Care Home: St Joseph`s Care Home

What the care home does well Staff engage positively with residents and treat them with dignity and respect. Relatives can visit whenever they wish and are made welcome when they visit. Residents have access to health care professionals and get medical treatment when they need it. Residents are cared for by people they know and who understand their needs well. The manager has a commitment to improving the service and an awareness of the areas in which the service needs to improve. What has improved since the last inspection? A new format for care planning has been introduced. This is a positive development but staff must ensure that all parts of the new care plans are completed. The home has advertised for a part-time activities co-ordinator to develop the range of activities available to residents. There have been a number of improvements to the home since the last inspection but further enhancements need to be made to make sure residents live in an attractive and secure environment. Staff have enrolled on training to develop the skills and knowledge they need to do their jobs well. Staff have had training in dementia and further training in dementia is planned for early 2010. What the care home could do better: Ensure that all parts of residents` care plans are complete, including moving and handling assessments, Waterlow assessments and any other risk assessments relevant to the resident. These assessments should be reviewed regularly to take account of any changes in need. Ensure that residents` care plans are dated and signed at the time of writing and contain a photograph of the resident. Ensure that medication administration records contain a photograph of the resident and that the allergy section is completed. Ensure that medication administration records are clear about the time medication should be administered. Introduce more fresh produce on the menu. Ensure that staff have up to date training in the protection of vulnerable adults (POVA).Fix the dividers in shared rooms to floor runners to improve their stability. Redecorate the parts of the home that need repainting. Address the urine odour that was present in some parts of the home. Ensure that all fire fighting equipment and the emergency lighting system is working effectively. Ensure that doors close automatically in the event of a fire. Fit window restrictors where necessary to ensure residents` safety. Arrange an inspection of the water system by a suitably qualified engineer. Key inspection report Care homes for older people Name: Address: St Joseph`s Care Home St Joseph`s 38-40 Hindes Road Harrow Middlesex HA1 1SL     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: Simon Smith     Date: 1 1 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 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: St Joseph`s Care Home St Joseph`s 38-40 Hindes Road Harrow Middlesex HA1 1SL 02088632868 02084272146 vsaunders@hazelwoodcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Hazelwood Care Ltd Name of registered manager (if applicable) Mr A.N.M.A Salim Khan Type of registration: Number of places registered: care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users who can be accommodated is: 19 The Registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Date of last inspection Brief description of the care home St Josephs is a privately-owned care home for up to 19 older people who have dementia or related conditions. The home is part of the Hazelwood Care Organisation. The home is situated close to local shops and transport facilities. The Service User Guide and fee range are available from the home on request. Care Homes for Older People Page 4 of 27 Over 65 0 19 1 2 0 1 2 0 0 9 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 one star. This means the people who use this service experience adequate quality outcomes. We used information from a range of sources when making this judgement about the home. This included visiting the home unannounced on 11th December 2009 and meeting the manager, staff and people who live at the home. We also spoke to a visiting relative and a visiting healthcare professional who has regular contact with the home. We checked some written records including residents care plans, staff files and health and safety checks. We also took into account any information the home had sent us since the last inspection. This included notifications of any accidents, incidents, complaints or safeguarding alerts. The manager filled in a Quality Assurance Assessment (AQAA) which gave us information about the home in the last year. Care Homes for Older People Page 5 of 27 Residents we spoke to during the inspection said that they liked living at the home and that they enjoyed the food provided. One resident said about the staff, Theyre all good. The relative we spoke to said that the home had improved in lots of areas in the last six months. The relative told us that new furniture had been bought for the lounge, new carpets had been laid and many parts of the home repainted. The relative also said that standards of hygiene and cleanliness had improved. When we asked what the home could do better, the relative said that standards sometimes slipped at weekends when the manager was not on duty. We fed this back to the manager who agreed to address the issue. The visiting healthcare professional we spoke to said that she had no concerns about the quality of care residents receive and that staff ensure residents are referred for treatment if they become unwell. The last inspection report identified many areas the provider needed to address and we made 18 requirements that the provider had to carry out to meet the National Minimum Standards. Many of these related to the environment in which residents live but there were also requirements about medication practice and staff training. At this inspection we found that there had been a good response to the requirements we made and that this has had a positive impact on the quality of residents lives. The new manager has also introduced a positive, person centred approach which he aims to instil in the staff who work at the home. The measures taken by the provider since the last inspection, and the work put in by the manager and staff, have improved outcomes for residents and are a sign that the service is moving in the right direction. However we found at this inspection that there are further improvements that need to be made to make sure that residents are safe at all times. These areas are outlined below, along with the areas in which we found the home performs well. These areas for improvement are the principal reasons that service has been awarded an adequate quality rating. Once the provider has addressed these areas there is no reason the quality rating should not improve. