Care Home: Shedfield Lodge

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What the care home does well Shedfield Lodge does well to ensure it provides prospective residents and their representatives with information about the home. It assesses if it can meet their needs and supports them to visit the home prior to moving in so they can become familiar with their new surroundings and others living in the home. The home has access to a local doctors surgery where most of the residents are registered. Weekly visits by the GP are made to the home to see residents and where necessary regular visits from the community nurse are organised. Other health care treatments and assessments are made as needed, such as eye tests, dental check ups and chiropody. The home recognises the diverse religious beliefs, hobbies and interests of the residents, and will support them to receive and attend religious services. Some residents routinely access the local community to carry out their preferred interests, such as socialising in the local pub with their peers and people they knew before moving into the home. The home offers a variety of activities to interest and stimulate residents. The home ensures residents receive a balanced diet, prepared from fresh foods. The home caters for people with special diets and ensures regular drinks and snacks are provided during the day. The home encourages residents to personalise their rooms with small items of furniture and personal effects. Bedrooms are redecorated and refurbished if required when they become vacant. The home is a large period building retaining many of its period features and gardens. It has been equipped to meet resident`s physical needs, with moving and handling equipment and access to the first floor by a shaft and stair lift. The home does well to provide a warm, friendly and homely environment for residents to live, residents tell us they are happy living at Shedflield Lodge. Friendly banter between staff and residents, and residents interacting positively with one another demonstrated this on the day of the unannounced visit. A resident told us: "This is an excellent home, recommended by my GP, he told me this is the best home in the area, the carers are exceptional and the food is marvelous, good English food". Health care professionals told us: "Shedfeild Lodge have provided good end of care to some of their long term residents, and they have been very good at ensuring residents are comfortable, turned regularly, fed and assisted in all aspects of daily living". "Shedfeild Lodge provides a kind caring approach towards residents, staff and families. They are aware they have had problems in the past, but are striving to continually improve and maintain an excellent service, and a homely home for all residents and their families". A General Practitioner told us, the home does well to: "Staff are very caring and have the residents best interests at heart". The residents are supported by staff who are encouraged to enhance their skills and knowledge in care by attending relevant training and undertaking a National Vocational Qualification (NVQ). What has improved since the last inspection? Following the last visit to Shedfeild Lodge in May 2008 seven requirements were issued, three relating to medication, one in respect of care planning, respecting the dignity of residents, improving ventilation in the conservatory and ensuring that all residents personal monies kept for safekeeping have a clear audit trail. Evidence gathered at the time of this inspection visit told us the seven requirements issued following the last visit to the home have been met. The home has adopted a new assessment and care planning process that focuses on the individual needs of the resident, prior to moving in and whilst living in the home. The home has adopted a person centred approach and a keyworking system that has improved continuity and delivery of care. Comments received from health care professionals and care managers told us, the service does well to: "Respects the privacy and dignity of individual residents and recognises their expression of individuality, care plans are comprehensive for my particular client". "There are excellent care plans in place and they provide a caring and friendly service". "Shedfield Lodge have made notable improvements to their standards of care over recent months". The home has adopted a new medication administration system since the last inspection visit to the service. During the implementation process staff undertook an in depth training programme. The three requirements which included safely storing and recording the use of Temazepam and ensuring risk assessments are in place for residents who wish to self administer have been met. The conservatory`s ventilation has been improved by fixing the ceiling fan, and the home is keeping a record of monies they hold on behalf of residents who are able to manage their own finances, but ask the home to put money by for saving. In addition to meeting the requirements the home has made improvements to its activity programme, its meal preparation and nutritional value, and continue to make improvements to the environment.Staff tell us they have received regular training, some undertaking an intensive course in dementia care and medication administration. The relocation of the managers office to the ground floor allows better observation of day- to-day practices, accessibility and visibility. New management and staff uniforms provides a professional appearance and staff tell us they feel valued by the owners. What the care home could do better: Despite receiving positive comments and evidence during the inspection visit that changes have been made, a number of concerns still remain. This tells us further improvements are required and that the home needs to sustain and embed those improvements in their every day practice. The home has taken steps to improve the care planning process using a person centred approach, however the standard of the care plans are variable in their quality and the information they give the carers, leading to the potential risk of inconsistency and the quality of care given. Examples of this can be found in the body of this report. The home must also ensure that it is taking a proactive approach and not a reactive approach when they identify there is a potential risk to residents health and welfare. A health care professional told us, the home could do better to: "To be consistent when implementing changes, plan more thoroughly/thoughtfully and practically, but in fairness to staff I have noted an improvement generally over the last few months". Despite the home adopting a new medication administration process and staff receiving in depth training in the safe administration of medication, discrepancies were found that could potentially place residents at risk and therefore a further requirement has been made in this area. The home continues to support staff to undertake appropriate and informative training, but it must ensure that its staff are carrying out what they have learnt in practice. The home must ensure when recruiting staff that it follows robust and appropriate procedures. The home must be able to demonstrate that they have taken correct steps to ensure the staff who are employed to work with vulnerable people are safe to do so. Despite requirements being met and improvements being made since the last visit to the service, which has been due to the current management arrangements, the home has been