Care Home: The Old Hall

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What the care home does well All people that wish to use service benefit from a pre-admission assessment and the care plans are then generated from this initial assessment. The pre-admission assessment is kept in the person`s individual care plan folder. The assessments are carried out by the deputy manager. Care plans and risk assessments contained enough information about the people using the service to allow staff to care for them appropriately. The staff spoken to on the day were knowledgeable about the care needs of the people using the service. They were observed to be interacting and speaking appropriately to the people in a calm manner. The standard of catering is high and the people using the service who we spoke to were complimentary about the quality of the food provided. The home is situated in well maintained grounds. People using the service are able to make use of the gardens with plenty of seating available and have access to shaded areas. The home is decorated to a high standard and maintenance and refurbishment takes place regularly. There are plenty of communal areas and newspapers and magazines are available. The home employs a team of physiotherapists who ensure that people who use the service are able to maximise their independence. The physiotherapists work between the two homes Boughton Hall and The Old Rectory. A member of staff accompanies people who use the service to all healthcare professional appointments. The staff member then reports in detail the outcome of the appointments and ensures that care plans are also adjusted if necessary. Regular training takes place and this includes the NVQ (National Vocational Qualification) which all staff have access to. What has improved since the last inspection? Following the inspection in August 2007 one requirement was made. The service user guide was being re-written and this has now been completed. What the care home could do better: The home`s safeguarding adults procedure to be reviewed to ensure that it matches that of the local authority`s. The training that takes place in the home should be reviewed to ensure that all members of staff receive the mandatory training and any training needed for their role in addition to the training that takes place at induction. The registered manager for the home is also running The Old Rectory. It is the intention for the current deputy of Boughton Hall to become the registered manager when the home has to renew its registration. The home has recently renewed its board outside of the home. This states the home is called The Old Hall which does not correspond with the registered name of Boughton Hall. The owners son told us that this again will be addressed when the home re-registers. The report from Regulation 26 visits should be made available for inspections. Key inspection report Care homes for older people Name: Address: The Old Hall Boughton Hall Send Marsh Road Send Ripley Surrey GU23 7DJ     The quality rating for this care home is:   three star excellent 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: Lesley Garrett     Date: 2 4 0 8 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 26 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 26 Information about the care home Name of care home: Address: The Old Hall Boughton Hall Send Marsh Road Send Ripley Surrey GU23 7DJ 01483211674 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: heidi@theoldgroup.co.uk www.theoldgroup.co.uk The Old Hall (Send) Co Ltd care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service suers to be accommodated is 40 The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category ; Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Boughton Hall (The Old Hall) is situated in a rural location a short distance from the village of Send. It is a large detached property set in its own substantial grounds. There are ample parking facilities at the front and the side of the building. Service users bedrooms are provided at ground and first floor level and all have en-suite Care Homes for Older People Page 4 of 26 Over 65 0 40 0 40 0 40 Brief description of the care home facilities. The home has a wide variety of communal spaces including several lounges and dining areas. These are all situated on the ground floor. The home has a large patio area and extensive gardens at the back of the building. Care Homes for Older People Page 5 of 26 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: three star excellent 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: This inspection of the care home was an unannounced Key Inspection. Mrs Lesley Garrett, Regulation Inspector, carried out the inspection. The deputy manager represented the service and we were also assisted by the owners son who is responsible for the quality of the hotel standards that the home provides. The registered manager for the service is currently on paternity leave. We arrived at the service at 10:00 and were in the home for three and a half hours. It was a thorough look at how well the home is performing. It took into account information provided by the home and any information that CQC has received about the service. The deputy manager for the service supplied CQC with an AQAA (Annual Quality Assurance Assessment) and this document was used to assist with the inspection. The inspector also spent time talking with some of the people using the service and staff members. Care Homes for Older People Page 6 of 26 We looked at how well the home was meeting the key national minimum standards and complying with the regulations and have in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes care plans, daily records and risk assessments, staff files, training records and the homes safeguarding and complaints policies and procedures. From the evidence seen by us and comments received, we consider that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Care Homes for Older People Page 7 of 26 What the care home does well: What has improved since the last inspection? What they could do better: The homes safeguarding adults procedure to be reviewed to ensure that it matches that of the local authoritys. The training that takes place in the home should be reviewed to ensure that all members of staff receive the mandatory training and any training needed for their role in addition to the training that takes place at induction. The registered manager for the home is also running The Old Rectory. It is the Care Homes for Older People Page 8 of 26 intention for the current deputy of Boughton Hall to become the registered manager when the home has to renew its registration. The home has recently renewed its board outside of the home. This states the home is called The Old Hall which does not correspond with the registered name of Boughton Hall. The owners son told us that this again will be addressed when the home re-registers. The report from Regulation 26 visits should be made available for inspections. 