Care Home: The Old Vicarage

What the care home does well The staff group was stable, with some staff having worked in the service for a number of years, which helped to provide consistency of care. People described the staff as `friendly and helpful`. The admission procedure was well-established and ensured sufficient information was gathered to be able to meet peoples` needs. Health services were called in when required and specialist help and advice was sought as necessary. Care and support needs were reviewed regularly with a health professional. One professional spoken with said the care was `very good` and another described the service as `supportive`. People using the service enjoyed the meals. Staff enjoyed working at the service and described it as `homely` and `like a family`. People using the service and their relatives made favourable comments; one described it as `fabulous`, another said staff were `very attentive` and `quite patient` and another that they `are good to me`. What has improved since the last inspection? This was the first key inspection of the service following a change in their registration with the Care Quality Commission. This section therefore does not apply. What the care home could do better: There must be more stringent controls on dealing with peoples` money to ensure that peoples` personal cash that is stored in the building is easily identified and accounted for. It must be recorded accurately and there must be an audit trail of what personal money people have and the record and actual cash must correspond correctly. Recruitment procedures must be tightened to ensure a copy of qualification certificates and identity verification is available on all staff recruitment files and the service`s job application form should be amended to obtain a full employment history. There must always be a care plan for an identified risk to ensure all health issues are addressed. All staff must receive updated safeguarding vulnerable adults training and the service should obtain a copy of the Derbyshire Local Authority safeguarding procedures. Care records should be more personalised so it is clear that care is provided on an individual basis. Bathrooms should be modernised and refurbished. The service should ensure all areas are odour-free. More activities should take place to ensure people are stimulated and not bored. Consideration should be given to replacing the carpet at the entrance and stairs. All relevant staff should have updated food hygiene training. Key inspection report Care homes for older people Name: Address: The Old Vicarage The Old Vicarage 13- 17 Breedon Street Long Eaton Nottingham NG10 4ES     The quality rating for this care home is:   two star good 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: Janet Morrow     Date: 2 6 0 1 2 0 1 0 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: The Old Vicarage The Old Vicarage 13- 17 Breedon Street Long Eaton Nottingham NG10 4ES 01159466760 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Old Vicarage Care Home (Long Eaton) Ltd Name of registered manager (if applicable) Mrs Elizabeth Ada Deakin Type of registration: Number of places registered: care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 29 The registered persons may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission are within the following category: Old age, not falling within any other category - Code OP. Physical disability - Code PD. Date of last inspection Brief description of the care home 0 29 Over 65 29 0 Care Homes for Older People Page 4 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: 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: This inspection visit was unannounced and took place over one day for a total of seven hours and an additional three hour visit was undertaken at the services administrative offices. Case tracking methodology was used, which means that the records of three people using the service were examined and relevant people spoken with to assess what impact the service had on those peoples quality of life and well-being. Care records, maintenance records, a sample of policies and procedures and staff records were examined. A partial tour of the building was undertaken. Seven of twenty-four people using the service, two relatives, six members of staff, one Care Homes for Older People Page 5 of 29 visiting professional and the manager were spoken with during the visit. Two relatives and two visiting professionals were spoken with by telephone following the inspection visit. Seven surveys were received prior to the inspection visit; three from staff, two from people using the service and two from visiting professionals. Written information in the form of an Annual Quality Assurance Assessment (AQAA) was provided by the service prior to the inspection visit and informed the inspection process. This information is referred to as the AQAA throughout the report. Care Homes for Older People Page 6 of 29 What the care home does well: What has improved since the last inspection? What they could do better: There must be more stringent controls on dealing with peoples money to ensure that peoples personal cash that is stored in the building is easily identified and accounted for. It must be recorded accurately and there must be an audit trail of what personal money people have and the record and actual cash must correspond correctly. Recruitment procedures must be tightened to ensure a copy of qualification certificates and identity verification is available on all staff recruitment files and the services job application form should be amended to obtain a full employment history. There must always be a care plan for an identified risk to ensure all health issues are addressed. All staff must receive updated safeguarding vulnerable adults training and the service should obtain a copy of the Derbyshire Local Authority safeguarding procedures. Care records should be more personalised so it is clear that care is provided on an individual basis. Bathrooms should be modernised and refurbished. The service should ensure all areas are odour-free. More activities should take place to ensure people are stimulated and not bored. Care Homes for Older People Page 7 of 29 Consideration should be given to replacing the carpet at the entrance and stairs. All relevant staff should have updated food hygiene training. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 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 9 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service was able to meet peoples needs, based on assessment information provided. Evidence: The AQAA stated that Two client assessments are carried out, one by the Primary Care Trust (PCT) nurse to assess banding and one by our nurse to assess needs prior to admission and to ensure those needs can be met. We examined three peoples care files and saw that there was assessment information from external professionals as well as information gathered by the service. This established that the service was able to meet peoples individual needs. Risk assessments were in place on the files for risk of falls, nutrition, pressure sores and moving and handling. Care Homes for Older People Page 10 of 29 Evidence: Those people using the service confirmed that their care needs were met. A visiting professional spoken with also confirmed that the needs of the people they were involved with were met and described the care as very good. Two surveys received from visiting professionals responded that the services assessment arrangements were usually accurate. Care Homes for Older People Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health needs were met by clear arrangements for contacting specialist help and accurate care planning. Evidence: The Aqaa stated that the service Provide a personal care plan based upon their assessments prior to admission and The plan is created with the clients involvement at all stages, this can be altered or added to at any time by client. We examined three peoples care files and all had a care plan in place that contained information on how to address needs. The plans covered a range of needs, predominantly linked to physical health needs such as personal care, mobility and eating and drinking. However, they followed a standard pro-forma and there was little information that was individualised. For example, all had the same care plan for the provision of personal care and two had the same for socialising. Although most key areas were addressed for people, there were some omissions noted in the care plans and associated recording. For example, one persons Care Homes for Older People Page 12 of 29 Evidence: assessment showed that they had nutritional needs and although a risk assessment was undertaken on a monthly basis, there was no specific care plan for this. Another persons assessment said weight should be recorded weekly but it was done monthly. People using the care and their relatives told us the care was good; one person said their relative had improved since using the service and said they were very well cared for. Another relative said they were quite satisfied with the care provided and that their relative was very settled. Access to health professionals such as General Practitioners and opticians was recorded in the files examined and there was monthly recording of weight, pulse and blood pressure on all three files. A visiting professional spoken with praised the service and described it as very caring and said that any health issues were promptly addressed. Two surveys from visiting professionals responded that the service always sought advice and acted on it to meet needs and improve well-being. A visiting professional we spoke with described the care as very good and thought the service had vastly improved. One survey from someone using the service responded that they always received the care and support needed and one responded that they usually did. Both surveys responded that the service always made sure they received medical attention when needed. Medication procedures were discussed with the nurse in charge. There was a policy that covered the essential areas, including what to do if an error was made. We looked at three peoples medication administration record (MAR) charts and all were completed accurately for administration with the chart corresponding with the blister pack. Two staff were signing handwritten charts to ensure they were accurate and the amount of medicine received was recorded. There were controlled drugs currently in use; we checked the controlled drugs register and the amount held corresponded with the record. There was secure appropriate storage for controlled drugs. Storage of medicines was satisfactory. There was a medication refrigerator and its temperatures were being recorded on a daily basis and were within safe limits. General observation during the inspection visit showed that staff and people using the Care Homes for Older People Page 13 of 29 Evidence: service enjoyed warm relationships and they confirmed that privacy and dignity was upheld. Staff displayed patience and kindness and interacted well with people. One person spoken with said staff were polite and another described them as lovely. Care Homes for Older People Page 14 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. Meals, contact with the community and activities were well managed, which enhanced peoples quality of life. Evidence: The Annual Quality Assurance Assessment stated that there was a Personal choice of menus daily, Newspapers, Outside entertainers, Outings and Meetings. It also stated that one of the ways the service wanted to improve was to plan more outings and hold more frequent resident/family meetings. People using the service and their relatives confirmed that the routines of the service were flexible and it was observed that people had the choice of whether or not to participate in activities. External entertainers were organised some people went out to local shops in the town centre. One person went to a day centre. There was a twice weekly movement to music session. Some people opted to remain in their own rooms. Discussion with people using the service confirmed that they were able to pursue their own interests if they wished and observation confirmed this. One survey received from a person using the service responded that there were always activities arranged and the other responded that Care Homes for Older People Page 15 of 29 Evidence: there usually were. However, staff, people using the service and a relative commented that more outings and social activities would improve the service. Relatives spoken with confirmed that they were able to visit at any time and stated