without a registered manager for nearly three years. This is an offense, by law a registered care home can not operate without a registered manager. Therefore the home is required to make application to the Care Quality Commission to register a manager. Key inspection report Care homes for older people Name: Address: Shedfield Lodge St Annes Lane Shedfield Southampton Hampshire SO32 2JZ     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: Christine Walsh     Date: 3 0 0 4 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Shedfield Lodge St Annes Lane Shedfield Southampton Hampshire SO32 2JZ 01329833463 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Andrew Robert Geach care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The additional room registered 9C must not accommodate any service user with dementia on admission. Two named service users over the age of 60 may be admitted in the MD category. Date of last inspection Brief description of the care home Shedfield Lodge is a residential care home. It is registered to provide support and accommodation for up thirty-three people over the age of sixty-five. The home is situated on the outskirts of Southampton. It is a large period house in its own grounds and gardens. Communal areas include a dining room, two lounges and a conservatory. The layout of the home is such that some of the bedrooms would not be Care Homes for Older People Page 4 of 40 Over 65 20 10 33 0 0 0 Brief description of the care home suitable for any person with mobility problems. Twenty-three of the bedrooms are single. Ten of these have en suite facilities. The remaining five bedrooms are double of which three have en suite facilities. The current fee charged is #335 to #480 per week. Care Homes for Older People Page 5 of 40 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 the people who use this service experience Adequate quality outcomes. This site visit formed part of the key inspection process and was carried out over one day by Mrs C Walsh, regulatory inspector, the deputy manager and the registered owners wife, assisted with the inspection visit. The Annual Quality Assurance Assessment (AQAA) document was completed and forward to the the Care Quality Commission on time. The AQAA informed us that the service feels they meet all diverse needs that they are aware of but will continue to meet any other assessed needs. The AQAA told us that several people who use the service attend a place of worship each week, two further faith groups attend the home once a month, and individual residents needs are met in Care Homes for Older People Page 6 of 40 private as agreed with the resident and the visiting minister. The home is equipped with specific aids throughout the home to assist with residents physical and mobility needs, these include a lift shaft, stair lift, hoists and specialist bath. The information obtained to inform this report was based on viewing the records of the people who use and work for the service, of which three service user and two staff records were viewed . The day-to-day management of the home was observed, and discussions with residents, staff and visitors took place. Following the last inspection visit to the home seven requirements were issued. The home was also required to complete an improvement plan, telling us how the service was going to improve outcomes for service users . The improvement plan was used as part of the inspection process to measure if the home had met the seven requirements. (Please refer to What has improved since the last inspection). The people who use this service are referred to as residents in the AQAA and at the time of the visit, therefore the people who use the service will be referred to residents throughout the body of the report. The last visit to Shedfield Lodge was undertaken on the 14th May 2008. Care Homes for Older People Page 7 of 40 What the care home does well: Shedfield Lodge does well to ensure it provides prospective residents and their representatives with information about the home. It assesses if it can meet their needs and supports them to visit the home prior to moving in so they can become familiar with their new surroundings and others living in the home. The home has access to a local doctors surgery where most of the residents are registered. Weekly visits by the GP are made to the home to see residents and where necessary regular visits from the community nurse are organised. Other health care treatments and assessments are made as needed, such as eye tests, dental check ups and chiropody. The home recognises the diverse religious beliefs, hobbies and interests of the residents, and will support them to receive and attend religious services. Some residents routinely access the local community to carry out their preferred interests, such as socialising in the local pub with their peers and people they knew before moving into the home. The home offers a variety of activities to interest and stimulate residents. The home ensures residents receive a balanced diet, prepared from fresh foods. The home caters for people with special diets and ensures regular drinks and snacks are provided during the day. The home encourages residents to personalise their rooms with small items of furniture and personal effects. Bedrooms are redecorated and refurbished if required when they become vacant. The home is a large period building retaining many of its period features and gardens. It has been equipped to meet residents physical needs, with moving and handling equipment and access to the first floor by a shaft and stair lift. The home does well to provide a warm, friendly and homely environment for residents to live, residents tell us they are happy living at Shedflield Lodge. Friendly banter between staff and residents, and residents interacting positively with one another demonstrated this on the day of the unannounced visit. A resident told us: This is an excellent home, recommended by my GP, he told me this is the best home in the area, the carers are exceptional and the food is marvelous, good English food. Health care professionals told us: Shedfeild Lodge have provided good end of care to some of their long term residents, and they have been very good at ensuring residents are comfortable, turned regularly, fed and assisted in all aspects of daily living. Shedfeild Lodge provides a kind caring approach towards residents, staff and families. They are aware they have had problems in the past, but are striving to continually Care Homes for Older People Page 8 of 40 improve and maintain an excellent service, and a homely home for all residents and their families. A General Practitioner told us, the home does well to: Staff are very caring and have the residents best interests at heart. The residents are supported by staff who are encouraged to enhance their skills and knowledge in care by attending relevant training and undertaking a National Vocational Qualification (NVQ). What has improved since the last inspection? Following the last visit to Shedfeild Lodge in May 2008 seven requirements were issued, three relating to medication, one in respect of care planning, respecting the dignity of residents, improving ventilation in the conservatory and ensuring that all residents personal monies kept for safekeeping have a clear audit trail. Evidence gathered at the time of this inspection visit told us the seven requirements issued following the last visit to the home have been met. The home has adopted a new assessment and care planning process