Care Home: St Katherine`s

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What the care home does well St Katherine`s provides a comfortable and homely place for people to live. People are encouraged to personalise their bedrooms with their own belongings such as photographs and ornaments. The atmosphere is relaxed and daily routines are flexible. People can choose whether to spend their time in the communal rooms or in their bedrooms. The staff are kind and know about people`s needs. The home has good working relationships with visiting health care professionals who told us the home is quick to contact them for advice/support if there are any concerns about people`s wellbeing. There are regular activities for people and people told us they enjoy these activities. What has improved since the last inspection? There were four requirements made at the last inspection. Two of these have been carried forward to this report as recommendations. The remaining two have not been met. These relate to the care records. Although the home has made some efforts to comply with these requirements by introducing a computerised system for care planning there are still significant shortfalls in record keeping. This could lead to people`s needs being overlooked. Therefore these requirements have been carried forward to this report with new timescales. We will be following these up to make sure they are dealt with and if they are not enforcement action may be taken. The menus have been revised and people are now offered more choice at meal times. The breakfast times have also been changed to give more flexibility. People living in the home told us they enjoy the meals. Work is continuing to improve the environment although the rate of progress is slow. What the care home could do better: The home must improve the way people`s care needs are recorded and everyone living in the home must have detailed care plans setting out how their health, personal and social care needs are to be met. This is to make sure that people`s needs are not overlooked and to ensure that care is delivered in a way that takes account of people`s abilities and preferences. Information obtained about people`s needs during the pre-admission assessment should be readily available to staff so that they know how to care for people when they move in. All the staff should attend safeguarding training scheduled to take place later this year to make sure that people are protected from abuse. The night staffing arrangements should be kept under review to take account of people`s changing needs. The correct recruitment procedures must always be followed to make sure that people are only cared for by staff that are suitable to work with vulnerable adults. The home must implement and maintain a formal system for reviewing the quality of the service so that they can show that people are able to share their views and contribute to the development of the service. The planned refurbishment work should go ahead without undue delay. Key inspection report Care homes for older people Name: Address: St Katherine`s 89 Shaftesbury Avenue Leeds West Yorkshire LS8 1DR     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: Mary Bentley     Date: 2 8 0 4 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 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: St Katherine`s 89 Shaftesbury Avenue Leeds West Yorkshire LS8 1DR 01132697797 01132697807 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: St Katherine`s (Leeds) Limited care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home St Katherines provides personal care only for up to 18 older people of both sexes. The community nursing service provides nursing support. The home is located in a peaceful residential area, close to Roundhay Park and Canal Gardens. Shops, pubs, churches, coffee shops and restaurants are all close by and the home is within easy reach of bus stops. There are four floors, three of which are used by the people living at the home. The office, laundry, storage rooms and staff room are all on the lower ground floor. Access to the upper floors is by passenger lift. Accommodation is provided in a combination of single and shared rooms, all of which have en-suite facilities. The ground floor has a lounge and dining room. There is a garden that is accessible to the people who live at the home, and a small car park. Care Homes for Older People Page 4 of 29 Over 65 18 0 Brief description of the care home Information about the home is available in the form of a Statement of Purpose, Service User Guide and an informative brochure. These documents together reflect the service provided. In April 2008 weekly fees ranged from 380.00 to 412.00 pounds. Additional charges are made for chiropody, dry cleaning, hairdressing, newspapers, toiletries and for staff to escort people to appointments. The home should be contacted directly for up to date information about fees. 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 last inspection of this service was carried out on 29 April 2008. Since then we have reviewed our practice when making requirements to improve national consistency. Some requirements from the last inspection may have been deleted or carried forward into this report as recommendations. We only do this when it is considered that people that use services at not being put at significant risk of harm. In future, if a requirement is repeated it is likely enforcement action will be taken. This is what we used to write this report: Information we have received about the service since the last key inspection The homes Annual Quality Assurance Assessment, this is a self assessment which Care Homes for Older People Page 6 of 29 focuses on outcomes for people One inspector made an unannounced visit to the home and spent approximately seven hours there. During that visit we spoke to people living in the home, staff and management. We looked at various records including care plans, staff files and maintenance records. We looked around the home and observed staff as they carried out their duties. We sent surveys to the home to distribute to people using the service, staff and visiting health care professionals. No surveys had been returned at the time of writing. 