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 26 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 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to use the service benefit from a pre-admission assessment from a suitably trained person from the home to ensure that the home can meet their needs. Evidence: We looked at the service user guide and statement of purpose. They contained all the information required for people to make a decision about living at the home. The deputy manager explained to us that all people that are admitted to the home have a pre-admission assessment which she carries out. This looks at their activities of daily living and the assessment is placed in their individual folder. Documentation sampled during the inspection showed us that these assessments had taken place and that care plans are then generated from this document. The home does not offer intermediate care. Care Homes for Older People Page 11 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care of people using the service is a good quality with staff knowledgeable about their needs. Care plans were well written with enough information available to allow staff to care appropriately for the people using the service. Evidence: Two care plans were sampled and all contained detailed information about each person using the service and they had been written in a person centred way. The way personal care was to be delivered was described and it was apparent that consultation had taken place with each person using the service. Risk assessments were detailed with clear instructions for staff. The documents were user friendly and allowed staff to identify easily the care needs of a particular person using the service. The deputy manager told us that the care plans had recently been reviewed and the paper work had been changed. Care plans are also kept in each bedroom. We were told that so far feed back from the people using the service and their relatives had been positive. The deputy manager told us that the relatives could see every day what their family Care Homes for Older People Page 12 of 26 Evidence: member had been doing and so felt more in touch with them. Consultation had also taken place about leaving the information in each bedroom before this was carried out. It was clearly documented, by the carers and nurses, that reviews had taken place and that the care plans had been agreed by the people using the service following a consultation. Staff spoken to on the day were knowledgeable about the care needs of the people using the service. Aids and equipment are provided to encourage maximum independence for people using the service and these are reviewed and replaced to accommodate peoples changing needs.The home shares physiotherapists from their other home who are involved with the assessment of people using the service with regard to their manual handling and mobilising. The deputy told us that the GP visits every week to see those people using the service who need a visit or who have requested one. The deputy manager told us that the GP was a good support to the home and that they would visit the home more often if someone was unwell. All healthcare professional visits are documented in the individual care plans and records of these visits were observed. We were told us that the chiropodist visits every six weeks and this is included in the fees. The people who use the service also have access to the dentist and optician. The deputy manager told us that the home provides a carer who will escort the people using the service to all hospital or other healthcare appointments. This ensures that the home has the information should any treatments change. There are medication policies and procedures in place. The deputy told us that all medications are delivered every month and are in blister packs. The AQAA told us that the home has a comprehensive policy relating to the receipt, storage, handling, administration and disposal of medication and has a sustained record of full compliance in this area. During a tour of the building it was observed that staff were speaking appropriately to the people using the service by their preferred name which had been documented in their care plan. All people were dressed in clothes appropriate for the weather with hair well groomed and nails clean. Staff were knocking on peoples bedroom doors prior to entering and responding to the call bells within a reasonable time. Care Homes for Older People Page 13 of 26 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 excellent 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 are able to take part in social, religious and recreational activities and are able to exercise choice in their daily lives. The standard and quality of the meals are high resulting in nutritional needs being met. Evidence: The deputy told us that the home employs an activity organiser who ensures there is a programme of events for the year. Her hours have been recently increased so that she now works thirty hours per week. There is a varied programme in place and on the day of inspection an exercise class was about to take place. The deputy told us these take place twice a week and are two different levels depending on peoples capabilities. Earlier in the morning we spoke with two ladies who were getting together in the lounge for a knit and natter session. The ladies told us they were knitting blankets for babies and these are then sent abroad.One lady told us that the home had purchased two watering cans for her as she liked to water the plants and tubs on the patio outside of the lounge. She told us she enjoyed this activity and it gave her something useful to do. Care Homes for Older People Page 14 of 26 Evidence: The AQAA states the activity organiser has recently undertaken an activity questionnaire