number of issues with the building were highlighted during the visit. The hall carpet is stained with black marks and is ruffled throughout making it a health and safety hazard for anyone either living in the home or visiting the service. In the kitchen the kitchen units are looking worn and damaged and the fridge is damaged. Although staff state they have attended a number of courses, the home do not have over fifty per cent of the staff team holding a care qualification. Key inspection report Care homes for adults (18-65 years) Name: Address: Featherbed Lane Care Home Featherbed Lane Care Home 1 Featherbed Lane Ryhope Sunderland Tyne and Wear SR2 0QE     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: Eileen Hulse     Date: 0 8 1 2 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 Adults (18-65 years) Page 2 of 30 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 Adults (18-65 years) 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 Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Featherbed Lane Care Home Featherbed Lane Care Home 1 Featherbed Lane Ryhope Sunderland Tyne and Wear SR2 0QE Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Linda Whitehead Type of registration: Number of places registered: care home 6 Choices Community Care Services Ltd Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: 1. The maximum number of service users who can be accommodated is: 6 2. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD, maximum number of places 6 Date of last inspection Brief description of the care home Featherbed Lane can provide personal care for six people who have a learning disability. The service cannot provide for those people who require nursing care. The home is a purpose-built detached bungalow with six bedrooms, which is set in its own grounds. The house has a kitchen, a dining room/conservatory and a large lounge area, with bedrooms arranged on one side of the house. Facilities, including bathrooms Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 6 Brief description of the care home and toilets, are adapted for service users who might be physically frail or disabled and access has been made easy for people who use wheelchairs. There is a private and secure garden around the home and a car park at the side. The home is located just off the main road in Ryhope and is within walking distance of local shops, pubs, churches and other community facilities. The area is well served by public transport, which includes those running to central Sunderland, and the people living at the home have the use of a privately owned vehicle. It costs 1075.60 each week to live at this home. Additional charges are made for toiletries, newspapers/magazines and hairdressing. Items which are included in the cost are listed in the homes terms and conditions. Care Homes for Adults (18-65 years) Page 5 of 30 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The first inspection of this service since it was registered with a new provider was completed on 8th December 2009 This is an overview of what the inspector found during this inspection The quality rating for this service is 2 STAR. This means that people who use this service experience Good quality outcomes. How the inspection was carried out. Before the visit we looked at information we have received since the home was reregistered with a different provider in September 2009 How the service dealt with any Care Homes for Adults (18-65 years) Page 6 of 30 complaints and concerns since the home was re-registered Any changes to how the home is run. The providers view of how well they care for people. The views of people who use the service their relatives and staff. During the visit we observed staff practice and talked with people who use the service and looked at how well their needs are met. We looked at other records which must be kept. We checked that staff had the knowledge skills and training to meet the needs of the people they care for. We looked around the building to make sure it was safe, clean and comfortable and checked if any issues needed to be addressed. Care Homes for Adults (18-65 years) Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Adults (18-65 years) Page 8 of 30 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 Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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. No pre-admission assessments are included within the plans of care for any service users and therefore do not help to form the basis of the individual care plan. This does not help the service to know if the care needs can be met by them. Evidence: The service has recently been registered with a new provider. There are no records within the plans of care to make sure that assessments have been completed prior to the admissions of people living in the home. The manager explained that all personal records regarding service users living in the home had been removed by the former registered provider and that the home had no access to them. There have been no recent admissions into the service but the Manager was able to explain in detail the process that would be followed should a vacancy occur. The care manager would make a referral to the home and the prospective service user would then make several visits there either having a meal with the people who live there or spending some time in the house with them and accompanying them on activities to eventually being offered overnight stays. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: An assessment is carried out at this time to ensure the placement is suitable and the service can meet the care needs. This gives the person the time to decide if they would like to move in and ensures the correct equipment and care plans are made available prior to moving in. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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. A new care plan format has been introduced with risk assessments linked in with the care plans and all service users have an individual care plan that is completed by staff. However, they are not fully completed and therefore give no guidance to staff on how the care needs of people living in the home will be met, during the visit some care plans were looked at. Evidence: The care plans are organised but many of the records such as the personal weekly planner, the support needs and the daily notes were all blank with no information at all. Service users living in this home have complex communication difficulties but through body language and facial expression staff know what they want and people can make some choices in their everyday lives. The care plans included entries such as staff to assist but no detail was given on how they were expected to do this. Another entry stated staff to give verbal prompts and encouragement but again no indication for staff on how to do this and at what level