Care Home: Wentworth Lodge

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What the care home does well People are given relevant information about the home, so they know what service to expect. Appropriate assessments should ensure people`s needs are met. Staff have access to detailed care plans, so they know how to meet people`s needs. People have access to relevant healthcare services to support their physical and mental health. People can be assured their right to privacy will be supported. People have access to a variety of social activities, so the can live a fulfilled and stimulating lifestyle. People are able to maintain contact with their family and friends, so they can have meaningful relationships. Access to information about how to make a complaint ensure people know how to share their concerns, so their rights are supported. The home`s menus ensure people have a choice of meals to reflect their dietary and nutritional needs. The cleanliness and hygiene standards of the home ensures people`s health and comfort. Skilled staff provided in sufficient numbers ensures people`s needs are met. These are comments from people who use the service: "The care is fantastic." "We are very happy with the care." "I feel like I`m on holiday." "The food is beautiful." What has improved since the last inspection? New carpet has now been fitted in parts of the home to ensure people`s comfort. What the care home could do better: To ensure controlled drugs are stored and recorded appropriately, so people are not placed at risk of harm. To ensure medications are stored in accordance to the manufactures instructions, so people`s health is not compromised. Medication Administration Records must be signed when medicines are given out. This should ensure people receive their medication regularly and provide an audit trail. To ensure people receive their medicines as directed by their doctor to promote their health. Key inspection report Care homes for older people Name: Address: Wentworth Lodge Wentworth Road Bushbury Wolverhampton West Midlands WV10 8EH     The quality rating for this care home is:   one star adequate 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: Dawn Evans     Date: 0 7 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 32 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 32 Information about the care home Name of care home: Address: Wentworth Lodge Wentworth Road Bushbury Wolverhampton West Midlands WV10 8EH 01902570208 01902570208 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Sandra Ann Dell care home 32 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 32 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 32 Dementia (DE) 32 Date of last inspection Brief description of the care home The last key inspection was 14 August 2007. Wentworth Lodge is a residential home that provides a service for older people. The home is also able to offer a service for people who have a diagnosis of dementia. The home is located in a residential area and is accessible by public transport. The home offers 30 single bedrooms situated on both the ground and first floor. Five bedrooms are equipped with en suite facilities. People also have access to four lounges, laundry, kitchen and conservatory leading to a well maintain garden. Ample off road car parking is available. Staffing is Care Homes for Older People Page 4 of 32 32 0 Over 65 0 32 Brief description of the care home available on a 24 hour basis to assist people with their needs when required. Local amenities, such as shops, pubs and restaurants are a short drive away from the home. People have access to relevant healthcare services to support their health. People are able to read the previous inspection reports, which are accessible in the home. This enables them to find out about the quality of the service provided and peoples experience of living in the home. The fees charged for the service was not made available to us, the reader is advised to contact the service directly for this information. Care Homes for Older People Page 5 of 32 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out over one day; the home did not know we were going to visit. The focus of inspections we, the Commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last key inspection and annual service review. This included notifications received from the home. These are reports about things that have Care Homes for Older People Page 6 of 32 happened in the home that they have to let us know about by law, and an Annual Quality Assurance Assessment [AQAA]. This is a document that provides information about the home and how they think it meets the needs of people living there. Three people living in the home were case tracked. This involves establishing individuals experiences of living in the care home by meeting them, observing the care they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked around some areas of the home. A sample of care, staff and health and safety records were looked at. Where people who use the service were able to comment on the care they receive their views have been included in this report. We sent 10 of Have your Say surveys to people who use the service and 10 to staff members. The manager confirms these were completed and returned but we have not received them. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: To ensure controlled drugs are stored and recorded appropriately, so people are not placed at risk of harm. To ensure medications are stored in accordance to the manufactures instructions, so peoples health is not compromised. Care Homes for Older People Page 8 of 32 Medication Administration Records must be signed when medicines are given out. This should ensure people receive their medication regularly and provide an audit trail. To ensure people receive their medicines as directed by their doctor to promote their health. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 32 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 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. People have access to relevant information, so they know what service to expect and the undertaking of a needs assessment will ensure their needs are met. Evidence: The manager said people are given a copy of the Statement of Purpose before they move in. The Statement of Purpose tells people about the facilities and service they can expect. The Statement of Purpose is currently not available in any other format. The manager said if and when necessary arrangements will be made, to have it published in relevant formats, such as different languages, pictorial or Braille, so everyone can understand it. Two people who use the service said they were given relevant information about the Care Homes for Older People Page 11 of 32 Evidence: home before they decided to move in. This enabled them to find out the homes suitability to meet their needs. Discussions with the manager and one visiting relative confirm people are able to visit the home before making a decision of where to live. The AQAA shows people have a needs assessment before being admitted. This assessment enables the home to find out about the persons needs and how to meet them. Two people who live there and two visiting relatives confirm the undertaking of this assessment and their involvement. This should ensure people receive a service the way they prefer. Care Homes for Older People Page 12 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident staff will know how to meet their needs but inadequate management of their medicines could place them at risk of harm. Evidence: We case tracked three people and looked at their care plan. A care plan should tell staff about the persons needs and how to meet them. The care plans provide relevant information, so staff know how to meet peoples needs appropriately. For example, one shows the person has restricted mobility, requiring the use of a walking frame and needs one carer to assist them. We spoke to two staff members who were aware of this. This person also confirms receiving the support they require. People can therefore, be confident staff will know how to meet their needs. One care plan shows the support required to meet the persons personal care needs. The staff we spoke to were also aware of this. This person said they are given the relevant support. Care Homes for Older People Page 13 of 32 Evidence: People are involved in their care planning where possible and those spoken to also confirm this. We also saw peoples signature within their care records indicating their involvement. This should ensure people receive the support specific to their needs. One person who lives there said, Staff do what I want them to do. The staff do look after us, they make you laugh and happy. The manager told us people have access to other healthcare services. We saw evidence of this contained within care records. This includes a dentist, general practitioner and chiropodist amongst others. Access to these services should promote peoples physical and mental health. These are comments from people who use the service and their relatives: The care is fantastic. We are very happy with the care. I feel like Im on holiday. I am very happy here. We looked at the homes systems and procedures for the management of peoples prescribed medicines. Practices in place are not robust to ensure the safe storage of medicines or to ensure people receive their medicines properly. For example, by law medicines identified as a controlled drug, need to be stored and recorded in a specific way, to ensure peoples safety. These were not and could place people at risk of harm. Information identified on a bottle of eye drops shows this should to be disposed of within 28 days of opening. We saw this was still in use after three months. The manager also acknowledged this. The failure to follow the manufactures instructions could compromise the persons health. One medication administration record [MAR] show When Required medicines are being given to the person four times a day, every day. When Required medicines are not prescribed to be given out on a regular basis, only when the person needs them. Care Homes for Older People Page 14 of 32 Evidence: The manager confirms this persons medication or health condition had not been reviewed to identify why they require their medicine so often. We did not see a written protocol for the use of When Required Medicines. The manager confirmed this was not in place. The absence of a written protocol does not ensure staff will know how to manage these medicines safely. We saw a prescribed cream stored in the cupboard, which should be stored in the refrigerator. This could compromise the medicines chemical balance. One MAR also shows the person has not received their medicines for eight days. Staff members were not able to explain why and there was no information recorded, to show why this person did not receive their medicine. This persons health could be at risk if they do not receive their medicines as identified by their doctor. The manager acknowledges these shortfalls and whilst we were there commenced action to address them. We looked at systems and practices that promote peoples right to privacy. The manager said all bedroom doors are fitted with a privacy lock. One person said, Staff do knock on my door before they enter. We also observed staff doing this. We saw staff talking to people in a respectful manner and addressing them by their preferred name. Care Homes for Older People Page 15 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to a variety of social activities so they live a active and stimulating lifestyle and access to a choice of meals ensure their dietary and nutritional needs are met. Evidence: People have access to various social activities. Staff are responsible to arrange specific social activities, which include music, skittles, trips, hairdressers, outside entertainment, going out for meals, library, shopping trips, nail painting, amongst others. We saw one person who lives there, playing the harmonica as staff sang and dance along to the tune. We also observed some people playing bingo, engaging in a sing a long, reading, watching television amongst other things. One person showed us their finger nails and said, I have just had them painted. Another person said, I go to the shops with an escort. The staff ask us if we want to go on a trip and we do. One visiting relative said, The home took my mum out for a Christmas meal. Care Homes