that focuses on the individual needs of the resident, prior to moving in and whilst living in the home. The home has adopted a person centred approach and a keyworking system that has improved continuity and delivery of care. Comments received from health care professionals and care managers told us, the service does well to: Respects the privacy and dignity of individual residents and recognises their expression of individuality, care plans are comprehensive for my particular client. There are excellent care plans in place and they provide a caring and friendly service. Shedfield Lodge have made notable improvements to their standards of care over recent months. The home has adopted a new medication administration system since the last inspection visit to the service. During the implementation process staff undertook an in depth training programme. The three requirements which included safely storing and recording the use of Temazepam and ensuring risk assessments are in place for residents who wish to self administer have been met. The conservatorys ventilation has been improved by fixing the ceiling fan, and the home is keeping a record of monies they hold on behalf of residents who are able to manage their own finances, but ask the home to put money by for saving. In addition to meeting the requirements the home has made improvements to its activity programme, its meal preparation and nutritional value, and continue to make improvements to the environment. Care Homes for Older People Page 9 of 40 Staff tell us they have received regular training, some undertaking an intensive course in dementia care and medication administration. The relocation of the managers office to the ground floor allows better observation of day- to-day practices, accessibility and visibility. New management and staff uniforms provides a professional appearance and staff tell us they feel valued by the owners. 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. Care Homes for Older People Page 10 of 40 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 11 of 40 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 12 of 40 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. To assist people who may wish to the use the service, the home has provided information that gives clear detail and information about the service and its facilities. The service will support and care for people who wish to use the home once they have established if they can meet their needs. This is done following a full assessment using the homes revised assessment documentation and processes. The home must however ensure they are proactive in meeting needs that have been assessed as at risk at the point of assessment. Evidence: The Annual Quality Assurance Assessment (AQAA) told us we do a full in depth assessment for any potential service users coming into our home, we feel the format to which we use makes a good core to any future care plan. The AQAA also told us that the home has a Statement of Purpose and Service User Guide. Care Homes for Older People Page 13 of 40 Evidence: This was tested by viewing the assessment documents of three residents, one who had recently moved in, speaking with the deputy manager and viewing the homes newly revised statement of purpose and service user guide. The newly revised statement of purpose and service user guide are easy to follow and provide the reader with details of the homes facilities and the care and support the service can provide. The service user guide includes a philosophy statement, which includes the home supporting service users to live their lives as normally as possible, respecting their individuality, independence, choices and privacy and dignity. The service user guide informs the residents of their rights, the complaints procedure, daily routines and activities. The home is advised to ensure the residents are aware that daily routines detailed in the service user guide are provided as per their individual needs, which includes mealtimes, personal care and activities. Since the last visit to the service it has revised its assessment documentation and processes, the deputy manager told us the service continues to obtain pre assessment information, obtains information from placing authorities and visits the prospective residents where possible. The deputy manager told us the information gathered is comprehensive and more person centred. The deputy manager went onto tell us the service is now involving senior care staff more in the process and are encouraging them to accompany the managers on pre admission assessment visits. The assessment records seen for three residents told us the home is capturing the holistic needs and wishes of the residents, such as, personal details, past and present medical needs, social history, preferred lifestyle, likes and dislikes and the name by which they wish to be known by. We were informed residents, where they are able are involved in the assessment process. The deputy manager told us relatives play an important role in the assessment process and are encouraged to be involved where residents have provided consent for them to do so. The deputy manager informed us that the assessment process includes where possible the potential residents visiting the home to look around, to view the accommodation and meet with other service users and staff. The deputy manager said the potential resident and their family can visit as often as they like prior to admission and are welcome to stay for a meal if they wish. A newly admitted resident was observed being supported and comforted by staff when they appeared disorientated and requested to leave the home. The manner in which Care Homes for Older People Page 14 of 40 Evidence: this was done was observed to be respectful and sensitive. We were informed by the deputy manager the service will obtain or undertake further assessments such as nutritional, waterlow (Waterlow is an assessment undertaken on residents where there are concerns that they could be at risk from developing pressure ulcers), mobility and psychiatric assessments are also carried out where a need has been identified. Based on the information provided in an assessment seen at the time of the visit, which identified a resident at risk from pressure ulcers the home must seek further advice from health care professionals. The home must ensure where a need or a risk is identified the service acts on the information, using a proactive approach rather than reactive. The home does not provide intermediate care but we were informed that the home will provide respite care. The assessment documents were viewed for a residents currently using the home for respite. The deputy manager informed us that the home will usually offer respite care to a service user with a view to the short term resident moving in at a later date. Care Homes for Older People Page 15 of 40 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. There is evidence that the home is taking steps to improve its care planning process, however the people who use the service require assurance that the home will meet their needs in the way they prefer and that staff are aware of those preferences. The people who use the service also require assurance that identified risks to their health and welfare will be met using a proactive approach. The home supports the people who use the service to access health care professionals when needed and addresses health care concerns of the people who use the service sensitively. Further improvements