Inspection on 25/02/09 for Haversham House

This inspection was carried out on 25th February 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haversham House 11/03/08

Haversham House 24/04/07

Haversham House 20/04/06

Haversham House 09/09/05

Haversham House 21/04/05

Haversham House 01/10/04

Haversham House 05/04/04

Similar services:

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Haversham House 327 Bromsgrove Road Redditch Worcestershire B97 4NH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Nick Richards     Date: 2 5 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 28 Information about the care home Name of care home: Address: Haversham House 327 Bromsgrove Road Redditch Worcestershire B97 4NH 01527542061 01527544732 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Springlea Limited care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Age: Physical disability - Code PD age 55 and above. Dementia - Code DE age 55 and above. The maximum number of service users who can be accommodated is: 16 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 16 Physical disability (PD) 16 Dementia (DE) 16 Date of last inspection 16 0 16 Over 65 0 16 0 Care Homes for Older People Page 4 of 28 Brief description of the care home Haversham House is a small home, which provides a service for 16 older people who may have a physical disability and/or a dementia type illness. The home is situated close to Redditch town centre. There is a local bus service available. Car parking is available for visitors and staff. The home is an adapted town house, which has accommodation on two floors; the first floor is accessed by a stair lift. Enquiries about fees charged by Haversham House should be made by contacting the home. The inspection report is available in the home. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The visit was carried out over one day - the home did not know we were going to visit. This was the homes first key inspection since March 2008. A key inspection is where we look at those areas that we, the commission, consider to be important when providing quality care. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Care Homes for Older People Page 6 of 28 Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home. We also looked at the information submitted to us by the home in the form of an AQAA. This stands for Annual Quality Assurance Assessment. An AQAA is a document that the home has to send to us, and helps them to assess their home, identify what they do well, identify the things they are not so good at, and it tells us what they are going to do to help improve things within the home. Three people who live in the home were case tracked. This involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. The people who live at the home, the deputy manager and the staff were spoken to. Time was spent observing care practices, interactions and support from staff. We looked at the premises during a walk around the home, and we also looked at care, and health and safety records. 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 set out 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 28 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 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all people living at the home are safeguarded through screening of need prior to admission, neither is information always used to provide effective care after people are admitted. Evidence: During our visit we looked at the way the home provides meaningful information to people who may be looking to live at, or move in to Haversham House, and we looked at how well the home prepares itself for the provision of services to people who are to be admitted into the home. The Statement of Purpose and the Service User Guide (hereafter referred to as the Guide) was available for examination at the home. These documents provide essential information about the home, and can be used to help people decide whether they would like to live at Haversham House. Care Homes for Older People Page 10 of 28 Evidence: Both documents contained a lot of information about the home, but are not available in formats (i.e. large print or audio) that would help people who, for example, have sensory problems understand the service the home sets out to provide. The documents contained information within the complaints section that was out-of-date i.e. contact addresses for the CSCI and reference to the former NCSC. This would make it difficult for people to contact us if they are not provided with accurate contact details. Neither document contained information about the range of fees charged by the home. This is an important piece of information that can influence people when they make a choice about which care service they want to use. We looked at the care files of three people using the service. One person had been assessed on the same day that they came to live at the home, one persons assessment was dated 48 hours after they came to live at the home and the third persons care file did not contain any pre-admission assessment information. Preadmission assessments give services insight into the needs of the people who are going to come to live at the home, and helps to make sure that staff within the home are prepared for, and know what to expect when a new person comes to live in the home. Failure to undertake pre-admission assessments prior to people moving into the home introduces an avoidable level of risk to people who are vulnerable. The two people whose care files contained pre-admission assessments had needs identified within the pre-admission assessments. Unfortunately, some needs identified within the pre-admission assessments (for example dementia, diabetes, asthma) had not been developed into care plans. This can potentially place people at risk as appropriate care may not be given to people. Other aspects of peoples care needs had been identified within pre-admission assessments which, in turn, had then resulted in staff developing and implementing plans of care for people. People using the service confirmed that they had been given the opportunity