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: Ensure that all parts of residents care plans are complete, including moving and handling assessments, Waterlow assessments and any other risk assessments relevant to the resident. These assessments should be reviewed regularly to take account of any changes in need. Ensure that residents care plans are dated and signed at the time of writing and contain a photograph of the resident. Ensure that medication administration records contain a photograph of the resident and that the allergy section is completed. Ensure that medication administration records are clear about the time medication should be administered. Introduce more fresh produce on the menu. Ensure that staff have up to date training in the protection of vulnerable adults (POVA). Care Homes for Older People Page 7 of 27 Fix the dividers in shared rooms to floor runners to improve their stability. Redecorate the parts of the home that need repainting. Address the urine odour that was present in some parts of the home. Ensure that all fire fighting equipment and the emergency lighting system is working effectively. Ensure that doors close automatically in the event of a fire. Fit window restrictors where necessary to ensure residents safety. Arrange an inspection of the water system by a suitably qualified engineer. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 27 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 9 of 27 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. New residents needs are assessed before they move into the home. Prospective residents are encouraged to visit the home before they move in. Evidence: The provider has produced a Statement of Purpose and service user guide for the home. These documents explain the service the home provides and set out residents rights and responsibilities. We saw evidence that residents needs are assessed by their placing authority before they move into the home. The manager said that residents are encouraged to visit the home before deciding to move in. The manager also said that residents move in initially on a trial basis. The AQAA told us that two residents had been admitted to the home in the last 12 months. There were 17 people living at the home at the time of inspection, one of whom was in hospital on the day of our visit. The home does not Care Homes for Older People Page 10 of 27 Evidence: admit people for intermediate care. Care Homes for Older People Page 11 of 27 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. New care plans contain good information about residents needs and their preferences in terms of how their care is delivered but the home must ensure that all sections of the plan are completed. Residents have access to health care professionals and get medical treatment when they need it. Information recorded on medication administration records needs to improve to ensure that all residents receive their medication safely. Staff engage positively with residents and treat them with dignity and respect. Evidence: Each resident has an individual plan that sets out their care needs and specifies how these will be met. We checked four care plans during our visit. The manager has introduced a new care plan format which aims to reflect residents needs and preferences in a more person centred way. Care Homes for Older People Page 12 of 27 Evidence: Two of the plans we checked were on the new format. We found that these contained good information about what residents can do for themselves and in which areas they need support, including their preferences about how their care is delivered. The care plans also contained information on residents lives before they moved into the home, such as family life, employment and significant events. In addition, care plans provided evidence that residents are supported to get treatment when they need it and to see healthcare professionals if they become unwell. Whilst the new format is good, a number of important areas were incomplete. For example neither of the care plans recorded on the new format contained a moving and handling assessment, Waterlow assessment, to assess the risk of pressure ulcers, or other risk assessments relevant to the resident. We also found that some of the care plans were not dated or signed and did not contain a photograph of the resident. The home has secure, lockable storage for medication. Most medication is administered using a monitored dosage system. We checked medication administration records for four residents. We found no errors or gaps in recording but noted that two of the medication administration records contained no photograph of the resident and that the allergy sections had not been completed. We also noted that some of the timings listed for administration of medication were not detailed enough, just stating morning or afternoon rather than specific times. We noted that staff interaction with residents was generally positive throughout the visit and that staff had a good knowledge of residents individual preferences. For example one resident refused a meal at lunchtime but staff knew that the resident