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Care Home: The Leys

  • Old Derby Road Ashbourne Derbyshire DE6 1BT
  • Tel: 01335233100
  • Fax: 01335238019

0The Leys Residential Care Home is located on the southern edge of Ashbourne. It provides care for 36 residents. The home is purpose built and all facilities are on one level. All residents are provided with their own bedroom, although none of these have en-suite facilities. The Home has four lounges and three dining rooms and front and rear gardens, which are well maintained. Information about the service is provided through the Statement of Purpose and Service User Guide, both of which are made available to residents. The previous inspection report is located in the reception area. Fees for the home were £404.06. Items not included in this fee are hairdresssing, toiletries and newspapers.

  • Latitude: 53.00899887085
    Longitude: -1.7289999723434
  • Manager: Terjeevan Kaur Bajwa
  • Price p/w: £404
  • UK
  • Total Capacity: 36
  • Type: Care home only
  • Provider: Derbyshire County Council
  • Ownership: Local Authority
  • Care Home ID: 16093
Residents Needs:
Old age, not falling within any other category

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for The Leys.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jill Wells     Date: 2 8 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 28 Information about the care home Name of care home: Address: The Leys Old Derby Road Ashbourne Derbyshire DE6 1BT 01335233100 01335238019 terjeevanbajwa@derbyshire.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Derbyshire County Council care home 36 Number of places (if applicable): Under 65 Over 65 36 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 The Leys Residential Care Home is located on the southern edge of Ashbourne. It provides care for 36 residents. The home is purpose built and all facilities are on one level. All residents are provided with their own bedroom, although none of these have en-suite facilities. The Home has four lounges and three dining rooms and front and rear gardens, which are well maintained. Information about the service is provided through the Statement of Purpose and Service User Guide, both of which are made available to residents. The previous inspection report is located in the reception area. Fees for the home were £404.06. Items not included in this fee are hairdresssing, toiletries and newspapers. Care Homes for Older People Page 4 of 28 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: two star good 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 the service is two star. This means the people who use the service experience good quality outcomes. The inspection visit was unannounced and took place over 7 hours. There were 32 people living at the home on the day of the inspection. 8 residents, 4 staff, 2 visitors, the deputy manager and the manager were spoken with during the visit. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. We also looked at all the information that we have received, or asked for, since the last key inspection on the 11 June 2008. This Care Homes for Older People Page 5 of 28 included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection report. Completed surveys from people living at the home, staff, relatives and professionals that visit. Case tracking was used during the inspection visit to look at the quality of care received by people living at the home. 4 people were selected and the quality of the care they received was assessed by speaking to them, observation, reading their records, and talking to staff. What the care home does well: What has improved since the last inspection? What they could do better: The manager was not always notifying the Commission when significant incidents had taken place. One person spoken with was registered blind and did not have accessible information available to them about the home. Security of the entrance was poor and staff did not know when visitors had entered the buiding. The office was regularly left unlocked and unattended, which left confidential information easily accessible. Care Homes for Older People Page 7 of 28 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 set out 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 28 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 28 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. Peoples needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. Evidence: The annual quality assurance assessment completed by the manager said that information was given to people regarding the service that they provide and confirmation that the home can meet individual needs is written on the care plan. During the inspection visit the statement of purpose and last inspection report were available for prospective people considering living at the home. People had a copy of the service user guide in their bedrooms. These documents provided all the information that people needed to know about the service. One person spoken with had been recently admitted to the home. They were registered blind and did not know that the service user guide was in their bedroom. They said that they would have liked Care Homes for Older People Page 10 of 28 Evidence: information about the home on a tape so that they could listen to it. Prospective residents or their family and friends were encouraged to visit prior to making a decision about whether the home will meet their needs. Most people came for short-term care, often several times, before deciding to stay at the home. A social worker spoken with said that the home was very popular with local people. A resident spoken with said that, I came here for day care first and knew that when the time came I would be happy to live here. Each file that was seen had a copy of a letter stating that the home could meet their needs. Copies of assessments that had been carried out were seen on peoples records. These were detailed and included information concerning each persons health and personal care needs, social interests, relevant history, care needs and family involvement. The home does not provide formal intermediate care and therefore standard 6 was not assessed. Care Homes for Older People Page 11 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are met and the principles of respect, dignity and