Care Home: The Woodlands

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What the care home does well This is a first inspection of a newly registered service. The Woodlands provides people that use the service with a purpose built, spacious, well decorated and homely environment. The home has a large lounge area, large kitchen/diner, activities room, gym, training kitchen and laundry. There is a large, beautiful landscaped garden to the rear of the home.The WoodlandsDS0000072919.V376035.R01.S.docVersion 5.2Assessments and care/support plans contain excellent detail about the person including areas of risk and help needed to promote independence in each activity of daily living. Individual goals are set, which clearly detail steps to achieve life skills and aid rehabilitation. The manager demonstrates a clear sense of leadership and staff working at the home are well trained and knowledgeable about the people they are providing care to. Comments made by people spoken to during the visit included, "The manager and staff are brilliant. Staff are approachable and they communicate well" and, "I like it here. The home is beautifully decorated and the staff really look after me" Activities and outings are varied. People that use the service are able to use the homes transport for a small weekly charge. Recruitment procedures are robust. What has improved since the last inspection? This is a first inspection of a newly registered service. What the care home could do better: Records looked at during the visit showed that some water temperatures of baths, showers and sinks were too warm. The home has a complaints procedure which needs to be updated to inform people of their rights to complain to funding authorities. Key inspection report CARE HOME ADULTS 18-65 The Woodlands Church Lane Acklam Middlesbrough TS5 7EB Lead Inspector Katherine Acheson Key Unannounced Inspection 16th June 2009 09:15 The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 1 This report is a review of the 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. 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 home adults 18-65 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. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 2 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 The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Woodlands Address Church Lane Acklam Middlesbrough TS5 7EB 01543 442500 01543 442568 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyage Ltd Anthea Gilleon Russell Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (0) of places The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either The maximum number of service users who can be accommodated is: 11 This service is primarily for people who have care needs in relation to acquired brain injury 2. 3. Date of last inspection Brief Description of the Service: The Woodlands is a detached, two storey, purpose built facility that is situated in a residential area of Acklam. The home is registered to provide personal care to eleven people who have care needs in relation to a brain injury. The aim of the service is to provide support, aid development and rehabilitation to enable people to return to independent living. On the ground floor of the home there is a large lounge that has french doors leading to a garden. There is a large kitchen/dining room, gymnasium, activities lounge, training kitchen, communal toilet and laundry. There are eleven bedrooms in total, one of which is contained with a small apartment and as such has a small lounge. Bedrooms are situated on both the ground and first floor of the home. All bedrooms are above average space requirements and have wet rooms that have a toilet, hand wash basin and shower. On the first floor of the home there is a communal bathroom. To the rear of the home there is a large beautiful landscaped garden for people that use the service. The home is near to shops, pubs, post office, places of worship and bus routes. The cost of care at the time of the inspection was a minimum of £1400 a week. This includes one hour of therapy provided by a physiotherapist, occupational therapist or speech therapist. Each person is assessed on an individual basis with the cost of care and therapy worked out according to their needs. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 5 Additional charges are made for extra therapy hours required and care provided during the day. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is two stars. This means that people who use the service experience good quality outcomes. We have reviewed our practice when making requirements to improve national consistency. In future if a requirement is repeated it is likely that enforcement action will be taken. This unannounced key inspection took place on 16th June 2009. The inspection started at 9:15am and finished at 5:00pm The Manager completed and returned an Annual Quality Assurance Assessment, (AQAA). The AQAA is the services self assessment of how they think they are meeting national minimum standards. This information was received before the inspection and was used as part of the inspection process. The reason for the inspection was to see how good a job the home does in meeting the national minimum standards set by the Government for care homes. Numerous records were examined including care records of people who were using the service, medication records, risk assessments, complaints and staff recruitment and training files. People using the service, a relative and staff working there were spoken to. Discussions took place with the manager. Before the inspection surveys for people that use the service and surveys for staff were sent out to the manager to distribute accordingly. Surveys sent to people that use the service were asked to comment on care received. Surveys sent to staff were asked to comment on what it was like working for the agency and training. We received two surveys from people that use the service. We did not receive any surveys from staff. Comments made in surveys received can be read in the main body of the report. What the service does well: The Woodlands provides people that use the service with a purpose built, spacious, well decorated and homely environment. The home has a large lounge area, large kitchen/diner, activities room, gym, training kitchen and laundry. There is a large, beautiful landscaped garden to the rear of the home. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 7 Assessments and care/support plans contain excellent detail about the person including areas of risk and help needed to promote independence in each activity of daily living. Individual goals are set, which clearly detail steps to achieve life skills and aid rehabilitation. The manager demonstrates a clear sense of leadership and staff working at the home are well trained and knowledgeable about the people they are providing care to. Comments made by people spoken to during the visit included, “The manager and staff are brilliant. Staff are approachable and they communicate well” and, “I like it here. The home is beautifully decorated and the staff really look after me” Activities and outings are varied. People that use the service are able to use the homes transport for a small weekly charge. Recruitment procedures are robust. What has improved since the last inspection? What they could do better: 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. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments of people who are to use the service are carried out before they move into the home to ensure all needs can be met. EVIDENCE: The manager said that people who are to use the service are assessed before coming into the home. They firstly receive an assessment from a social worker and/or other health care professionals. The manager and a senior care planner for the company then carry out a further assessment by visiting the person and their relatives to discuss needs, care package and rehabilitation programme. She said that this also gives people the opportunity to ask questions about The Woodlands. The next stage of the process is for finances to be assessed and funding determined. When funding and fees have been agreed and the manager of the home feels that needs can be met, people are invited to spend some time at the home. This gives everyone the opportunity to meet staff, other people who are using the service and have a look round. The AQAA advises, “We collect information and process a package of care with each individual that incorporates a multi disciplinary team approach. This is The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 10 completed by a pre admission assessment of needs. New service users are offered introductory visits to the service, structured and appropriate transition plans. This care is ongoing and reviewed and can be subject to change at any time.” One person spoken to during the visit said, “I visited the home with my family, everyone was really helpful.” The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 us the service are involved in everyday decisions and choices about their lives. Plans of care reflect needs, aspirations and goals to ensure that people receive the care, support, treatment and rehabilitation that they need. EVIDENCE: The care files of two people that use the service were looked at during the visit. Assessments and care/support plans examined contained excellent detail about the person including areas of risk and help needed to promote independence in each activity of daily living. Individual goals are set, which clearly detail steps to achieve life skills and aid rehabilitation. Examples of this included individual support needed to prepare an evening meal or make a hot drink. Care/support plans are developed with the person who uses the service and contain evidence of personal choice and preferences. One plan of care The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 12 contained excellent detail on how to support/improve a person’s mobility another detailed how to communicate effectively and another contained specific individual diversion therapy techniques to be used. It was evident following discussion with people that use the service and staff that the manager and other staff working at the home know the people they are caring for extremely well. Indirect observation on the day of the inspection showed that The Woodlands was a friendly, homely and lively service. Care plans and risk assessments are reviewed and evaluated on a regular basis to ensure that they are effective. People spoken to during the visit said, “The staff are brilliant, they have lots of patience with me” and, “He/she has improved loads. The staff are really supportive and tell me everything I need to know.” The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the 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 this service are enabled to make choices about their life style and are supported to develop their life skills. Social, educational and recreational activities meet individual expectations. Food provided is nutritious, varied and enjoyed by all this helps to ensure wellbeing. EVIDENCE: Files of people that use the service that were looked at during the inspection contained information about what they liked to do in their leisure time. Each Sunday people that use the service sit with staff and decide what activities and outings they would like to do for the week ahead. One schedule detailed activities for a person that included, going for a daily walk with staff, working with physiotherapist, spending time in the garden, playing board games, going for a drive out in the car and a visit to the cinema. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 14 Other activities taking place at the home include croquet, badminton and football. The manager said that these activities help with assessing peoples cognitive skills. At the time of the inspection visit the manager was in the process of accessing a computer course for a person that was using the service. People that use the service are able to use the homes transport. People pay a small weekly charge for the use of the transport. The manager said that people have enjoyed recent trips to Redcar and Seaton Carew. The home is close to shops, barbers, hairdressing salons, post offices and pubs. There are a number of churches near to the home; however at the time of the inspection visit nobody was expressing a wish to practice their religion. The service has a large beautiful garden to the rear of the property. The manager said that she and a person that uses the service have designed a plan to use an area of the garden for planting vegetables and fruit bushes. She said that a poly-tunnel is to be purchased. People that use the service have a programme of treatment and rehabilitation and spend time in the gym with both the physiotherapist and staff working at the home. Family and friends are made to feel welcome. A relative visiting at the time of the inspection said, “The staff are great, they make me feel welcome. The manager is brilliant she always has a chat”. A lengthy discussion took place with the manager regarding equality and diversity. The Manager demonstrated through discussion an in depth knowledge. People who use the service are actively encouraged in planning the menus. Every Sunday staff and people that use the service plan the meals for the week ahead. The breakfast menu for week commencing 16th June included porridge, cereal, toast, kippers, sardines, pancakes, croissants and bacon and eggs. Lunchtime menus included, sandwiches, mackerel salad, beans on toast with grated cheese and hot dogs. Tea time menus included chicken pie with chips, sausage casserole with potato and vegetables, curry and rice and rabbit pie with mash potato and vegetables. People are supported and encouraged to participate in meal preparation. On arrival at the home one person was being supported to make their own breakfast. At lunch time another person was being assisted to make a sandwich. One person that uses the service said, “The staff are really good, I The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 15 have made rabbit pie, I had never had it before but it was lovely. I have also made vegetable soup.” The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 health and personal care that people receive is based on their individual needs. Support provided is flexible, consistent, reliable and responsive to their changing needs. This helps to ensure wellbeing. EVIDENCE: People who use the service are involved in planning their care and enabled to make day to day decisions about their life. One person spoken to said, I like to get up early at about 5:00am and sit in my room sometimes I watch a movie. I go to bed at about 10:00pm.” Staff were observed to promote the independence of people whilst respecting people’s preferences and dignity. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 17 The AQAA states, “Individual care support plans contain information about the service users general health, dietary requirements and details of any specific ailments and medical conditions. Constant monitoring of health is undertaken and recorded with the health care needs addressed by service users own doctor and other community based professionals eg. dentist, podiotrist, occupational therapist, epilepsy nurse, community nurse and physiotherapist”. Appropriate systems are in place for dealing with medication. The manager said that no one at the home is able to self medicate. She said that all staff working at the home have undertaken medication training and have their competency assessed on a regular basis. Medication was appropriately stored and recorded. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 are confident that their complaints would be listened to, taken seriously and acted upon. Staff working at the home receive adult protection training which will help to ensure the safety of people living at the home. EVIDENCE: The home has a complaints procedure, however, this needs to be updated to inform people of their rights to complain to funding authorities. People who use the service said that they would feel comfortable in raising any concern that they have and that it would be acted upon. The home has received one complaint since registration of the service. The home has an adult protection policy which details action that staff should take if abuse is suspected. The Manager said that all staff have received adult protection training which includes signs and symptoms of abuse. People have access to advocacy services if required. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 standard of the environment is good providing people that live there with an attractive, homely and comfortable place to live. EVIDENCE: The Woodlands is a detached, two storey, purpose built facility that is situated in a residential area of Acklam. On the ground floor of the home there is a large lounge that has french doors leading to a garden. There is a large kitchen/dining room, gymnasium, activities lounge, training kitchen, communal toilet and laundry. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 20 There are eleven bedrooms in total, one of which is contained with a small apartment and as such has a small lounge. Bedrooms are situated on both the ground and first floor of the home. All bedrooms are above average space requirements and have wet rooms that have a toilet, hand wash basin and shower. On the first floor of the home there is a communal bathroom. To the rear of the home there is a large beautiful landscaped garden for people that use the service. The Inspector walked around the home with the manager. The home is beautifully decorated and furniture provided is of a very good standard The home is near to shops, pubs, post office, places of worship and bus routes. On the day of the inspection the home was clean and tidy. Appropriate laundry facilities were in place. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 homes recruitment procedure is good, which helps to ensure that people are protected. Mandatory training and other training relevant to the job staff do is provided ensuring that staff are knowledgeable and experienced to meet the needs of people using the service. EVIDENCE: Records were available to confirm that the manager follows good recruitment procedures. Two files of staff working at the home were examined. Appropriate references were on file as was proof of identity and evidence of Criminal Record Bureau checks. Records were available to confirm that staff working at the home receive induction training. Staff files examined during the visit contained certificates to confirm that staff had recently attended training in moving and handling, food hygiene, health and safety, fire and adult protection. Staff had also attended training specific to problems associated with brain injuries. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 22 The manager said that 54 of staff working at the home have achieved a NVQ level 2 in Care or equivalent. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager has worked in health and social care since 1986. She is both experienced and qualified having a personal experience of acquired brain injury and having achieved an NVQ level 4 in Care and Management. The home is well run with a manager who communicates and demonstrates a clear sense of leadership. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 24 The manager said that regular quality assurance monitoring takes place. She said that people that use the service regularly sit down with their key worker to make sure that they are happy and that their needs are being met. She said that staff meetings take place on a regular basis. A sample of health and safety records were examined and found to be in order. Water temperatures are taken and recorded on a regular basis to ensure that they are within safe limits. Examination of records showed that some water temperatures of baths, showers and sinks were too hot. The manager said that she would take immediate action to address the problem. Records were available to confirm that weekly tests of the fire alarm system take place and that there are regular fire drills involving staff. The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Version 5.2 Page 26 The Woodlands DS0000072919.V376035.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 13 Requirement The registered person must take action to address the water temperatures that are too hot to avoid scalds and ensure the safety of people that use the service. Timescale for action 23/06/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA22 Good Practice Recommendations The homes complaint procedure should be updated to inform people of their rights to complain to funding authorities The Woodlands DS0000072919.V376035.R01.S.doc Version 5.2 Page 27 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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. 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