Inspection on 11/10/07 for Burley Hall Nursing Home

This inspection was carried out on 11th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burley Hall Nursing Home 22/02/07

Burley Hall Nursing Home 16/03/06

Burley Hall Nursing Home 26/07/05

Burley Hall Nursing Home 05/10/04

Burley Hall Nursing Home 27/04/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Burley Hall Nursing Home Cornmill Lane Burley In Wharfedale Ilkley West Yorkshire LS29 7DP Lead Inspector Pamela Cunningham Key Unannounced Inspection 10:30 11th October 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burley Hall Nursing Home Address Cornmill Lane Burley In Wharfedale Ilkley West Yorkshire LS29 7DP 01943 863363 01943 863392 mosslo@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd 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 Sandra Elizabeth Hustwick Care Home 45 Category(ies) of Dementia - over 65 years of age (20), Physical registration, with number disability over 65 years of age (25) of places Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2007 Brief Description of the Service: Burley Hall is in the village of Burley in Wharfedale and is accessible to all local amenities. There is a large car park and extensive private gardens that are accessible to residents. The home is registered to provide nursing care for up to 45 people over the age of 65 years. The home has two separate units, one providing general nursing care and the other providing specialist care for people with dementia. Accommodation is on two floors accessed by a passenger lift. There are 39 single bedrooms and three doubles, all with en suite facilities. There are two lounges and two dining rooms as well as a licensed bar. There are a number of communal bathrooms and toilets throughout the home. The administrator informed the inspector that fees on the day of the visit range from £700.00 to £850.00 per week. Additional charges include hairdressing, private chiropody, Physiotherapy, newspapers and some selected activities. Service users can receive Information about the home and the services provided in the statement of purpose and service user’s guide, which can be obtained by contacting the home. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One visit was made on 11th October 2007 by a visiting inspector. The home did not know that this was going to happen. Feedback was given to one of senior nurses who were present for the inspection during and at the end of the visit. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents. Before visiting the home the lead inspector asked for information from the manager (The AQAA – Annual Quality Assurance Assessment) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. The views of doctors and district nurses who visit the home were also asked for. At the time of writing this report one relatives response and three residents responses had been returned. In order to find out how well staff knew residents, care plans were looked at during the visit and residents, visitors and staff were spoken to. Other records in the home were looked at such as staff files, training records and complaints received. What the service does well: Information about services provided by the home is available and lets residents and their relatives decide if the home will be suitable for them. They can make trial visits to the home if they want to. The home is well maintained and there is a continual programme of redecoration and refurbishment. It has been tastefully decorated and furnished to provide residents with a pleasant, comfortable and homely place to live. Residents said that they can bring in their own belongings to personalise their rooms and that the home was always clean and tidy and it did not smell. They said that the food was good, they enjoyed the meals and alternatives to the planned menu are offered if they want them. They said they could choose how and where to spend their time and whether or not they want to join in with planned activities. Visitors said that they could visit the home at any time and they were made welcome. They said that staff kept them informed and up to date with any Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 6 changes in their relatives care needs, and that they were satisfied with the services provided by the home. Relationships between staff and residents were warm and friendly. Residents said that the staff were pleasant, friendly and caring. They said that they respected their privacy and would listen to and act upon what they said. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 7 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 Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents and their relatives have enough information about the home to decide if it will meet their needs. EVIDENCE: Information for residents and visitors is available in the reception areas and can be posted out on request. Files of useful information are in every bedroom. Residents and visitors spoken to during the visit said that they received enough information about the home when they came to look round and they were offered a trial visit. They said that contracts were in place setting out the terms and conditions of living at the home and the services that would be provided. (This was confirmed by sight of a contract during the visit.) Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 9 Before a resident comes to live at the home a pre admission assessment is carried out to make sure that the home will be suitable for them and be able to provide the care they need. Six were looked at which identified basic needs. These would have been better if they were more detailed, and showed clearly that the information had been used to identify that the homes facilities and skill mix of staff would meet the individuals needs. At the present time these have to be used in conjunction with the current care plan, and therefore care must be taken to update these assessments when any improvement or deterioration in the persons’ condition is noted. Some residents in the home have dementia. The assessments were in the same style as those on the General Nursing unit, but in addition did not identify the type of Dementia the people had been diagnosed with. The nurse in charge said she thought one of the service users had vascular dementia. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Resident’s health and personal care needs are met and their privacy is respected. EVIDENCE: Since the last Inspection, a new style of planning and recording care has been introduced. Six care plans were looked at, three on each unit, and two of the residents they were about were spoken to. Care plans on the general nursing area were very detailed, identified clearly the care required and gave clear instructions so that the care staff could understand what care was needed. Risk assessments were in place where a risk to the person receiving a service was identified, and there was evidence of regular care reviews along with evidence that the resident and the family had been involved. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 11 There was also important additional information present, for example, about what type of pressure relieving equipment was being used and what setting it should be on for one resident, and Information about eating and drinking that stated what the individuals preferences, likes and dislikes were. There was also information seen that a resident who had been assessed as being at high risk of falling and had fallen while in the home and had been referred to the falls prevention team. Information was also seen regarding arrangements for health and personal care, with evidence that this was being provided. Care plans on the dementia care unit were equally informative, but did not identify what type of dementia they had, how it affected them and how staff could help them. There was evidence relatives had been involved with the care planning process but not all of them showed that the resident had been. The senior nurses on duty at the time of the visit said that staff make sure each person’s plan is reviewed monthly and if the person is willing and capable, they are asked to get involved in the review. Family members can also take part if agreed by the service user. There is evidence to show that the plans are updated and the necessary action staff are to take to respond to any changes is documented. Although there was a section in the new care plan documentation about social activities, there were no social/activity care plans present in the documentation. For care plans to be fully person centred, more information needs to be recorded about social activities. Information gained through speaking to the activity organiser, and certain residents identified a full social care programme was in place, and there was evidence of residents being taken for a walk around the sensory garden Information from talking to residents and surveys returned said that: ‘They got the care and support they needed, including medical support. They had been able to keep their usual GP if they had not moved out of their allocated areas.’ ‘Staff listened and acted on what they said, and respected their privacy, and that Staff were very friendly and caring and give 100 .’ Information from relative’s surveys said that they were kept informed about changes and matters involving their relatives, and were consulted about their care. They said they were happy with the standards of care provided. This was confirmed by relatives spoken to during the time spent at the home. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 12 Residents can self medicate if they want to providing they are safe to do so. The senior nurses said that nobody is self-medicating at the moment. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Resident’s lifestyle in the home matches their expectations and they are helped to exercise choice and control over their lives. EVIDENCE: Burley Hall has two activities organisers who work on the two units. Speaking to one of the activity organisers during the visit identified arranged and one to one activities take place. I was told these are recorded in the daily life record as they occur. It was recommended that these are recorded more formally in a plan of care so that care planned and provided can be more person centred. It would also benefit the people who receive a service if relatives were involved in the development of activity care plans to make sure they are not generalised and more specific about what each resident likes to do. In the summer months there are trips out to places of local interest. Visiting clergy of each denomination visit the home monthly and conduct Communion. People who receive a service and who were spoken to during the inspection Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 14 said that they enjoyed the activities that were on offer and could join in if they wish. Observations made on the day show that staff treat people politely and respect their individuality. Service users said that friends and family are encouraged to visit at any time, and are made to feel welcome by the staff. Several service users said that they were happy with the meals provided and that there was always plenty of choice available, the menus confirmed this. Service users are able to eat their meals in the dining rooms or in their own room if they prefer. Meals were seen presented in an attractive manner and in pleasant surroundings. Tables were very attractively set, and members of staff was observed to be helping service users to eat in a calm, relaxed manner with appropriate conversation. I looked around the kitchen. It was scrupulously clean and well ordered. The chef showed me the records he keeps and they were all in order. Special diets are provided including diets for those people who receive a service and whose first language is not English. The chef showed me a copy of the last Environmental Health report on the kitchen, where it was shown the home had been awarded four stars. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents and their relatives can be confident that any concerns they might have will be listened to, taken seriously and acted upon. EVIDENCE: The organisations complaints procedure is in place and is included in the information files in resident’s rooms. It is clear and easy to follow. Since the last inspection the home has investigated four in house complaints. One was about a member of night staff sleeping on duty. One was regarding a sensitive issue regarding a carer and a resident. One was about an inappropriate incident between a care and a resident, and one was regarding the use of inappropriate language about a resident. One of the complaints was referred to the Adult Protection unit but investigated by the home. Records show all these were dealt with adequately by the manager and referred to other agencies where necessary. I was told there is another complaint currently in the process of being investigated. The senior nurse in charge of the home said all staff in the home have recently attended elder abuse training, which was facilitated by the Adult Protection team and the manager of the home. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 16 Copies of the organisations adult protection procedures and the local authority adult protection procedures are kept in the manager’s office, and on the units for staff to access. The manager has also done the two day managers course about adult protection. Staff spoken to during the visit gave good responses to questions asked on this subject, confirming that they were aware of their responsibilities in reporting any abuse to the manager. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents live in a safe, comfortable, clean and well-maintained home that is suitable for their needs. EVIDENCE: The home enjoys extensive gardens that are beautifully kept. Certain bedrooms have patio doors leading out onto the garden are with individual plots allocated to those residents who are. interested in gardening. There is also a sensory garden and a safe area for the people who receive care on the dementia care unit to wander out onto in good weather. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 18 A tour of the home identified all areas of the service were clean and fresh smelling, this was commented on by relatives and residents spoken to during the visit. Service users’ bedrooms were personalised with their own belongings such as ornaments, pictures and small pieces of furniture. Staff on the unit which cares for service users who have a dementia type illness have made very good attempts to make the area easy for the residents to recognise by placing picture boxes on the outside of the door. Contained in these boxes were photographs and objects, which would help the service users to identify their rooms. This is good practice. There are a number of communal lounges were service users can sit. There is also a licensed bar were service users can purchase alcoholic drinks if they wish. Communal areas and service users bedrooms are decorated to a very high standard and were bright and airy. There are a number of communal toilets and bathrooms near to the lounges and bedrooms. Bathrooms contain assisted baths for service users who have mobility problems. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Residents are in safe hands and are protected by the homes recruitment policy and practices. EVIDENCE: The home has two units consisting of a 28 bed nursing unit and a twenty-bed unit for people who have a dementia type illness. Each unit is staffed separately. Staffing on the general nursing unit in the mornings consists of 1 qualified nurse and four care staff. In the afternoon and evening, 1 Qualified Nurse and three care staff, and on night duty there is 1 Qualified Nurse and 1 carer. On night duty there is one qualified nurse and one carer with one extra carer as a floating member of staff for the home. Staff on the dementia care unit consists of one qualified nurse and two carers by day and one qualified and two carers by night. Concerns was expressed that there are none of the qualified staff in the home with a mental health qualification, however the senior nurse on the dementia care unit said all staff had completed dementia care training through Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 20 Sunderland University, and that this training was repeated annually if necessary. She also said advice was obtained from the community mental health teams if this was deemed necessary. Currently there are no staff shortages, and very little agency staff is used as the home has its own bank of staff they can fall back on if necessary. There is a very comprehensive induction pack in use in the home that complies with Skills For Care Common Induction standards, and there is also a mentoring system in place. Evidence was seen of a Matrix recently developed by one of the senior nurses regarding formal supervision. This and comments from staff during the inspection confirmed formal supervision was taking place. Training records seen provided evidence the following training had taken place. All qualified staff have had training in the safe handling of medication. All mandatory training has been carried out. The home has copies of the Mental Capacity Act and codes of practice, and two of the qualified staff have been on training regarding this. All staff have had training to care for people with Dementia related illnesses, and abuse awareness training has taken place. Other training that has taken place in the home includes training on the application of bed rails. First Aid, managing violence and aggression and CPR updates. NVQ training is of course on going. Staff files inspected identified all necessary pre recruitment checks were in place prior to commencement of employment. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home is managed and run in the best interests of residents. EVIDENCE: The manager of the home who is a very experienced registered nurse and has successfully completed the registration process with the CSCI was not present during the inspection, however the two senior nurses were able to assist adequately and professionally throughout the visit. All Health and Safety information was made available which demonstrated the providers were vigilant in making sure the home was a safe place for the people receiving a service to live in. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 22 One of the senior nurses said that residents and their relatives meetings are held every three months and a newsletter is produced afterwards. Copies of these are given to each residents and posted out to the relatives. She also said the manager has an open door policy and is available to residents, visitors and staff when she is on duty. Staff spoken to during the visit said they receive good support from the manager and her senior staff. The manager completes monthly audits of the home and the services they offer to ensure these meet the expectations of the service users. Areas audited included, medication, care documentation, complaints and accidents and health and safety. The manager also completes monthly statistics and is responsible for ensuring staff receive the training they require in order for them to be competent at the job they are performing. Evidence was seen that most of the staff have received training in moving and handling, fire prevention and health and safety training. The home also seeks the views of the service users and relatives about the care that they receive by sending out service users questionnaires annually; the results of which are sent out to service users and relatives. The home does not hold any personal monies for service users. Service users either have their own bank accounts or their relatives deal with their finances. Staff meetings are held regularly to discuss any issues, training and to introduce new staff to the team. Staff said these were helpful and that the manager was accessible and supportive. Policies and procedures in place revised and updated by organisation as needed and when laws change. Copies are kept in managers office and nurses station and easily accessible to staff. Information from the AQAA (Annual Quality Assurance Assessment) showed that safety and maintenance checks of equipment and installations in the home were carried out and were up to date. Records of checks made on fire safety systems and equipment were up to date. Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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 3 3 3 x 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 x 4 4 4 4 4 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 3 3 3 Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 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 OP3 Good Practice Recommendations It would be seen as good practice if there was more information recorded in the pre admission assessment of needs section in the new care plan documentation. It is also advisable that the type of dementia service users are diagnosed with is clearly identified in the pre admission assessment documentation. To make sure holistic and person centred care is identified and planned, activity care plans should be formulated and kept with the care plan documentation. 2. OP7 Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burley Hall Nursing Home DS0000019893.V340970.R01.S.doc Version 5.2 Page 26 - 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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