Care Home: Southover Care Home

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What the care home does well People told us they were happy living in the home. One said `it`s lovely here`. People told us they get the care they need, comments included `they look after you well` and `they make sure you`re clean` The home is kept clean and tidy and people`s bedrooms are personalised. People told us they got on well with staff. Their comments included `the staff are lovely here`, `there`s always somebody about`, `the staff are very good` and `the staff are very very good, very pleasant`. What has improved since the last inspection? Staff training has improved, meaning that people are looked after by staff who are more skilled to do their jobs. The systems for recruiting staff have improved, meaning that people are better safeguarded against unsuitable workers. Care planning has improved, which means there is less chance that care needs will be overlooked. There is continued investment in the environment, with improved heating systems, garden and bathing facilities. The management of health and safety has improved. A private consultancy has been sourced to give health and safety advice and regular health and safety audits are in place, so people are cared for in a safer environment. People`s personal monies were being handled in a safer way. What the care home could do better: The organisation of paperwork needs to be better so there are clear records to support staff training. Two members of care staff need to attend training required to do their job safely and competently, or produce evidence that they have undertaken this. We need to be notified when significant events affecting people`s lives occur to help us monitor the home between visits. The management of medicines needs to be improved so topical preparations are kept safe and records are correctly maintained. Key inspection report Care homes for older people Name: Address: Southover Care Home 397 Burton Road Derby DE23 6AN     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: Helen Macukiewicz     Date: 0 8 1 2 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 29 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 29 Information about the care home Name of care home: Address: Southover Care Home 397 Burton Road Derby DE23 6AN 01332295428 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: White Doves Residential Home Limited care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 22 The registered provider may provide the following categories of service only: Care Home only - PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Southover is a two-storey building situated on the Burton Road, approximately a mile and half from Derby city centre. A passenger lift allows access for residents all around the Home. There is ample dining space, and leading from this large room are two sitting rooms. From one of these rooms there is access to a glass conservatory and from there to the large garden. Tables and seating are also provided in the garden. Ample parking space is available outside. The weekly fees for the home are 380.00 GBP, extra costs are charged for hairdressing, chiropody, toiletries, take-aways, some contribution towards trips out Care Homes for Older People Page 4 of 29 Over 65 22 0 1 5 0 9 2 0 0 9 Brief description of the care home depending on cost of the trip and newspapers. Copies of the inspection report can be gained through asking the manager and in the managers office there is a copy. Care Homes for Older People Page 5 of 29 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 inspection was unannounced and involved a visit to the site on at 9.30am. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people using the service and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgments such as notifications from the provider, complaints or concerns. We also use information from an Annual Quality Assurance Assessment (AQAA), referred to throughout this report as the pre-inspection self-assessment, which the provider is required to complete prior to a visit to the service. This provides evidence for us to Care Homes for Older People Page 6 of 29 make informed judgments when assessing the National Minimum Standards (NMS). The primary method of inspection used during the visit to this service was case tracking. This involved selecting three people and tracking the care they receive through review of their records, discussion with them where possible, the care staff and observation of care practices. Time was spent in discussion with the acting manager and staff. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. All of the key standards were inspected on this occasion. An interim unannounced Inspection took place on 15 September 2009. The purpose of this visit was to follow up on the requirements made at the previous inspection on 24 June 2009. The outcome of the interim Inspection is not available as a public document but should be available by the Manager of this Home. Reference to the Inspection and any requirements will be made in this report where necessary. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 8 of 29 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 29 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 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are admitted appropriately to the home. However, incorrect written information about the service means they may not be able to make a fully informed choice about whether the home is right for them. Evidence: In her self-assessment the acting manager told us that residents are given the opportunity to visit the home, spend time at the home, have dinner if they wish. Residents are assessed prior to admission to ensure their needs can be met at Southover. A service user guide is given on admission. We saw that people had been given information about the home. People told us they had enough information before they moved in and had been given the chance to look around. People told us they had been happy with their choice of home. One said its lovely here. Care Homes for Older People Page 11 of 29 Evidence: We saw that some of the information about the home in the Statement of Purpose and Service Users Guides was out of date, including contact points should people have complaints. Updating this information was a requirement of the last Inspection that has not been met. We gave an extension to the timescale for this to be completed. There had been one person admitted to the home since we last visited. This person had their needs assessed on a pre-admission form, although the form used did not clearly state who did the assessment and when. On the day of admission to the home, care records supported that they had received a thorough and personalised assessment of need. A Social Services support plan was also in place. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the care they need in a private and dignified way. Evidence: In the acting managers self-assessment she told us they had a new care plan system in place to enable staff to record and review effectively. We saw that where care files had been updated, they were logical, personalised and updated to a good standard. Risk assessments in areas such as skin condition, moving and handling and nutrition had also been completed. There was evidence to show that people had been consulted about their care and involved in subsequent care reviews. Some care files still contained both old and new sets of documentation, meaning that information was not easily found and had the potential to get recorded in the wrong place. Health professionals who completed a pre-inspection survey for us said staff are always able to provide clear reports on the progress of clients known to our team. They will always ask advice on care and treatment and respond accordingly and Care Homes for Older People Page 13 of 29 Evidence: prompt calls for Doctors if clients are unwell. We saw plenty of evidence to support that people attended hospital appointments when needed, and that they saw health professionals in the Community. In their pre-inspection surveys, people living in the home told us they got the care and support they needed. One wrote the home take care of me. People we spoke to on the day confirmed this view. Their comments included they look after you well, they make sure youre clean, I have been well looked after and staff look after me. People also told us their privacy and dignity was upheld by staff. Staff administering medications had a tabbard to wear so they would not be disturbed during medication rounds. Records of medicines given were signed in full. The incorrect code had been used for medications that had been refused and destroyed. This meant that there was an incomplete audit trail to account for medications kept in the home. One pot of cream found in a persons bedroom had an opening date of 2007 recorded on it. In another persons room we found some ear drops that were not accounted for in their medication records, and were not stored safely. People were being supported to manage their own medication where possible. Risk assessments had been carried out where needed and safe storage provided in their bedroom. We found that the controlled drug cupboard had not yet been replaced by one which conformed to pharmaceutical standards. However, the acting manager told us that she was due to obtain a replacement in the near future. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to lead a varied lifestyle of their choosing. The meals provided meet peoples needs. Evidence: Most people had an assessment of their social and spiritual care needs in their file. This was accompanied by a care plan to meet social needs. We saw that people were going out on a regular basis supported by staff. In some cases, staff had accompanied people in their own time. Photographs of two recent trips out were on display in the dining area. Care staff told us that there was no specific activity person, but they had an activity programme for each month and one staff on shift undertook this with people. One person told us they liked baking and confirmed that they had been doing this. There was a clothing show and carol service planned for December. People told us they were given a choice of how they spent their time. Some liked to sit in the lounges, others could return to their bedrooms at any time. Visitors were welcomed at any time during the day. One person had been able to bring their pet with them to the home. Care Homes for Older People Page 15 of 29 Evidence: People told us they enjoyed the food provided. One said you are well fed and another told us theres always an alternative and plenty of food. People told us they had enjoyed their lunch. We saw plenty of food supplies including fresh fruit. Care staff had offered people a choice for lunch, and assisted people with their meals where needed. A menu book supported people were offered a choice of meal every day and that there was a hot or cold option at breakfast and tea time. The cook told us she had met with people living in the home recently to find out what changes they would like to the menu. She had an understanding of peoples individual dietary needs. She had completed a National Vocational Qualification in catering and confirmed that she had completed her basic food hygiene qualification last year. She had started to carry out a monthly kitchen risk assessment in addition to her regular safe food hygiene checks. In their pre-inspection surveys, people living in the home told us they liked the meals and always had activities offered that they could take part in. Care Homes for Older People Page 16 of 29 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. People