Care Home: Madeira House Nursing Home

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What the care home does well People told us that they are satisfied with the care they receive at the home. They said they are looked after very well, staff talk to them nicely, and they feel safe living there. They told us that they have enough activities to do, and they can make their own choices and decisions about their daily lives. People are encouraged to give their views about the care they receive, and say how they would like things to improve. The staff are trained to provide the right support to people, and there are systems in place to help keep them safe. What has improved since the last inspection? At the last inspection we said that the way some medication is recorded must be improved and we saw that this has now been done. Double rooms have now been changed into single rooms to give people more privacy, and the programme of decorating and replacing carpets has continued. The home has now employed a second activity coordinator and there are a wider range of activities for people to choose from. The activity coordinator and the manager also now produce a regular magazine for the home. Records to show what people have eaten are now more detailed so that their diet can be monitored in a better way, and the way staff are recruited has been reviewed and updated to help keep people safe. What the care home could do better: During this inspection we found that there were some areas in which the provider organisation did not effectively support the way the home is being run by the manager. Because we think this will affect the standards that the manager and staff have so far achieved, we said that the provider organisation must improve the way in which they support the home and the manager, and show that they have the right skills and competence to do this. This includes responding to complaints in the way that their policy says they will, and making regular visits to the home to monitor the quality of the service with a report to show what they have found. We also made a suggestion that they continue to look for ways to provide a consistent hot water supply to all bedrooms, so that everyone has their personal hygiene needs managed in a better way. As well as saying what the provider organisation must do to improve the service, we made some good practice suggestions that may help to improve the day to day operation of the home. We said that care plans and risk assessments could be improved by including more details about things like finance and decision making, and making sure that all of the information is cross referenced. The manager also acknowledged that there could be more details put into initial assessments and she said that this would be done. These things would mean that there is better information to help staff care for people. We said that they could better advertise the alternative foods that are available if people do not want to eat what is on the set menu, and they could display thecomplaints procedure in a more prominent way. This would help people to make more informed choices, and better understand the systems in place to support them. Lastly we said that they could develop a more formal system to monitor that they have the right number of staff on duty to meet everyone`s needs at all times. This will help to show that the home has considered people`s dependency needs. As well as the things that we have suggested, the manager said that they would like to be able to provide better transport so that more people can have outings from the home. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Madeira House Nursing Home 129 131 High Holme Road Louth Lincolnshire LN11 0HD     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Wendy Taylor     Date: 2 8 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Madeira House Nursing Home 129 131 High Holme Road Louth Lincolnshire LN11 0HD 01507607452 01507601246 manager.madeira@aermid.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Aermid Health Care (UK) Limited care home 54 Number of places (if applicable): Under 65 Over 65 54 old age, not falling within any other category Additional conditions: 0 The maximum number of service users to be accommodated is 54 The registered provider 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 category:- Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Madeira House provides personal and nursing care for up to 54 older people. It is owned by Aermid Health Care Group PLC. Since the last inspection there has been no change to the manager who is a State Registered Nurse and has worked at the home since it opened in 1986. The home is situated on the outskirts of the market town of Louth, and is on a bus route into the centre of town, which has a variety of services and facilities. It is a large two-storey building offering accommodation to residents on both floors. There is a passenger lift giving access to the first floor. The home benefits from well-maintained gardens and has ample parking space to the rear of the building. Care Homes for Older People Page 4 of 28 Brief description of the care home The manager told us that the current weekly fees range from £360:00 to £512:00, depending on peoples assessed needs. Chiropody and hairdressing are additional to the fees. Further information about these fees, as well as how the home operates can be obtained from the main office of the home. 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: 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 quality rating for this service is 1 star. This means that people who use the service receive adequate quality outcomes. The key unannounced inspection visit took place on one day in August 2009 and lasted for approximately 8 and a half hours. Forty seven people were living in the home on the day of the visit. The care received by a selection of people was followed in detail using a method called case tracking. This method involves things like talking to people about the care they receive, looking at their care plans and health records, talking to the staff who support them, and watching how staff put care plans into practice. We also looked at their daily Care Homes for Older People Page 6 of 28 notes and some general house and staff records. The manager was available throughout the visit and we spoke to her about the management arrangements within the home. As part of the inspection process we have also used information that we already held, such as the homes self assessment. People made comments to us such as I get everything I wish for here, staff are caring and helpful, and its a wonderful place, I get everything I want. Other things that people told us, as well as comments made by staff are included in the main part of this report. What the care home