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: The home must improve the way peoples care needs are recorded and everyone living in the home must have detailed care plans setting out how their health, personal and social care needs are to be met. This is to make sure that peoples needs are not overlooked and to ensure that care is delivered in a way that takes account of peoples abilities and preferences. Information obtained about peoples needs during the pre-admission assessment should be readily available to staff so that they know how to care for people when they move in. All the staff should attend safeguarding training scheduled to take place later this year to make sure that people are protected from abuse. The night staffing arrangements should be kept under review to take account of peoples changing needs. The correct recruitment procedures must always be followed to make sure that people are only cared for by staff that are suitable to work with vulnerable adults. Care Homes for Older People Page 8 of 29 The home must implement and maintain a formal system for reviewing the quality of the service so that they can show that people are able to share their views and contribute to the development of the service. The planned refurbishment work should go ahead without undue delay. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 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. Peoples needs are assessed before they move in however the information is not always readily available to staff therefore there is a risk that peoples care needs may be overlooked Evidence: The home told us they always carry out detailed pre-admission assessments to make sure they will be able to meet peoples needs. They said that whenever possible they encourage people to spend some time at the home before making a decision about moving in permanently. We looked at the care records of some people that had recently moved into the home and the pre-admission assessments were not available. The files did contain copies of assessments carried out by other agencies for example Social Services. The manager was on leave and the deputy manager said the completed pre-admission assessments might be filed away somewhere, however they could not be located. This information should be available for staff so that they know about peoples needs at the time of admission. Care Homes for Older People Page 11 of 29 Evidence: The home has changed the format of the pre-admission assessment and the form now allows more detailed information to be recorded about peoples needs. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall peoples health and personal care needs are met but this is not reflected in the care records and this means there is a risk of needs being overlooked. Evidence: At the last inspection we told the home that everyone must have a detailed care plan with details of how their health, personal and social care needs are to be met. Since then the home has introduced a computerised system for recording peoples care needs. In their self-assessment the home told us that people have personalised care plans which are regularly updated as their care needs change. During this visit we looked at five peoples care records. In one case the person moved into the home in January 2009. The pre-admission assessment was not available and there were no care plans to show how the persons needs would be met. The person was identified as being underweight and the records showed they had been weighed in February and March 09. The deputy manager told us what was being done to meet this persons nutritional needs and about their dietary Care Homes for Older People Page 13 of 29 Evidence: preferences but none of that information was recorded. A nutritional risk assessment had not been done. A falls risk assessment had been done and this had been reviewed following a fall. The daily notes made by staff show that the District nurses are involved in meeting this persons health care needs. The daily notes also show that the person is being helped to meet their personal care needs. There was some information about the persons dietary intake in the daily notes but this was not detailed enough to show whether or not the person is having an adequate diet. Staff said the person had seen their GP but this was not evident from the records. In four other peoples records we found that no risk assessments had been done to identify if they are at risk of falls, pressure sores or malnutrition. In three cases there were no care plans and one person had a care plan for social care but none relating to their health or personal care needs. In three cases peoples weights had not been recorded since January 09 and there was no recorded weight in the fourth persons records. The deputy manager told us that peoples weights are recorded every month. She said they are recorded on paper and then transferred to the computer records, however this could not be found. All four sets of records had daily notes made by staff and these generally showed that people are being helped to meet their care needs. In most cases the daily notes showed when other professionals such as GPs and district nurses visited. There was no evidence that people or those close to them are involved in planning how their care needs will be addressed. A health care professional who visits the home frequently told us they feel people are well cared for. They said staff are quick to get support from external professionals and always follow the advice/instructions given. They said that peoples privacy and dignity are respected. People looked well cared for and staff know people well however they rely heavily on verbal information about peoples needs and this could lead to peoples needs being overlooked. There are systems in place to make sure that medicines are managed safely. There were some gaps on the medication charts where staff had not singed to show that medicine had been given. On checking we saw that in most cases the medicines had been given. Care must be taken to make sure that medicines are always signed for to Care Homes for Older People Page 14 of 29 Evidence: make sure that people get their medicines as prescribed and to reduce the risk of mistakes being made. One person in the home looks after some of their own medicine with support from staff. Care Homes for Older People Page 15 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 offered the opportunity to take part in a variety of activities and are supported in making decisions about