that they were always made to feel welcome. Visitors were observed to be calling throughout the inspection visit. People using the service also confirmed that visitors were welcome at any time and they are able to go out with their relatives if they wished. One relative spoken with said the staff attitude towards them when visiting was good. The manager was aware of who to contact for an advocacy service and was aware of the Mental Capacity Act 2005 and its implications for decision making with people who have impaired abilities and had undertaken training in this area. She stated that no one using the service currently had an advocate. There was information in the service about the Act and the associated Deprivation of Liberty Safeguards. One member of staff we spoke to said they had received training in this area. The practice of people eating their meals in their armchairs continued. This was discussed with staff and the manager and they stated that attempts had been made to use dining tables but that people using the service preferred the current arrangement. The serving of the lunch-time meal was observed and showed that the food was plentiful and nutritious with a choice offered. Those people spoken with during the lunch-time period said that they enjoyed their food. Menus were examined and showed that there was a good variety of nutritious and wholesome food. Food stocks were good and there was fresh fruit available. Staff spoken with were knowledgeable about individual food likes and dislikes and were able to cater for these. Specialist diets, such as diabetic, were catered for. However, there was no culturally appropriate meal offered for two people using the service and discussion with staff stated that this rarely occurred. One of the two surveys received from people using the service responded that they always liked the meals and the other responded that they usually did. One survey commented that the food was something the service did well. A relative we spoke with described the food as very good and said their relative had picked up since using the service and was eating better. Another person said the food was nice. Care Homes for Older People Page 16 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. Clear procedures ensured that peoples concerns were listened to objectively and that they were safeguarded. Evidence: The AQAA stated that We hold meetings to inform residents and relatives about our complaints procedures, as a result we now have a communication book for residents and their families to voice their opinions or concerns. We saw the complaints procedure and that it stated complaints would be dealt with in seven days. The AQAA stated that three complaints had been received in the last twelve months and that all had been responded to within timescales.The complaints record was examined and we saw what action had been taken in response to the complaints. People were generally satisfied with the outcome and one relative said that any issues raised were sorted out straight away. One concern had been reported to the Local Authority and we saw the records relating to this and what action the service had taken in response to it. The two surveys from people using the service responded that they knew who to speak to informally about a complaint and how to make a formal complaint. All three staff surveys received confirmed that they knew what to do if someone had Care Homes for Older People Page 17 of 29 Evidence: concerns about the service. We saw a safeguarding policy that stated any allegations of abuse should be reported to the appropriate authority. However, the service did not have a copy of the Derbyshire Local Authority procedures. Staff spoken with were aware of their responsibilities to report any suspicions of abuse and confirmed that they had undertaken training in this area. However, they told us that this training had not occurred since the last inspection visit in December 2007. 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. A need for repairs and refurbishment did not always ensure that people had pleasant accommodation. Evidence: The premises were clean, tidy and generally odour free at the time of the inspection visit, although there was a mild odour in certain locations including one persons bedroom. Two surveys received from people using the service responded that the premises were always fresh and clean. The AQAA supplied by the service stated that We provide and maintain a bright, clean, friendly, safe environment. However, there were areas that were in need of refurbishment; one bathroom was old fashioned and needed updating and the carpet at the main entrance and up the stairs was worn. A relative described the premises as a liittle shabby. The laundry was neat and tidy. There were two washing machines, one with a sluice wash facility. Staff spoken with reported that there was adequate protective equipment such as gloves and aprons and they knew how to prevent the spread of infection. The kitchen was neat and tidy and the service had been awarded four stars, very Care Homes for Older People Page 19 of 29 Evidence: good, by the Local Authority Environmental Health Department for food safety and hygiene in the kitchen in December 2009. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were sufficient, well-trained staff to ensure people were cared for safely. Evidence: The AQAA stated that We have a very low staff turnover and therefore hold a strong nursing team who deliver continuity and quality care. The staff rota for 4th - 31st January 2010 was examined and showed that there were two nurses and five care staff on duty each morning, one nurse and three care staff in the afternoons and one nurse and two care staff at night. This was consistent with the staff on duty on the day of the inspection visit. There was also a cook on duty each day and a kitchen assistant at tea-time, one laundry staff member each day and one domestic staff member each day. A visiting professional spoken with said they thought the service was well staffed. One of the two surveys received from people using the service responded that there were always staff available when needed and the other responded that there usually were. Two of the three staff surveys received responded that there were always enough staff to meet individual needs and one responded that there