to visit and test out the home before making a decision about moving in. One person said Ive been here several times before so I knew what the home was like. People who returned surveys to us all confirmed that they had received a contract prior to moving into the home. Everybody who returned surveys to us said that they had received a contract. This is important as the contract provides a safeguard for people using the service. It allows people to see what they can, and what they cant expect from the service, and also sets out each persons rights and responsibilities. The home does not provide intermediate care, therefore Standard 6 is not applicable. Care Homes for Older People Page 11 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are safeguarded through the care provided. However, inconsistent care records could potentially fail to ensure that people using the service receive care in a consistent manner. Evidence: Every person living at Haversham House possesses care records that had been completed by the manager and the care staff. The records should provide information that enable staff to meet the needs of people living at the home. The home usually contacts healthcare professionals - such as general practitioners (GPs) and district nurses - for advice and in response to the changing healthcare needs of people. However we saw documentary evidence to show that, at times, the home can not prove that they had followed up instructions about peoples healthcare. For example, staff had contacted the district nurse as they had concerns about one person using the service. The district nurse told the staff to contact the GP (general practitioner) the following day as the individual may need to be prescribed antibiotics. The GP was not, subsequently contacted about the concern. Care Homes for Older People Page 12 of 28 Evidence: Although each persons care file contained a range of healthcare needs identified through assessment, the assessments did not always result in a plan of care when a need had been identified, and when plans of care had been written, the plans of care did not always help staff to meet the care needs of people. Some risk assessments had identified that one person had sustained unplanned weight loss. No follow-up action had been recorded to deal with this potential problem. At times, plans of care failed to contain enough information for staff to follow and, at times, were extremely vague about what staff needed to do to help people with their needs. For example, one person is diabetic, and the plan of care said ensure x is offered a varied diet suitable for her diabetes. This does not explain to care staff exactly what the persons needs are or what support and assistance the person needs. Another person wore a hearing aid and the care file said that the person experiences mild panic when she she cant hear. No plan of care had been written for this which may place the person at risk if staff are not fully aware of the problem and how to deal with it. Although there was no clear evidence to indicate that peoples needs were not being met or people were being placed at risk, the failure to provide effective care documentation creates a potential risk for people using the service as consistent care may not always be provided. Some care plans seen had been discussed with peoples representatives or next-ofkin, but this wasnt consistent practice. It is important to include routine discussions with peoples representatives into the care process because it shows that the home is including the person in the whole care process, and are taking their wishes into account. People using the service were very positive about their healthcare needs when we talked with them. One person said Its the best (home) Ive ever been in, while staff were seen to interact very well with people using the service. We saw staff helping and supporting people with their personal care. The size of the home helps staff to get to know people and their needs very well however, the failure to effectively record care could place people at risk, as information about people is not clearly available to all staff so they may not be able to deliver care consistently. However, we found no clear evidence of people being currently placed at risk as a result of inconsistent care records. People using the service were very positive about the care they were receiving, and were very positive about the quality of staff who provide the care. Care Homes for Older People Page 13 of 28 Evidence: People living in the home are reliant on staff to help them with their prescribed medication due to their physical and psychological healthcare needs. All medication is administered by appropriately trained staff. We looked at the way the home manages the medicines for several people using the service and found that the staff within the home are managing medicines safely, and safeguarding people from unsafe practice. Care Homes for Older People Page 14 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The individuality of each person living at the home is respected and acknowledged by staff. While the home strives to provide social, recreational, occupational and leisure activities, further work is necessary to ensure that people using the service have their social, recreational, occupational and leisure needs effectively met. Evidence: We talked to people living at the home about how well they believed staff respected their individuality. Each person we spoke with said that their individuality was respected, and the choices they made were respected by staff. We took time to look at the social, recreational, occupational and leisure activities provided at, and by the home. People using the service said that, generally, there were activities arranged by the home that they can take part in, and the deputy manager showed us an events sheet displayed in the entrance foyer of the home. This included a film afternoon and a bingo session. The activities for the week when we visited comprised of a sing song session, a reminiscence session, a bingo session, a keep fit to music session, a board games session and