so that she can take into account the wishes and preferences of the people using the service. The AQAA told us that the home owns a number of vehicles which are used to take the people using the service to activities outside of the home. The home also has access to a wheelchair friendly vehicle which ensures that all people using the service have access to outside visits. The deputy manager told us that visitors are welcome to the home at any time and the home promotes open visiting. On the day of inspection it was observed that people using the service had visitors during the day in individual bedrooms and in the communal areas. The AQAA told us that people who use the service are encouraged and assisted to attend church if they wish and a local vicar visits the home monthly to give communion. A regular evangelical service takes place in the home. We were also told that staff are aware that people using the service may have different religious and cultural beliefs and will adjust the care provided accordingly. It was observed that in the care plans it was clearly documented the preferences of the people using the service. It stated preferences for getting up in the morning and going to bed. It is also documented those people who prefer an early morning cup of tea. People using the service can also choose daily newspapers and magazines that are delivered to their bedroom. All people using the service have access to telephones in their bedrooms and post is always delivered to their bedroom unopened. The AQAA told us that the home serves high quality food and the chef had a good understanding of the nutritional needs of the people using the service and could accommodate those people who required soft, pureed or liquidised food. People using the service that we spoke to on the day were complimentary about the quality of food served. Pre lunch drinks are served in the drawing room and people who use the service and their relatives and friends are encouraged to socialise before a three course lunch is served. Care Homes for Older People Page 15 of 26 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 can be confident that their complaints are listened to and that they should be protected from abuse as the staff team have received training in safeguarding adults. Evidence: The deputy manager said that during the last year they had received no complaints but lots of compliments. The complaints policy is available in the service user guide. The AQAA told us that the home has an open culture and people using the service and their families are encouraged to communicate their concerns at the time. The deputy manager said that any complaints that are received by the home would be documented and placed in a complaints folder. The home has not had a safeguarding referral during the last year. Training takes place regularly for all staff and they are knowledgeable about the procedure. The homes policy on safeguarding adults is not in line with the local authoritys policy and procedures. It will be a requirement at the end of the report for this document to be reviewed and updated. CQC have not been made aware of any complaints about the home or any referrals under the safeguarding procedures. Care Homes for Older People Page 16 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home enables people who use the service to live in a safe, well maintained and very comfortable environment. Standards of hygiene and cleanliness are high. Evidence: During the tour of the building it was observed that people using the service benefit from a well maintained and decorated environment. The interior and exterior of the home is excellent. All bedrooms are single and have en-suite facilities. It was observed that the bedrooms had been personalised and the AQAA states that the management of the home encourages people to bring in their personal belongings. There are plenty of communal facilities which include lounges and dining rooms. The deputy manager told us that they have applied for planning permission to improve the facilities at the home but this was refused. They have appealed the decision and revised the plans and await the outcome The bedrooms benefit from adjustable beds, bed-rails (if required), and plenty of equipment to aid manual handling including hoists. The gardens are large and well maintained and some rooms on the ground floor have patio doors which open into the garden. The home has domestic staff who work every day to ensure the home is clean and free from offensive odours. Standards of cleanliness within the home is high with Care Homes for Older People Page 17 of 26 Evidence: evidence seen that the staff are working to COSHH (control of substances hazard to health) guidelines. Soap dispensers and paper towels were available in the communal areas to assist with infection control within the home. Records showed that staff have also received infection control training. We spoke with the head housekeeper who stated that she had not received some mandatory training including infection control procedures. The deputy said that this will be addressed and training will now take place for all grades of staff. A requirement will be made at the end of the report. The deputy manager and owners son told us they unaware that this training should be given to other members of staff including housekeepers, administration staff, chefs, cooks and kitchen assistants. Care Homes for Older People Page 18 of 26 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. Staff numbers at the home on the day of inspection were sufficient to meet the assessed needs of the people using the service. NVQ training for the care staff continues to ensure a good skill mix of staff on duty. Evidence: The home benefits from an experienced staff team and when sampling the staff rota it was observed that staffing levels are consistent. The AQAA told us that many of the staff live locally who have worked for the home many years. The deputy manager told us that she does the rotas for the staff and that they always try to ensure that there is a high ratio of staff to people who use the service. We were also told that the home does not have to use agency staff as very often empty shifts are covered by the current staff team. The deputy manager also told us that staff levels can be increased if the dependency levels of the people using the service increases.The home has two heads of care who work