Care Home: Haylands

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What the care home does well People receive assessments of their needs before they move into the home. This makes sure that the service will be able to meet their needs. People accommodated in the home have access to regular activities that provide stimulation and interest. People can receive visitors in private and at all reasonable times. One of the visitors we spoke to said that she got on well with staff. Staff are carefully selected to make sure they are safe to work with older people. Following their appointment all staff have a full induction and ongoing training to make sure they have the required knowledge and skills to meet the needs of the people accommodated. People living in the home are provided with a clean and well maintained environment. What has improved since the last inspection? On our last visit we found several shortfalls in the way medication belonging to the people accommodated was being handled. Overall we found continued improvements that meant medicines were now being handled in a much safer way. Our checks of the medicines stocks and records showed they were usually given to people correctly and were safely kept. During our last visit to Haylands we were concerned to find that fire doors were being propped open, placing people at risk of smoke inhalation in the event of a fire. During this visit we found no evidence of fire doors being propped open. What the care home could do better: We found several serious shortfalls during this inspection. The care plans we looked at were not accurate and up to date. Reviews of the plans were not thorough in identifying where peoples` needs had changed and daily records did not provide evidence of the care and support that people had been provided with. One care plan told us that the person suffered from diabetes, yet we were told that he was not provided with a special diet, This placed his health and welfare at risk. Care plans did not consistently record individuals` preferences in relation to meals so it was difficult to assess if they were being provided with the food they liked to eat. One person told us that there was a lot of repetition on the menu and a relative was dissatisfied with a decision taken in January to reduce availability of cooked breakfasts from seven to one morning a week. On the second visit we observed the five staff on duty having their break together in the dining room. This meant that there were no staff available to monitor and supervise peoples safety in other areas of the home. In January we were informed that the door to the cellar was not secure and people living in the home were at risk of accidentally falling down the cellar steps. Although the manager told us at the time that this would be rectified, we were concerned to find that no action had been taken by the time of our visits in June. The manager has now confirmed that a suitable lock has been fitted to the door. Registered managers of care homes are required to notify us of incidents and events that affect the welfare of people living in care homes. We had received one notification from the manager in the previous 12 months. however, when we examined the home`s records we found numerous incidents that had not been notified to us. This prevented us from monitoring how the home manages serious incidents to safeguard the welfare of people using the service. Key inspection report Care homes for older people Name: Address: Haylands 93 Crofts Bank Road Urmston Manchester M41 0US     The quality rating for this care home is:   zero star poor 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: Val Bell     Date: 1 0 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Haylands 93 Crofts Bank Road Urmston Manchester M41 0US 01617483185 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Urmston Housing Society Name of registered manager (if applicable) Stacey Jayne Niven Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC. To service users of the following gender: Male. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 24. Date of last inspection Brief description of the care home Haylands home for retired gentlemen is registered to accommodate a maximum of twenty-four service users who require personal care by reason of old age. The home is situated within walking distance of Urmston town centre with public transport routes close by. The building is a large detached Victorian house with well-maintained enclosed gardens. There is off road parking at the front of the property. There are fourteen single rooms and five twin bedded rooms. Two of the single rooms have ensuite facilities and there are toilets and bathrooms on each floor. A stairlift provides Care Homes for Older People Page 4 of 28 Over 65 24 0 2 6 0 8 2 0 0 9 Brief description of the care home access to all floors and there are additional toilet facilities on the ground floor with disabled access. The fees for accommodation are 250 pounds per week and the fees include all meals, laundry, domiciliary chiropody and entertainment. Additional costs include hairdressing, dry cleaning and telephone calls. 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: zero star poor 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 was a key unannounced inspection, which means that the manager was not told beforehand that we were coming to visit. As part of the inspection visits were made to the home by two inspectors on 10th and 15th June 2010. During the visits we spent time with people living in the home and had conversations with care staff, management and ancillary staff and a visiting relative and district nurse. We looked at written information including care plans and medication records and assessed procedures and systems used in the home. We looked round the home to see if it was clean, hygienic and safe. The manager completed and returned an Annual Quality Assurance Assessment prior to our visits. This document is a self-assessment of how well the manager and staff consider the home to be operating. We also issued a number of surveys to be completed by people living in the home, although none of these were returned to us. Care Homes for Older People Page 6 of 28 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: We found several serious shortfalls during this inspection. The care plans we looked at were not accurate and up to date. Reviews of the plans were not thorough in identifying where peoples needs had changed and daily records did not provide evidence of the care and support that people had been provided with. One care plan told us that