this could be understood by Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: service users. Personal care records with headings such as bathing, dressing and toileting were all blank documents with no entries made to guide staff. A daily monitoring sheet was looked at and it stated, if (name) has an unsettled night staff will reassure them again no guidance on how staff will do this or why they are unsettled. Another entry stated I need to wear special boots to help my mobility but the attached risk management was a blank sheet of paper. One of the service users has to have the help of two staff at all times but the records in place were not completed and did not state the level of care and support this person required throughout the day and night, again records were not completed. Staff know the service users well and this helps to complete the care needs of people. The care plans are not monitored or evaluated making it difficult for staff to know if they are providing the correct level of care. Daily notes are evident but again give no detail, the content is very hard to understand and many of the entries do not make any sense and during the visit when staff were shown the records they could not explain about the content as they also could not understand what was written. Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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. There is a good range of social activities made available to all service users to fulfill lifestyles and this ensures people are able to choose how to spend their leisure time. However, the records do not support the level of activities that are offered. Staff support is given to maintain service users personal relationships and to maintain contact with their families and friends. Service users are offered nutritious and varied meals with good choices for everyone. Evidence: All daily routines of the house are centred on the preferences of the people who live there. Service users are frequently out and about and on the day of the visit, three service users were attending day centres and one service user went out to help with the weekly food shopping. People living in the home use the local shopping areas and enjoy having meals out and during the visit, plans were being finalised for two people to have a monday to friday break at Centre Parcs the following week supported by the Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: home manager and a support worker. However. this was not recorded within the activity records, activity record sheets within the care plans were blank records. Service users attend the local disco two nights a week and one service user enjoys bowling and likes to go to the golf driving range and lunch out in the finer weather. The home has its own transport, a people carrier vehicle and this helps people to get out and about and all service users have at least one annual holiday to destinations of their choosing apart from one person who prefers days away. Staff access information from the local newspapers, local posters and information leaflets to help service users plan and choose what they want to do. People are encouraged to continue with relationships outside of the home and service users have close contact with their families and two service users regularly visit their relatives. Service users are unable to help staff to prepare meals but help with the shopping and help with the menu planning. Healthy option choices of meals are offered and a weekly menu is available but if people prefer something different then an alternative choice is offered. During the visit, a lunchtime meal was taken with the people who were in the home, the meal consisted of a snack type meal of sandwiches as their main meal is a hot meal in the evening when everyone has returned home from visits out or returning from day centres. There was good rapport between service users and staff and staff clearly know people well, it was evident throughout the day everyone was comfortable with each other. In talking with one service user they made the following comments, I like to get out into the garden I like to watch the television in the lounge and my videos in the bedroom Its alright here the staff are alright Another service user made the following comments, I am going shopping later on I like painting at college Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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. A number of specialist health professionals are used by the service and good systems are in place on the safe administration of medicines and this ensures that the healthcare needs of service users are identified and met. Evidence: Within the plans of care there was evidence to suggest that the healthcare needs of service users are addressed. Service users are escorted by staff to attend all healthcare appointments including hospital and GP visits and should a hospital stay be necessary, then staff will continually support the person twenty four hours a day whilst in hospital. Most appointments take place outside of the home. The home uses a monitored dosage system of medication and they have a policy and procedure on the administration of medication used in the home and the policy covers areas on the recording, administration, safekeeping and disposal of unwanted or unused medicines. A monitored dosage medication system is used and the three staff responsible for administering medication have completed the accredited Medication training. At this time no service users are able to administer their own medication. All medication is recorded on individual medication administration record sheets (MAR) Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: sheets that are up to date and well maintained. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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. The home has a complaints policy and procedure that is accessible to service users and their families should they have a complaint or concern about the service, however, records are not fully completed and therefore the home cannot know if the complaint has been dealt with effectively. good safeguarding procedures help to protect people should and abuse situation arise or be suspected. Evidence: The complaints policy is used whenever anyone has a complaint or concern about the service. Although service users have limited or no communication skills, staff know the service users well and can usually identify any concerns or if people are obviously upset about something, body language and behaviour patterns also alert staff if something is wrong. Staff confirmed they are aware of how to deal with a complaint should one be made whilst they are on duty and stated they had received training regarding complaints during various aspects of training completed and that they had also received Safeguarding of adults training. A new complaints record has been introduced but this does not enable staff to complete it fully following any concerns or complaints made. It states how and who to make a complaint to with addresses etc but it does not include the action to be taken following the complaint or the outcome of the complaint so, the service are not made aware if the complainant was satisfied on how it was addressed or if they feel it had been dealt with effectively. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: when looking at records regarding complaints, the last complaint made was in March 2009 and no detail is recorded that informs staff if the complainant was satisfied with the outcome. Safeguarding of vulnerable adults procedures are available in the home for staff guidance that also includes whistle blowing. Care Homes for Adults (18-65 years) Page 20 of 30 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. 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 is clean and homely however, some furnishings need to be replaced and some maintenance issues need to be addressed to ensure the home is safe and comfortable for the people living there. Evidence: The bungalow consists of lounge, dining room/conservatory, kitchen, laundry six bedrooms and a staff sleepin room. A number of areas within the home have recently been redecorated and these include the hallway, two bathrooms and some bedrooms and one bedroom has had the floor covering replaced at their own choice. However, a number of issues needing attention were identified during the visit. The hall carpet is badly stained with black marks and bleach stains and it is ruffled in several places and due to the poor mobility of people living in the home this carpet must be replaced to reduce the risk of trips and falls. In the kitchen, the fridge that is positioned in front of the double radiator is damaged and the edging to one of the wall cupboards is peeling off. Many of the fitted kitchen units need replacing as handles are loose and cupboards are damaged and chipped showing the inner chip board wood. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: In the bathroom a number of incontinence pads are stored. To preserve the dignity of people, these pads should be stored in service users own bedrooms. Care Homes for Adults (18-65 years) Page 22 of 30 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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. Staffing levels within the home are adequate and some staff hold a care qualification and this helps service users to lead fulfilling lives and to ensure their care and support needs are met. Evidence: There are ten support staff employed in the home and four members of staff hold an NVQ qualification in care, at present the service has not achieved the required fifty per cent of the of staff holding a care qualification but five staff are currently working towards gaining level two in the same qualification and once completed the home will have the correct qualified members of staff. There were three members of staff on duty and the numbers of staff were adequate to ensure the needs of service users could be met. However, one service user is currently staying temporary in another home and once they return home staffing levels will need to be reviewed. The home has a low turnover of staff and most of the staff have worked in the home for a number of years. The manager has introduced a staff training matrix and this highlights training that has been completed and identifies further training that staff need to complete. In discussions with the staff on duty they made the following comments, Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: The home is ok I am leaving soon to work in the area where I live I have completed all the mandatory training and some specialist training such as epilepsy training The manager is very fair There has been many changes in the home and its a lot different Staff stated that the needs of service users can be met better due to one service user not currently living in the home Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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 run in the interests of service users and management arrangements helps to ensure staff receive the leadership and direction they need to make sure service users are cared for, supported and that their needs are met. Evidence: The manager has worked in various posts in the last twelve years and has NVQ qualifications in levels two, three and four as well as attaining a D32/33 Assessor Award qualification. She has recently updated her knowledge by completeing some awareness training courses that included care planning, risk assessment, staff recruitment and selection and mental capacity act. Care Homes for Adults (18-65 years) Page 25 of 30 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 Adults (18-65 years) Page 26 of 30 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 1 13 16 All activities taking place must be recorded within the plan of care This ensures that service users interests are maintained or changed when needed 15/02/2010 2 30 12 All service users personal support items should be stored in their bedrooms So that the privacy and dignity of people is not compromised 15/02/2010 3 42 13 The manager should identify 15/02/2010 health and safety issues and report them This ensures service users, staff and relatives are kept safe whilst on the premises 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 2 14 All service users living in the 15/02/2010 home must have in place a completed pre admission assessment Care Homes for Adults (18-65 years) Page 27 of 30 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 Thensures all needs are recored within the personal plan of care 2 6 15 Care plans for service users must be fully completed and include monitoring and evaluation This ensures guidance for staff and that all needs are met on a daily basis 3 9 13 Risk assessments must be fully completed within plans of care This ensures any possible risks are managed and minimised 4 22 22 All complaints records must be fully completed This helps the service to know the complaint has been dealt with satisfactorily 5 24 16 Kitchen cupboards and the fridge are damaged and in need of replacing This would ensure the enviroment is pleasant for people 6 24 16 The hall carpet needs to be repaced as it is a falls hazard 15/02/2010 15/02/2010 15/02/2010 15/02/2010 15/02/2010 Care Homes for Adults (18-65 years) Page 28 of 30 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 would help to ensure service users are free from hazards 7 32 18 Fifty per cent of the staff team must hold a care qualification This ensures staff have the knowledge and skills to care and support people 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 15/02/2010 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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