opposite one another and a nurse who works three mornings and one day a week. The nurse is responsible for for monitoring the clinical care and also accompanies the GP when they visit the home every week. The deputy said that well over 75 of the care staff have NVQ certificate and some at level three. The training at the home is on going and that they benefit from having assessors and verifiers on the staff team. Records confirmed that this training takes Care Homes for Older People Page 19 of 26 Evidence: place. Three staff employment folders were sampled and were found to have most of the necessary paper work to enable the home to employ those people safely. This ensures that the people who use the service are protected by the homes recruitment procedures. It was observed that one staff member had only one reference in place and another had previously worked with children but no reference had been obtained from that job. We spoke with the deputy manager about this. A requirement will be made at the end of the report for recruitment folders to be reviewed to ensure that all the necessary references are in place. The deputy manager is also the training manager and ensures that all training necessary for staff takes place. The home has recently employed two training officers who will work with the deputy manager to ensure that training takes place for all staff and records are kept. The training officers will work at both homes. Records showed that mandatory training takes place which includes fire awareness, safeguarding adults, food hygiene and first aid. Staff spoken to on the day told us that they had received lots of training and that the owners of the home are very supportive with the training that is provided. As mentioned in the previous outcome area, training has not taken place for some staff so a requirement will be made at the end of the report. The AQAA told us staff also receive a comprehensive induction programme which is in line with the national induction programme called Skills for Care. The training manager provides the classroom element of the course and the training assistant provides the practical element. Care Homes for Older People Page 20 of 26 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. Management arrangements at the home ensures the staff team is adequately supported and there are clear lines of managerial accountability. Quality assurance systems are in place which improve the quality of care offered to the people who use the service. Evidence: The registered manager of Boughton Hall is currently on extended paternity leave and is also in charge of The Old Rectory. Another son of the owner was at the home on the day of inspection. He told us he was responsible for the financial aspects of the home and the hospitality element of the business. We were told that when the home has to submit their new registration the deputy manager will be nominated as the manager. Both homes are owned by the same company and is a family run business. The owner has regular contact with the home also. The deputy manager told us that she is also a nurse and keeps her registration up to date. The deputy manager told us that she has an open door policy and encourages people who use the service and their relatives to Care Homes for Older People Page 21 of 26 Evidence: talk to her if they are worried or have any concerns about the service provided. The signage outside the home was also discussed during the visit. A new board has been placed outside calling the home The Old Hall. This is not the name that the home has been registered in. We were told during the day that when the home is re registered they will change the name of the home from Boughton Hall to The Old Hall. The deputy manager told us that questionnaires are sent to the people who use the service and their relatives or representatives to seek their views on the quality of the service and care provided. Regular meeting are also held for the people who use the service which enables them to pass comments to the home directly. The results of the last survey was observed and all comments received were positive about the quality of the care available at the home. Regular audits have taken place internally to seek people views in relation to the quality of the food and the activities. Adjustments were made following the results to ensure that the service can meet the needs of the majority of people using the service. The deputy manager told us that Regulation 26 visits take place by the provider but no reports are held by the home. A requirement will take place at the end of the report. No personal money is held by the home. All invoices are passed to the relatives, representatives or to the person using the service for them to settle the bill themselves. All necessary health and safety certificates are in place and we also observed a range of policies and procedures relating to health and safety. Care Homes for Older People Page 22 of 26 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 26 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 18 13 To review and update the homes safeguarding adults policy and procedure to ensure that it follows the local authoritys procedures. To ensure that staff have the understanding of the agreed protocols for their area in which they work. 01/10/2009 2 29 19 Review the current 01/10/2009 recruitment folders for recently recruited staff to ensure that there are two references in place and if a person has worked previously in a care home or worked with children this is included in the references. To ensure that the home safely recruits staff to protect the people using the service. Care Homes for Older People Page 24 of 26 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 30 18 Training should be made available to all grades of staff within in the care home. To ensure that all staff that have contact with people using the service are appropriately trained and skilled. 01/10/2009 4 33 26 Records of the monthly visits to the home by the provider must be made available for inspections. To ensure the visits are taking place as another quality audit tool for the home. 01/10/2009 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 Care Homes for Older People Page 25 of 26 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 26 of 26 - 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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