their lives. However, more attention should be given to recording peoples social care needs to make sure that individual needs are not overlooked. Evidence: The home offers a range of activities for people to take part in if they wish. One person told us they do not want to join in activities and prefer to spend their time in their bedroom where they can watch what they want on TV. An activities organiser visits four times a week and organises games, bingo, sing a longs and exercise, people said they really enjoy these activities. The hairdresser was in the home when we visited and people were looking forward to having their hair done, she visits every Tuesday. The home has a church service once a month for people who want to attend. Some people go out with family or friends and others go out with staff either individually or in small groups. Staff said people like to sit outside when the weather is Care Homes for Older People Page 16 of 29 Evidence: nice and one person likes to work in the greenhouse. There are no restrictions on visiting and people can have visitors at times that are convenient to them. There was very little information about peoples interests, hobbies or social care needs in the care records we looked at and this could lead to needs being overlooked. The home told us they have made changes to the menus since our last visit and people are now offered three choices at each meal, two hot and one cold. They have also changed the time for breakfast and this is now available from 8 am on-wards. The meals served at lunch time looked appetising, the service was relaxed and where necessary people were helped or prompted discreetly. People said they enjoy their meals. Care Homes for Older People Page 17 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. There are suitable systems in place to make sure that complaints are taken seriously and acted on and to protect people from abuse. Evidence: The home has a complaints procedure and this is made available to people using the service. The home has not had any complaints in the last 12 months and none have been referred to us. The home told us they occasionally have minor complaints which are quickly and easily dealt with, for example someones tea not being hot enough. The home has policies and procedures in place to make sure people are protected from abuse. The majority of staff have done training on safeguarding (adult protection) but this was some time ago. The home told training has been booked and will take place in June and July this year. 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 comfortable and well maintained. The planned refurbishment should continue to make sure the home provides a pleasant environment for people to live in. Evidence: The home was clean when we visited however it is need of refurbishment. The home told us the refurbishment programme has been delayed however they said they have decorated four bedrooms since our last visit. The home told us work was due to start in the week following our visit on installing double glazing and on creating a patio area in the garden. The front door bell cannot be heard by staff when they are working on the upper floors of the home. When we arrived in the morning the front door was not locked and we were in the building for several minutes without any of the staff being aware of our presence. This should be addressed for the security of people living and working in the home. The communal rooms on the ground floor are comfortable and homely. The bedrooms are comfortable and suitably equipped to meet peoples needs. People have lots of their personal belongings in their rooms. There is no separate area for the hairdresser and hairdressing is done in one of the Care Homes for Older People Page 19 of 29 Evidence: bedrooms on the ground floor. The home told us they people who live in this room have agreed to their room being used for this purpose. The bathroom on the top floor does not have a wash basin so there is nowhere for staff to wash their hands when they are helping people. There was no bath thermometer when we visited, the deputy manager said there is usually one available. Generally the systems in place to reduce the risk of cross infection are satisfactory. However, we saw some communal bars of soap in the bathrooms; this is not good practice as it can lead to cross contamination. This was discussed during the visit. 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. There are usually enough staff available to meet peoples needs. The correct recruitment procedures are not always followed and this could put people at risk. Evidence: There are usually 3 care staff on duty in the morning until 2:30 pm and 2 care staff between 2:30 pm and 9:30 pm. At night there is one waking staff and one on call who sleeps on the premises. Night staff are responsible for doing the laundry. The home said the night staffing arrangements are adequate to meet peoples needs. However, they should be kept under review to take account of changes in the dependency needs of the people living in the home and to take account of the homes fire risk assessment. During the day there are also housekeeping and catering staff on duty. People did not express any concerns about the availability of staff. There is very little staff turnover and this helps to give continuity to people living in the home. The home has only employed one new member of staff since the last inspection. A PoVA (Protection of Vulnerable Adults) check has been done and the person is working under supervision pending the return of a full CRB (Criminal Records Bureau) check. There were no references on file, the owner said the person has not worked for over 10 years and is finding it difficult to provide references. However, the law on employing staff makes it clear that staff must not start work until all the required Care Homes for Older People Page 21 of 29 Evidence: checks have been completed and this includes two written references. This was discussed during the visit. Newly employed staff attend induction training with an external organisation. The company provides induction training which meets national standards and this helps to give new staff the knowledge and skills they need to care for people properly. There is an ongoing programme of NVQ (National Vocational Qualification) training and approximately 75 of care staff have achieved an NVQ at level 2 or above. Two of the senior care staff have an NVQ at level 4 in care. The owner said the home has concentrated on NVQ and mandatory training over the past 12 months. Over the coming months more training is booked for staff, this includes training on diversity and dementia care. Training records are kept in individual staff files. A training matrix has not yet been put in place but there are plans to do this to make it easier to get an overview of what training staff have done and what training they need. 