privacy are put into practice. Evidence: During the inspection visit the care records of 4 people living at the home were seen. Each person had a plan of care in their file. The care plans were written in a person centred way to support care staff to provide individualised care. Records included individuals social history, preferences, as well as information about their health. They were written in plain language, and were easy to understand. Individual records also included moving and handling plans, falls risk assessment, nutritional assessment and tissue viability assessments. Peoples care needs were reviewed on a monthly basis. Although staff spoken with were aware of individuals care needs, they were not always aware of their personal history, reason for coming to the home or hobbies and interests as they were not always reading peoples files. A care worker said that they were usually told about peoples care needs and other information about them was Care Homes for Older People Page 12 of 28 Evidence: usually picked up through conversation with the resident or family. Recently residents had been offered more frequent baths if they wanted this. Records, staff and people living at the home were all able to confirm that GPs and other health professionals were contacted and visited when required. The chiropodist was visiting on the day of the inspection. Some peoples health records were on the computer system, but had not been transferred to their individual files which were accessible by care staff. One person spoken with had a sore skin area and confirmed that the manager had involved the district nurse to monitor this. A visiting health professional commented in our survey that the home has, good communication with the multi-disciplinary team and any concerns are dealt with in a professional manner. Each person had a moving and handling plan, and training record showed that staff had been trained in this area. Peoples wishes concerning terminal care and arrangements after death were discussed and recorded. A staff member spoken with said that she was concerned that incontinence aids were not meeting peoples needed at night. The manager was advised to seek guidance from the specialist continence advisor about this. The manager was observed administering medication. A care assistant gave the medication to each person and the manager observed the medication being taken. The medication administration records were seen and were in good order, although one persons records did not have a photograph in place. Medication in the home was stored securely. There were no controlled drugs at the time of the inspection visit. Care records showed that individuals had been assessed or asked if they were able to keep their own medication. Eye drops were given in peoples bedroom for privacy and one person had requested that their medication be given in their room and this was respected. People spoken with said that they were treated with respect by staff. Care staff spoken with were very aware of the importance of respecting peoples privacy and could give examples of how they did this. One person said that, staff are always kind . One person said that they were encouraged to use the call bell rather than struggling. A recent outbreak of illness, that had quickly spread through the home had been managed well. Visitors were asked to keep away and residents were asked to remain in their rooms to minimise further spread. A visitor confirmed that they were communicated with well during this period. A resident spoken with about this said, staff really looked after me when I was ill. Care Homes for Older People Page 13 of 28 Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The range of activities and standard of meals offered met the needs and wishes of people living at the home. Evidence: Since the last inspection visit the provider had agreed that the home should have an activities co-ordinator. This position was appointed to, but quickly became vacant again. Therefore the manager intends to re-advertise the position, meanwhile care staff are covering this role. Activities were advertised in the entrance hall. These included table games, dominoes, word search, Holy Communion and music. The care assistant assigned to providing activities on the day of the inspection was spoken with. The activities shift was 9 a.m.-1 p.m., however a significant amount of this time was used undertaking care duties, for example supporting the manager administering medication, assisting at lunchtime and providing drinks for residents. The manager was spoken with about this and was advised to reconsider the expected duties of the person in this post. There was a clear record of activities provided and which residents had been involved. A resident spoken with said, we get lots of entertainment, and I enjoy the singing and another person said, we are all old here, we dont want lots of activities. Care Homes for Older People Page 15 of 28 Evidence: There were several visitors to the home on the day of the inspection. One visitor spoken with said that staff made you feel welcome and would sometimes ask if you wanted a drink. A resident spoken with had many visitors and said that they thought that staff were very pleasant to them. People were helped to exercise choice and control over their lives. They were informed on admission of their right to access personal records and had signed this document. They were encouraged to bring personal possessions with them. Information concerning advocacy was displayed in the entrance hall. People were encouraged to handle their own financial affairs if they were able. People were offered a key to their bedroom doors, and several people chose to have one. During the inspection visit a meal time was observed. There was a menu displayed on the dining tables as well as in the communal areas. There was a choice of meals and most people spoken with were satisfied with the food provided. One person said, most of the food is good, but you cant like it all. The recent quality assurance survey undertaken by the service said that 100 of people replying to the surveys rated the food as either excellent or good with regard to meeting special dietary needs. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have their rights upheld, are able to express their concerns and are protected from abuse. Evidence: The annual quality assurance assessment completed by the manager said that they had a Derbyshire County Council complaints and protection policy and promptly investigate and feedback after any concerns or complaints. There was a complaints procedure displayed at the home which included how to contact the Care Quality Commission. There had been 8 complaints recorded since the last inspection visit. The home was generally recording low-level complaints, which was good practice. There had been a serious incident regarding an agency worker bathing a person in water that was too hot. This had been dealt with well, the resident received an apology and the worker no longer comes to the home. One person spoken with said that they had two cardigans ruined from the laundry service in February. They had been told that when the clothing sale next came to the home, two new cardigans would be purchased for them. This issue had not been recorded in the complaints record. The manager agreed to talk to the resident and offer to purchase the cardigans sooner, as a clothing sale was not planned. A resident had reported money missing. The manager had involved the police, but no Care Homes for Older People Page 17 of 28 Evidence: further action was taken. The person was advised not to keep large amounts of money in their bedroom. The person was not happy with this advice, believing that it was their right to do this if they wished to do so. They did have a drawer that locked and a key to their room. There had been no further reports of theft. Several training records were seen and these evidenced that staff were receiving training in recognising and alerting others to suspected abuse. The policy was displayed in the entrance hall. Two residents spoken with confirmed that they felt safe and were confident that if they had any concerns, they would be dealt with. There was a record held in peoples files of the date that their address had been changed on the electoral register to ensure that they have the opportunity to vote, including a postal vote. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well-maintained and comfortable environment, which encourages independence. Evidence: The manager explained that since the last inspection visit the middle courtyard had been much improved with a sensory garden and work was still in progress by volunteers. The entrance had been re carpeted as well as some bedrooms and a corridor. Self-closing devices had been placed on bedroom doors to ensure safety in the event of a fire. The kitchen had been rewired. There were plans for 4 toilets to be replaced, including one to be more easily accessible for people using a wheelchair. A bedroom with a fire exit in the room, previously used for people on respite care had now been converted into a quiet room, after advice given from the fire service. The Commission had not been informed of the reduction in bedroom numbers. Two bedrooms were visited with residents. They had their personal possessions around them, although they were small rooms. There was a record of people being offered an additional chair and small table. A resident commented that there was not room for this. One person described their bedroom as adequate, with a very comfortable bed. There were adaptations and equipment around the home to assist people with mobility problems. One person recently admitted to the home said that they found the toilets Care Homes for Older People Page 19 of 28 Evidence: very low. The manager was spoken with about this and agreed to place a raised toilet seat on this toilet until this area had been refurbished. A visitor was observed in the entrance hall clearly unsure where to go and staff were unaware that they were there and were left for some time in this area. The person was visiting for the first time. The inspector also walked into the building and had to go into the communal areas to find a member of staff. The manager later pointed out the doorbell, although this was difficult to see. There were several lounge areas and people could choose where they sat. The lounge areas were well decorated and furnished. One person commented in our survey that sometimes the lighting in the corridors were not good due to bulbs not working. On the day of the inspection there was a bulb not working in one of the shower rooms. The manager explained that as soon as any failed bulbs were reported to her, they were dealt with. Several people commented on the cleanliness of the home, with no unpleasant odours. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment practices and staff training programme were good and ensured that people were protected by competent, well-trained staff. There were sufficient numbers of staff to support the people who use the service. Evidence: The annual quality assurance assessment completed by the manager said that the Leys has an experienced staff group in both management and care assistant roles, with commitment to staff training. The manager stated that there were sufficient staff to meet the needs of residents. At the last inspection visit this outcome area had been assessed as poor. There have been improvements made since the last visit. This includes additional care staff, an activities co-ordinator and laundry hours. The rotas showed that agency staff were used in an emergency. The home was not yet fully staffed as there were vacancies and the manager was in the process of recruiting. They did have relief staff to cover vacant shifts. The manager was monitoring dependency levels and she explained that her budget allowed additional staff if they had people to care for with high dependency needs. Comments received in surveys were mixed concerning staffing levels. Comments included, residents are well looked after and receive excellent personal care, staffing Care Homes for Older People Page 21 of 28 Evidence: levels need to be boosted and more staff are needed to enable better individual care with each person. A staff member spoken with said that there had been a big improvement in staffing, although another person felt that staffing levels were hit and miss and staff were really rushed trying to get everything done. A staff member commented that some but not all managers will support care staff when they are very busy. This was discussed with the manager who said that this had also been