the person suffered from diabetes, yet we were told that he was not provided with a special diet, This placed his health and welfare at risk. Care plans did not consistently record individuals preferences in relation to meals so it was difficult to assess if they were being provided with the food they liked to eat. One person told us that there was a lot of repetition on the menu and a relative was dissatisfied with a decision taken in January to reduce availability of cooked breakfasts from seven to one morning a week. On the second visit we observed the five staff on duty having their break together in the dining room. This meant that there were no staff available to monitor and supervise peoples safety in other areas of the home. In January we were informed that the door to the cellar was not secure and people living in the home were at risk of accidentally falling down the cellar steps. Although the manager told us at the time that this would be rectified, we were concerned to find Care Homes for Older People Page 8 of 28 that no action had been taken by the time of our visits in June. The manager has now confirmed that a suitable lock has been fitted to the door. Registered managers of care homes are required to notify us of incidents and events that affect the welfare of people living in care homes. We had received one notification from the manager in the previous 12 months. however, when we examined the homes records we found numerous incidents that had not been notified to us. This prevented us from monitoring how the home manages serious incidents to safeguard the welfare of people using the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Thorough assessments of need ensure that the care needs of people admitted to the home can be met. Evidence: We looked at the procedures in place for assessing the needs of people admitted to the home. Two care records that we examined belonged to people that had moved into Haylands in the weeks prior to our visit. On both occasions care manager assessments of need had been obtained. Additionally, the manager had visited both people to undertake the homes assessment of needs. This provided people with the opportunity to learn about the services provided by Haylands and to decide if the home would be a good place to live. The assessment records provided evidence that people had been asked about their choices and preferences in relation to meals, assistance with personal care and the things they enjoyed doing on a daily basis. This process made sure that only Care Homes for Older People Page 11 of 28 Evidence: those people whose needs could be met by the service would be offered a place in the home. Haylands did not offer an intermediate care service. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inaccurate care plans mean that people living in the home do not always have their personal and health care needs met. Evidence: We looked at three care plans to determine if the needs of people living in the home were being met according to their assessments. The three care plans generally included instructions informing care staff what tasks they must undertake to meet each persons assessed needs. However, we found shortfalls in each of the care plans that potentially placed people at risk. For example, one of the care plans described the person as receiving medication to control diabetes, when it should have stated that this was controlled by diet. It was of further concern to find that the individual was not being provided with a diabetic diet. There was some confusion as to whether the person had a definate diagnosis of diabetes. This needed to be determined by referral to the persons general practitioner. Other concerns related to a failure to accurately record skin marks following a persons Care Homes for Older People Page 13 of 28 Evidence: admission to the home and failings in keeping care plans up to date when individuals needs had changed. Reviews of care plans must be improved to record the outcome of providing care and support and to assess individuals progress in meeting their stated goals. Records provided evidence that people living in the home generally had access to the full range of community health services. However, it was of concern that no action had been taken for four days to refer a person to their doctor in relation to a suspected urine infection. Delay in seeking medical attention potentially places the health and welfare of people using the service at risk. As part of the inspection a pharmacist inspector visited on 15th June 2010 to look at how medicines were being handled because we found some shortfalls on previous visits. Overall we found continued improvements that meant medicines were now being handled in a much safer way. Our checks of the medicines stocks and records showed they were usually given to people correctly and were safely kept. We found medicines could be easily accounted for because the records of medicines received, administered and disposed of were usually clear, accurate and complete. These records had significantly improved since our last visit helped by a new pharmacy that supplied the medicines in more suitable packaging along with computer generated medicines records. The general storage arrangements for medicines had also been improved and this had helped improve the organisation of the medicines. However, we found medicines that should have been given on an empty stomach were not always given correctly because staff had not identified they should be given before food so we gave some general advice about how this could be managed better. Giving medicines at the right time and dose is important because it helps make sure they work properly. General information about how medicines should be used was now more detailed in the care plans and medicines records. When required medicines were recorded much better and more information about how and when they should be given was available so care staff knew how to use them properly. The recording of external medicines such as creams was much improved and there was detailed information about where and when they should be applied. Doctors visits were clearly recorded when new medicines were prescribed and when changes were made to current medicines the records were amended accurately. Accurate records and detailed information about medicines are important because they help prevent mistakes when handling medicines. Care Homes for Older People Page 14 of 28 Evidence: We checked how controlled drugs, medicines that can be misused, were handled. A new cupboard had been obtained and this was secure and