Care Home: Greystones Nursing Home

What the care home does well Staff were seen to be polite and helpful when interacting with the people who live in the home. People looked well cared for. Their clothes were clean and they were well dressed. The home does have an activities coordinator who is very enthusiastic and provides regular activities to all groups. Evidence was provided to show activities such as baking, foot spa and chair aerobics are provided to people if they want to get involved. People told us they enjoyed the food and said there was always enough. People said that they felt comfortable in going to a senior member of staff or the provider as they felt that any concerns they may have would be addressed. The home was clean and free of unpleasant odours when we visited. People told us the home is always clean and fresh. What has improved since the last inspection? Work is continuing to improve the environment. Some bedrooms, bathrooms, and corridors have been decorated and refurbished recently. Since our last visit new driers and washing machines have been purchased and the laundry floor has been repaired. The new machine has a sluicing facility which will help to reduce the risk of cross infection. Staff said training opportunities are generally good and had improved over the last year. What the care home could do better: The assessment process at the home must improve and people`s needs must be assessed by a suitably qualified or suitably trained person. Improved procedures will help to ensure that the service can meet people`s needs before they are admitted. To help protect people any restrictions must be discussed, agreed where possible, and always recorded in the person`s support plan. To protect people new staff must not start work until all the required employment checks have been completed. To help protect people the service must notify us of any event which adversely affects the wellbeing or safety of any person. Training should be provided to staff that is linked to people`s specific needs, for example mental health. This will help to ensure that people receive care and support from suitably qualified and skilled staff. Key inspection report Care homes for older people Name: Address: Greystones Nursing Home Parsons Road Heaton Bradford West Yorkshire BD9 4DW     The quality rating for this care home is:   one star adequate 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: Mike ONeil     Date: 1 2 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 31 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 31 Information about the care home Name of care home: Address: Greystones Nursing Home Parsons Road Heaton Bradford West Yorkshire BD9 4DW 01274542625 01274480322 greystones.nursing@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Adam & Co Accountancy Ltd care home 25 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 25 The registered person may provide the following category of service only: Care home with nursing - Code N; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Dementia Code DE; Mental Disorder, excluding learning disability or dementia - Code MD. Date of last inspection Brief description of the care home Greystones Nursing home is located in a residential part of West Bradford, close to Lister Park. Accommodation is provided in a converted turn of the century house, set in its own grounds and within walking distance of main bus routes to Bradford. Greystones provides 24 hour psychiatric nursing care to older people over 65. Bedroom are on three floors. There are 14 single bedrooms and 5 double bedrooms in the home. Access to the first floor is via a shaft lift and stairs. Access to the second floor is via stair lift only. This places limitations on people who may have problems with Care Homes for Older People Page 4 of 31 25 25 Over 65 0 0 Brief description of the care home mobility. The current fees range from 408.11- 585.00 pounds per week with additional charges payable for services like transport, chiropody and newspapers. This information was provided at the October 2009 inspection. The home should be contacted directly for up to date information about charges. Care Homes for Older People Page 5 of 31 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: one star adequate 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 inspection process included looking at the information we have received about the home since the last key inspection in January 2008. We had not requested that the service send us an Annual Quality Assurance Assessment (AQAA). The AQAA can provide information such as what the service was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. We will be requesting an AQAA from the service in the next couple of months. Before the visit we sent surveys to the home to distribute to people using the service, visiting health care professionals and staff. No surveys had been returned to us at the time of this report being written. We made an unannounced visit to the home. This was carried out by two regulation inspectors on 12th October 2009 over seven hours. We talked to 4 staff about their work and the training they have completed. We checked some of the records, policies Care Homes for Older People Page 6 of 31 and procedures the home has to keep. We also looked at some parts of the home and observed staff as they carried out their duties. We spoke with 6 people who use the service ,their views are included within this report. A registered general nurse was in charge of the home at the time of our visit. At the end of our visit we also provided feedback to Mrs Munir, owner of the home. We also gave additional feedback to Mr Munir,owner of the home the day after our visit. 