Care Home: Three Willows

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What the care home does well Relatives were enthusiastic in their praise of the home. One family said that their mum had "settled from day one" and considers Three Willows her home. They said that there is "always someone about" and that the staff really care. They said that activities are good, varied and well presented. They also said the home is always tidy and clean, that their Mum has a sparkle in her eye, and is treated as an individual. They don`t think they could have found her a better home. Another relative said she had been very happy with the care of her aunt who calls Three Willows her home. She said that she feels the quality of life for residents is good because carers have a "vocation" and give residents one to one attention. She said that relatives are kept informed of any changes like a change of manager. She has found the proprietors very helpful with information. A resident said "we love it" "everyone is always so friendly". The home provides a pleasant environment with high quality care and carers who build up good relationships with individuals. We noted that the home observes residents carefully and records this information. We noted that they have a robust attitude to manual handling and staff are made aware that they must follow their training. There was evidence that staff had been very supportive to a resident in his spiritual beliefs. We commend the home for their thorough risk assessments and their pro active approach to the Mental Capacity Act 2005 and the implications of the Deprivation of Liberties part of that Act, for residential care. What has improved since the last inspection? The two requirements of the last inspection regarding, the statement of purpose and the disposal of clincal waste have been met. The home has been upgraded with a newly painted exterior, and refitting of the manager`s office. An activity room and store have been built in the garden. New mattresses have been purchased and the proprietors have invested in a range of staff training. What the care home could do better: The deputy manager must ensure that decisions regarding care needs, particularly medical care are recorded in assessments and service user plans so that they don`t get overlooked. Adequate and unobstructed means of escape from fire must be provided. Key inspection report Care homes for older people Name: Address: Three Willows 35 Woodberry Way Chingford London E4 7DY     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: Anne Chamberlain     Date: 2 6 1 1 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 25 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 25 Information about the care home Name of care home: Address: Three Willows 35 Woodberry Way Chingford London E4 7DY 02085291881 02085297088 admin@stiveslodge.freeserve.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr James Deary,Mrs Catherine Deary Name of registered manager (if applicable) Type of registration: Number of places registered: care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: One place for a service user, under the age of 65 years, with dementia. To allow the home to provide care and accommodation for two (2) named service users with dementia category needs. Date of last inspection Brief description of the care home Three Willows is a home providing care to 21 elders, situated in the Chingford area of the London Borough of Waltham Forest. The home is in a residential area, and is in character with other homes in the area. The home is close to shops and other local amenities, including transport networks. The home is privately run. 1 0 Over 65 2 21 Care Homes for Older People Page 4 of 25 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 was an unannounced inspection covering all the key standards. At the time of the inspection there were nineteen residents inthe home. We spoke with several residents and two relatives. We also spoke with the acting manager, the proprietors, and two members of staff. We also joined the staff at their mid morning tea break. We looked at key documentation, policies and two service users and two key worker files. We viewed the arrangements for the administration of medication and toured the environment including the kitchen and garden and garden activity room. We would like to take this opportunity to thank all who contributed to the inspection for their assistance and co-operation. Care Homes for Older People Page 5 of 25 What the care home does well: 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. Care Homes for Older People Page 6 of 25 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 7 of 25 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 8 of 25 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. Prospective service users know their needs are well assessed before they are offered a place in the home. Information is available to them and they can pay a visit. Intermediate care needs are also properly met. Evidence: The acting manager told us that either she or her deputy visits prospective residents either in hospital or in their own home. They gather as much information as possible including any medical diagnosis. A pre-admission assessment is made to determine whether or not their needs could be met in the home. The prospective resident or a member of their family or a friend is invited to view the home. The last resident who moved in had a friend visit the home before he came. If the placement is accepted the resident moves in and a more in depth assessment is undertaken. The home has a statement of purpose and a service user guide which are given to new residents. We saw evidence of this in a letter on a file. It welcomed a resident to the Care Homes for Older People Page 9 of 25 Evidence: home and enclosed these documents. We formed the view that no service user moves into the home without having his or her needs assessed and being assured that these will be met. We were