usually were. However, one survey commented that a way the service could improve was by ensuring that relief staff are available to cover for sickness and absence. One member of staff spoken with described the staffing as brilliant. Care Homes for Older People Page 21 of 29 Evidence: Three staff files were examined and generally showed evidence of good recruitment processes, although more information was needed in some areas. Most of the documentation required by Schedule 2 of the Care Homes Regulations 2001 was in place, including a Criminal Record Bureau check, a Protection of Vulnerable Adults (POVA) First or Independent Safeguarding Authority (ISA) check, identity information and two written references, with the exception of one file that had no identity information available. Qualified staff also had verification of their license to practice from their governing body. However, one file did not have a copy of their qualification certificate. Application forms also needed updating as they only asked for the previous four posts of employment history. The AQAA stated that there were nineteen of twenty-four care staff that had achieved a National Vocational Qualification (NVQ) at level 2. This meant that the service was meeting the target of having a minimum of 50 of care staff with an NVQ2. Staff training certificates showed that they had received training in mandatory health and safety areas in 2009 and staff spoken with confirmed this. There had also been some training undertaken in areas relevant to care issues such as care of the terminally ill (Liverpool Care Pathway), wound care, catheterisation and medication procedures. A member of staff spoken with described the access to training as good and all three staff surveys received confirmed that relevant training was provided. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service was well managed in peoples best interests. Evidence: The registered manager was also the proprietor. She was suitably qualified and experienced to run the home and showed a high degree of commitment to the service, the residents and staff. However, due to a period of ill health a deputy manager had been appointed who was overseeing the day to day management of the service. Quality assurance processes were in place and included staff and service user meetings and satisfaction surveys. The most recent survey had been undertaken in March 2009 and an analysis of the findings was available. There were good levels of satisfaction and comments such as all very good and we are always made to feel welcome were part of the responses. The service had also received individual letters from relatives that included comments such as friendly and helpful, constant good care and attentive to every detail. Care Homes for Older People Page 23 of 29 Evidence: The system for handling peoples finances was not adhered to properly. There were inadequate records and unlabelled purses containing cash that did not identify the owner. Staff on duty did not who the purses belonged to and they were not recorded in the valuable book as being received. One purse had less cash in than indicated. Other peoples cash was stored in envelopes with the amount written on the outside. One persons cash corresponded with what was written on the envelope and the other was twenty-pence short. This was discussed with the manager and she rectified this by the second day of the inspection visit by returning cash to relatives. She stated that the service would no longer deal with anyones cash and had recorded the anomalies as an incident with a record of her actions. The AQAA stated maintenance checks were undertaken. A random sample of maintenance records for fire alarms and water safety confirmed these checks were up to date. Staff training certificates showed that mandatory health and safety training had occurred in 2009; for example, moving and handling in October 2009, fire safety in November 2009 and infection control in November 2009. However, food hygiene was not up to date for those people working in the kitchen. Care Homes for Older People Page 24 of 29 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 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 There must always be a care 31/03/2010 plan for an identified risk. This is to ensure that all peoples care needs are addressed and good health is maintained. 2 18 13 All staff must receive updated safeguarding vulnerable adults training. This is to ensure that staff are clear about what to do if there is an allegation of abuse and to ensure people using the service are safeguarded. 30/04/2010 3 29 19 All the information legally 31/03/2010 required by the Care Homes Regulations 2001 must be in place before a person commences work at the service. Care Homes for Older People Page 26 of 29 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 This is to ensure legal requirements are met and that suitable people are employed. 4 35 17 Accurate records must be kept of peoples money and valuables stored by the service and the service user financial policy must clearly state the procedure for dealing with peoples money. This is to ensure legal requirements are met and peoples personal finances are safely maintained. 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 31/03/2010 1 7 There should be greater efforts made to personalise peoples care records to ensure that individual preferences are taken into account. The service should consider arranging more activities and greater use of community facilities. There should be more effort made to provide culturally appropriate meals for people using the service. The service should obtain a copy of the Derbyshire Local Authority safeguarding procedures. The service should ensure all areas are odour-free. Consideration should be given to replacing the stair and hallway carpet. 2 3 4 5 6 12 15 18 19 19 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 7 8 9 10 11 21 29 29 29 38 The identified bathroom should be refurbished. A copy of qualification certificates should be on staff recruitment files. Identity verification should be available on all staff files. The services job application form should be amended to obtain a full employment history. Staff food hygiene training should be updated. 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. 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!