Care Home: Marsden House

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What the care home does well People can be confident that their needs will be fully assessed before they move into Marsden House, so that the home can be sure that it can meet people`s individual needs. The home provides a good standard of personal care and makes sure that people`s healthcare needs are met. Medication is managed safely. The home provides a range of social and leisure activities, which meet people`s individual needs. The food at the home provides a nutritious and balanced diet.Marsden HouseDS0000054060.V377885.R01.S.docVersion 5.2People can be confident that any concerns will be listened to and resolved promptly. The home takes seriously its responsibility to protect people from the risk of neglect or abuse. Marsden House provides a comfortable and safe environment for people to live. The home is kept clean and infection control is well managed. Staff are kind and caring. The home`s recruitment procedures help to protect people by making sure that only suitable staff are employed. The home has a clear management structure which helps to ensure that the home is run in the best interests of people living there. What has improved since the last inspection? The home makes sure that care plans are regularly reviewed. Care plans include information on people`s preferred lifestyle and activities. What the care home could do better: Care plans do not always contain full details of the care that people require. Staff training could be improved to ensure that all staff have up to date knowledge and skills. Risks from the lack of restrictors on upstairs windows need to be managed so that people are protected from the risk of harm or injury. Key inspection report CARE HOMES FOR OLDER PEOPLE Marsden House Whitchurch Symonds Yat Ross on Wye Herefordshire HR9 6DJ Lead Inspector Sarah Blake Key Unannounced Inspection 2nd October 2009 09:00 DS0000054060.V377885.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. Marsden House DS0000054060.V377885.R01.S.doc Version 5.2 Page 2 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 Marsden House DS0000054060.V377885.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marsden House Address Whitchurch Symonds Yat Ross on Wye Herefordshire HR9 6DJ 01600 890869 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Graham Winston Fillery Care Home 23 Category(ies) of Dementia (23), Mental disorder, excluding registration, with number learning disability or dementia (23), Old age, of places not falling within any other category (23), Physical disability (23) Marsden House DS0000054060.V377885.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 23 Dementia (DE) 23 Mental Disorder (MD) 23 Physical Disability (PD) 23 The maximum number of service users to be accommodated is 23. 2. Date of last inspection 8th September 2008 Brief Description of the Service: Marsden House is a well-established Care Home situated in the centre of the village of Whitchurch between Ross-on-Wye and Monmouth. It is within easy access of the main A40 road. Village facilities e.g. post office and general store, are within easy walking distance. The Provider is also registered as the Care Manager. The service accommodates 23 people over the age of 65 who have needs arising from the normal ageing process or because they have additional needs associated with physical disability, dementia illnesses or other mental health difficulties. The home is situated in large grounds. There is an additional lounge/hairdressing room with ramped access to the gardens. Information about the schedule of fees can be obtained from the home. There are additional charges for hairdressing, chiropody, toiletries and newspapers. A copy of this inspection report is available to view at the home. Marsden House DS0000054060.V377885.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good outcomes. This was an unannounced inspection. One inspector spent a day at the home, talking to the people who use the service and the staff, and looking at the records, which must be kept by the home to show that it is being run properly. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. We looked in detail at the care provided by the home for three people. This included observing the care they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. Some of the managers comments have been included within this inspection report. We received completed survey forms from people who live at the home and their relatives. The information from these sources helps us understand how well the home is meeting the needs of the people using the service. What the service does well: People can be confident that their needs will be fully assessed before they move into Marsden House, so that the home can be sure that it can meet peoples individual needs. The home provides a good standard of personal care and makes sure that peoples healthcare needs are met. Medication is managed safely. The home provides a range of social and leisure activities, which meet peoples individual needs. The food at the home provides a nutritious and balanced diet. Marsden House DS0000054060.V377885.R01.S.doc Version 5.2 Page 6 People can be confident that any concerns will be listened to and resolved promptly. The home takes seriously its responsibility to protect people from the risk of neglect or abuse. Marsden House provides a comfortable and safe environment for people to live. The home is kept clean and infection control is well managed. Staff are kind and caring. The homes recruitment procedures help to protect people by making sure that only suitable staff are employed. The home has a clear management structure which helps to ensure that the home is run in the best interests of people living there. 