impressed to see that the home had undertaken some mental capacity assessments regarding residents abilities to take decisions on their daily living needs. These were in line with the four part test which is explained in the Mental Capacity Act 2005, and the home has clearly grasped that each test applies to one decision. They are commended on this pro-active work. The home does provide intermediate or respite care, and a temporary resident would be encouraged to maximise their independence as part of their care package. There was evidence on file of the frequent review of care plans and risk assessments and a relative told us she had been invited to a review shortly after her aunt had been admitted. We also saw in a file an invitation to a relative for a review. This is good practice and the home is commended for inviting relatives to reviews. Care Homes for Older People Page 10 of 25 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. Service user plans are individualised and comprehensive, health care is well supported and medication practice is sound. Residents privacy and dignity is upheld. Evidence: We viewed the personal files of two residents. One was the most recently admitted and has been at the home for just a month, and one was for a resident who has been at the home for several years. Both files were clearly sectioned and contained up to date information in standardised formats. The files had personal information about the residents, contact details and some social history. Pre admission assessments were evidenced and also assessment on admission. The assessments were comprehensive and from them followed detailed care plans and risk assessments. The risk assessments were comprehensive with strategies identified to reduce risks and the home is commended on the quality of these. An individual had not signed his care plan agreement. The deputy manager stated that Care Homes for Older People Page 11 of 25 Evidence: he had been given the opportunity, but had declined. In this case it is appropriate to note the agreement with this information. The same applies to terms and conditions of placement forms. We noted that one resident has developed a pressure sore. The home are encouraging him to sleep on his side and turning him regularly. However there was no record of this kept, and we recommend that a turning sheet be used to record turning by carers. One resident had a good nutritional tool completed which showed that he was at a high risk of poor nutrition. The tool had a scale which showed what is a high score etc. However the deputy manager who had completed it had not recorded that the following action would be to ask the general practitioner for advice. Again it would be helpful to record this decision in the file so that it cannot be overlooked. One resident had an injury to his hand and later developed a pressure sore. These are managed by the district nurse who keeps her own record, but it would be helpful to have a body map completed in the personal file, so that carers are aware of any new marks. A recommendation has been made. The service user plans evidence the involvement of a range of health professionals. As previously mentioned the district nurse calls when needed. Residents also see their general practitioners, opticians, chiropodists and dentists. We were impressed that for a new resident a plan had been made to get his lost dentures replaced. The residents we spoke to in the home all appeared to have either teeth of their own or dentures. On the day of the inspection all the residents looked very well groomed and turned out, in well fitting attractive clothes. We viewed the arrangements for the administration of medication. We were shown these by the deputy manager who takes responsibility for the medications. It was positively noted that the keys to the medication room and cabinet were kept on a member of staff. We also noted that the medication policy is available in the medication room and that there was a list of specimen signatures of staff. We examined the Medication Administration Record (MAR) sheets for the two service users whose files we had viewed, plus another. We noted that each resident had his photograph name and room number prefixed to his MAR sheets. The first five medications we checked showed no stock discrepancies and we had no queries with the MAR sheets. Care Homes for Older People Page 12 of 25 Evidence: One MAR showed a gap where a medication had not been administered. The reason for this had been recorded on the reverse of the sheet and the deputy manager agreed that this was a good reason not to administer the drug. However rather than leave a gap a code letter should have been inserted to link to the explanation. Another MAR sheet had a signature missing for a medication which was prescribed to be given the night before. The medication was missing and the deputy manager said he believed he had given the medication but not signed the sheet. He agreed this was an error. We viewed the arrangements for the administration of controlled drugs. These were in order. We were however a little concerned that the temperature in the medication room was around 25 degrees Celcius which is the maximum temperature at which the preparation should be kept. The medication room has no heat source but does have a thermometer and we suggested the home keep a close eye on the temperature in that room, particularly in the summer months. The medication room has a refrigerator with a thermometer for preparations which need to be kept cool. Medications are checked into the home by the pharmacist assistant and a member of the care staff. Medication left over at the end of the cycle is disposed of back to the pharmacist who signs a record compiled by the home. The manager stated that the privacy and dignity of residents is upheld. She stated that staff knock on doors and all the bathing and toilet facilities lock. We were told by a relative that the domestic worker and maintenance man always