often preferred to eat once other residents had finished their meals and reserved a meal for her, which she ate later. We observed that two staff in particular were very good at engaging with residents and clearly had a good knowledge of them and their history and interests. Care Homes for Older People Page 13 of 27 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. Residents have access to a range of activities, which the home aims to increase through the appointment of an activities coordinator. Relatives can visit whenever they wish and are made welcome when they visit. Residents enjoy the food provided. Evidence: One member of staff is responsible for organising activities, although has additional responsibilities in the home. The manager said that the home has advertised for a part time activities co-ordinator whose role will be to develop the range of activities available to residents. The manager said that the home also aims to increase opportunities for residents to be involved in their local community and to encourage residents to involve themselves in the routines of the home, such as preparing food and household tasks, if they wish. Friends and relatives are able to visit at any time and several family members visited residents during the inspection. Care Homes for Older People Page 14 of 27 Evidence: The inspector joined residents for lunch and observed that people enjoyed the food provided. Two fish options were available and a choice of desserts. Staff provided support with eating and drinking where necessary. We checked the kitchen and found that standards of hygiene and food storage were satisfactory. We noted that the majority of food is frozen and recommend that the home introduce more fresh produce. Care Homes for Older People Page 15 of 27 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. All complaints are recorded. Records indicate that complaints receive an appropriate response. Staff have access to training in the recognition and reporting of abuse but some staff need to attend this training. Evidence: We checked the homes complaints record. There had been one complaint in the last 12 months. This was from a residents family member who complained that some items belonging to the resident had gone missing. The manager told us that the items had been found and that the complainant was satisfied with the outcome of the complaint. The manager said that there had been no referrals to the local authority under safeguarding vulnerable adults procedures in the last 12 months. We checked the training record and found that staff do have access to training in the protection of vulnerable adults (POVA) but that some staff needed to attend this training. Care Homes for Older People Page 16 of 27 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. There have been a number of improvements to the home since the last inspection but further enhancements need to be made to make sure residents live in an attractive and secure environment. Evidence: The home is situated in a residential area close to Harrow town centre. On-street parking is restricted but parking is available on the forecourt outside the building. The home comprises two semi-detached houses that interlink on the ground and first floor. One of the staircases between the ground and first floor has a chair lift. The communal rooms on the ground floor including a large lounge, which is split into two sections, and dining area. There is a good sized garden at the rear of the home. The manager said that he plans to install a ramp to enable people who use wheelchairs to access the garden more easily. Residents accommodation is arranged across the ground floor and first floor and staff accommodation is provided on the second floor. Some of the bedrooms provide shared accommodation. The home has considered how best to provide privacy for residents living in shared accommodation and installed a screen in one of the rooms. The screen is an opaque plastic divider so lets in natural light and is retractable. The screen needs fixing to additional runners in the floor to improve its stability. Care Homes for Older People Page 17 of 27 Evidence: The provider has made a number of improvements to the home since the last inspection. New carpets have been installed throughout the home and wire radiator covers have been replaced with more homely units. A walk-in bath shower has been installed in one of the bathrooms and the flooring in this room and the adjacent toilet has been replaced. The furniture in the lounge has been rearranged to make this area more homely. Whilst these improvements have made residents environment more homely and attractive there are some further enhancements that need to be made. Some areas of the home would benefit from redecoration and some of the furniture in residents bedrooms is basic. Some of the windows in the home need to have restrictors fitted for residents security. Some bedrooms had a strong urine odour and this must be addressed. Care Homes for Older People Page 18 of 27 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. Residents are cared for by people they know and who understand their needs well. The home carries out appropriate checks on staff when they start work. Staff have access to relevant training and one to one supervision. Evidence: The manager said that the home was fully staffed at the time of inspection, with one member of staff on maternity leave. The AQAA told us that the home had used no agency staff in the last three months. This means that residents are cared for by staff who know them well. In addition to the manager and care staff the home employs two senior carers, a cook and a domestic. Staff support during the night is provided by one member of waking staff with another member of staff on call. We checked four staff files. These contained proof of identity, two references and evidence of Criminal Records Bureau disclosure. There was also evidence that staff are issued with a