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. The management team are clearly committed to providing a good service to people. However, at present there are a number of areas where the home is not providing good outcomes for people. Evidence: The registered manager was on leave when we visited, the deputy manager and owner were available throughout the visit. The manager has completed an NVQ (National Vocational Qualification) at level 4 in care and is doing the Registered Managers Award. At the last inspection discussions took place with the home about developing the quality assurance/monitoring systems. However, no progress has been made with this. The systems for consulting with people using the service are informal. This means there is no evidence to show that people using the service are consulted and able to contribute to the development of the service. In the absence of formal feedback from people it is difficult to see how the home can identify areas where it is Care Homes for Older People Page 23 of 29 Evidence: performing well and areas where improvements are needed. This was discussed during the visit. The management team are clearly committed to providing a good service for people. However, having taken account of some mitigating circumstances, for example the registered manager being on maternity leave we are concerned about the lack of progress in meeting all the requirements from our last inspection. The home does not get involved in managing peoples money but does hold a small amount of spending money for some people. Records are kept of all transactions and receipts are available. During this visit we found a number of shortfalls in the homes records particularly in relation to peoples care plans. The self-assessment completed by the home indicated that all the required servicing and maintenance of equipment is up to date and the records we looked at confirmed this. The home confirmed that staff are up to date with moving and handling training, however we did not see any moving and handling assessments in peoples care records. 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 7 15 All the people using the 06/10/2008 service must have a detailed care plan that gives staff clear instructions on how to deliver care. This will ensure that people receive care that meets their individual needs. Timescale of 21/12/07 not met 2 8 13 (4) (c) All the people using the 08/09/2008 service must have their nutritional needs assessed. If a person is identified as being at nutritional risk than a plan of management must be in place to make sure that people receive the nutritional support they need. Timescale of 01/10/07 not met 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 7 15 Everyone living in the home must have detailed care plans showing their health, personal and social care needs and how these needs are to be addressed. To make sure that peoples needs are not overlooked and to make sure that care is delivered in a way that takes account of peoples preferences and abilities. 21/08/2009 2 8 13 All the people using the 21/08/2009 service must have their nutritional needs assessed. If a person is identified as being at nutritional risk then a plan of management must be in place to show how this need will be addressed. To make sure that peoples nutritional needs are met. 3 29 19 New staff must not start 30/06/2009 work until all the required checks have been completed Page 26 of 29 Care Homes for Older People 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 and all the required documents have been obtained. This is for the protection of people living in the home. 4 33 24A The Commission must be provided with a written improvement plan setting out how the service will be improved, and this must include details of the action to be taken, the person responsible for the action and the timescale within which it will be done. This is to make sure that action is taken to protect people from unnecessary risks and to improve outcomes for people using the service. 5 33 24 A system for monitoring the 28/08/2009 quality of the service must be established and maintained and must include taking account of the views of the people using the service. So that people using the service are able to share their views and contribute to the development of the service. 24/07/2009 Care Homes for Older People Page 27 of 29 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 Information obtained during the pre-admission assessment should be made available to staff so that they know about peoples needs at the time of admission. The medicine records should always be signed to show when people have been given their medication to make sure people get their medicines as prescribed and to reduce the risk of mistakes. All staff should attend the safeguarding training that is scheduled to take place in June and July 2009. The arrangements for access to the home should be reviewed to make sure that staff know when people are entering the building to protect the security of people living and working in the home. Suitable arrangements should be made to make sure that staff are able to hear the front door bell wherever they are in the building. The night staffing arrangements should be kept under review to take account of the needs of the people living in the home and the homes fire risk assessment. Moving and handling assessments and plans should be included in peoples care records so that staff are clear about how people are to be helped. This is to reduce the risk of injury to people living in the home and staff. 2 9 3 4 18 19 5 27 6 38 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). 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. Care Homes for Older People Page 29 of 29 - 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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