call out good-bye to the residents when they leave the home, treating them like friends. The home ensures that residents are on the electoral register and can vote should they choose to. We noted that one ladys skirt had ridden up and a care worker noticed and pulled it down for her straightaway, in a natural and caring manner. Residents choose their own clothes each day and they have a choice of a lively lounge or a quiet lounge to sit in, or they can stay in their rooms if they prefer. Assessments give a space for the views of residents on death and dying to be recorded. We noted in a file a letter from a relative stating that her brother would like, when the time comes, to die in the home. In discussion with the manager and proprietors we understand that such wishes are respected which is good practice. Care Homes for Older People Page 13 of 25 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents enjoy social contact and activities. They have some access to the community. Residents also have autonomy and choice and their meals, and mealtimes are pleasant. Evidence: As previously mentioned we were able to speak to relatives who told us that they are always made welcome in the home. One relative told us that she understood residents sometimes go out to local restaurants. One resident is very able and popped into the office to consult the dictionary for his crossword. He is able to access the community indpendently. During the inspection there was activity in the morning and afternoon in one lounge, with music and games mid morning and mid afternoon tea and biscuits. The home will be having its Christmas party next week and all relatives and friends will be invited. We were told by a relative that there is a lovely summer barbecue which is very well attended. The library is close by and residents are sometimes escorted by staff to visit it. On the day of the inspection the hairdresser was in the home. Several of the ladies had their hair done and we spoke with one who said she enjoyed having her hair done. The room used is very suitable, attractive and accessible, with two large Care Homes for Older People Page 14 of 25 Evidence: mirrors. Everyone spoken to about food agreed that it was a strong point for the home. Relatives and residents spoken to said the food was good. We met the chef and viewed the kitchen as part of the environment. It was very well equipped and stocked. The meals are organised on a cycle which changes with the seasons. We were satisfied that a variety and choice of nutritious and appealing food is served to residents. Care Homes for Older People Page 15 of 25 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. The home takes complaints seriously and resolves them. Residents are safeguarded. The home has started working on deprivation of liberty legislation implementation. Evidence: We viewed the complaints folder, examining the two most recent complaints. The home had dealt with them appropriately and had recorded the complaint details. However we felt the system could be improved significantly by the additional recording of how the complainant had been responded to, like a copy of a letter, and on what date. Apparently these documents exist in other files.We have made a recommendation. The home has an appopriate safeguarding policy in place with good procedures, including the need to inform the local authority of any safeguarding allegation or suspicion. They also have a copy of the local authority policy and understand that they need to work in conjunction with this. The home has also developed a Deprivation of Liberty (DOL) policy for which they are commended. Care Homes for Older People Page 16 of 25 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 environment is homely and comfortable, clean and well furnished. The home is hygienic and good practice is in place for infections to be contained and controlled. Evidence: We toured the environment of the home including with their permission, the bedrooms of two residents. We also included the garden and outdoor activities room. The environment is generally very good and the proprietor said they had invested quite heavily in it recently with new mattresses and the building of the outdoor activities and store rooms as well a refitting the managers office, and painting the exterior. There are two communal lounges, one which is lively where activities take place and one which is quieter. One gentleman was observed reading his paper in the quiet lounge in the morning and some ladies chose to sit there in the afternoon. The managers office is small but well fitted out with plenty of storage. There is as previously mentioned a good sized well equipped kitchen and a laundry room with industrial washer and dryer. There are adequate bathing, showering and toilet facilities and residents also have toilets and basins en suite to their rooms. The home is generally adapted for wheelchair use and there is an adapted bath. There were no unpleasant odours and the bedrooms were well aired. One room was quite plain as that is how the resident prefers it and one was personalised with family photgraphs etc. Rooms vary in size, one we saw was very pleasant with a large bay window. However both were well furnished and comfortable. Care Homes for Older People Page 17 of 25 Evidence: The garden at the home is a delight, beautifully kpet and wheelchair accessible. The larger lounge has a panoramic view of the garden and this is a real asset to the home. As mentioned the laundry machines are industrial and the manager stated that there is a soil wash programme. The manager and proprietor were quite knowledgeable about hospital acquired infections. Almost all the carers have undertaken infection control training and they are issued with latex gloves and encouraged to change them between residents. Residents do not share any items and there is handscrub available in the home. The clinical waste we were told is stored in a locked bin for collection by the local