are required to ensure the people who use the service receive their medication using safe administration practices. Improvements have been made to ensure the people who use the service have their privacy and dignity respected at all times. Care Homes for Older People Page 16 of 40 Evidence: The AQAA told us, each resident has a care plan covering a range of physical, emotional and social care requirements individual to them. Where needed risk assessments are in place and regularly updated. The homes receives excellent health care support from the local GP surgery and they have adopted a new company for their medications, which appears to be working well.and they believe in promoting the dignity and privacy of the residents at all times. The AQAA also told us the the home will provide where needed pressure relieving appliances such as mattresses or cushions, which is arranged by the district nurse. This was tested by viewing the personal plans of four residents, associated information such as daily records and recording charts, viewing medication administration procedures, observing day to day practice and speaking with residents, staff and managers. Following the last visit to the service five requirements were issued in Health and Personal Care, which included residents, medication and dignity and privacy. It was observed that some improvements have been made in the area of care planning and promoting residents dignity and privacy. However concerns remain within the areas of medication administration, and the home using the information in the assessment and care planning process to be proactive in maintaining residents health and welfare. The home has adopted a new care planning process and documentation that identifies the individual needs of each resident, the deputy manager told us the care plans were very near completion and had been developed in some cases with the residents or their families and senior staff have played a bigger role in developing the plans. A member of staff told us: The care plans are very in depth and are very good despite all the paper work involved. The member of staff went onto tell us the new keyworker system and the person centred approach is working well in the home. Residents who were spoken with told us they were happy and felt well cared for. One resident told us: I am very well looked after here, the staff respect who I am and treat me very well, they do a tremendous job looking after us. Care Homes for Older People Page 17 of 40 Evidence: There is evidence that the home has taken seriously the need to improve the care planning process and the documentation, providing evidence that they have applied a person centred approach and consulted with residents and other stakeholders in their development. This meets the requirement issued following the last visit to the home, however it was agreed with the owner that further improvements were required to ensure resident needs were met and their health and welfare promoted. Three residents personal plans were viewed, especially how the residents need to be care for. evidence seen in the three residents care plans told us they did not provide a clear description of how the resident wishes to be supported. This included using words such as prompt but not telling the reader what prompt is needed to encourage or support the resident to carry out specific tasks, such as mobilising, eating and managing personal care. In some personal plans risk assessment had been completed identifying the risk and in some cases what action was required to minimise the risk, an example of this was the completion of a care managers assessment, identifying the resident at high risk of pressure sores, but there was no indication of what action the home had or was taking to minimise the risk to prevent sores occurring. Despite being aware of the risks the deputy manager confirmed that they had not consulted with a district nurse to obtain a pressure relieving mattress or other health care professionals to assess the persons mobility, nutritional needs or mental health. The deputy manager confirmed that this would be dealt with without delay, the registered owner is reminded that identified risks require a proactive response to minimise the risk of the residents health deteriorating. The home must also ensure where clinical procedures require staff intervention that there are care plans in place to describe what staff must do, i.e when supporting someone who requires oxygen. The health care needs of the three residents were viewed, their personal plans provided better detail of their past and present health care needs and records were seen of visits made from or calls made to health care professionals. On the day of the visit the service made several calls to the local GP surgery regarding concerns raised by carers or residents about their health. The home was observed to give clear detail of the concerns and relay to all staff the advice given by the GP. Surveys received from health care professionals told us they have a good working relationship with the home and improvements have been made in the last year in how the home reacts to the health care needs of the residents. This was demonstrated at Care Homes for Older People Page 18 of 40 Evidence: the time of the visit when an incident required emergency first aid and calling emergency services to attend. The home demonstrated a sympathetic and caring approach to the resident, offering reassurance whilst establishing what the ailment was. Further demonstration of the sympathetic and caring approach was observed when a resident because of a recent illness required encouragement to eat and take their medication. The home has a dedicated treatment room for the safe storage of medication and consultation with health care professionals. Positive comments have been received from healthcare professionals, who view the treatment area as a positive place for treating residents and preserving residents privacy and dignity. The home told us they have introduce a new medication administration system from a company who supported and trained staff in its implementation. Staff who were spoken to said the new medication system was much improved and they had benefited from intensive medication training. The home provided evidence that they have met the three requirements issued following the last visit to the service and a senior member of staff spoken with at the time of the visit appeared knowledgeable in the practice of administering medication. However through observation it was noted that a resident had been left unsupervised to take their liquid medication during a mealtime. This action places the resident at potential risk of not receiving their prescribed medication or others being placed at risk of taking medications that could be harmful to their health. It was also noted that the home was supporting a resident to manage their own medication, the system used to do this was to secondary dispense, this is where a medication has already been dispensed by the pharmacy into appropriate storage containers but is then further dispensed by the home into alternative containers. This process goes against the Royal Pharmaceutical Guidance and places residents at risk. The home were unaware that the practice was not acceptable and took immediate steps to deal with the issue, calling the dispensing pharmacist for advice and an alternative process. It was confirmed by the end of the inspection visit that the pharmacy had come up with an alternative