compliant with the law. No controlled drugs had been handled since our last visit so we could not assess whether they were being recorded properly. We looked at how medicines were checked by the manager and saw efficient recorded audits that found mistakes. When mistakes were found suitable action was usually taken to help prevent them happening again. All staff had received regular medicines training and this was repeated on a regular basis. Formal competency assessments were routinely carried out to help make sure staff were following the correct medicines handling procedures and these were now being repeated on a regular basis. Regular audits, good training and formal competency assessments help make sure staff have the necessary skills to handle medicines safely. The manager was present for the first day of our visit. We observed staff interacting well with the people they cared for. Staff addressed people by their preferred names and spoke to them in a respectful manner. We spoke to several people accommodated in the home. They told us they were satisfied with the care they received. On the second day of our visit the manager was not present. We overheard a member of the care staff speaking in an abrupt manner to some of the people living in the home. We also observed that the five staff on duty sat together in the dining-room for their break. This meant that no staff were available to supervise the welfare and safety of people in other areas of the home. Care Homes for Older People Page 15 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Food provided by the home does not meet each persons dietary needs or meal preferences. Evidence: The home employed an activity co-ordinator for 20 hours per week. Good records were in place to detail the outcome of individuals participation in the activities provided. The records provided evidence that people had regular opportunities to go out for walks to the park or the shops, join in with exercise programmes or to play cards, darts or dominoes. We observed visitors coming and going during the time we spent in the home. People told us that visitors are made welcome and they can choose to receive them in private if they wish. We asked one of the visitors their views about the service provided by the home. The told us that they were generally happy with the care provided and they got on well with staff working in the home. However, this person expressed disappointment that cooked breakfasts were no longer available each day and were currently only provided on a Sunday. This change had occurred at a service users meeting in January 2010. We looked at the minutes of this meeting. We did not find evidence that people living in the home had requested this change. The minutes told Care Homes for Older People Page 16 of 28 Evidence: us that a cooked breakfast would only be available each Sunday, whereas this had previously been available each day. It was recorded that this would be reviewed after six weeks, although the review had not taken place. The manager agreed to meet with the person accommodated and their relative to discuss the situation. We asked other people living in the home their views of the meals provided. Two people thought that the menus could be improved. One person told us that they found the menus repetitive. We observed the lunch time meal provided on the day of our first visit. The majority of people were served with a fishcake and green beans with yoghurt for dessert. Although this was not the main meal of the day it did not appear to be a substantial meal for some of the people accommodated. Additionally. more care and attention could have been taken to present the meal in a more attractive and appetising manner. It was difficult to assess if people were being provided with meals according to their preferences, as care plans failed to identify each persons likes and dislikes in relation to food. We were also concerned to find that a person, whose care plan said they suffered from diabetes, was not being provided with a special diet. This potentially placed the persons health and welfare at risk. Care Homes for Older People Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are potentially placed at risk of accidental harm if staff are not available to supervise and monitor their welfare at all times. Evidence: The home had a suitable policy and procedures for dealing with complaints. The people we spoke to knew who they would talk to if they had a complaint. Social services recently received an anonymous complaint alleging that the personal spending money of people living in the home had not being properly accounted for. This was fully investigated by the police and found to be unsubstantiated. Staff had been trained in safeguarding procedures and they knew what action they should take if they suspected someone was at risk of abuse. There had been one safeguarding referral that had been investigated by the local authority in the previous 12 months. On the second day of our visit the manager was not present, although a senior person had been left in charge. We overheard a member of the care staff speaking in an abrupt manner to some of the people living in the home. We also observed that the five staff on duty sat together in the dining-room for their break. This meant that no staff were available to supervise the welfare and safety of people in other areas of the home. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People accommodated in the home are provided with a clean and well maintained living environment. Evidence: We looked round the home to assess cleanliness, hygiene, health and safety and infection control. The home was found to be clean with no unpleasant odours present. Each member of staff had been trained in the control of infection and procedures in place were generally being followed. However, we noted that terry towelling was being used for hand-drying. We recommend that paper towels be provided to minimise the potential spread of infection. The home and its equipment had been subject to regular maintenance and equipment replacement as necessary. However, we did not see evidence of a current gas equipment test certificate. Suitable facilities had been provided for the laundering of clothing and linen. Care Homes for Older People Page 19 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment and staff development procedures ensure that staff have the knowledge and skills to meet the assessed needs of people accommodated in Haylands. Evidence: The home was suitably staffed on the day that we visited and the rotas provided evidence that these staffing