Care Home: Rosalyn House

What the care home does well The home itself is a pleasant building that enables people to live in small units. It is well decorated and furniture and equipment are replaced as necessary. There is no odour detectable in this home. The staff recruitment process is thorough; this means that people living at Rosalyn House are protected by the safe recruitment of professional and friendly staff. Relatives told us they were generally happy with the service and care provided, they particularly expressed they could approach the manager at any time with any concerns they may have and be confident they would be dealt with appropriately. Visitors to the care home are made to feel welcome. One relative was particularly grateful for how staff welcomed her father, whose wife was a resident at the home. People were offered nutritious well cooked meals. One relative told us `the staff try very hard to find food that my mother will enjoy....they do everything to make her as comfortable as possible`. What has improved since the last inspection? Since the last inspection the service has another new manager who has worked hard to met the requirements made at the last inspection. One relative told us, `the new manager is making all areas better. Care plans are being kept under review so that they reflect the changing needs of the residents and the documentation, including the medication charts, are kept up-to-date. Staff supervision is back on track and it is planned that all staff will have two monthly supervision from a line manager. What the care home could do better: Requirements and recommendations have been made as a result of this report, which include the following areas:The service has been managed, but for the past six years not by a manager who has progressed to become the registered manager. There have been a variety of different reasons given for this but it is essential that this situation does not continue. Care plans are well written but care must be taken that a care plan for any aspect of care provided, is produced by staff in a timely fashion. Further training and personal development is required to ensure all staff have the skills and competence to meet residents` needs. Particular attention must be provided for those conditions associated with the needs of older people,including those with dementia, and safeguarding. Medication audits must be robust and provide the evidence that the correct medication has been given to the correct person at the correct time. People should be offered a meal that they fancy at the time the meal is served. This refers to people not having choices at the time the meal is delivered. Consideration should be given to what needs to be done to encourage staff to remain working at Rosalyn House. Two staff told us that at times they were under pressure to work long or additional shifts. Key inspection report Care homes for older people Name: Address: Rosalyn House King Street Houghton Regis Dunstable Bedfordshire LU5 5TT     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sally Snelson     Date: 1 9 0 4 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: Rosalyn House King Street Houghton Regis Dunstable Bedfordshire LU5 5TT 01582896600 01582896601 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): SAH Nursing Homes Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 46 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia learning disability mental disorder, excluding learning disability or dementia physical disability Additional conditions: Mental nursing care for Elderly people (over 65 years) Up to 16 Adults (40-64 years) Date of last inspection Brief description of the care home Rosalyn House is a purpose built Care Home (with nursing) specialising in caring for both younger and older adults with mental health and Dementia care needs. The home is in Houghton Regis very close to the town centre and in walking distance of local amenities and public transport routes. Care Homes for Older People Page 4 of 28 Over 65 46 46 46 46 16 0 0 0 2 6 0 5 2 0 0 9 Brief description of the care home The home can accommodate up to 46 individuals in single rooms with en-suite facilities arranged over three floors. There is passenger lift access to all areas of the home. The home has a secure courtyard area at the rear and a designated parking area. The fees for this home vary from £786.38 to £2000.00 per week, depending on the needs of the resident and funding source. If a higher staff ratio is required due to the assessed needs of the resident, fee levels will be above this figure based on the additional staffing costs. These fees are negotiable and the home takes a number of service users at social services rates. 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: This inspection was carried out in accordance with the Care Quality Commissions (CQC) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users views and information received about the service since the last inspection in the During the inspection the care of three people who used the service was case tracked. Case tracking involved reading residents records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home and staff were spoken to and their opinions sought. Any comments received from staff or service users about their views of the home plus all the information gathered on the day was used to form a judgement about the service. Prior to the inspection we received surveys from four people who lived in the home and four people who worked at the home. Care Homes for Older People Page 6 of 28 The inspector would like to thank all those involved in the inspection for their input and support. 