written contract, which sets out the terms and conditions of their employment. Care Homes for Older People Page 19 of 27 Evidence: The manager said that all but one staff are working towards NVQ level 2 or NVQ level 3. Training records demonstrate that staff have access to training in core areas including moving and handling, health and safety, fire safety, infection control, food hygiene and equality and diversity. We found that staff have had training in dementia and that further training in dementia was planned for early 2010. Staff files contained evidence that staff have ongoing supervision from the manager. We also found evidence of staff meetings and that manager uses these meetings to reinforce important messages to staff. Care Homes for Older People Page 20 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is competent and has access to appropriate management support and relevant professional training. Residents have opportunities to have their say about the service they receive. The provider needs to carry out some remedial work to ensure residents safety. Evidence: The manager has been in post since June 2009. The manager said that he has completed NVQ level 4 in Health and Social Care and has started an NVQ assessors course. The manager has applied to join a distance learning course in dementia to further his knowledge and skills in supporting this client group. The manager said that he has regular contact with and support from the organisations regional manager and Chief Executive. The manager has a commitment to improving the service and an awareness of the areas in which the service needs to improve. The Care Homes for Older People Page 21 of 27 Evidence: manager is not yet registered with the CQC and the provider must submit an application for registration as soon as possible. We saw evidence that the provider carries out monthly monitoring visits to the home and seeks residents feedback at these visits. Residents are also encouraged to give their views about the home at residents/relatives meetings. We saw evidence that the home encourages relatives and healthcare professionals to give their feedback about the home when they visit. The feedback we read in questionnaires completed by relatives and healthcare professionals was positive. The home has an appropriate fire alarm system. We saw evidence that staff test the alarm weekly. The last inspection of the emergency lighting system found that three lights need replacing. The manager said that these lights would be replaced by 16th December 2009. The homes fire-fighting equipment was serviced in October 2009. The report of the inspection states that some of the fire extinguishers need replacing. The manager said that the fire extinguishers would be replaced by 15th December 2009. The manager said that a fire drill was held two days prior to inspection. A fire risk assessment of the building was carried out in December 2009. We found that the home had obtained a quotation to fit automatic door closures in February 2009 but there was no evidence that these had been installed. Three windows in the home have yet to have window restrictors fitted. The manager said that these would be installed by the homes maintenance man. We checked health and safety records and found that: The gas safety record was issued in May 2009. The five-year electrical installation report was issued in October 2009. Electrical appliances had been tested for safety in October 2009. Lifting equipment had been tested for safety in November 2009. The Certificate of Employers Liability Insurance was valid until November 2010. The homes water system was last tested in 2006 and therefore needed retesting. The manager said that he had arranged for a water engineer to test the water supply on 16th December. Care Homes for Older People Page 22 of 27 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 23 of 27 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 Ensure that residents care plans are dated and signed at the time of writing and contain a photograph of the resident. 29/01/2010 2 7 15 Ensure that all parts of 29/01/2010 residents care plans are complete, including moving and handling assessments, Waterlow assessments and any other risk assessments relevant to the resident. These assessments should be reviewed regularly to take account of any changes in need. Ensure that medication administration records are clear about the time medication should be administered. 31/12/2009 3 9 13 Care Homes for Older People Page 24 of 27 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 4 9 13 Ensure that medication 31/12/2009 administration records contain a photograph of the resident and that the allergy section is completed. Ensure that all staff have up to date training in the protection of vulnerable adults. 29/01/2010 5 18 13 6 19 23 Address the urine odour that 29/01/2010 was present in some parts of the home. Redecorate the parts of the home that need repainting. Fit window restrictors where necessary to ensure residents security. Fix the dividers in shared rooms to floor runners to improve their stability. 29/01/2010 7 19 23 8 19 23 29/01/2010 9 19 23 29/01/2010 10 31 9 The provider must submit an 29/01/2010 application to register the manager with the CQC. Arrange an inspection of the water system by a suitably qualified engineer. Fit window restrictors where necessary to ensure residents safety. 29/01/2010 11 38 13 12 38 13 29/01/2010 Care Homes for Older People Page 25 of 27 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 13 38 23 Ensure that doors close 29/01/2010 automatically in the event of a fire. Ensure that the emergency lighting system is working effectively. 29/01/2010 14 38 23 15 38 23 Ensure that all fire fighting 29/01/2010 equipment is fit for purpose. 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 15 Introduce more fresh produce on the menu. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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