levels had been consistently maintained. The manager had to cover personal care on the morning of our visit as a care assistant was escorting a service user to a hospital appointment. The manager told us in her self-assessment document that all staff working in the home had achieved a National Vocational Qualification in care at level 2 or above. We looked at the personnel file belonging to a member of care staff who had been recruited since our last visit. The required pre-employment checks had been undertaken to make sure that the candidate would be suitable to work with older people. We made one recommendation in relation to recruitment. Photocopies of documents, such as passports and birth certificates should be signed to verify that the original documents have been seen. The person recruited had undergone a suitable induction programme and further training had been provided as necessary. Records were held detailing the training Care Homes for Older People Page 20 of 28 Evidence: undertaken by staff working in the home. Care Homes for Older People Page 21 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current management systems do not ensure that people using the service have their needs consistently met in a safe manner. Evidence: The registered manager was suitably qualified and experienced in running a care home for older people. One of the managers responsibilities is to notify the Commission about significant events in the home that affect the welfare and safety of the people accommodated. This includes deaths, accidents and thefts. This enables us to monitor the conduct of the home and to determine if such incidents are being managed in the best interests of the people accommodated. In the previous 12 months we had received one notification in relation to an unexpected death. When we examined the records we found there had been a significant number of deaths, accidents and incidents that we had not been notified about. We spoke to the local authority about this and made a referral for investigation under their safeguarding adults procedures. Care Homes for Older People Page 22 of 28 Evidence: Satisfaction surveys had been issued by the home to people using the service and their relatives. We looked at completed surveys and found relatives comments to be positive. Surveys issued to people living in the home had been completed with the assistance of a member of staff. These did not contain any comments or views from people using the service. We recommend that the home enlists the support of independent advocates to assist people with completing surveys in the future. This service has shown some improvement in relation to the manner in which medication is administered to the people accommodated. This has been achieved by implementing a regular system of audits that identifies and rectifies mistakes. During this visit we found serious shortfalls in the system of care planning used in the home. The manager told us that a new care plan format is to be introduced. We recommend that this be audited on a regular basis to ensure that the assessed needs of the people accommodated are being met consistently. We did not undertake an assessment of the management of peoples personal spending money during this visit. In January 2010 we were notified by the environmental health officer that the cellar door was unsecured and that this potentially placed people living in the home at risk of falling down the cellar steps. When we were told about this we phoned the manager to ask her what she was going to do to make the door safe. We were told that a suitable lock would be fitted. When we arrived at the home on this visit we found that no action had been taken to make the door safe. We made a requirement for a suitable lock to be fitted. The manager has since confirmed that this had been done. Care Homes for Older People Page 23 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 18 13 Staff must be available at all 16/07/2010 times to supervise and monitor the health and safety of people accommodated in the home. To ensure that people are not placed at risk of accidental harm. 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 7 12 Care plans must contain sufficient detail to demonstrate that peoples needs are being met appropriately in accordance with their preferences. To ensure that people are receiving care and support that promotes their wellbeing. 16/07/2010 2 8 12 Staff must ensure that people living in the home receive the right care and appropriate treatment. To ensure that peoples personal and health and safety needs are being met. 16/07/2010 Care Homes for Older People Page 25 of 28 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 15 16 The home must provide evidence that menus reflect the meal preferences and assessed needs of people living in the home. To ensure that people have access to a varied, wholesome and nutritious diet according to their individual preferences. 16/07/2010 4 31 37 The registered manager 16/07/2010 must notify the Commission of all incidents and events in the home that affect the welfare of the people accommodated. To enable the Commission to monitor the dafety of people using this service. 5 37 26 The registered person must submit written monthly reports on the conduct of the home to the Commission. To enable the Commission to monitor progress on improving outcomes experienced by people living in the home. 16/07/2010 6 38 13 The cellar door must be adequately secured at all times. 16/07/2010 Care Homes for Older People Page 26 of 28 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To prevent people living in the home from accidentally falling down the cellar steps. 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 19 Evidence should be made available to demonstrate that gas equipment used in the home is subject to annual safety checks by a CORGI registered contractor. Paper towels should be used for hand-drying facilities to minimise the potential spread of infection in the home. Photocopies of passports and birth and marriage certificates should be signed to verify that the original documents have been seen. The manager should consider enlisting the support of an advocate to assist people living in the home to express their views about the qulaity of this service. The care planning system should be subject to regular audits that identify and rectify shortfalls in meeting the needs of the people accommodated. 2 3 26 29 4 33 5 33 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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. 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