for Older People Page 16 of 32 Evidence: One person said, It was lovely here at Christmas with all the activities. I enjoy playing bingo, quizzes, cards, in fact I love living here. The home has four lounge areas and those people who do not wish to participate in particular activities, their choice is respected and they are able to reside in the quiet lounge. The Statement of Purpose shows people are able to participate in their chosen religious faith. Discussions with people who use the service and staff members confirm the local church visits the home on a regular basis to carry out a Christian service. Peoples family and friends are also able attend this service if they so wish. The manager showed us a folder containing information relating to various religious faiths and said we would use this information, when necessary to broader our awareness of specific faiths. People can therefore, be confident that their religious needs will be respected and supported. Discussions with people who live there, staff members and our observations confirm people are able to maintain contact with their family and friends. We spoke to three visiting relatives who said they are always made welcome by the home. This means people are able to maintain contact with people important to them. Information given to people before they move in, show they are able to bring in their personal possessions if they so wish. This was also confirmed by the manager. We observed that bedrooms are decorated with peoples possessions to reflect their style and interests. The home has a four week menu providing people with range of choices to reflect their dietary needs. During meetings with people who live there, menus are discussed to ensure everyones likes and dislikes are catered for. Information relating to peoples dietary needs is located within their care record and in the kitchen. We observed lunch being served, which was well presented and appeared appetising. These are peoples comments: The meals are very suitable, I dont like fat and the staff make sure all the fat is cut off my meat. Care Homes for Older People Page 17 of 32 Evidence: The food is beautiful, I love porridge and they give me seconds. The meal today was lovely. The Christmas meals was lovely, we had turkey. The meals smell wonderful and mum eats it all. They have a choice of meals. Care Homes for Older People Page 18 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured their complaints will be listened to and taken seriously, so their rights are supported and staff are skilled to protect them from potential abuse. Evidence: The homes complaint procedure is located in main reception area and information on how to make a complaint is also contained within the Statement of Purpose, which is located in each bedroom. The AQAA shows the home have not received any complaints since the last inspection visit. The manager also confirms this. One visiting relative said, I have never made a complaint but if I was unhappy, I would speak to the manager. They are all brilliant. Another person said, If I am unhappy, I would speak to my grandson, he would sort things out. One person who lives there said, I had problem with my heating and I told the staff and this was dealt with promptly. This means people can be confident their complaints will be listened to and acted on, promoting their rights. Care Homes for Older People Page 19 of 32 Evidence: We have not received any concerns or complaints about the service. The AQAA shows and the manager confirms they have not received any safeguarding referrals since the last inspection visit. A safeguarding referral is where an allegation of abuse is made or where care practices may compromise peoples health or safety. The manager said staff members have received safeguarding training. The training records we looked at and discussions with staff also confirm this. The undertaking of this training should ensure staff have the skills to recognise potential abuse and protect people from this. We spoke to two staff members who said if they received an allegation of abuse they would report it to the manager and the Care Quality Commission. These actions should ensure people are protected from further abuse. Care Homes for Older People Page 20 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are suitable to meet peoples needs and the cleanliness of the home will ensure their comfort. Evidence: The two storey property is located in a residential area and is accessible by public transport. All bedrooms are single and five rooms are equipped with en suite. The home offers four well furnished lounges and a newly built conservatory. The lounges are named after neighbouring streets to assist people with dementia and these signs also included Braille, for people who are visual impaired and use this form of communication. Bathrooms and toilets are located on both floors, near to bedrooms and communal areas. Equipments and adaptations are in place to assist people with restricted mobility. These include assisted baths, grab rails and a passenger lift. A kitchen and laundry is located on the ground floor. People are able to make drinks and light snacks within the kitchenette in the lounge. The manager said new carpets have recently been fitted and new windows in some areas of the home. This should ensure peoples comfort. Care Homes for Older People Page 21 of 32 Evidence: People have access to a well maintained garden. Ample off road car parking is also available. The hygiene and the cleanliness of the home are of a good standard. One person who lives there said, I say this most sincerely, its like the Ritz here. A visiting relative told us, The home is always clean and tidy. A person who lives there said, The home is always nice and clean, its beautiful. Care Homes for Older People Page 22 of 32 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. People can be assured their needs will be met by skilled staff, provided in sufficient numbers but recruitment practices, are not entirely thorough to ensure staff will be of sound character to promote their wellbeing. Evidence: The manager was confident that sufficient staffing levels are provided to meet peoples needs. Discussions with staff members and the staff working