said to her and she will monitor the situation. On the day of the inspection visit, although staff were very busy there were enough staff on duty to meet peoples needs. Residents and relatives were very happy with the quality of care provided by staff. Comments from relatives included, they are a very caring team and very approachable, residents seemed to want for nothing. Another person said, mums needs are met very well. Staff were described as being friendly, helpful and caring. One resident said, I can honestly say we are well looked after. Several peoples training records were seen. These showed that staff were welltrained. New staff received in depth induction training, which included training in developing as a worker as well as moving and handling, fire safety, first aid, food safety, dementia care and infection control. Long-term staff received regular refresher training. End of life and bereavement and dementia care training were planned in the near future for all staff. The main recruitment records were held centrally. However information was e-mailed during the inspection visit to confirm that all relevant checks had been completed before new staff started work. A staff member wrote in our survey that, all checks were carried out before I started work. Information from the manager was that 80 of care staff had undertaken NVQ 2 Care, which should be commended. Care Homes for Older People Page 22 of 28 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. There are effective quality assurance systems, ensuring that people are listened to and the home continues to develop and improve. Evidence: The annual quality assurance assessment (AQAA) completed by the manager said that she had completed the registered managers award and has had previous nursing experience. The deputy managers were also completing the NVQ 4 qualification. She stated that all risk assessments for people and the building had been completed and were up to date. The completion of the AQAA was discussed with the manager at the time of the inspection. Evidence that was not relevant to each outcome area had been recorded in this document, making it confusing and difficult to use. Advice was given on how to improve completing this document, which is a legal requirement. Training records showed that the manager had undertaken periodic training to update her knowledge and skills. Care Homes for Older People Page 23 of 28 Evidence: There were mixed comments concerning the management approach. A relative commented in our survey that the management team were very approachable. However some staff commented that they felt they needed more praise and support from the management. This was discussed with the manager at the time of the inspection. She agreed to give some thought as to how this could be done more effectively. The service manager visited regularly to support the management team. The monthly reports evidenced that she was very involved with the home, talking to residents, staff and relatives during her visit. A staff member spoken with said that she was very approachable and staff felt able to go to her directly if they needed to. There was an annual survey to gauge the views of residents who use the service. Workers from Age Concern provided assistance to residents if this was needed. The results were analysed and the manager was expected to complete an action plan as a result of the findings. This was still to be done. There were also residents meetings and a suggestion box that residents and visitors could use. Records were well maintained and in good order. However the office was seen regularly empty throughout the day with the door open. There were times when confidential information was on display in this room. Fire records were checked and found to be generally in good order. However the records showed that the last fire drill was February 2008. The manager was able to confirm that a fire drill had been undertaken in 2009, but this had not been recorded. Emergency lighting was checked, but not on a monthly basis as recommended by Derbyshire County Council, however there was a formal inspection on an annual basis. Information in the annual quality assurance assessment was that all servicing was up to date. Accidents were recorded in individuals files. Most but not all of the necessary incidents had been reported to the Commission, for example the theft of a residents money and a recent disciplinary and dismissal of a new worker had not been reported. Care Homes for Older People Page 24 of 28 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 25 of 28 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 38 37 The Commission must be 29/05/2009 notified in writing of the death of any service user, any serious injury or illness, any theft, burglary or accident, any allegation of misconduct by any person who works at the care home and any event in the care home which adversely affects the well being or safety of any service user. This is to meet the legal requirement as stated in Regulation 37 of the Care Homes Regulations. 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 1 The service user guide should be in alternative formats where appropriate to ensure that everyone has full access to information about the home. Care Homes for Older People Page 26 of 28 2 7 All care staff should be given the time and opportunity to read individuals personal care plans and other records to ensure that they have good knowledge about their social history, hobbies and interests as well as there basic care needs The GP and district nurse records should be available on individuals files as well as on the computer system so that they are accessible to care staff as well as managers. Each person should have a photograph on their medication records at the point of admission for easy and safe identification. Consideration should be given to a system that ensures that the staff and managers are aware of people entering the building. This is so that people are safe and the building is secure. Confidential information should be secure at all times in the office area. This is to ensure that individuals records are kept confidential. 3 8 4 9 5 19 6 37 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 28 of 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

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