does well: What has improved since the last inspection? What they could do better: During this inspection we found that there were some areas in which the provider organisation did not effectively support the way the home is being run by the manager. Because we think this will affect the standards that the manager and staff have so far achieved, we said that the provider organisation must improve the way in which they support the home and the manager, and show that they have the right skills and competence to do this. This includes responding to complaints in the way that their policy says they will, and making regular visits to the home to monitor the quality of the service with a report to show what they have found. We also made a suggestion that they continue to look for ways to provide a consistent hot water supply to all bedrooms, so that everyone has their personal hygiene needs managed in a better way. As well as saying what the provider organisation must do to improve the service, we made some good practice suggestions that may help to improve the day to day operation of the home. We said that care plans and risk assessments could be improved by including more details about things like finance and decision making, and making sure that all of the information is cross referenced. The manager also acknowledged that there could be more details put into initial assessments and she said that this would be done. These things would mean that there is better information to help staff care for people. We said that they could better advertise the alternative foods that are available if people do not want to eat what is on the set menu, and they could display the Care Homes for Older People Page 8 of 28 complaints procedure in a more prominent way. This would help people to make more informed choices, and better understand the systems in place to support them. Lastly we said that they could develop a more formal system to monitor that they have the right number of staff on duty to meet everyones needs at all times. This will help to show that the home has considered peoples dependency needs. As well as the things that we have suggested, the manager said that they would like to be able to provide better transport so that more people can have outings from the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out 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. People are assured that the home can meet their needs by way of a clear assessment process. Evidence: We looked at four peoples files when we visited the home. All of the files contain assessment information that was gathered before the person moved into the home. The assessments generally contained lots of information about needs and preferences such as moving and handling, nutrition and pressure area care. There are also details of personal life history, family and friends, and hobbies. Some sections of the assessments did not contain very much detail such as the finance section, and the manager said that she would review and update all of the files in regard to this. People and their relatives told us that the manager or staff came to visit them before they moved in and they told us things like they asked us lots of questions, and they Care Homes for Older People Page 11 of 28 Evidence: asked us and our relative what we wanted and needed at the home. People said that they were able to look around and make up their mind if the home was suitable for them or their relative, and most people said that they got enough information about the home to help with this decision. The manager told us that the home was not providing intermediate care at the time of our visit. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured that their care needs will be met by way of clear care plans. Evidence: Care plans are in place for needs such as communication, personal care, nutrition, and comfort and safety. The plans are signed by people or their representatives to show that they agree with them, and they refer to making choices and maintaining independence. There are also care plans that talk about how families like to receive information, and short term care plans for things like chest infections or skin soreness. Although the plans refer to making sure that people have choices they do not show how people make their own decisions or what to do if they cannot do this. Staff were able to tell us how individual people make their wishes and choices known, and we know that staff have received training about new laws regarding this. Risk assessments are also in place for things like using bed rails, mobility, and diabetes. Some of the assessments do not contain a lot of details, and they do not Care Homes for Older People Page 13 of 28 Evidence: cross reference clearly with care plans. Records show that peoples care plans are reviewed regularly, and that there is regular monitoring of health needs, including reports of visits to see health professionals. During this visit we saw that medication storage and administration records were up to date, and the report of a recent visit by the local pharmacy did not highlight any issues. We watched staff giving out medicines to people and saw that they did this in the right way. They did things like making sure that people were happy to take their medicines, helping them to take the tablets in the way they wanted, and signing the medicine cards as soon as the medicine had been taken. People who live at the home told us through discussions and surveys that they were happy with the service they get. They said things like they look after us very well, staff always talk to you nicely, I can see a doctor whenever I want to, and I didnt want to come into a home but Ive settled here and have nice friends. A relative told us that staff keep them up to date with everything they need to know. During the visit we saw staff attending to peoples needs in good time, using peoples preferred names, and helping them to do what they could for themselves. We saw that staff used moving and handling equipment in the right way, and staff told us that there were enough hoists available for them to use. We also saw that there were good stocks of things like continence aids and medical dressings, and staff told us that these type of things are easily ordered from the local pharmacy when needed. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a choice of activities, and from a well balanced diet that suits their needs and preferences. Evidence: People told us that there were generally enough activities for them to join in when they wanted to, but it was their choice if they did or not. Some people said that they would like to be able to get out of the home more, and we know from information we had before we visited that the home would like to get a mini bus to help people with this. The home now employs two activity coordinators who work across five days each week. One activity coordinator told us that she is soon to go on a training course to learn more about helping people to reminisce. They have introduced new activities like developing a memory scrap book, and a photo book which shows people taking part in activities such as going out to garden centres, gardening, and doing crafts. They also produce a monthly magazine which contains information about the home, puzzles, and photographs. Care Homes for Older People Page 15 of 28 Evidence: Activity programmes are advertised on the notice boards in the main hallway and show activities such as painting, basket making, poetry sessions,and musical entertainers. During the visit we saw people joining in with an exercise session, and individual support being given to people with puzzles and games. One lounge had a television on for people to watch and the two other lounge areas were being used by people for quieter activities such as reading. Notice boards in the main hallway have information for people and their representatives about community based support services such as patient liaison groups, Alzheimers groups, and advocacy groups. People told us that they can say what they want and staff and the manager will listen to them, and they can make their own choices about things like where to eat meals, what they want to do with their time, and when to receive visitors. They also made comments like I brought my own furniture in so I could feel at home, and I can have my photos in the lounge to make me feel at home. Records show that people have an assessment of their nutritional needs when they move into the home, and their diet preferences are also recorded. People said that the food served to them is very nice. There is a four weekly menu which is based around peoples known likes and dislikes, and meals are advertised on a board in the dinning room. Alternatives to the set menu are not listed however the cook told us that there are always alternatives available. In a survey conducted by the home four people said they dont have a choice of meals, and the rest of the people who live in the home said that they prefer a set menu and will say when they want something different. The manager told us that peoples views about menus are regularly monitored and changes can be made where ever necessary. During the lunchtime meal we saw that staff know what people like and ask them if they want anything different from the menu. We saw people asking for alternatives and being provided with them, for example omelets. Records are now kept for what people eat that is different from the set menu. There were good stocks of foods and drinks in the home, and freshly baked cakes and other home made desserts. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are clear systems in place to assure people that that they will be protected from abuse. However people cannot be confident that the provider will deal with their complaints in a timely manner. Evidence: People and their representatives told us that they know how to make a complaint if they need to, and they said that they can talk to staff or the manager about any concerns they have. There is a complaints procedure available in the home but it was not easy to find on the day of the visit. Records show that since the last inspection no complaints have been made about the service provided in the home. However one complaint has been made to us about the way the provider has managed the arrangements for paying care fees. We have asked the provider to investigate the issues but they have not yet responded to us within the timescales of their policy. There are policies and procedures in place to make sure that people are protected, including the Local Authority guidance on keeping people safe. Staff were able to tell us how they would identify any forms of abuse, and what they would do if they saw or suspected such. Records show that they have had training in this subject. People told us things like I feel that I am safe here and looked after very well, and I feel safer here than living on my own. One referral has been made to the Local Authority Safeguarding Adults Team since the last inspection. We know that a protection plan Care Homes for Older People Page 17 of 28 Evidence: was put in place and the home has completed all of actions in the plan. 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 enjoy a clean and comfortable environment that suits their needs and wishes. Evidence: When we looked around the home we saw that it was clean and tidy throughout. We know that since the last inspection some bedrooms have been decorated, and some carpets and curtains have been renewed. We also know that double bedrooms have been changed into single rooms so that people have more privacy and personal space. People told us that the home is always fresh and clean, and they said things like I have a lovely view of the garden, the living room is comfortable and I can have personal things on the tables around me, and I like my bedroom because Ive got everything I need in it. Issues were raised in one survey about there being no facilities for visitors such as chairs, coat hangers or drinks machines. During the visit we saw visitors sitting in comfortable chairs with friends and family, and being offered refreshments. We passed on the suggestion about visitors coat hangers to the manager for her to consider. Before we visited we were told that there was no hot water supply to two bedrooms. During the visit the manager told us that a new boiler system has been put in but there are still problems getting a consistent supply of hot water to the rooms in Care Homes for Older People Page 19 of 28 Evidence: question. The manager said that they are continuing to try to solve the issue and alternative arrangements are in place. Records show that there are two infection control link nurses identified within the home, and we saw staff using appropriate hand washing techniques and using gloves and aprons where necessary. We also saw that staff carry and use their own hand disinfectants to help prevent the spread of any infection. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by robust recruitment and training systems for staff. Evidence: People and their representatives told us things about the staff like theyre lovely girls who work very hard, Im confident they will help with anything I need, and I dont have to wait long for them to come. Surveys we received also showed that people think there is generally enough staff to look after them, although two people said that they could employ more staff. Staff told us that there are generally enough staff on duty and the manager will make sure shifts are covered if someone is off sick. One comment was made that staff do not have time to sit and talk to people. During the visit we saw that staff were busy but they were responding to peoples request for help and support in a timely way, and two staff were allocated to stay around the lounge areas so that people could always find someone to help them. Rotas show that staffing levels are flexible depending of the number of people in the home, and the type of needs they have. Staff told us that they have good access to training courses and they had a good induction to the home when they started working there. Records show that a nationally recognised induction programme is used as well as an introduction to the Care Homes for Older People Page 21 of 28 Evidence: home and people who live there. Records also show that staff are trained in subjects such as end of life care and moving and handling practice. We saw that training courses have also been booked for subjects like dementia awareness, health and safety, and new laws about protecting peoples rights and freedoms. Many of the staff team are also working towards or have achieved a nationally recognised care qualification. We saw that the manager has a system to monitor what training is needed so that staffs knowledge and awareness of issues is kept up to date. Staff files contained all of the information needed to show that they have been recruited safely. We saw things like criminal record bureau checks, application forms, written references, and identification. The files also show that the home regularly checks that qualified nurses remain on a register that allows them to continue to work as a nurse. We know from our records that since the last inspection, recruitment practice has been reviewed and updated to make sure that the process provides more protection for people. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from the clear leadership and management arrangements within the home. However the organisational support is inadequate and will undermine the the work of the manager and staff in sustaining the standards that they have achieved. Evidence: There have been no changes to the management arrangements in the home since the last inspection. The manager has worked at the home for many years and she demonstrated to us that she has kept herself up to date with good practice, and has attended training courses to maintain her skills. People who live at the home, and staff told us that the manager is a lovely person, and that she is approachable and supportive. They also told us that they think she manages the home well. People told us that they are often given questionnaires to fill in so they can say what they think of the service. We saw a report of the latest survey carried out in July 2009 and the manager told us what actions had been taken to address issues raised. We Care Homes for Older People Page 23 of 28 Evidence: saw that there is also a box outside the main lounge area for people, their representatives, and staff to post their suggestions for improvements to the service. Records show that a yearly service audit is carried out which covers issues such as the quality of care plans, staff records, the environment, medication arrangements, and social activities. We also saw records for weekly quality checks on all of the communal living areas, bathrooms, and bedrooms. The checks show where any maintenance or replacement is needed. The manager also showed us that she monitors things like accidents, pressure area damage, and falls on a monthly basis so that any any safety issues or training needs can be identified. Our records show that the manager makes sure that we are told about anything that happens in the home that may affect the health, safety or welfare of the people who live there. We saw that environmental risk assessments are available for issues such as infection control and fire safety, and there are systems in place to make sure that things like fire safety equipment and hoists are serviced and maintained in working order. There are also information sheets available for any substances that may be harmful to people, and we saw that substances of this kind are stored securely. There is a system in place to help keep peoples personal money in a safe way. This includes records to show when money has been deposited with the home, how much has been spent, and what the money was spent on. At present there is no area manager in post to offer organisational support to the registered manager. The manager told us that a representative of the provider has visited once since April 2009, however there was no report of the visit available at the home. Since the last inspection people who live at the home and their representatives have raised concerns about how the provider has managed the payment of care fees. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 22 All complaints must be investigated and responded to in a maximum of twenty eight days, in accordance with the homes complaints policy. This is so that people are assured that their complaints with be listened to and taken seriously. 07/11/2009 2 33 26 Unannounced monthly visits 10/10/2009 must be undertaken at the home by the registered provider or their representative in accordance with this regulation. This is so that the provider can monitor and maintain the quality of care provided to the people who live there. 3 33 10 The registered provider must carry on the care home with sufficient care, competence and skill. 10/10/2009 Care Homes for Older People Page 26 of 28 This is so that people continue to receive a consistent and appropriate service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 It is recommended that risk assessment are reviewed to ensure that they contain sufficient detail about how to manage the risk, and that they cross reference with care plans. This is so that risks are managed in a consistent way. It is recommended that care plans contain more information about how the Mental Capacity Act, 2007 affects the person. This is so that their rights are upheld. It is recommended that alternative foods that are available, aside from the set menu, are better advertised. This is so that people have a more informed choice of alternatives if they do not want the set menu food. It is recommended that the complaints procedure is displayed in a more prominent way. This is so that everyone has access to it, and they can see what how their complaints will be dealt with. It is recommended that the home and the company that owns the home continues look for solutions to provide a consistent hot water supply to all bedrooms. This is so that peoples personal hygiene needs can be met in a more appropriate way. 2 7 3 15 4 16 5 19 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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. 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