process. Despite intensive training in medication, which included the legal aspects of administering medication the home had not picked up what they were doing was poor practice. The owner must ensure that all staff responsible for administering medication are fully aware of their legal responsibilities. Following the last visit to the home a requirement was issued in respect of preserving the dignity of the residents, this included ensuring that where the residents allowed Care Homes for Older People Page 19 of 40 Evidence: staff supported them to maintain a good standard of cleanliness, grooming and clothing. The home tells us they have introduced a keyworker system, this is where members of staff are responsible for a small number of residents whilst on duty, ensuring the residents are provided with the care and support they need, which includes encouraging them to take pride in their appearance. A member of care staff told us she felt the keyworker system was working well, having dedicated residents to support meant they could give more time to ensure additional care needs, such as, ensuring residents have clean fingers nails, clean glasses and clothing. Through observation at various times of the day told us that staff engage with residents in a respectful and dignified manner, calling the resident by their preferred name and taking time to engage in meaningful conversation. Staff who were spoken with told us they are aware of the rights of the residents and the importance of treating each resident as an individual. Care plans enforced the importance of treating residents with dignity and ensuring their privacy is respected. A resident told us: The staff are very respectful and very kind. Care Homes for Older People Page 20 of 40 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. The service does well to ensure the people who use the service are involved in a variety of activities, maintain contact with family and friends and receive meals that meet their nutritional needs. Evidence: The AQAA told us the service has a varied choice of activities that take place within the home and consideration is given to residents who have dementia, or a visual and/or hearing impairments. The AQAA goes onto tell us that they provide information for families and friends and encourage them to take part in activities and share a mealtime with their loved one. The service recognises it could do better to place information in residents plans that detail their likes and dislikes in terms of preferred activity. This was tested by viewing the personal plans of three residents, speaking with residents about their day, observing activity and mealtimes. Speaking with staff and observing the implementation of a new menu planning and mealtime presentation. The service continues to demonstrate that the activity and stimulation of residents is important to the home. The home has a range of activities that have been Care Homes for Older People Page 21 of 40 Evidence: implemented with the dedication of a senior member of staff, residents personal choice and through adopting a person centred approach. The home has a large notice board dedicated to displaying what activities are taking place during the week, which includes morning and afternoon. These activities are displayed using various forms of media, and tools to assist the residents who have a cognitive disability to have a better understanding of what is available. The senior member of staff responsible for organising activities showed enthusiasm and a keenness to expand the available activities and ensure that residents have a say about what they would like to do. Activities include arts and crafts, singing, watching old time movies, visits from outside entertainers, religious groups and a hairdresser. At the time of the visit residents were observed singing along with staff and the senior carer spoke of her plans for the forth coming fete which will be held in the grounds of the home. The senior carer went onto say that residents relatives and friends will be invited to the fete as well as the local community and people from the local church. There was evidence on the wall that residents had been busy in designing and making Easter cards for their family and friends. The senior carer told us that this had gone down very well with family and friends and the residents appeared to enjoy this activity. The deputy manager told us that more staff would be attending an in depth training course in dementia care, which will provide them with an in sight into appropriate activities for people suffering with cognitive disabilities. Residents personal plans told us what interests and hobbies they enjoyed prior to moving into the home. The deputy manager told us that the home is working to-wards implementing a more person centred approach when it comes to residents personal interests and hobbies. The deputy manager said she is confident with the implementation of a keyworker system and increase in staff that this would be more achievable. Residents told us they were happy with the range of activities available to them, a resident told us of how they enjoyed shopping with staff and how staff support them to attend Sunday Service at the local church. Residents appeared to be happy, observed smiling, singing and engaging in general discussion amongst themselves. During the course of the visit the home received visitors, visitors were observed to be greeted warmly by staff, offered beverages and a quiet place to spend time with their loved one. Where visitors requested information about the care and wellbeing of their loved one staff were observed to respond sensitively, respecting the confidentiality of Care Homes for Older People Page 22 of 40 Evidence: the resident at the same time. Visitors with whom we spoke with at the time of the visit told us they are very pleased with the service their relative receives from the home, speaking highly of the staff and the managers. The home is demonstrating they are working to wards using a person centred approach to establish the individual needs, wishes and preferences of the residents. Documentation held in residents personal plan tells the staff how residents likes to spend their day, from getting up to going to bed. The home must however ensure this information is correct, for example if a residents preference is to have a shower then to be asked if they would like a bath will be met with a no. This example of contradiction was found in a residents assessment and care planning documentation. It stated in the assessment that the resident prefers a shower, however the care plan asks staff to prompt the resident to have a bath. The residents daily notes told us that the resident regularly refuses to have a bath and there are concerns regarding their personal hygiene. The deputy manager said she would deal with the oversight immediately. The use of a picture menu board, activity board and a keyworking system is providing support for residents to make informed choices. Staff were observed and heard offering a variety of choices throughout the course of the day from what residents would like to drink, eat, do and where to go. On the day of the inspection visit the home was in the process of introducing a new menu and catering system, known as Apetito. The deputy manager informed us that the home has introduced this new system in order to improve the quality and variety of meals residents have access to. Apetito is in its early stages of implementation and will be reviewed in a months