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: Requirements and recommendations have been made as a result of this report, which include the following areas:The service has been managed, but for the past six years not by a manager who has progressed to become the registered manager. There have been a variety of different reasons given for this but it is essential that this situation does not continue. Care plans are well written but care must be taken that a care plan for any aspect of care provided, is produced by staff in a timely fashion. Further training and personal development is required to ensure all staff have the skills and competence to meet residents needs. Particular attention must be provided for those conditions associated with the needs of older people,including those with dementia, and safeguarding. Medication audits must be robust and provide the evidence that the correct medication has been given to the correct person at the correct time. People should be offered a meal that they fancy at the time the meal is served. This Care Homes for Older People Page 8 of 28 refers to people not having choices at the time the meal is delivered. Consideration should be given to what needs to be done to encourage staff to remain working at Rosalyn House. Two staff told us that at times they were under pressure to work long or additional shifts. 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. Admissions were not made to the home until a full needs assessment had been undertaken. The home was able to provide people with sufficient information to make an informed choice about the home. Evidence: The home had a Statement of Purpose and a Service Users Guide that detailed all the required information and was kept under review and updated as changes occurred. We had been sent a copy of the updated documents. The AQAA told us that people using the service or their families were provided with a welcome pack, that included these documents at the time of admission. During the inspection we tracked the care of three people using the service, including two people who had been admitted to the home since the last inspection. All of the files included copies of a detailed preadmission assessment that had been carried out by the manager. We discussed with Care Homes for Older People Page 11 of 28 Evidence: the manager the levels of care that the home could provide. All of the prospective residents were encouraged to visit the home prior to making the decision that Rosalyn House could meet their needs. Rosalyn House did not offer intermediate care. 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. The staff were successful in delivering appropriate care, although this may not have always be documented or recorded appropriately so continuity and consistency could not be assured. Evidence: We case tracked the care provided to three residents including two who had been admitted since the last inspection. On the whole care plans had been written in detail using information from the pre-admission assessment. However for one resident we tracked continuity of care could not be guaranteed. He had been at the home for five weeks and a number of plans had yet to be written, including his sleeping plan. Since the last inspection plans were now regularly reviewed and appropriate changes made as care needs altered. The AQAA told us that, there is a named nurse responsible for the overall care and care planning for each individual resident, ensuring accountability for care. Care plans were supported by risk assessments for moving and handling, nutrition and skin integrity. It was a generic approach to risk assessments as a diabetic did not have a risk assessment associated with the condition and how to deal with any problems that may be identified or occur. Care Homes for Older People Page 13 of 28 Evidence: In our last report we commented that, daily records were not always reflective of the care prescribed in the care plan. This had improved but we still had to read trough a lot of documentation to ascertain whether a prescribed dressing had been carried out. We discussed with the manager the use of a quick reference chart to support dressings, similar to those in place to support blood sugar monitoring. People using the service were registered with a GP and the staff told us they were able to seek advice from a variety of community health professionals. Moving and handling equipment was available and the majority of staff had had the required training to use this equipment. Staff told us that they always worked in pairs. We looked at medication records (MAR charts) held for the people whose care we were case tracking and then choose to look at more charts. There were no gaps on the records (that is, no missing signatures that confirmed that the medication had been given or an appropriate code used to explain if the medication had not been given, why not). However despite the medication being correctly received into the home and any medication carried forward correctly recorded we were unable to correctly reconcile the medications to the signatures. This is a process where we check that the number of tablets held in the home tally to the number received in, minus the amount signed as given. In all we checked at least one medication for nine residents and could only correctly reconcile three. A medication audit had been introduced following concerns raised at the last inspection, and while it had improved the medication processes it needed to be more robust to ensure reconciliation at all times. While medications do not reconcile we can not be confident that they have been correctly administered despite fully completed MAR charts. The manager who had worked hard on the medication audit told us there had been a heavy reliance on agency staff and most of the errors picked up during audit were linked to nurses who did not work regularly at the home. Any errors identified had been correctly dealt with and will be discussed in the safeguarding section of this report. People we spoke with had no concerns about the way staff treated them. They told us staff respected their privacy and dignity, and we observed staff knocking on bedroom doors, and making sure doors were closed when any personal care was being carried out. We did notice two female residents in one unit, wearing dresses or skirts and short socks; staff were not able to confirm that this was their choice. 