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 services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 31 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 Older People Page 8 of 31 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 31 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 31 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are not always assessed by suitably qualified staff or accurately recorded.This means that people can not be confident that the home can fully meet their needs. This home does not provide intermediate care. Evidence: We checked three peoples care files.In two files records showed that pre admission assessments had been undertaken. This told us that prior to the admission taking place, staff from the home carried out an assessment of peoples needs. This confirmed that the service was appropriate for the person and provided staff with information to formulate an individual plan of care. We saw in the files, the home was consulting with, and requesting reviews from professionals when peoples needs were changing. Regular review meetings were also held with the person, their representative and health care professionals. Care Homes for Older People Page 11 of 31 Evidence: However one persons assessment recorded that they were detained under Section 3 of the Mental Health Act 1983.This section of the act is to enable a person to receive treatment whilst being detained. The home is not registered with us to accept people under this section. The homes own policies and procedures state. The home cannot accept referrals on behalf of people compulsorily detained under sections of the Mental Health Act. Some qualified staff we spoke to have little knowledge of the Mental Health Act and specifically their roles and responsibilities under the Act. This means that people may not be fully protected. We asked the registered provider to arrange an urgent review of this persons mental health status. On 16th October 2009 we were informed by the home that the person was no longer detained under section 3 of the Mental Health Act. We were told that the section 3 was rescinded the day before the persons admission to Greystones and staff had therefore wrongly assumed that the person was still being detained under section 3 of the Act. We remain concerned that we had to bring this issue to the homes attention and staff had to request a fax from the hospital to be sure of the persons status under the Mental Health Act. Therefore the persons rights during the last few months had not been protected. We saw in peoples care plans that the assessment of peoples needs had sometimes been carried out by a member of staff who is not a suitably qualified or trained person. The assessment does not always have to be carried out by the most senior member of staff rather a staff member with specialist knowledge surrounding the likely needs of the person. Care Homes for Older People Page 12 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated with respect and said they were happy with the care they received. Peoples health and personal care needs are met and in the main medication procedures ensure that people are protected. Care plans generally reflected peoples care needs and choices,which means that staff know what care each person needs. Evidence: We looked at three care plans which showed that peoples needs were assessed. There were care plans in place to assist the carers with ensuring care needs could be met. Three carers spoken to during the inspection said they had access to the care plans and recorded the daily interactions they had with people they were providing care to. The care plans inspected were written clearly and contained good detail as to how care needs were to be met. Two care plans contained evidence that the person receiving the care was involved with the care planning process. They were also reviewed monthly. Care Homes for Older People Page 13 of 31 Evidence: We saw evidence that people were risk assessed in areas such as moving and handling, pressure area care, nutrition and continence. The documentation showed people were weighed weekly and action was taken when a person was identified as losing significant weight. During the inspection we saw that staff were polite and helpful when interacting with the people who live in the home. People looked well cared for. Their clothes were clean and they were well dressed. Individually people said: The staff are fine Im quite happy here. People have some restrictions placed on choice. People we spoke with said they had agreed to these restrictions as part of their support plan. There are many people in the home who have a dependency on different social drugs such as alcohol and tobacco. The person in charge told us that the staff control the amount of alcohol and number of cigarettes people can have. The person in charge was not aware of any consent to this being in the care plans. The care plans inspected showed no evidence that these restrictions have been agreed.To help protect people any restrictions of peoples choice the restriction must be discussed, agreed where possible, and always recorded in the persons support plan. The MAR (Medication Administration Record) charts were randomly inspected. There were some gaps where the registered nurses had not signed the chart, but overall the standard of record keeping was good. Each persons drugs are contained within a monitored dosage system and the medications are stored in a locked room. There is a controlled drug cupboard but no controlled drugs were being administered on the day of the inspection. The controlled drug record book was looked at and this showed evidence that there is a good standard of administration of these drugs. There was a concern raised about one person who was receiving her medication covertly. There was a letter in the notes from the general practitioner to say this was OK. When the homes policy regarding this practice was asked for we informed that there wasnt one. No written consent from the persons family or representative could Care Homes for Older People Page 14 of 31 Evidence: be found in the care documentation. Any restrictions of peoples choice over medication should be recorded in their support plan. This will help to make sure people can make agreed choices in their lives and people are protected. Care Homes for Older People Page 15 of 31 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 have a choice of lifestyle within the home and are able to maintain contact with family and friends ensuring that they continue to be involved in community life. People are able to make choices about daily living and be involved in some social activities. Meals served at the home are of a good quality and offer choice to ensure people receive a balanced diet. Evidence: Those people who