Care Home: White Lodge Rest Home

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• St Vincents
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What the care home does well The service has robust recruitment procedures in place and staff only start work at the home once all recruitment checks have been undertaken and this provides protection for service users. We observed staff interacting with service users and we saw that people are treated with respect and their right to dignity maintained. Those service users we spoke to told us that staff listen and act on what they say. The daily routines in the home are flexible and service users are able to make informed choices, there was evidence in care plans to show that service users were able to make their own decisions wherever possible and this allows service users to be in control of their lives as much as possible. The visiting routines at the home are flexible and family and friends can visit at any time What has improved since the last inspection? The home has introduced a new care planning system in the home and this provides better information for staff on the support needs of residents. A new cooker has been fitted and the kitchen has been rearranged to facilitate this What the care home could do better: There were 2 requirements made as a result of this visit and other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report. The home has secure storage for controlled drugs and they are kept in a suitable controlled drugs cupboard, however the cupboard is not fixed to a solid wall or a wall that has a steel plate mounted behind it as required by law. The Misuse of Drugs (Safe Custody) Regulations 1973 gives full details. The home does not currently have a formal quality assurance system in place to obtain the views of interested parties to see if the home is achieving its goals. By developing a quality assurance system the home will be able to ensure that views of service users, staff and other interested parties are sought so that the home can measure its success in meeting its aims and objectives. Key inspection report Care homes for older people Name: Address: White Lodge Rest Home 79-83 Alma Road Portswood Southampton Hampshire SO14 6UQ     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: Mick Gough     Date: 2 4 0 8 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 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 27 Information about the care home Name of care home: Address: White Lodge Rest Home 79-83 Alma Road Portswood Southampton Hampshire SO14 6UQ 02380554478 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Michael J Foot care home 28 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 28 The registered person may provide the following category of service: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category; Old age, not falling within any other category (OP) Dementia (DE) Mental disorder, excluding learning disability or dementia (MD) Date of last inspection Brief description of the care home White lodge is a care home situated in Southampton and is close to local facilities. The home is registered for twenty-eight service users within the categories of old age, dementia and mental health. The home provides accommodation in a range of double and single rooms and some rooms are on the ground floor. The home has two lounges, Care Homes for Older People Page 4 of 27 28 28 0 Over 65 0 0 28 Brief description of the care home two dining areas, a kitchen and suitably located bathrooms and toilets. To the front of the house is a small garden and to the rear is a nicely maintained garden and patio, which is accessible to service users. The home is owned and managed by Mr Foot. Care Homes for Older People Page 5 of 27 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 report details the evaluation of the quality of the service provided at White Lodge Rest Home and takes into account the accumulated evidence of the activity at the home since the last key inspection which was carried out in August 2007 and the last Annual Service Review which was carried out in August 2008. The inspection also took into account the homes Annual Quality Assurance Assessment (AQAA), which arrived when we asked for it and was completed satisfactorily. The AQAA is a self assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Prior to the site visit we sent out surveys to service users, staff and health care professionals to obtain their views on how the home was meeting the needs of service users. We received responses from seven users of the service and all the responses were positive and comments included; they look after me well, The staff are wonderful, they listen to what you want and I get all the help I need. Six staff members also Care Homes for Older People Page 6 of 27 returned surveys and these were also positive and comments from staff included; we have very good carers who truly care about the residents, We all work together as a team, the care and support for residents is paramount and I love working at white lodge One health care professional also returned a survey and the responses were Always or Usually to the questions asked. Comments included White lodge care home always seeks specialist help for the residents when needed and they readily accept training and advice. Included in the inspection was an unannounced site visit to the home, which was conducted on the 24 August 2009 between 1000 and 1400. For this visit we involved 8 users of the service and 4 members of staff who we spoke with on the day of the visit and this provided us with information about the home. Other evidence for this report was obtained from reading and inspecting records, including pre admission assessments, plans of care, medication records training and recruitment records and records relating to health and safety and quality assurance. We also looked at how the home deals with any complaints and issues regarding the protection of vulnerable adults. We looked at some of the homes policies and procedures and throughout our time in the home we also observed the interaction between staff and users of the service. We were assisted through the visit by the manager of the service. The home is registered to provide support for 28 residents and at the time of the inspection there were 27 people living at the home. Care Homes for Older People Page 7 of 27 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. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 27 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 27 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. Prospective users of the service can be confident that their needs would be assessed before they move into the home. Evidence: The home carries out an individual needs assessment prior to residents moving into the home and there is a clear admission process and assessments were on file at the home and were looked at for the 3 residents case tracked. The assessments seen had information on mobility, mental state, diet continence, dressing and undressing, nutrition, washing, personal hygiene, social interaction, sight and hearing, communication, history of falls and religious needs. Assessments were made using a needs assessment form and therefore covered the same issues for everyone with a separate section for any additional information for each individual. We were told by the manager that himself, the deputy manager or a senior carer carried out the assessment and if possible the assessment was undertaken at the home. Potential new residents are able to visit the home, stay and have a meal and spend as much Care Homes for Older People Page 10 of 27 Evidence: time as they like at the home before making a decision. All new residents are offered a one month trial period so they can be sure that the home can meet their needs. Intermediate care is not provided at the home Care Homes for Older People Page 11 of 27 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. The health, personal and social care needs of residents are contained in an individual plan of care, which give information on what care is needed. The health care needs of residents are met by the home and the home has medication policies and procedures in place to help protect residents, however the storage arrangements for controlled drugs must be in accordance with the misuse of drugs regulations. Evidence: Care plans were inspected for 3 residents and those care plans seen had information on dressing and undressing, washing and bathing, continence, drinking and eating, mobility, social interaction, mental state and cognition,emotional needs, tissue viability, choice, recreation and leisure, overall health, dementia and personal care. The home has introduced a new care planning system and we found that care plans were well written and they provided good information for staff on the support that residents needed and also gave staff information on how residents would like their care to be given. Staff members spoken with said that the care plans were now much better and provided them with good information to enable them to give the right type Care Homes for Older People Page 12 of 27 Evidence: of support at the right time. Residents said that staff were always very helpful and one commented I am well looked after here and another said they help me whenever I ask and nothing is too much trouble. The care plans contained risk assessments and these gave information on the type and level of risk and there was also information for staff on what action they needed to take to minimise any risk. The home had not yet completed transferring all care plans to the new system but we were informed this should be completed shortly. Daily recording was carried out on a cardex system and recording took place at the end of each shift and there was a good handover to oncoming staff. Care plans were reviewed monthly, but this was mainly a small box, which indicated if there had been any change to the plan, if there was a change there was not a space where this change could be recorded. We pointed out to the manager the need to expand on the recording of reviews to provide some evaluation on how the care plan was working for the individual and this would also give information on residents progress of lack of it as the case may be. Residents may keep their own GP if they wish but the majority are registered with a local GP surgery which is just across the road from the home and they have a number of different GPs, district nurse visits are arranged though the GP surgery and there was evidence of visits by occupational therapists, community psychiatric nurses (CPNs), and a continence adviser. Dental checks are carried by a visiting dental service and a visiting optician calls at the home. The GP surgery provide residents with access to all relevant health care professionals and a visiting chiropodist visits the home every 5 to 6 weeks. The home has a policy for the receipt, storage, return and administration of medication and all staff at the home who are authorised to administer medication have undertaken training with regard to medication. The home uses a monitored dose system from a local pharmacy and the medication administration records sheets (MARS) were inspected and found to be up to date. We looked at the storage arrangements for medication and this was satisfactory with the exception of the storage arrangements for controlled drugs. Although controlled drugs were kept secure in a suitable container with a double locking facility, the cabinet was not secured in accordance with the misuse of drugs (safe custody)regulations and This was discussed with the manager of the home who told us that he would address this issue. Staff were seen to behave appropriately with residents and we observed staff interacting with residents and using their preferred form of address. Staff were seen to knock on residents doors before entering and residents spoken to confirmed that staff treat them with dignity and respect, comments from residents included; the staff Care Homes for Older People Page 13 of 27 Evidence: are wonderful; they are so kind and caring; they always have time for a chat and I dont know what I would do without them. Staff members spoken to told us that they got on well with the residents and that they always treat residents with dignity and respect. Care