time. During which time we were informed the operators of Apetito will be in the home supporting staff with the delivery of meal preparation. The inspector was informed by the deputy manager and a member of Apetito staff that all meals are nutritionally balanced, cooked, frozen and reheated to a high standard to ensure quality of the meals. We were informed that Apetito can accommodate all dietary needs and consistency of foods to meet residents individual eating requirements. We were informed that every meal is nutritionally tested by dietitians working for Apetito. The home needs to meet a certain criteria before Apetito will work with them, this includes appropriate storage and kitchen facilities. Staff are trained how to use the system and receive training in food hygiene and associated risks. The staff member representing Apetito went onto tell us that they provide a four week menu, which they are planning to devise in a picture format in Care Homes for Older People Page 23 of 40 Evidence: order to support residents who have cognitive disabilities to make choices. Residents were asked about the quality of their meal of, which all who were asked said they had enjoyed their meal very much. The deputy manager told us the home was holding an open day for friends and relatives to try out the meals and seek their views on the standard and quality. Care Homes for Older People Page 24 of 40 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. The home does well to ensure the people who use the service are provided with information they need to raise concerns or make a complaint. The home provides staff with training in safeguarding to minimise the risk of the people who use the service becoming harmed. The home must however ensure all staff are aware of the procedure for obtaining information and informing the correct authorities. Evidence: The AQAA told us the service has a user friendly complaints procedure on a notice board and the complaints procedure can also be found in the homes service user guide. The AQAA goes onto tell us that all staff have received training in safeguarding adults from abuse and they believe staff have a good understanding of safeguarding issues. This was tested by viewing the homes most up to date complaints procedure, documents used for recording complaints, staff training files in respect of safeguarding training, speaking with staff and seeking the views of the residents regarding what they do if they are unhappy. The home has reviewed its complaints procedure and made it more accessible for residents, the complaints procedure is positioned in a central area of the home and Care Homes for Older People Page 25 of 40 Evidence: clearly laid out in the homes service user guide. It was brought to the deputy managers attention that the complaints procedure would need to be updated to include the change of the regulating authority from the Commission for Social Care Inspection to The Care Quality Commission. The deputy manager agreed that this would be done. The complaints log held details of a recent concern raised by a resident, a detailed description of the concern and the action taken by staff was recorded. Due to the nature of the concerns raised the home is advised to store sensitive information in a confidential and secure place. Residents who were spoken with told us they had no reason to complain because they were very happy, but if they were unhappy they would speak with a member of staff. Staff who were spoken with appeared aware of the complaints policy and their role and responsibilities in ensuring the concern/complaint is dealt with efficiently. Through a regulation 37 notification, (A notification is sent to the Care Quality Commission when an event has occurred in the home that has effected the health and welfare of the people living in the home, this includes suspected abuse), the home informed us of a concern that is reportable under the joint authorities safeguarding protocol. The notification informed us of the action taken by the home to address the concerns. Despite evidence that staff have received training in abuse awareness and what to do if a resident discloses they have been harmed, one notification told us that a resident was on a number occasions questioned by several members of staff and managers, causing confusion and the residents information to change. This was discussed at the time of the visit with the managers and owner, who agreed that action taken by staff was inappropriate and all staff have been reminded of the role they play in reporting concerns. At the time of the visit an incident occurred that required the service to make a safeguarding referral to social services, a regulation 37 later sent to the Commission told us the home took appropriate action, including informing other stakeholders such as helath care professionals to assess the needs of the residents concerned. A member of staff who was spoken with gave a clear description of what she would do if suspected or witnessed an abusive act. The member of staff was a little unclear who other than the managers an incident of abuse needs to be reported to. The managers and the owner are advised to re-affirm this information and include in the next training plan. Care Homes for Older People Page 26 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home does well to provide a homely and comfortable environment where the people who use the service have the risk of cross infection minimised by standards adhered to by staff and the homes policies and procedures. Evidence: The AQAA told us the service provides a homely environment, which has great character, and is comfortable and well furnished. The AQAA goes onto tell us that the home has ancillary staff and all staff have received infection control training. This was tested by viewing the homes environment where changes have been made, viewing the conservatory, speaking with residents and staff regarding the environment, and viewing the cleanliness of home. Following the last visit to the home a requirement was issued in respect of improving the ventilation in the conservatory, which was very hot and stuffy at the time. This requirement has been met, the ceiling fan has been repaired, however the conservatory would still benefit from blinds or curtains to deflect glare and heat on sunny days and assist in keeping the conservatory warm in colder months. It was evident that some areas of the home have been decorated and refurbished and Care Homes for Older People Page 27 of 40 Evidence: new furniture and furnishings are of a good quality. The dining room provides a comfortable and pleasant environment for residents to eat their meals. The deputy manager told us the circular dining room tables have provided a better opportunity for the residents to socalise at mealtimes and more room for staff to assist residents when required. The home has rearranged the lounge and fixed a large flat screen television to a wall where all residents can view the television from where they are seated. Residents who were spoken with at the time of the visit were complimentary of the environment and the new television. On resident told us she was very happy with her room and had been able to bring her personal belongings with her and some of her own furniture. During the last visit to the home it was noted that the kitchen was in need of a thorough clean, better organisation of kitchen utensils and crockery and some kitchen cupboards were in need of repair. During this visit it was noted that repairs