authority. Care Homes for Older People Page 18 of 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff at the home are safely recruited, well trained, motivated and competent. Evidence: We viewed two staff personnel files. The evidence showed safe recruitment practice with two professional references taken up and a Criminal Records Bureau (CRB) disclosure. We emphasised to the manager that staff are only allowed to start work with a Protection of Vulnerable Adults (POVA) first check if there is a compelling reason and they are supervised by another carer. There are seven carers on the staff, nearly all full time, also a domestic worker, maintenance man and chef. The home is usually staffed by a registered manager, a deputy a supervisor and one carer with a ratio of three staff to nineteen residents. The manager stated that any absences can be covered from within the staff group as staff are often happy to take on an extra shift. Training records evidenced comprehensive induction and a good level of training including regular updating of core basic training to include, first aid, fire, health and safety, infection control, manual handling and safeguarding. We were told that the proprietor is a qualified as a fire marshall to train in fire safety, and trains the staff. We spoke with two staff members, they both said that they had undertaken a Care Homes for Older People Page 19 of 25 Evidence: significant amount of training since they had worked at the home. One carer said that she enjoyed her dementia training and found it very interesting. She was able to talk knowledgeably about short term memory loss. The deputy manager has a Registered Managers Award and the level of NVQ 3 and NVQ 2 attainment in the home is good. The proprietors stated that they have invested in staff training last year and we believe this contributes to the positive performance of this home. Care Homes for Older People Page 20 of 25 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 acting manager is quite competent to run the home. The proprietors take quality assurance very seriously and monitor it in a number of ways. Service users monies are not at at any risk and working practices are safe. Evidence: The acting manager has only been in post for four months but appeared to have a strong grasp on the working of the home. She is qualified and competent to run the home but needs to be registered as manager with the Care Quality Commission (CQC). We were told that the proprietors call into the home every day and are involved in some tasks like invoicing and wages. They also undertake regulation 26 visits auditing aspects of quality. We saw evidence of residents quality surveys. A residents meeting is held every two months and we viewed the minutes which are Care Homes for Older People Page 21 of 25 Evidence: kept. A relative told us that she attended a meeting where residents said they would like sauces served in sauce boats rather than on their plates. She said this preference was implemented. The home has a development plan for the next year. The home does not keep service users monies. Social workers or families are invoiced for care fees, hairdressing etc. The home uses a health and safety company to oversee this area of work. We noted that Control of Substances Hazardous to Health (COSHH) are locked away and the home keeps data sheets for the products. The home had a gas inspection certificate for 2009 and the gas cooker was inspected on 14/1/09. The home had a fire risk assessment which was comprehensive and due to be reviewed in March 2010. The fire alarm system had been tested on 12/11/09 and the fire extinguishers on 12/11/09, the emergency lights on 12/11/09, the electrical circuits on 1/8/09. We viewed weekly fire systems tests. There was no record of evacuation drills and the proprietor stated that these are only held once a year and evacuations are timed but no records had been kept. We recommend twice a year would be better with records of evacuation and any notes kept. As previously stated one of the proprietors is a fire marshall. We were concerned to note that on entering the home the front door which is a fire exit had to be opened with a key kept on a hook inside. We were further concerned to note that the other fire exit from the ground floor, in the sitting room, could not readily be opened by us. There was a lock of some kind at the top and bottom and one or other or both were on, but it was not possible to open the door with the handle. There is a stair gate on the first floor. It opens on to the stairs and is marked as a fire exit. It is held in place with a bolt. We doubt if all residents would be able to operate this bolt and the home must risk assess the situation and replace the bolt with a fastening which residents can more easily operate. We advised the home that fire exits must be such that you can pass through them without needing to unlock them first. Care Homes for Older People Page 22 of 25 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 25 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 38 23 Adequate means of escape from fire must be provided and fire exits from the bulding must not be obstructed by locks. So that there is adequate means of escape from a fire. 15/12/2009 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 1 7 We reccommend that a record of turning be kept on the residents record to evidence how often the resident is turned. We reccommend the use of body maps in the residents file to record any injuries or marks observed. We reccommend that the complaints recording be further improved by the inclusion of information on how the resolution of the complaint had been conveyed to the complainant and when. We recommend that the home holds two evacuation from fire drills a year and they are recorded with evacuation times and notes. 2 3 7 16 4 38 Care Homes for Older People Page 24 of 25 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. 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