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. A variety of activities provided people with stimulation throughout the day. Meals appeared nutritious, but more thought should be given to how and when people using the service make choices about what they eat. Evidence: The home had a new full time activities coordinator to organise, provide, and support care staff to provide, activities for the residents. She was spoken to and conveyed a good understanding of the needs of older people and people with dementia. She had developed a support network from staff members and the activity coordinator at the sister home to Rosalyn House and was introducing a number of new ideas and themed activities such as St Georges day events. The home had a good variety of equipment, games and puzzle to use. An activity plan, and individuals records, told us that people participated in activities such as quizzes, puzzles, reminiscence, church service and bingo. On the day of this visit a resident went out to the shops with a staff member and we saw one to one and group activities taking place, facilitated by the activity coordinator and the care staff. A musical entertainer was brought in from outside the home to entertain people in the Care Homes for Older People Page 15 of 28 Evidence: afternoon. This entrainment encouraged good interaction between residents and staff. We saw people spending time in various parts of the home and moving about from area to area. Peoples bedrooms were personalised, showing that individuals could bring their personal possessions into the home with them. Relatives visiting the home told us they could visit at any time and were made welcome. The AQAA told us, We Provide attractive and nutritious meals, and ample menu choices. We have an excellent chef overseeing the service and ensuring that it meets the high quality standards expected. We pride ourselves on the quality of food. We have a picture menu enabling residents to choose meals from photographs of the choices available. During the visit we saw people being offered attractively presented food but we did not see how choices were made. We were told this would have been done in advance, but for people with dementia this is not the most suitable way to make a choice. We did see alternatives being prepared if the meal was not eaten. The mealtime in the conservatory area was quite chaotic, despite residents being offered their meals in two sittings and we witnessed the potential for a person to have been forgotten. Care staff offered residents support with eating in a sensitive way. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Lack of updated training for all care staff may result in poor practices or people being put at risk. Evidence: There was a copy of the homes complaints policy on the wall in the entrance hall and it was included as part of the Statement of Purpose and Service Users Guide . The complaints policy gave people a clear indication of what a person lodging a complaint could expect in respect of response times and procedures that the home would follow. We received four completed surveys from residents. These had been completed by a family member on the residents behalf and all told us that they knew who to talk to if they had a concern, and how to make a formal complaint. There had been eight complaints received by the management of the home since the previous inspection visit. There was documentary evidence available in the form of letters to complainants and records of investigations carried out to confirm they were dealt with appropriately in line with the homes policies and procedures. The home also had a number of complimentary letters. The management were proactive in referring many potential safeguarding incidents to the local authority and had dealt with issues correctly. This included incidents of medication errors, unexplained injury and resident to resident abuse. However because of a recent turn over of staff the training matrix showed that only 50 of the Care Homes for Older People Page 17 of 28 Evidence: staff team had had a recent safeguarding update and the manager told us that staff had yet to have Mental Capacity Act (MCA) training and Deprivation of liberty training (DOLS). Following inspection we were advised that 87 of the original staff had had SOVA training. It was planned that the remainder would have SOVA training and all staff would have MCA and DOLS training by 01/08/10 as a new deputy manager, with a training background, had been appointed. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The general standard of the environment was excellent and provided an appropriate environment for everyone living at the home. Evidence: At the last inspection the environment had been described as good with refurbishment work in progress in the main dining / therapy area on the ground floor of this home. Since then there had been been a number of improvements, including the purchase of new furniture and the rearrangement of the serving area in the dining / activities room to provide more space. The kitchenette had also been enclosed for safety reasons. The home provided a physical environment that was appropriate for the specific needs of the people who lived there. It allowed people to live together in small clusters in a non institutional way. The home was clean, comfortable and well maintained. The AQAA told us of, Refurbishment of the conservatory, new artwork displayed in the dining areas, new memory wall with displays of 1940s and 1950s memorabilia in the conservatory. We looked at some bedrooms and all were clean and tidy with no odours. All bedrooms had en suite facilities. The external grounds were well maintained and provide a pleasant area that was secure. Staff were observed to wear suitable protective clothing when carrying out certain Care Homes for Older People Page 19 of 28 Evidence: activities. Cleaning schedules were in place and clinical waste was disposed of in an appropriate manner. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were supported by caring and safely recruited staff however, because of the continuous change of staff they may not be cared for by people who had documentary evidence to support that they had all the experience and qualifications necessary. Evidence: Staff rotas confirmed that there were always sufficient staff on duty to meet the needs of the people living at the home and that the number of care staff had increased from eight to nine during the day plus two nurses, and ancillary staff for cooking and cleaning. However once again the AQAA reported a high turnover of staff and a reliance on agency staff. In total we were told that 36 staff had left the employment in the last 12 months. Some had been asked to leave and others had left for a variety of reasons. This high turn over of staff is likely to affect staff morale and a consistent approach to care provision. One member of staff said, care staff here are good but they keep changing. We need to work together more. As a consequence of staff leaving the training matrix showed that despite a good amount of training being provided the staff team, at any one time, did not all have some of the mandatory or specialist training expected by the home. Most staff had undertaken fire training, manual handling training and food hygiene but a number needed infection control and as already mentioned around 50 of staff had not had safeguarding training at the home and 25 needed dementia awareness. The training Care Homes for Older People Page 21 of 28 Evidence: provided was of a good standard and was backed up by evaluation and assessment of what had been learnt. We looked at staff recruitment documents for two recently recruited staff members. This was to assess if the relevant checks had been made to ensure people were cared for by safely recruited staff members suitable to work with vulnerable people. All the checks and references had been seen before the person started work and the administrator told us of a system to check that the nurses PIN number (nurses permission to continue to work for a further year) were checked as they expired. Recruitment files were very well kept. 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. The management need to be more proactive to ensure the safety and protection of the people living there. Evidence: This home had not had a registered manager for the past six years. The provider had kept us informed of her decision not to keep a manager or of the managers decision to leave, and given us a reason. However this is a breach of the Care Standards Act and we have written to the provider and told her that she must ensure that this situation does not continue. The current manager had worked at the home for a few months and had worked as a deputy in the sister home and had the support of the registered manager of that service and the provider. The provider visits the home at least weekly and plays an active role. The manager told us that she was committed to the role and intended to start the process to become the registered manager. We were advised following the Care Homes for Older People Page 23 of 28 Evidence: inspection that the process hd been started. The AQAA form completed by the manager prior to this visit contained clear and relevant information that was supported by a wide range of evidence. The AQAA told us about changes they have made and where they still needed to make improvements. It showed clearly how they are going to do this. The data section of the AQAA was not fully completed. This was e-mailed to us following the inspection. The AQAA told us that, the Home carries out a bi-annual Quality Survey which is analysed and the results published. We have carried out the survey twice in 2009, in June and October. The results of the October survey were published to service users, relatives and other stakeholders in January 2010. The home held limited amounts of petty cash on behalf of residents. Two were checked and found to be correct and to tally with the receipts held. Because of the change of manager staff supervision and appraisal had been allowed to slip. This was now back on track and needed to be kept up-to-date. No major health and safety issues were noted at this site visit. As already mentioned from training information available most staff were up to date in moving and handling and fire safety training. Fire records viewed were satisfactory. Regular fire drills and testing took place and evidence was available to show that equipment checks also took place. 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 7 15 Care plans need to be produced for all activities of daily living. So that residents needs can be met in a way that they would prefer. 01/06/2010 2 9 13 Medication audits must be robust and provide the evidence that the correct medication has been given to the correct person at the correct time. This is to prove that individuals received their medication correctly. 21/05/2010 3 18 13 Staff must have regular 01/08/2010 safeguarding training and must be aware of the Mental Capacity Act (MCA) and Deprivation of Liberty (DOLS). This ensures people using the service are not at risk of suffering abuse or being 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 placed at risk of harm or abuse. 4 30 18 Staff must be trained and competent to undertake all the duties and responsibilities that they have. This is so that residents are cared for and kept safe by a skilled and competent staff team 5 31 9 The relates to the Care Standards Act that a requires a service to have a registered manager This ensures continuity and consistency for staff and residents 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 01/08/2010 01/07/2010 1 2 3 15 27 36 People should be offered a meal that they fancy at the time the meal is served. Consideration should be given to what needs to be done to encourage staff to remain working at Rosalyn House. The supervision programme started should be continued. 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. 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