and replacements had been made to the kitchen, it was cleaner and tidier and alterations had been made to accommodate the new meal preparation and serving procedures. The AQAA told us the home is aware of where improvements can be made in the environment and what intentions there are over the next twelve months to make improvements, these include redecorating and refurbishing bedrooms as they become vacant, improving residents orientation (Signage) and redecorating one of the homes lounges. The AQAA told us that all staff have received infection control training and the home undertakes regular audits of bathrooms to ensure residents individual toiletries are not left in bathrooms. Staff are issued with protective clothing such as disposable gloves and aprons, antiseptic hands gels and cleaning materials that are used in minimising the spread of infection. A member of staff spoken with at the time of the visit confirmed that she had received an in depth training session on infection control and provided us with verbal evidence that procedures being used in the home assist in minimising the risk of infection. Care Homes for Older People Page 28 of 40 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. The home does well to ensure the people who use the service are supported by sufficient numbers of staff to assist them with their needs and wishes, however the home must ensure appropriate steps are taken to recruit staff. This is to ensure the people who use the service are safeguarded from the potential risk of harm. Evidence: The AQAA told us the service does well to have sufficient numbers of staff on duty to meet the numbers and needs of the residents, it tells us staff are only employed once all necessary checks have been undertaken, including a a criminal record bureau (CRB) check and two references. The AQAA goes onto tell us the home encourages staff to undertake a national vocational qualification (NVQ) and calls upon outside trainers to provide staff with mandatory training. This was tested by viewing day-to-day practice, the duty rota, speaking with residents and staff and viewing recruitment records for two new starters and staff training files. The deputy manager informed us that the home has increased its staffing levels, adopted a keyworker system and the home is using a person centred approach, which has allowed for flexibility and residents to spend their day how they wish. Staff were observed working in an un rushed and relaxed way, giving time to residents when requests were made and providing support where required. It was observed that there Care Homes for Older People Page 29 of 40 Evidence: was a member of staff available and visible in communal areas throughout the day and call bells were answered promptly. Staff spoken with at the time of the visit said they enjoyed working at Shedfield Lodge and have found the increased staffing levels and keyworker system beneficial to the time spent with residents. The AQAA tells us that ten of seventeen staff have an NVQ 2 or above, this meets the National Minimum Standards. The recruitment records for two new members of staff were viewed, it was found that not all areas of the recruitment process had not been followed correctly i.e the application. Although there was evidence that an application had been completed, the person had attended an interview and checks were in place it could not be established on the application who the person had nominated as referees and when they actually started working in the home. The application did not have a section where a name of a referee could be recorded, despite two references in place for both applicants it could not be established if a last employer had been called upon to give a reference. There was no evidence of a contract being provided, the start date of the carer had been written on a scrap of paper and kept in the carers personal file. This administration practice dose not provide concrete evidence that the carer did not start before all checks were in place as the paper was not signed either by the carer, the manager or both. The registered owner is advised to improve its administration practices in the respect of recruitment and ensure appropriate steps are taken to safeguarded residents from the potential risk of abuse. The home provided evidence that new staff undertake the Skills for Care Induction programme and are supported by the manager and senior staff to complete the induction in a timely manner. The deputy manager informed us that all new staff are supernumerary for the first week, working alongside senior staff and completing their induction as they progress through the next few weeks. The deputy manager went onto tell us new staff will undertake mandatory training such as moving and handling and fire safety in the induction period. Discussion with staff and evidence in staff training files told us the service provides a varied training programme which includes regular mandatory updates and is specific to needs of the residents such as, medication administration and Dementia. At the time of the visit a training provider was visiting the home to enroll staff on an in depth Care Homes for Older People Page 30 of 40 Evidence: course on Dementia. The deputy manager who has already undertaken the Dementia care course said she had really benefited from the training and it has provided her with a very good in sight into the needs of people who suffer with the condition. A senior member of staff confirmed that she had received a variety of training which included, fire safety, infection control, safe administration of medications, moving and handling, first aid, intense Dementia care training and safeguarding adults. Care Homes for Older People Page 31 of 40 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 people who use the service benefit from a well run home that seeks to listen to their views and provide a safe environment for them to live, however the home is in breach of regulation 8 of the Care Homes Regulations, Care Standards Act 2000 and must make application to registered a manager without delay. Evidence: The AQAA told us the home has had difficulty recruiting a manager but believe the current management arrangements they have had since Autumn 2008 have been effective and have started to show results. The AQAA told us they carry out surveys with residents and other stakeholders and have an external consultant to carry out their monthly regulation 26 visits. (Regulation 26 visits are carried out unannounced on a monthly basis, the purpose of the visits is to audit the standards in the home against the Care Homes for Older Peoples National Minimum Standards and provide a written report detailing the outcomes for the people who use the service, the provider is required to keep a copy Care Homes for Older People Page 32 of 40 Evidence: of the regulation 26 report in the home in order that it can be viewed at the time of an inspection). The AQAA goes onto tell us the home has done well to implement staff supervisions and apply with all health and safety procedures including fire safety regulations. This was tested by spending time with the current managers, to observe their practice and management of the home, speaking with residents and staff re the running of the home, viewing regulation 26 reports and documentation in respect of health and safety checks and procedures. Following the last visit to the home it was issued with two requirements in respect of management and administration, these included the