are safeguarded through staff training and have their rights to complain upheld. Evidence: In their pre-inspection surveys people living in the home and their relatives confirmed that they knew how to make a formal complaint. In her self-assessment the acting manager told us we have residents meetings, talk to relatives and friends, have a complaints, concerns and suggestions form which we encourage people to complete as necessary. She also confirmed that staff are trained and certificates held in adult abuse training. People on the day of the visit told us they could see the staff if they had any worries. One person told us they didnt worry about anything, another said they had no worries but could speak to staff if they had. This person told us they had been happy so far. One said they had no complaints, Im quite happy here, theres nothing to grumble about. Although the manager did not have a folder for keeping records of complaints in, a completed concern form was seen. This clearly recorded what the issue was, what action the manager had taken to resolve it and dates for when it was resolved. This had been addressed within 24 hours. The acting manager told us they had received Care Homes for Older People Page 17 of 29 Evidence: two concerns since we last visited the home. Both were minor concerns rather than complaints, but had still been recorded on a concerns sheet. Although people did not have accurate information about who to contact for complaints in their Service user guides, the contact details for the Care Quality Commission were on display in the foyer, along with a suggestions box for internal concerns. Staff had been trained in safeguarding adults and had access to Derby City Council safeguarding policy. Some staff had received Mental Capacity Act training. Care Homes for Older People Page 18 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally well maintained although some outstanding maintenance work impacts negatively on peoples privacy, dignity and quality of life. Evidence: Since we last visited there has been financial investment in the building. There had been a new central heating system and new fencing has been erected in the garden to improve safety and security of the outdoor areas. A new shower room/hairdresser room had been created. Bedrooms we saw were very personalised, and all areas were very clean and tidy with the exception of one odour in an unoccupied bedroom. A relative, in their completed survey wrote the home is always kept clean. Some improvements were still required to improve privacy, dignity and quality of life. Some bedrooms had no lockable space for people to keep things private and secure. Privacy locks were not working on the new shower room door, and bathroom near room 18. The ground floor toilets off the dining room had no heating and were cold. Also, the corridor wall near the new shower room needed to be painted. Staff had been trained in infection control. We saw alcohol hand rub, gloves and aprons for staff to use. Care Homes for Older People Page 19 of 29 Evidence: People told us they were satisfied with the laundry service, their comments about this, and general cleanliness, included its very clean, your bed is made, your clothes are washed for you and waiting when you get up in a morning. Care Homes for Older People Page 20 of 29 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 are cared for by sufficient numbers of suitable staff. Gaps in training records means the staff may not be suitably skilled in all areas of care. Evidence: In her self-assessment prior to this inspection the acting manager told us staff are trained and continue to be updated, offering new courses regularly. This ensures staff are meeting the needs of the residents. Staffing levels have improved. At the time of this inspection there were 14 people living in the home. The acting manager provided cover during office hours Monday to Friday. Two care staff were employed to cover day shifts. One waking and one sleep-in staff covered the night time. Domestics and a cook were provided every day. Volunteers who had been Police checked also came to spend the occasional day with people. People told us that said staff were busy but theres usually someone around and quick to come to answer the call bell if needed and staff are always available. The most recently employed member of staff had been subject to appropriate preemployment checks. No other new staff had been employed since we last Inspected. However, the acting manager was getting advice about good employment practice from a private consultancy firm. There was evidence to suggest that staff undertook a basic induction when they were first employed. Care Homes for Older People Page 21 of 29 Evidence: Staff and training records were able to support that there was a programme of training in place for staff. However, records kept at the home were not well organised and made it difficult to evidence what training had been received by which staff member. A staff training matrix had been produced to try to assist the acting manager to identify gaps in training needs, but this was out of date. Two members of care staff had no records of training at the home although the acting manager told us they had undertaken some. Staff had not received first aid training, but the acting manager told us she had recently received the go-ahead for funding from Derby City Council and intended to book this. All staff were trained to at least National Vocational Qualification level 2. People told us they got on well with staff. Their comments included the staff are lovely here, theres always somebody about, the staff are very good and the staff are very very good, very pleasant. Care Homes for Older People Page 22 of 29 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. Gaps in administrative systems and quality assurance leaves