Care Home: St Brendans

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What the care home does well When staff are recruited to care homes there are safety checks that need to be done, this helps to protect the people living at the home. Management must make sure for example, that they receive at least two references and carry out a check known as a Criminal Records Bureau check, this helps them to decide if the person is going to be suitable to work with vulnerable people. One of the areas of concern raised with us was about the recruitment of staff. We looked St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 at all the files for the most recently employed staff and found that all the required checks had been done before those staff had been allowed to work. We spoke with people living at the home; all those we spoke to stated that they found the staff team to be friendly. Comments included, “lovely girls they are” and “they have always been kind enough to me”. What has improved since the last inspection? Written records known as care plans are in place for everyone living at the home. Since the last inspection they have developed further as another management change took place at the home. All of the care plans are now of a very good standard, they give very good guidance to staff and provide personal details about the individual. Plans that we looked at were up to date, and contained the guidance needed by staff to ensure continuity of care. Medication systems have now changed to allow medication audits to be carried out to identify any shortage of stock, invalid entries being made on to records and checking people have actually received their medication. This makes sure that if there has been an error by a member of staff, it is identified quickly and action taken to remedy this. What the care home could do better: There are risks that should be re assessed by staff at least once each month and this should be recorded, we said that there should be an improvement in this area at the last inspection. Risks include, of falling or developing pressure ulcers for example. This is important as it shows any changes in a persons needs very quickly and this means staff can alter the care provided or seek medical attention for the person if needed. Although there had been an improvement in this area, it was not the case for everyone, and the owners need to look at this now. The way people are responded to when they make a complaint is very important. They need to know that they have been listened to and what they are unhappy about is being taken seriously. There had been a complaint made in November 2008. The written response and action taken by management at that time was poor. The person had complained that a staff member had not treated them correctly. This information should have been referred to the local safeguarding team, it was not. The written response also intimated that the complaint had not been believed. This did not follow the homes own policy in complaints management or safeguarding.St BrendansDS0000014959.V376478.R01.S.doc Version 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE St Brendans 175 Ashburnham Road Luton LU1 1JW Lead Inspector Katrina Derbyshire Key Unannounced Inspection 18th June 2009 11:45 DS0000014959.V376478.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Brendans Address 175 Ashburnham Road Luton LU1 1JW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 728737 01582 726022 jetha@hotmail.com Mr Jethra Kara Mrs Bhavna Kara Manager post vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2008 Brief Description of the Service: St Brendans is a three storey period house in a residential area of Luton. It is on a bus route and within a short drive of nearby shops, post office, public houses and places of worship. Accommodation is provided on all three floors of the home, with 20 single bedrooms and 3 shared bedrooms. Access to the upper floors is via stairs or usually a lift. There is a small lounge on the fist floor and two further lounges and dining room on the ground floor. The kitchen and laundry facilities are located on the ground floor. A new passenger lift has now been fitted. There is a garden with an enclosed patio area at the rear of the home with raised flowerbeds and garden furniture. The fees for this home vary from £443.00 per week, to £490.00 per week, depending on the funding source and needs of the person. Inspection reports are stored in the entrance hall and available to residents and their families. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out on the 18th June 2009. The home was not yet scheduled for an inspection; however we had received concerns from a person who contacted us by telephone in the areas of recruitment, management of continence for one person, and other care practice issues. The information was also shared with the Luton Safeguarding team; however as there were no names given they were not able to look into the matters raised by the complainant. We decided to bring forward the key inspection as a result of this information. The care of three people was looked at in detail and this is known as case tracking. Tracking people’s care is the methodology we use to assess whether people who use social care services are receiving good quality care that meets their individual needs. Through discussion, observation and reading records, we track the experiences of a sample of people who use a service. During the visit the communal areas of the home were seen alongside some of the individual rooms. Time was spent with many of the people who live at the home in one of the sitting areas. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The management’s submission of documentation was also considered prior to the site visit. The focus of this inspection was to look at the key standards. What the service does well: When staff are recruited to care homes there are safety checks that need to be done, this helps to protect the people living at the home. Management must make sure for example, that they receive at least two references and carry out a check known as a Criminal Records Bureau check, this helps them to decide if the person is going to be suitable to work with vulnerable people. One of the areas of concern raised with us was about the recruitment of staff. We looked St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 6 at all the files for the most recently employed staff and found that all the required checks had been done before those staff had been allowed to work. We spoke with people living at the home; all those we spoke to stated that they found the staff team to be friendly. Comments included, “lovely girls they are” and “they have always been kind enough to me”. What has improved since the last inspection? What they could do better: There are risks that should be re assessed by staff at least once each month and this should be recorded, we said that there should be an improvement in this area at the last inspection. Risks include, of falling or developing pressure ulcers for example. This is important as it shows any changes in a persons needs very quickly and this means staff can alter the care provided or seek medical attention for the person if needed. Although there had been an improvement in this area, it was not the case for everyone, and the owners need to look at this now. The way people are responded to when they make a complaint is very important. They need to know that they have been listened to and what they are unhappy about is being taken seriously. There had been a complaint made in November 2008. The written response and action taken by management at that time was poor. The person had complained that a staff member had not treated them correctly. This information should have been referred to the local safeguarding team, it was not. The written response also intimated that the complaint had not been believed. This did not follow the homes own policy in complaints management or safeguarding. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel that they have sufficient knowledge and information to assist them in making an informed decision on whether they wish to move into the home. EVIDENCE: We reported inconsistencies in the information entered onto pre admission assessments at the last inspection and made a requirement. Through our selection of people for case tracking we looked at people who had recently moved into the home at this visit. The care files examined included preadmission assessment. Assessments included information from visiting the person wherever he or she was living prior to admission and information from any referring social worker or health professional. The information given was St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 10 recorded on documents that had varying sections including physical, social, emotional and psychological needs of the people. The information was now clear and linked to the care plan. People spoken with as stated at the last inspection confirmed that they had been asked about themselves and they felt that they had been able to part of that process. The statement of purpose was examined. The document provided information on the staffing, accommodation and services available at the home. People had been offered a copy of this. Feedback from people living at the home indicated that they felt that they had been given sufficient information about the service, before moving into the home. Intermediate care is not provided at the home. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning is sufficient to provide staff with the information that they need to ensure people receive the care that they need. EVIDENCE: The concerns that were raised to us about the care of someone living at the home did not give us the name of the person; this is the reason why the safeguarding team did not accept the referral. However with the description of needs it enabled us to identify the person when we visited and their care was looked at. Evidence read and witnessed at this unannounced inspection did not support the concern raised on the wound care and continence management for this person, or that they were isolated. The person was sitting in the main lounge, staff and records supported that this was part of the person’s daily routine. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 12 The care documentation seen in all instances for each person gave sufficient detail to show the individual needs. We had made a requirement at the previous inspection as there had been inconsistencies in the standard of entry. However all care plans have now been changed and are of a very good standard, they included information that made them very personal and provided a comprehensive picture of the person and their needs. Observation of care practice during this visit showed that the care team followed the guidance contained within them. Medication storage in the home was noted to be satisfactory as was the ordering of medicines. A requirement had been made in this area at the previous inspection as balances had not matched the records. This was noted to have been met. Any carried forward balances from a previous 28 day cycle had been entered onto the new medication administration record. Balances that were checked were correct. People as reported at the last inspection said that staff treated them with respect and maintained their privacy. Everyone spoken to had positive comments to make about most of the staff. Risk assessments relating to tissue viability and falls for example had not in all instances been reviewed monthly at the previous inspection. Although there had been improvements we found one gentleman whose assessments were last reviewed on 20th February 2009, leaving a four month gap. Therefore action must be taken now to ensure everyone’s risk assessments are up to date and this practice must be maintained. At the time of this visit a person living at the home became unwell suddenly and unexpectedly. The owner and staff on duty were observed to contact the emergency services immediately. Staff stayed with the person and were heard giving verbal reassurances to the person constantly. Records of General Practitioner or District Nurse visits were seen. In addition letters from Luton and Dunstable Hospital were also seen demonstrating people’s attendance at specialist clinics when required. Staff are able to describe and know the need to contact medical professionals if a person became unwell as outlined within the above paragraph. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at this home feel that the choice of meals provided are sufficient to meet their tastes and preferences. EVIDENCE: Several people spoke of the activities available to them and all advised that at times they felt that they had enough things to occupy them, however there were times when they felt that there was not anything for them to do. Documents examined showed that activities were provided but not fully consistent in their availability. The Bedfordshire library service also visits the home. People were seen to receive visitors. Everyone as indicated at the previous inspection confirmed they were able to receive visitors when they wished and many would chose to see them in the privacy of their own rooms. Entries were also seen within people’s care records that demonstrated that the staff at the St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 14 home would contact the nominated next of kin if there had been a change in their well being, one example of this was following an accident and the contact details had been recorded by the staff member. Options available to people in maintaining control, independence and choices in their lives remain, choice of meals, voting, choice of clothing, access to a complaints procedure and access to community healthcare support. People living at the home and records confirmed that the choices associated with people’s daily lives were available to them whilst living there. All the people spoken to stated that they enjoyed their meals. An observation of a meal was undertaken most people had chosen to eat this in the dining area. People had been offered two choices and their selection had been written down on a menu sheet. The most recent environmental health inspection found that there were sufficient standards in this area being maintained. In addition nutritional risk assessments were seen to have been undertaken for the people living at the home, although not all were up to date as described within the Health and personal care section. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inconsistencies in safeguarding and complaints management results in people feeling that their concerns are not taken seriously or acted upon as they should. EVIDENCE: Records examined showed that staff had undertaken training in the safeguarding of vulnerable adults. In addition the homes procedure in this area was examined; it’s content reflected the local guidance. The management had sought a copy of the local protocols and these were seen. Complaints received at this service had been kept alongside documents to show the investigation carried out, response and any recommendations made following the investigation. A complaint in November 2008 indicated that a person living at the home had not been treated correctly by one member of staff. The information given to the manager at that time should have resulted in them making a safeguarding alert, they did not. They proceeded to undertake an investigation themselves, St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 16 which is against all protocols including the homes for the safeguarding of adults. The written response made to the complainant was dismissive and led the reader to feel that the person had not been believed. On reviewing other information from the history of this service since the last inspection, they had demonstrated that they did make referrals for other concerns. This shows an inconsistent approach and lack of regard for the safeguarding protocols. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Many areas in the home provide a good standard of accommodation however there are other areas that do not fully provide a homely environment for people to live in. EVIDENCE: People’s rooms that were seen contained personal items for example photographs and pictures and this has been consistent over the past few inspections of the service. Assisted bathrooms are in place and grab rails were also in place to assist people with their mobility. The large ground floor sitting area has been refurbished. The space had been opened up to provide an St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 18 increase in natural light and ventilation. A new carpet and chairs had been purchased. People spoken to felt very satisfied with the changes. Acknowledgement is given for work that has been undertaken. A new lift has been fitted and new carpeting been fitted in the ground floor corridor. not yet been fitted so a chair lift was the only means of moving between floors. However there remains a need to carryout further work to ensure all areas provide a homely environment. One example is the ceiling in the first floor lounge, at the time of this visit there were four areas where the paper was coming away from the actual ceiling. As stated at the last inspection requirements will not be made at this time as acknowledgement is given that the current work programme has not yet concluded. Cleaning schedules were seen to be in place alongside clinical and domestic type waste contracts. Protective clothing such as gloves and aprons were seen to be used by staff and hand washing facilities were situated throughout the home. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home feel staff that work there treat them kindly and will spend time with them. EVIDENCE: The induction and training of staff was recorded in the individual records of all employees. We looked at the induction of staff at this visit and noted that the records of the employees learning and understanding did not meet national guidance; this was discussed with the owner. A basic checklist does not meet this standard. Staff through interviewing confirmed that they had undertaken a variety of courses these included health and safety, moving and handling and national vocational qualifications in care. References are taken prior to staffs’ commencement and the relevant Criminal Records Bureau check is also carried out and evidence of this having been undertaken was seen. Certificates of qualifications are present within staff files. A concern had been raised that the home did not safeguard people in this area. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 20 All records that we examined showed that all checks required were in place prior to the person starting work at the home. Senior support workers, care assistants, catering and housekeeping staff are employed at the home. The rotas supplied by the home show that there are sufficient numbers of staff on duty throughout the day and night to meet the needs of the residents at this time. People confirmed that staff were available to help and assist them when they need help. Training records examined that were supplied by the home show that staff had undertaken statutory training, including moving and handling, fire safety and food hygiene. In addition staff confirmed that they had attended a variety of courses including dementia awareness. . St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and safety systems are sufficent to reduce the risks associated with this area for the people living at the home. EVIDENCE: There have been numerous changes to the day to day management in the home as we reported at the last inspection. The once Registered Manager left, then the owner oversaw the service, then another managed was employed for 3 months and then the previous manager returned all within a 12 month St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 22 period. On our return at this inspection the former manager that had returned has left again and the owner is currently managing the home on a day to day basis again. It was discussed with the owner that stability is now needed. She advised that she consulted with a consultancy firm to assist in this. Resident and relative surveys to influence the running of the home was noted to have been sent out. The home has a policy on how peoples monies managed on their behalf should be administered. Only senior staff have specific responsibility in this area and their practices were seen to follow the guidance within the home policy. All records, receipts and other information seen were of a good standard and provided a clear audit trail. All balances checked were noted to be correct and receipts of any expenditure are kept. The home has a Health and Safety policy. There was evidence within the training records that staff had undertaken fire, manual handling, food hygiene and first aid training. Risk assessments had been undertaken and were seen within care files. Records evidencing that maintenance and checks were undertaken relating to fire prevention and electrical and gas equipment was seen. Staff were observed to follow safe practice in the following areas, moving and handling, risk assessment, first aid, food hygiene, infection control and COSHH. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation Requirement Timescale for action 18/06/09 12,14,&15 Risk assessments must be reviewed regularly and this must be documented. This is to ensure changes to peoples needs are acted upon in a timely manner. This was a previous requirement that had not been met in full. 2. OP12 16 (2) 3. OP16 22 There must be a consistent provision of activities, so people know what to expect each day and choose to participate if they wish. All complaints must be investigated in accordance with the homes policy. Responses must show the complainant that their concerns have been taken seriously and that the appropriate action has been taken. All allegations of abuse must be reported to the relevant safeguarding team. An investigation must not commence by home staff unless DS0000014959.V376478.R01.S.doc 30/09/09 31/08/09 4. OP18 12 (6) 31/08/09 St Brendans Version 5.2 Page 25 5. OP30 18 (c) directed to by the safeguarding team, to ensure people are protected. Induction training must be provided for all new staff which meets national guidance in this area. 31/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. St Brendans DS0000014959.V376478.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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