safe keeping of residents personal monies and fire safety procedures. It was established that both these requirements have been met but there was some confusion over the management of residents personal monies. The discrepancies was cleared up at the time of the inspection, the home can demonstrate that monies they hold for residents for safekeeping now have an audit trail and the procedure does not dis-empower or deny the residents their independence. The requirement in respect of fire procedures has been met and the home can demonstrate that they are following recognised recording procedures as required by fire safety authority. In the absence of a registered manager the service has been managed by the registered providers partner and the deputy manager. Both members of staff demonstrate that they have the best interests of residents and are keen to improve outcomes for them. Staff tell us they have confidence in their ability to manage the service and many changes have come about for the good in the period they have been jointly managing the service. A member of staff said They show enthusiasm and a keenness to get things right, however concerns regarding medication practices and staff recruitment processes provide us with evidence that they are not familiar with all important aspects of running a registered home and minimising the risks to residents. The home has been without a registered manager for nearly three years and despite attempts to recruit to the position of manager the home has been unsuccessful. Discussion took place regarding the law in respect of carrying on a registered care home without a registered manager, the owner told us he plans to put forward a member of the management team to be registered. A requirement will be made in respect of registering a manager, which will have a tight timescale made against it. Care Homes for Older People Page 33 of 40 Evidence: The home supports some residents with their personal finances but where residents have been deemed competent to manage their own monies they are supported to do so. This was fully viewed during the previous inspection visit to the home and documents found to be in good order other than those documents the home holds on behalf of residents who can manage their own money but wish to put some by to save. The outcome of the discrepancy that followed is recorded above. The home undertakes an annual quality review of the service by seeking the views of the residents, relatives, staff and other stakeholders. A small sample of the surveys and the outcomes were viewed and on the whole a positive response was received from all parties. The deputy manager informed us that as part of her daily responsibilities she will meet informally with as many residents and visitors as possible, making herself available and visible. The relocation of the office to the ground floor has assisted in this process. As part of improving the vision and quality of the service all staff and the managers have been issued with new uniforms which are practical and smart. The staff said they feel more professional in their new uniforms and feel that the investment made in them by the owners shows that they are appreciated for the work they do. Staff supervisions was not covered in full during this inspection visit, however staff who were spoken with said they were receiving supervision from the managers. A senior carer informed us she was in the process of being trained in order that she can formally supervise care staff. The home provided evidence that all serviceable utilities such as gas and electrics are regularly tested and following a recent boiler blowout the boiler has been replaced. Records tell us that the home carries out regular checks on hot water outlets, food and fridge/freezer temperatures and undertakes regular checks on all fire safety appliances. The home provided us with documentation that they have had a fire risk assessment undertaken on the building, fire safety equipment is tested as per fire safety regulations and staff have received fire safety training. Staff spoken with at the time of the visit confirmed they have received fire safety training, which included using fire safety equipment, such as extinguishers and undertaking a full evacuation of the building. Training records confirmed that staff receive regular health and safety training which Care Homes for Older People Page 34 of 40 Evidence: includes, moving and handling, first aid and food hygiene. Whilst touring the building it was noted that a bathroom floor was covered with talcum powder and slippery under foot. This was brought to the attention of the managers who agreed that they would remind staff of the importance of clearing up potential slip hazards. Care Homes for Older People Page 35 of 40 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 36 of 40 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 The people who use the service must have care plans in place that provide detail how they wish and need to receive their care. The people who use the service must be assured they will receive their care in the way that they wish, prefer and require. Such as having a shower instead of a bath, and when requiring specific medical treatments such as oxygen therapy. 29/07/2009 2 8 12 The home must take a 08/08/2009 proactive approach to minimise health care risks to people who use the service. The people who use the service who have been at risk from pressure ulcers must have the appropriate equipment, treatment and support in place to minimise the risk. Care Homes for Older People Page 37 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 9 13 The home must ensure that 12/06/2009 the practices they have adopted to store and administer medications meet the 1973 Misuse of Drugs Act and Royal Pharmaceutical Guidance. The home must ensure medications are not left unsupervised and safely administered using systems recognised by pharmasits The people who use the service must be assured they will recieve their medication as perscribed and by way of safe procedures. Medications left unsupervised place people at risk of consuming medications that dont belong to them and those who it is perscribed for, without their required dose. The process of secondary dispensing can potentially lead to errors. 4 31 8 The home must make application to registered a manager with the care Quality Commission without delay. 15/09/2009 Care Homes for Older People Page 38 of 40 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 It is an offense to carry on running a registered care home without a registered manager. 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 18 It is recommended that the registered owner updates staff on the appropriate procedures for obtaining information in respect of allegations of abuse and are aware of who else they can alert other than the manager/owner of the home. It is recommended the registered owner consider adding blinds or curtains to the conservatory to minimise glare and heat generated on sunny days and provide additional warmth on colder days. It is recommended that the home creates an area on the application form where applicants can record who they have appointed as referees. It is recommended that the registered provider have a copy of staffs contracts on site that clearly state the start date of new employees and is both signed by the registered persons and employee. 2 19 3 29 4 29 Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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