Homes for Older People Page 14 of 27 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 home provides a range of activities for residents, which meet their expectations and their religious and recreational needs are met. Residents are able to maintain contact with family and friends and visitors are welcome at any time. Residents are supported to exercise choice and control over their lives as much as possible and they are provided with a balanced diet at time convenient to them. Evidence: Activities at the home are displayed on the notice board and these include; films, visiting entertainers, card games, skittles, chair aerobics exercise class (twice per week), indoor gardening, hand massage, reminiscence, quiz and bingo. We were told that outside companies come to the home to organise some activities and the homes staff undertake other activities. Staff members we spoke with told us that they enjoy organising activities and that they try and get as many people as possible involved, however they respect the wishes of those people who do not wish to do so. Residents spoken with said they were happy with the activities provided at the home and that there was always something going on every afternoon and that they were able to take part if they wanted but could make their own decision. One resident said that she preferred to watch what was going on rather that getting involved herself. Comments received from 2 residents who completed surveys said that they would like the home Care Homes for Older People Page 15 of 27 Evidence: to organise trips out and we brought this to the managers attention who told us that they would look into organising this for residents. 2 residents access the community independently and one told us that he can come and go as he pleases. The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway, residents spoken to said that their visitors were always made welcome and could visit whenever they wanted. We observed staff supporting residents and they were consulted about life in the home, residents spoken to confirmed that they are able to make informed choices and are able to control their own lives as much as possible, they said that they were consulted regularly and that staff at the home respected their views and that if they wanted anything all they had to do was ask. The majority of residents had bought some of their own possessions into the home and rooms had been personalised. The home operates a four week rolling menu and residents spoken with were happy with the choice of food provided by the home. Comments received were; the food is very good; I always have enough to eat and; there is nothing to complain about. The cook told us that breakfast is normally cereals and toast but a cooked breakfast can be provided on request, the main meal of the day is lunch and the cook told us that most people have the main choice but if anyone wants something else then this can be provided. The lunch time meal on the day of the visit was steak pie, boiled potatoes with fresh vegetables. We observed the lunch time meal and this was unhurried and staff provided suitable support for those residents who required it. Residents are able to eat their meals in the dining room or elsewhere if they prefer. We were told by the cook that the kitchen is open 24 hours a day and staff are able to make snacks and drinks for residents at any time. Care Homes for Older People Page 16 of 27 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. There is a simple, clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures help protect users of the service from any form of abuse Evidence: The home has a clear complaints procedure, which contains all of the required information and residents spoken to said if they had any complaints they would speak to a member of staff. Staff members spoken to were aware of the complaints procedure and said that they would support any service user to make a complaint if they wished to do so. The home keeps a record of all complaints and there have been 5 complaints to the home since in the last 12 months, we looked at the complaints log and this showed that all complaints had been taken seriously and had been appropriately investigated by the homes manager. Staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. The manager told us that there had been one adult protection issue since the last inspection and this was appropriately reported to the relevant authorities by the home. Care Homes for Older People Page 17 of 27 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. Residents live in a safe and well maintained environment and have access to comfortable indoor and outdoor facilities. residents have the specialist equipment they require to maximise their independence and the home was clean and hygienic and free from offensive odours. Evidence: During the visit to the home we looked around all the communal areas of the home including bathrooms, toilets, the two lounges/dining areas as well as a number of bedrooms and the homes kitchen and rear courtyard garden. Discussions with the people who live at the home indicated that they were happy with their private accommodation and could bring in personal items should they wish to do so. All areas of the home were in a reasonable state of repair and the home was clean and tidy. We were told that bedrooms were decorated on an opportunity basis as they became vacant and that there was a programme for decorating communal areas of the home. The home has 2 shower rooms on the upper floor and on the ground floor there was a bathroom with a walk in bath. The laundry is housed in a conservatory on the side of the home and there were 2 industrial washing machines and 2 industrial tumble driers. The laundry area had suitable hand washing facilities and there was appropriate protective clothing available. The floor and walls of the laundry were tiled and easily cleaned. Currently Care Homes for Older People Page 18 of 27 Evidence: carers undertake the laundry throughout the day, however the manager told us that the home is looking to recruit a dedicated member of staff to carry out laundry duties. Care Homes for Older People Page 19 of 27 