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 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. Marsden House DS0000054060.V377885.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. The home does not provide intermediate care, so Standard 6 was not assessed. People using the 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 can be confident that their needs will be fully assessed before they move into Marsden House, so that the home can be sure that it can meet peoples individual needs. EVIDENCE: The home provides written information for people who are considering moving into Marsden House. This is in the form of a brochure, a Statement of Purpose and a Service User Guide, which give detailed information about what life is like at the home. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 9 In the AQAA, the provider told us We are happy for people to visit our home at any reasonable time, and do not require an appointment to be made so that people can see the home as it truly is. On the day of the inspection, we saw that someone was being shown round the home by staff. We spoke to a relative of someone who lives at the home, and they told us that they had visited the home prior to their family member moving in, and had found the staff to be welcoming and friendly. Records showed that senior staff from the home visit people before they move in, so that their needs can be assessed. This assessment ensures that the home knows that it can meet peoples individual needs, and also gives staff the information they need so that they can provide the care that is required. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the 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 good standard of personal care and makes sure that peoples healthcare needs are met. Medication is managed safely. EVIDENCE: We looked in detail at how the home manages the care needs of three people who live at Marsden House. We saw that each person had a care plan which gave staff clear instructions about their individual care needs. The plans had been regularly reviewed and updated. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 11 The care plans were generally written in a person-centred way. This means that they are written to take into account each persons individual needs and wishes. We saw that staff had written pen pictures which contained background information about each person and their likes and dislikes. For people with a dementia illness, the home uses a dementia behaviour profile form to set out how the dementia affects each person. The use of this profile should be reviewed, to ensure that it is consistent with person-centred planning. Some care plans did not include all the information that staff would need. For example, the home has a book where visits from healthcare professionals such as GPs and District Nurses are recorded. With reference to one person, the book stated to carry on washing and creaming feet … we can take tubigrip off each time. This information had not been transferred to the care plan. Records showed that the home carries out risk assessments whenever necessary. One person had been assessed as being at high risk of falling, and the home had reassessed the risk following a fall, which is good practice. However there was no action plan in place to manage the risk. People told us that staff provide a high standard of care, and on the day of the inspection, we saw staff treating people with kindness and respect. We saw staff explaining a task to someone living at the home, and repeating their explanation patiently when the person clearly didnt understand. We looked at the records which the home must keep to show how medication is managed. We saw that each person had a risk assessment to assess whether or not they were able to take responsibility for their own medication. This is good practice, as it encourages people to maintain their independence as far as possible. We saw that any allergies were clearly recorded on the Medication Administration Record (MAR) sheets. There were no photographs to help staff identify people when giving medication. It is good practice to make sure that photographs are kept with each persons MAR sheet, so that staff who are not familiar with the home, such as agency staff, are able to identify each individual person. This is especially important in a care home where people may have dementia. The home has robust procedures for the receipt, storage, administration and disposal of medication. We checked a sample of medication which had been prescribed to be given as required. This included some strong painkillers. We found some discrepancies in recording, which meant that it was not possible to determine whether or not some medication had been given. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the 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 range of social and leisure activities, which meet peoples individual needs. The food at the home provides a nutritious and balanced diet. EVIDENCE: People told us that they enjoy the activities provided at the home. We saw a monthly newsletter with a list of this months activities, which included cake decorating, movie afternoons showing old movies, a visit from the Stepout theatre company, bingo, music to movement, a pamper afternoon, and a painting & drawing session. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 13 The home uses a community mini-bus for trips out to local places of interest, such as the Forest of Dean. Staff also take people into Monmouth for shopping or to a local garden centre for coffee. On the day of the inspection, we saw that some people were sitting in a small group, watching television together, and other people were entertaining visitors in their bedrooms. We spoke to people and they told us that there is plenty to do at the home to keep them occupied. The deputy manager explained that the home has recently bought some memory games, and also some games such as quoits so that people can practise hand-eye co-ordination skills. The home has recently appointed a new chef, who has qualifications in food hygiene training and is now training staff in this. The chef told us that he meets with people when they move into the home to find out their food likes and dislikes. We saw that there was a list of peoples preferred drinks and breakfast menu on the wall of the kitchen. Some people prefer to eat their meals in their bedrooms, and in the AQAA, the provider told us residents are free to choose whether they have their meals in their rooms or in the dining room. The menu is rotated on a four weekly basis. On the day of the inspection, lunch was fish with chips or mash, peas and sweetcorn, followed by lemon torte. It would be good practice to offer a choice of main meal at lunchtime. We saw staff supporting people to eat their lunch, and this was done sensitively and in an unhurried manner. We saw that some people were wearing blue plastic disposable aprons to eat their lunch, and the deputy manager told us that this is done to protect their clothing. The use of disposable aprons does not promote dignity, and other ways of protecting clothing should be used. People told us that they enjoyed the food at the home, and comments included lovely and plenty of it and not quite like home-cooked but better than it was. The chef explained that he tries to use fresh fruit and vegetables as often as possible. The food storage areas were seen to be clean and very tidy. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the 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 can be confident that any concerns will be listened to and resolved promptly. The home takes seriously its responsibility to protect people from the risk of neglect or abuse. EVIDENCE: People living at the home and their relatives told us that they knew who to talk to if they had any concerns. They also said that they would feel comfortable raising any issues and were confident that they would be listened to and any issues would be resolved. The home has a clear and detailed complaints policy which is made available to everyone living at the home. We, the Commission, have received one complaint about the home in the past year. This was referred to the provider to investigate, and he kept us informed of the progress of this complaint until it was resolved. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 15 We spoke to staff, who knew how to report any concerns about possible abuse or neglect. There was no evidence that staff had received training in the protection of vulnerable adults, but the deputy manager told us that this is covered as part of the induction of new staff. One of the ways in which care homes can help to protect the people living there from the risk of abuse is by the use of robust recruitment procedures. We looked at the records for three recently appointed members of staff. These showed that the required checks had been carried out before the staff had started work at the home. These checks include a Criminal Records Bureau (CRB) check and two written references, one of which is from a previous employer. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Marsden House provides a comfortable and safe environment for people to live. The home is kept clean and infection control is well managed. EVIDENCE: Marsden House is an adapted and extended country house, standing in its own spacious grounds. There are two lounges and two conservatories on the ground floor for people who live at the home to use. The quiet lounge is at the front of the house and is furnished with a three piece suite and a piano and ornaments. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 17 The TV lounge has armchairs grouped around small coffee tables. This arrangement of chairs promotes interaction between people and gives the room a homely feel. Cushions, vases, pot plants, fresh flowers, books (some large print) and videos add to the ambience of the room. The conservatory is a small lounge area, which the hairdresser uses when she visits. There is access to the patio and garden via French doors. The patio has garden furniture, and there is a large, well maintained, garden with seating. The dining room has been upgraded with a new carpet. We saw that the tables were laid with fabric cloths, new placemats and silk flowers. The bedrooms are mainly large and have armchairs, and folding chairs available for visitors. The home encourages people to bring their own furniture. We saw that people had personalised their bedrooms with photos and ornaments. Bedroom doors have large numbers, so that people with visual impairment can easily identify their own bedroom. The deputy manager told us that people are offered keys to their bedrooms. The home has an exceptionally well appointed laundry room, with all laundry sorted into labelled baskets. One designated carer deals with the laundry on each shift. We saw that staff were taking special care when drying delicate clothing. The deputy manager told us that towels and flannels are replaced after every use. Throughout the inspection, we saw staff using protective equipment, such as gloves and aprons, appropriately. Staff showed a good understanding of infection control. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are kind and caring. They do not always receive the training they need to give them the skills and knowledge they need to carry out their work. The homes recruitment procedures help to protect people by making sure that only suitable staff are employed. EVIDENCE: People we spoke to at Marsden House spoke highly of the staff. Comments included theyre very kind indeed, always on hand to help and friendly and always stop for a chat if theyve got time. During the inspection, we saw that staff had a friendly and relaxed relationship with people living at the home, and obviously knew them well. On the day of the inspection, there were three care staff on duty to care for seventeen people, of whom six were self-caring. The rotas showed that this is the usual level of staffing. The deputy manager assured us that staffing levels Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 19 are dependent on the needs of the people at the home, and more staff can be brought in if necessary. We have already described earlier in the report how the homes recruitment procedures help to make sure that only suitable staff are employed. We spoke to a new member of staff, who told us that she had spent her first few shifts shadowing more experienced staff and had completed an induction programme which gave her useful knowledge about procedures at the home. The deputy manager told us at the start of the inspection that training for staff was not up to date. Records showed that First Aid training had been organised for eight staff, to take place soon. At the time of the inspection, there were only three staff who were up to date with First Aid training. The staff training records did not provide evidence that required training had been undertaken by all staff at the home. We saw that some staff had attended training in dementia care. This is positive, as some of the people living at the home have a dementia illness. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a clear management structure which helps to ensure that the home is run in the best interests of people living there. Generally health and safety is managed well, but there are minor shortfalls. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 21 EVIDENCE: The provider, Graham Fillery, has shown that he works well with the Commission. He keeps us informed of events within the home, and has a proactive approach to managing issues. The home sent us the AQAA when we asked for it, and it contained detailed information about the home, the accuracy of which was confirmed at the inspection. The AQAA included information about the homes plans for improvement. The provider told us that the deputy manager will be applying to become the registered manager. This will give the home an even more stable management structure. The home does not take responsibility for peoples personal finances, but prefers that relatives take on this role. Because some of the people living at Marsden House have a dementia illness, we looked to see if the home had carried out assessments under the Mental Capacity Act (MCA). This would ensure that peoples interests are protected if decisions need to be taken by the home on their behalf. There were no MCA assessments in place, but the deputy manager assured us that she would be making sure that senior staff were trained to do them in future. We saw that a first floor window was wide open, and we confirmed that this was a bedroom window. There was no restrictor fitted to the window, and no risk assessment in place to show how the risk of falling from the window was being managed. We will be requiring the home to carry out risk assessments for any area of the home which might present a risk to people living there. Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X 3 X 4 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 23 Are there any outstanding requirements from the last inspection? nO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) (b) Requirement You must ensure that care plans clearly direct staff as to how they should care for and support people who use the service across all of their changing needs and conditions. This is so that people can be confident that their needs will be met. You must ensure that staff receive regular training updates. This will support them in providing the care that is required. You must ensure that the potential risks of first floor windows are assessed, and control measures put into place where a risk has been identified. This is to make sure that peoples health and safety is protected. Timescale for action 22/12/09 2. OP30 12 (1) 22/12/09 3. OP38 13 (4) (a) 22/12/09 Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations You should ensure that the use of the dementia profile is reviewed, to ensure that it is consistent with personcentred planning. You should ensure that an effective system is in place so that medication can be accurately audited. You should ensure that a photograph of each person living at the home is kept with the medication administration record so that all staff can easily identify each person. You should ensure that peoples clothing is protected at mealtimes by the use of suitable protective wear. You should ensure that people are given a choice of main meal, so that they are enabled to exercise choice and control over their lives at the home. 2. 3. OP9 OP9 4. 5. OP15 OP15 Marsden House DS0000054060.V377885.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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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