are able to leave the home are enabled to do so. There is a coded lock on the front door which people have the code to so they can come and go as they please. We saw evidence in picture format that showed people have regular access to excursions outside of the home. These are recorded in their care documentation along with other activities that are organised on a daily basis within the home. There were some activity games provided on the day of the inspection. These were available to people in the main lounge and they appeared to be enjoyed by those who got involved. The home does have an activities coordinator who is very enthusiastic and provides regular activities to all groups. Evidence was provided to show activities such as Care Homes for Older People Page 16 of 31 Evidence: baking, foot spa and chair aerobics are provided to people if they want to get involved. Two people we spoke with said they are not interested in the activities and preferred going outside. There are plans for a Halloween party and a bonfire night. These are not highlighted around the home but assurances were given that these were annual events. We observed people having their meals at lunchtime. Three people told us they enjoyed the food and said there was always enough. There are people from different cultural backgrounds living at the home. Their food needs were met by the cook in the kitchen who has a good awareness of the diverse needs of the people living at the home. Care Homes for Older People Page 17 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service cannot fully evidence that peoples complaints are taken seriously and resolved. There are appropriate systems in place to make sure that people are protected from abuse. Evidence: People had been provided with a copy of the homes complaints procedure, which was also on display in the home. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People said that they felt comfortable in going to a senior member of staff or the provider as they felt that any concerns they may have would be addressed. Complaints procedures were not sufficient to fully protect people however as there were no records available of any concerns /complaints that have been made and /or the action taken to resolve these complaints. Staff and the owner of Greystones were unaware as to the whereabouts of these records or if any recent complaints had been received at the service. We had recently been copied into some concerns that had been sent to the Bradford council safeguarding team. We looked at some of the concerns raised as part of our visit and also spoke with the registered provider about these concerns. The providers are to look into the concerns as part of their internal complaints procedures. We have Care Homes for Older People Page 18 of 31 Evidence: also discussed information with the safeguarding team following our visit. They will assess what further action, if any,needs to be taken under local safeguarding policies. Adult safeguarding policies and procedures are available to the staff. Staff said they had undertaken safeguarding adults training within the last 18 months and the training records we saw confirmed this. Care Homes for Older People Page 19 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable, pleasant and safe place for people to live. Evidence: The home was clean and free of unpleasant odours when we visited. People told us the home is always clean and fresh. Work is continuing to improve the environment. Some bedrooms, bathrooms, and corridors have been decorated and refurbished recently. The communal rooms on the ground floor are comfortably furnished and the standard of decor is generally good. The home has pleasant gardens where people can sit when the weather permits. Some bedrooms have en-suite facilities. People have lots of their personal belongings in their rooms. People told us they have a lockable cupboard in their rooms to store valuables. One person complained about the poor state of his mattress. This was pointed out to the member of staff on duty and the mattress was changed straight away. It was also pointed out that his TV was not working properly as he could only view one channel due to poor reception. He did say that staff were already aware of the issues above Care Homes for Older People Page 20 of 31 Evidence: but had not done anything about it. The laundry is suitably equipped. Since our last visit new driers and washing machines have been purchased and the laundry floor has been repaired. The new machine has a sluicing facility which will help to reduce the risk of cross infection. Care Homes for Older People Page 21 of 31 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. There are enough staff to meet peoples needs. However people are not fully protected because some staff do not have all the training required to meet peoples needs and all the required checks are not completed before new staff start work. Evidence: People spoke highly of the staff team and said staff always listened and acted on what they said. People said that staff were always available when needed. Staff confirmed that staffing levels were adequate and they were able to meet peoples needs with the current numbers of staff on duty each day. We saw that staff were available to support people when needed. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. We saw some records that showed that the staff have received the mandatory health and safety training specific to the needs of people at Greystones. Staff said training opportunities are generally good and had improved over the last year. However some staff had not received training specific to the mental health and physical needs of Care Homes for Older People Page 22 of 31 Evidence: people at Greystones. We looked at three recruitment files.One person had been recruited from a recruitment agency. However, we were not provided with evidence that the information needed before the member of staff started working with vulnerable people was properly checked. Another person started working in the home without having two written references obtained and a Criminal Record Bureau check was not received until six weeks after she was employed. The owner was unable to show evidence that a student on placement from another