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. The home has a mix of staff that has a range of skills and there were sufficient numbers of staff on duty to meet the needs of residents. The homes recruitment policy and practise supports and protects residents and they benefit from a staff team that has had training to meet their needs, however the home needs to fully develop its induction procedure. Evidence: Staff morale was good and there was a good rapport between residents and staff. The homes staff rota was examined and this showed that the home provides 1 senior staff member plus 3 carers between 0745 to 1345. Between 1345 to 2030 there is 1 senior staff member and 2 carers and between 2015 and 0800 there are 2 staff members on duty who are awake throughout the night. In addition to care staff there are 2 cooks, 2 cleaners and a handyman. The wife of the provider, the homes manager and deputy manager work at the home flexibly and are in addition to the care staff on duty. We discussed staffing numbers with the homes manager and were told that at present he felt that staffing levels were sufficient. The home employs a total of 17 care staff and 9 have achieved a minimum of NVQ level 2., The home has policies and procedures in place with regard to recruitment and staff Care Homes for Older People Page 20 of 27 Evidence: recruitment records were inspected for 3 staff members and the recruitment records seen contained all of the required information and included, application form, Interview notes, 2 references, Criminal Record Bureau and Protection of Vulnerable Adults checks, Birth certificates, passport and photo. Recruitment records were kept secure in the office at the home. Staff training records showed that staff have completed training in, fire, medication, moving and handling, first aid, adult protection, food hygiene, infection control, managing aggression, dementia care, care practises. health and safety, COSHH and foot health awareness. The home did not have a training matrix for staff and certificates for training were kept in staff files, the manager told us the new care planning system that was being introduced had a programme for keeping records of staff training and this would flag up when refresher training is needed. Staff spoken to confirmed that they receive regular training and they were confident that they could meet the needs of service users. The home has an in house induction procedure which covers procedures within the home, however there is not a formal induction based on skills for care induction and foundation standards, we discussed this with the manager who told us that he was in the process of making up an induction booklet and staff handbook that will cover this issue. Care Homes for Older People Page 21 of 27 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 home has an effective manager in place to over see the day to day management of the home. The home communicates with residents on a regular basis, however they needs to develop a formal quality assurance system to seek the views of residents, relatives and other professionals to measure the effectiveness of the service. Systems are in place for the safekeeping of residents personal spending money and the health, safety and welfare of residents and staff are promoted and protected Evidence: The manager of the home has been running the home for over 30 years and has the skills knowledge and experience to effectively manage the home, he operates an open door policy and staff told us that they could speak to him at any time. The home employs a deputy manager who assists in the day to day running of the home. Care Homes for Older People Page 22 of 27 Evidence: The home does not have a formal quality assurance system in place, there are regular staff meetings and staff seek the views of residents as they chat with them throughout the day, however the home does not send surveys or questionnaires to residents, staff or relatives to obtain their views so that they can measure the homes success in meeting its aims and objectives. The home needs to develop a quality assurance system to ensure that the views of residents and other interested parties are sought on how the home is achieving its goals and to ensure that the home is run in the best interests of service users. The home does not manage any residents money, however money can be kept for safekeeping and personal spending. Normally the home will pay for hairdressing and chiropody etc and then invoice relatives their behalf. There is good recording with any transactions, balances, deposits and withdrawals detailed and this provides a clear audit trail. There is an in date fire risk assessment for the building and regular health and safety monitoring takes place. The fire logbook was inspected and all appropriate testing and checks have been recorded. Appropriate certificates were in date for, fire alarms systems and equipment, private electrical equipment, stair lift and fixed hoists. On the day of the visit the home could not find its gas safety certificate, there was a contract in place for the maintenance and servicing of gas appliances. We spoke with the manager who contacted the engineers on the day of the visit to chase up the gas safety certificate. Care Homes for Older People Page 23 of 27 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 24 of 27 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 1 9 13 The registered person must ensure that any controlled drugs are stored in accordance with the misuse of drugs safe custody regulations 1973 To comply with the law 30/09/2009 2 33 12 The registered person must develop a quality assurance system so that the the wishes and feelings of service users are taken into account This will ensure that views of service users, staff and other interested parties are sought so that the home can measure its success in meeting its aims and objectives 30/10/2009 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 Care Homes for Older People Page 25 of 27 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 26 of 27 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 27 of 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!