rotas we looked at also evidenced this. One person who live in the home said, Staff always answer my buzzer [nurse call alarm] quickly. People can therefore, be confident staff will be provided in sufficient numbers to support them. The home has a training matrix showing what courses staff have attended. Two staff members spoken to say they have received the following training: dementia awareness, deaf awareness, fire safety, food hygiene, moving and handling, safeguarding adults, first aid, amongst others. The AQAA shows 22 out of 26 staff members has obtained the National Vocational Qualification Level 2 or above. Two staff members spoken to say they have obtained this qualification. The undertaking of training should ensure staff have the skills to meet peoples needs Care Homes for Older People Page 23 of 32 Evidence: properly. A visiting relative said, The staff are unbelievable, they make you feel at home. Another visitor told us, The staff are lovely. A person who lives there said, The staff are very good, they are here for you. Another person who lives there told us, The staff are lovely. We looked at the homes recruitment procedure and at two staff personnel files. Both files contain evidence of the undertaking of a Criminal Record Bureau [CRB] clearance and a Protection of Vulnerable Adult check [PoVA 1st]. These safety checks should ensure people are suitable to work with vulnerable adults. These files only contain one written reference. Two written references should be obtained to ensure people are of sound character to work for the home. Care Homes for Older People Page 24 of 32 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 management style is open and transparent to ensure peoples needs are met but this is compromised by the lack of management of key areas, which could place people at risk of harm. Evidence: The home is run by a registered manager who is also the owner. Discussions with the manager confirms she is experienced in social care and undertakes periodical training to keep abreast of matters relating to social care. This should ensure she has the skills to run the home in a way that meets peoples needs. We looked at systems in place that promote quality standards within the home. We saw a Service User Admittance Form. This form is given to people during the first few days of admission. This asked questions about the standard of care they receive, staffs approach and about the environment. We looked at two forms these were complimentary of the service provided. Care Homes for Older People Page 25 of 32 Evidence: Quality assurance questionnaires are also given to relatives. The manager said they will be commencing relative meetings, so this information can be fed back to them. The home provides assistance in managing peoples financial affairs. Account sheets are maintained to show all financial transactions. We looked at two account sheets, which tallied with funds held in safekeeping. People can be assured their finances will be well managed to protect them from potential financial abuse. We looked at systems and procedures in place that promote health and safety standards. We saw an up to date fire risk assessment, this tells staff how to assist people in the event of a fire. Training records show staff have received fire safety training. This should ensure staff have the skills to safeguard people in the event of a fire. Care Homes for Older People Page 26 of 32 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 27 of 32 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 9 13 Measures must be taken to ensure the Medicine Administration Record and care notes show why people have not received their medicines. This should ensure practices are robust to support peoples health and provide an audit trail. 25/02/2010 2 9 13 Measures must be taken to ensure controlled medicines are recorded appropriately. This should reduce the possibility of misuse of medicines. 25/02/2010 3 9 13 The necessary measures must be taken to ensure all medicines are stored appropriately. This should ensure people are not placed at risk of harm. 08/04/2010 Care Homes for Older People Page 28 of 32 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 4 9 13 Action must be taken to ensure people receive their medicines as directed by their doctor. This should promote peoples health. 25/02/2010 5 9 13 Action must be taken to ensure manufactures instructions relating to the use and disposable of eye drops are adhered to. This should ensure peoples health is not compromised. 25/02/2010 6 9 12 To ensure the identified persons When Required Medicines are reviewed. This should ensure the person receives the necessary medical intervention if needed. 25/02/2010 7 9 13 The necessary measures must be taken to ensure staff have access to a written protocol for the use of When Required Medicines. This should ensure staff know how to use these medicine safely. 25/02/2010 Care Homes for Older People Page 29 of 32 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 8 9 13 Action must be taken to ensure Medication Administration Records are signed when medicines are given out. This will ensure people receive their medicines appropriately and provide an audit trail. 25/02/2010 9 9 18 Action must be taken to ensure staff receive the necessary refresher training in the safe management of medicines. This should ensure staff have the skills to manage peoples medicines safely. 30/04/2010 10 29 19 Action must be taken to ensure two written references are obtained before people start working in the home. This should ensure people are of sound character to work with vulnerable people. 25/02/2010 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 33 To ensure future AQAAs are completed to reflect the quality of the service provided to people. Care Homes for Older People Page 30 of 32 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 2 33 To ensure quality review systems are closely looked at, to improve the management of medicines, so people are provided with the relevant support. Care Homes for Older People Page 31 of 32 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 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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