organisation had the correct checks carried out before she started working at the home. These are unsafe recruitment practices which mean that people may not be fully protected. Care Homes for Older People Page 23 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes procedures and ethos do not fully promote the health, safety and welfare of people who use the service. Evidence: There has been no registered manager at Greystones for one year now. The manager has not submitted a registration application to us despite assuring us in March 2009 that she would do. The manager was not available on the day of our visit. We have spoken with Mr Munir regarding the need to have a registered manager which will ultimately provide stability to the service. He has assured us that he will make the management of the service his priority. We had not requested that the service send us an Annual Quality Assurance Assessment (AQAA) yet. The AQAA can provide information such as what the service was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. We will be requesting an AQAA from the service in the next couple of months. Care Homes for Older People Page 24 of 31 Evidence: The management team have ways in which to check out the quality of the service that they are providing. Regular staff meetings are arranged. Minutes of these meetings were seen. People said they saw and spoke with the manager and registered providers of the home on a regular basis. Some people did say they had problems communicating with the manager. They said they Just didnt get on. Efforts should be made to improve channels of communication between people and the manager of the home so that the ethos of the home can be fully inclusive for all people. Generally the views of both people who use the service and staff are being listened to, and valued. A sample of monies that was looked after on behalf of people living at the home was checked. Records and receipts are kept and money tallied with the records. These measures will help safeguard peoples finances. Records show that the manager has attended training on the Mental Capacity Act and the Deprivation of Liberty legislation. However staff said they had not received training and had little knowledge of the legislation and guidance. Staff were unsure if anybody was being deprived of their liberty when we visited. The home did not have a policy/procedure on the Deprivation of Liberty when we visited. This means that peoples rights and choices are not fully protected. Information leaflets about the Mental Capacity Act and deprivation of liberty are however available in the home. There were records seen in peoples notes that advice from their local social services had been sought on whether somebodys liberty was being deprived. The assessment result was that their liberty was actually being restricted and not deprived. Some of the homes procedures do not fully promote the health, safety and welfare of people who use the service or the staff. The service, over the last 4 months, has failed to notify us of any event which adversely affects the well-being or safety of any person. Evidence was found in peoples notes which we should have been informed of. This is a legal requirement. We looked at a selection of service records. Servicing of the homes utilities and equipment were carried out at the required intervals. The fire risk assessment had been reviewed earlier this year. Mrs Munir said that all fire safety work had been completed and signed off by West Yorkshire Fire and Rescue Care Homes for Older People Page 25 of 31 Evidence: Service. Staff said they had received recent fire safety and other health and safety training. These measures will help to promote the safety and welfare of people. Care Homes for Older People Page 26 of 31 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 27 of 31 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 3 14 Peoples needs must be assessed by a suitably qualified or suitably trained person. So that the service can meet peoples needs. 01/12/2009 2 7 12 Any restrictions of peoples choice must be discussed, agreed where possible, and always recorded in the persons support plan. To protect people and to enable them to make choices. 01/12/2009 3 9 12 Any restrictions of peoples 01/12/2009 choice over medication must be discussed, agreed where possible, and always recorded in the persons support plan. To protect people and to enable them to make choices. Care Homes for Older People Page 28 of 31 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 9 12 Medication policies and procedures in the home must be updated to include the procedures for the dispensing of medication covertly. These policies and procedures when followed will help protect people. 01/12/2009 5 16 17 Records should be kept and made available of any complaints received by the service. Action taken to resolve complaints should also be recorded. This will help to make sure people are protected. 01/12/2009 6 29 19 New staff must not start work until all the required checks have been completed. This is to make sure that people protected. 01/12/2009 7 38 37 The service must notify the CQC of any event which adversely affects the wellbeing or safety of any person. This will make sure people are protected. 01/12/2009 Care Homes for Older People Page 29 of 31 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 12 The reception of the TV signal should be improved. This will mean that people can have a choice of the programme they can watch and have choices in their social activities. Training should be provided to staff that is linked to peoples needs.This will help to ensure that people get support from suitably qualified staff. Efforts should be made to improve channels of communication between people and the manager of the home.This will help ensure that the ethos of the home can be fully inclusive for all people. To protect peoples rights and choices staff should receive training on the Mental Capacity Act and deprivation of liberty. The home should also have clear policies and procedures in place which cover these issues. 2 30 3 32 4 33 Care Homes for Older People Page 30 of 31 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. 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