potential for shortfalls in the management of staff. People are not always consulted formally about the running of the home. Evidence: The owner of the home was still acting in a management capacity due to the long term absence of the registered manager. The acting manager is a registered nurse with management experience. In her pre-inspection self-assessment, she acknowledged that due to the long term absence of the registered manager she had difficulties keeping up to date with recording of supervisions, appraisals and risk assessments. The acting manager had sourced the support of a management consultancy who had been providing advice and support regarding recruitment and health and safety practices. We found there had been improvements in both of these areas as a result. Care Homes for Older People Page 23 of 29 Evidence: The acting manager told us that she was monitoring medication and care planning records although this was not always recorded as evidence and we found some errors in recording standards with regard to medication. The monitoring of quality within the home was not generally well developed and tended to be undertaken informally. The acting manager told us she was aware this was an area for improvement, through her self-assessment. We also found that the organisation of paperwork and filing systems within the office were not well developed. Therefore some key documents concerning recruitment, staff training and supervision could not be located. Peoples personal finances were being managed in a safer way and record keeping had improved in this area. We had not been routinely notified of incidents affecting people in the home in line with the requirements of Regulation 37 of the Care Homes Regulations 2001. The acting manager told us she was aware they needed to be sent, but not that we needed to receive these without delay. There was documentation to support that regular risk assessments of all parts of the service were being carried out. Also that equipment in use was being regularly serviced. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 1 5 The registered person must provide an accurate and up to date Service Users Guide for people. An extension is given to meeting this requirement. This must be met by 31.3.2010. This is to ensure people are fully informed about whether the home is right for them. 31/08/2009 2 1 4 The registered person must 31/08/2009 have an up to date and accurate Statement of Purpose available for people. An extension is given to meeting this requirement. This must be met by 31.3.2010. This is to ensure people are fully informed about whether the home is right for them. Care Homes for Older People Page 25 of 29 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 9 13 2) All medication charts must contain the correct code when medications are refused and destroyed. Topical creams past their use by date must be removed and destroyed. Ear drops must be accounted for in medication records and stored securely. This is to ensure people have their medications managed safely in the home. 31/01/2010 2 19 12 4a) Functional privacy locks must be fitted to the new shower room and bathroom near room 18. This is to ensure people have privacy. 31/01/2010 Care Homes for Older People Page 26 of 29 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 19 23 2p) Heating must be provided in the two ground floor toilets off the dining room. This is to ensure people are warm when using these facilities. 31/03/2010 4 30 18 c) Staff must undertake the first aid training. This is to ensure that people are cared for by suitably trained staff. 28/02/2010 5 30 18 c) The two members of staff without training records must produce them as evidence of prior learning or undertake all mandatory training required for their role. This is to ensure people are not placed at risk through unskilled workers. 31/03/2010 6 33 24 Systems for monitoring quality in the home must be further developed and administrative systems improved. This is to ensure people are better consulted about their care. Also that gaps in staff training, recruitment and supervision are easily identified and acted upon. 28/02/2010 Care Homes for Older People Page 27 of 29 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 7 33 37 The Care Quality 31/01/2010 Commission must be notified of events without delay. This is to ensure people are safeguarded in the home. 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 3 The pre-admission assessment form should state who did the assessment, where it was carried out and include the date. This is to support people are having their needs assessed prior to being admitted. Care files that still contain both old and new sets of documentation should be checked. Any outdated information should be archived. This will help staff to find information and record in the right place. Social care assessment and social care plans should be completed for all people living in the home, to support that all their needs are known to staff and are being met. All concerns/complaints should be kept in a file to assist management to audit records and review quality. All staff should receive training on the mental capacity act and deprivation of liberty, to ensure they know how to uphold peoples rights. All bedrooms should have private lockable space, be kept free from unpleasant odours and be painted. Staff training records should be kept to enable clear identification of all training that staff have received and what training they require. Ongoing issues in relation to the registered managers absence should be resolved without delay to ensure that there is a manager in charge who is registered in respect of the home. 2 7 3 12 4 5 16 18 6 7 19 30 8 31 Care Homes for Older People Page 28 of 29 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). 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