Care Home: Wisteria Lodge Care Home

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What the care home does well This was a positive inspection where it was noted that the registered provider, manager and staff have responded well to the one requirement and the good practice recommendations of the last inspection. People can be assured that before making a decision to move to Wisteria Lodge their needs will be assessed and they will be consulted throughout the whole process to ensure they are confident that the service can meet the person’s needs. Care plans are written with the service user and are regularly reviewed and health and medication needs are well managed. People living at the home are treated respectfully and their dignity is maintained by promoting their rights to make decisions and choices about their care routines and social activity. Friends and family are welcomed and encouraged to visit frequently. Residents are protected by policies and procedures avaialble to staff to ensure their safety; staff are safely recruited and trained and health and safety features of the home are assessed and documented. Wisteria Lodge provides a comfortable, clean and well maintained environment for residents to enjoy as their own home. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 The home is well managed by the provider and the manager in an open and inclusive manner, staff are supported in their roles. Surveys received from people who work at the home and from service users all provided positive responses to questions asked. Additional comments included: ‘this home is like a ‘home’ where I can be cared for’ ‘makes me feel very welcome and certainly makes me feels safe, any worries or problems brought to the attention of staff are soon settled’ ‘Wisteria Lodge is a wonderful place to work, the owners are very nice and very fair. Food is excellent, furnishings are high quality, it’s a home from home’ ‘lovely place to stay, staff are so friendly and helpful’ ‘looks after my every need, lovely gardens to sit in nice sized rooms, good food’. ‘I enjoy being here as part of the Wisteria lodge family and contributing to the life of the residents by trying to ensure that their time here is as happy as possible’. What has improved since the last inspection? One requirement was made at the last inspection concerning medication management, this has been addressed and correct procedures are now in place. The last inspection also left 12 good practice recommendations, the manager has worked hard to address these and all but one remains following this inspection. What the care home could do better: One recommendation from the last inspection remains, this is concerning the home’s internal procedure for adult protection. Whilst staff have been equipped with the skills and knowledge through training events to manage any incidents appropriately, it is recommended that the home’s own procedure reflects in more detail the information provided by the trainers and the local authority guidance.Wisteria Lodge Care HomeDS0000071528.V377866.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Wisteria Lodge Care Home 25 Friars Road Friars Cliff Christchurch Dorset BH23 4EB Lead Inspector Jo Palmer Key Unannounced Inspection 29th September 2009 09:30 DS0000071528.V377866.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care 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. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wisteria Lodge Care Home Address 25 Friars Road Friars Cliff Christchurch Dorset BH23 4EB 01425 272718 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Alexandra Waltham Mr Richard Charles Waltham Deborah Usher Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only (Code PC) to service users of either gender whose primary needs on admission to the home are within the following category: 2. Older people, not falling within any other category - (Code OP) The maximum number of service users that can be accommodated is 4. 8th September 2008 Date of last inspection Brief Description of the Service: Wisteria Lodge was first registered during March 2008. Wisteria Lodge is a traditionally built house, set in its own grounds. The home is located in a residential area of Friars Cliff, close to the sea front and within walking distance of the local amenities including shops, and a doctor’s surgery. The registered parts of the house are all on the ground floor; the first floor comprises the owner’s accommodation. The home is registered to accommodate a maximum of 4 older people. All bedrooms are for single occupancy and each has en-suite hygiene facilities. Car parking spaces are available for visitors and staff. The weekly fee quoted in the service user guide at the time of inspection was £700. Up to date fee information may be obtained from the service. Additional charges are made for hairdressing and chiropody. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection on 29th September 2009 started at 9.30am and ended at 13.30. This was a statutory inspection in accordance with the Care Standards Act 2000. Mrs Alexandra Waltham, Registered Provider was present and assisted with the inspection process providing necessary information and access to records. Deborah Usher, Registered Manager also arrived to assist with part of the inspection. Registered for four, there were two residents accommodated, and two vacancies. The inspector spoke with the registered persons, took a tour of the property and examined relevant records and medication systems. Of the two residents living at Wisteria Lodge, one was sleeping; the inspector met and spoke briefly with one resident. Three surveys were received to inform the inspection process from people who work at the home and two from service users. What the service does well: This was a positive inspection where it was noted that the registered provider, manager and staff have responded well to the one requirement and the good practice recommendations of the last inspection. People can be assured that before making a decision to move to Wisteria Lodge their needs will be assessed and they will be consulted throughout the whole process to ensure they are confident that the service can meet the person’s needs. Care plans are written with the service user and are regularly reviewed and health and medication needs are well managed. People living at the home are treated respectfully and their dignity is maintained by promoting their rights to make decisions and choices about their care routines and social activity. Friends and family are welcomed and encouraged to visit frequently. Residents are protected by policies and procedures avaialble to staff to ensure their safety; staff are safely recruited and trained and health and safety features of the home are assessed and documented. Wisteria Lodge provides a comfortable, clean and well maintained environment for residents to enjoy as their own home. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 Page 6 The home is well managed by the provider and the manager in an open and inclusive manner, staff are supported in their roles. Surveys received from people who work at the home and from service users all provided positive responses to questions asked. Additional comments included: ‘this home is like a ‘home’ where I can be cared for’ ‘makes me feel very welcome and certainly makes me feels safe, any worries or problems brought to the attention of staff are soon settled’ ‘Wisteria Lodge is a wonderful place to work, the owners are very nice and very fair. Food is excellent, furnishings are high quality, it’s a home from home’ ‘lovely place to stay, staff are so friendly and helpful’ ‘looks after my every need, lovely gardens to sit in nice sized rooms, good food’. ‘I enjoy being here as part of the Wisteria lodge family and contributing to the life of the residents by trying to ensure that their time here is as happy as possible’. What has improved since the last inspection? What they could do better: One recommendation from the last inspection remains, this is concerning the home’s internal procedure for adult protection. Whilst staff have been equipped with the skills and knowledge through training events to manage any incidents appropriately, it is recommended that the home’s own procedure reflects in more detail the information provided by the trainers and the local authority guidance. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.2 Page 7 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. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An initial assessment of need is carried out to ensure the service can fully meet the care needs of the prospective resident. EVIDENCE: Both the current service user’s care files were examined, these contained good assessments undertaken prior to the resident moving into the home. The documents seen were comprehensive and explored all areas of the persons well being including areas such as their social and emotional needs. The assessments also demonstrated that the individual and their family/next of kin had been consulted about the process and agreed with the outcomes. Further Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 10 and ongoing assessments are undertaken when a resident has made the decision to move into the home Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide detailed instruction for staff in order that they are able to meet assessed health and care needs. Staff treat residents with respect and dignity, promoting residents’ feelings of worth as valued members of the household. There are satisfactory arrangements for managing medication in the interests of residents EVIDENCE: Following initial assessment, a series of other assessments are undertaken and are regularly reviewed. The inspector examined both residents care files, each contained detailed assessment of need including risk assessments with reference to pressure area care, nutrition, mobility and falls. As a result of the Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 12 assessments, care plans are written and it was evident that the resident had been party to this process. Each care plan is very well personalised and refers to the individuals preferences with regard to personal care routines. A record is held of each resident’s contact with other health care professionals and it was evident that access to such services is supported. Staff write records daily detailing the residents life in the home, these records were noted to be particularly sensitive, well written and respectful and provided evidence of personal care routines, dietary intake and general health as well as a pleasing account of each residents social interaction with their visitors and with staff. A requirement of the last inspection concerning the management of medicines has been addressed. Examination of stocks of medicines held, ordering, administration and disposal of medicines showed them to be using accurate procedures. Medicines are audited regularly and stored appropriately. Controlled drugs storage is available although not in use at time of inspection. A record of temperature of medicines storage is held. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to organise their own day with regard to social and recreational activity. Friends and family are welcomed. The food is home cooked and offers a balanced diet to those who live at Wisteria Lodge. EVIDENCE: ‘Extend’, an exercise group is held weekly with a trained instructor and film nights are arranged at the weekends. Mrs Waltham confirmed that outings are arranged occasionally although most activity is self directed with the resident deciding what they want to do. One resident particularly enjoys gardening and this has been made possible with assistance from the home staff and the resident’s family. Family and friends are encourage to visit and take part in life within the home. It was evident from reviewing residents care records that their social life is not compromised by living at Wisteria Lodge and that they are able to enjoy opportunities available. Only one resident was spoken with Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 14 during this inspection as of the two living at the home, one was sleeping. The resident spoken with in her room confirmed that she was comfortable, well cared for able to engage in activities of her choice. She had recently celebrated a birthday and enjoyed a large family party at the home with many visitors. This resident confirmed that she was extremely happy at Wisteria Lodge and that everybody was very kind. She had no cause to complain but said she would know who to talk to if she had. Meals in the home are provided from a domestic style kitchen with modern facilities. There is no set menu but residents are asked daily what they would like from available stocks. Mrs Waltham confirmed that a weekly shop keeps supplies topped up and there is always fresh vegetables and fruit available. Care records held demonstrate individuals dietary requirements and intake, there are no special diets currently required. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures are in place to protect the residents living at the home Staff training is provided to ensure that any incidents will be managed appropriately staff. EVIDENCE: The home has a complaints policy and procedure; no complaints have been received and there have been no allegations or investigations regarding the ‘safeguarding of vulnerable adults’. All staff receive training on the safeguarding of vulnerable persons and the home has a written policy and procedure for the protection of vulnerable adults. The last inspection made the recommendation that this policy is improved to provide staff with correct procedural guidance. This inspection evidenced that whilst all staff have received appropriate training since the last inspection and have obtained all the relevant information from the training provider and local authority on protection, the home’s internal policy still needs to be reviewed to ensure that it directs staff to the correct Dorset procedures. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 16 Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can enjoy comfortable, safe and well maintained surroundings and are at liberty to personalise their own rooms. Communal areas of the home are ‘homely’, comfortable and well appointed. The home was clean and tidy and hygiene procedure were in place. EVIDENCE: The communal areas of the home including bathrooms and toilets, bedrooms, hallways, laundry and kitchen were visited along with two resident’s bedrooms. At the time of inspection, two rooms were vacant, one of these seen was ready for occupation when a new resident enters the home, it was well equipped and furnished, clean and well maintained. The second bedroom visited was occupied and exhibited many of the trappings of a very pleasantly personalised Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 18 space, the resident confirmed she was happy, comfortable and enjoyed her room, she benefited from views across the gardens of the home. There is one assisted bathroom with hoists and aids to help residents in and out of the bath, this area was clean, well equipped and attractively decorated. Each bedroom has en-suite facilities. The laundry are of the home was well maintained and operational. Mrs Waltham confirmed the process of ensuring soiled laundry is properly handled with reference to spread of infection. Correct hand washing facilitates are available for staff with ant-bacterial hand wash and disposable towels and an alcohol based hand rub is available for visitors. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient numbers of trained staff to meet the needs of residents EVIDENCE: Staffing rosters showed there to be two staff on duty at all times during the day and one at night. A recommendation of the last inspection regarding night time calls to residents has been met and a record is now held demonstrating any night time interaction with residents. There are 8 staff in total including the registered provider and manager who are always available. The registered manager, Debbie Usher is a new appointment since the last inspection, the previous manager having retired. Mrs Usher successfully went through the registration process in July 2009 and since that time has been reviewing the home’s recruitment documentation and staff training records. Staff files were examined and found to be in order, any gaps in employment history are explored although care needs to be taken to ensure this is clearly documented as in one case it was easily missed; the applicant had left a gap on the application form although this was referred to in her accompanying CV. A record of the interview is held which would be a good place to document any perceived anomalies. All staff employed had copies of identification, Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 20 photographs, evidence of training, references and safety checks (CRB and POVA checks) held on file. Staff training is ongoing with updates being organised as necessary, a record was seen evidencing that staff have attended courses on moving and handling, health and safety, first aid, food hygiene, dementia awareness, risk assessment and adult protection. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered persons provide good leadership and manage the service in the best interests of those living there. An internal audit system is being developed to enable monitoring of standards. Residents financial interests are protected by procedures that are in place. The health, safety and welfare of residents is promoted. EVIDENCE: Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 22 The registered manager, Debbie Usher is a new appointment since the last inspection. Mrs Usher’s qualifications and experience were therefore not examined at this inspection as this would have been done at the registration process with CQC in June 2009. Mrs Waltham, the registered provider confirmed that she is pleased with the skills and enthusiasm of the manager and that they work well together. A recommendation of the last report regarding self monitoring and internal auditing procedures has been addressed although this is an on-going process requiring continual evaluation. Since the last inspection systems have been put in place to audit the home’s health and safety process and mechanisms, the call bells usage and effectiveness, accidents and medication audits have commenced. Residents and their representatives are sent surveys with a range of questions about service provision, all responses have been favourable and no improvements have been required. Mrs Waltham confirmed that quality monitoring in the home will be a continuous, cyclical process with new systems being developed and confirmed that contact has been made with another care provider locally who has been supportive in developing systems in the home, particularly reviewing effectiveness of care planning and risk assessment documentation. Residents manage their own finances or where unable to do so, have a representative to do this on their behalf, Wisteria Lodge does not take a role in managing residents monies and valuables other than to keep a record of any valuables that a resident has. Each room has a lockable storage facility for resident’s private use. The last inspection made the recommendation that an accident policy was developed; this has been addressed and this inspection evidenced that an accident policy is now available for staff reference, accidents are properly recorded in the home and the manager is aware of the process of reporting incidents as they arise; to date, there has been no call for this. An audit of accidents is being undertaken and advice was given on ways of developing this. A record is held of the regular testing of the home’s fire fighting equipment, alarms and emergency lighting. A fire risk assessment is in place which had been reviewed. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations The policy/procedure for reporting and investigating alleged or suspected abuse should be improved to ensure staff have clear and correct guidance. Wisteria Lodge Care Home DS0000071528.V377866.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission South West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. 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