amovie afternoon. We were told that the activities sessions usually took place between the hours of 2pm and 4pm. The activities listed were not extensive and did not reflect the diversity of Care Homes for Older People Page 15 of 28 Evidence: interests held by people using the service. No specific consideration had been given to people with memory loss. It is important for people using the service to be given the opportunity to engage in meaningful activities and interests to promote their mental health and emotional wellbeing. We discussed with the deputy manager the use of technology in social, recreational, occupational and leisure activities. We were told that, at present, there is no seperate budget for activities and staff raise funds themselves. When we visited, we observed many people asleep in the main lounge area. There was little interaction between people using the service and staff, although we did witness several people engaging in conversation between themselves. Staff told us that they sometimes take people into town to do some shopping. We saw peoples relatives welcomed into the home during our visit, and staff were pleasant and helpful to those visiting. People can visit the home at any time, and there are no restrictions imposed by the home on visiting times. Most people using the service told us that they liked the food provided by the home. One person told us that the food was good, and confirmed that people get enough food. The homes menu is written in advance, and when we visited, lunch was braising steak with mashed potatoes, carrots, cabbage and gravy followed by either peach crumble or milky jelly. The alternative to the main course was ham salad. The weekly menu did not effectively show variety. A lot of the food provided was homemade with no evidence of the home using convenience food. The evening meal was oxtail soup with scrambled egg and bread and butter followed by fruit cake. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported to express concerns, and are safeguarded by the homes open culture, complaints procedure and investment in staff training. Evidence: Each person living at the home has access to a copy of the homes complaints procedure, which is readily available within the home. The culture within the home is open and allows and supports people to raise concerns. People that we spoke with said that if they had any concerns they would raise them with the home manager, and were confident that any such concerns raised would be addressed. This was clearly supported by the record of concerns and complaints retained by the home. The complaints register contained just three concerns raised since the time of the homes last inspection. The record of concerns raised clearly show what action staff and the manager have taken to resolve the concern/s. The fact that concerns are recorded along with the outcomes clearly demonstrate the culture within the home - one whereby staff and management are eager to make sure that everyone is happy and receive the service they want. Concerns are used by management to learn and adapt practice. Two people who live at the home said that they have never needed to raise any concerns. Staff we spoke to all confirmed that they were aware of safeguarding procedures, and the home has a training programme that includes training about the Protection Of Vulnerable Adults (POVA) and the Deprivation of Liberties Safeguards (DOLS). The Care Homes for Older People Page 17 of 28 Evidence: training is being provided by an external agency who specialise in staff training. The home has copies of the local authoritys safeguarding protocol. This ensures that, should the home have need to raise a concern about safeguarding, they know the correct procedures to follow. Care Homes for Older People Page 18 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean, homely, safe and well maintained and meets the needs and expectations of those people living there. Evidence: There has been a lot of work done since the last inspection to improve the physical environment at the home. For example, the lounge areas have been re-decorated to a very good standard and additional communal space has been provided through the building of a conservatory, which is being used as a dining area. The home can demonstrate its ability to maintain and improve the quality of the environment through effective quality monitoring and an improvement plan. The providers have carefully counterbalanced the needs of the service with effective financial planning and management. We were told that the home intends to redecorate and refurbish the entrance area and corridors, along with corridor areas on the first floor of the home. We saw evidence that the homes maintenance man is in the process of decorating some areas of the home. Several bedrooms have been redecorated to a nice standard and people have been encouraged to bring their own possessions and furnishings (whenever possible) into the home. This helps people to personalise their rooms and helps people gain and maintain their own identity. Care Homes for Older People Page 19 of 28 Evidence: It is acknowledged that, as the building is not purpose-built, it has some design limitations. The proprietor has worked well to try to limit the impact of the environmental restrictions, while several people said that they liked the uniqueness of the building. People told us, The home its lovely and I couldnt imagine being anywhere nicer. We talked about how the home could assist people with memory loss problems through the use of, for example, signage and pictoral orientation aids. The deputy manager said that she would talk with the manager to see what could be done to make it easier for people to find themselves around the home. All areas of the home were clean and tidy, and people using the service said that Every day it is cleaned. (Its a) nice place to stay. all rooms were warm and well lit. The hygiene standards within the home are a credit to the staff who work hard to keep the home nice, tidy and fresh. Staff have received the necessary training to make sure that cross infection does not occur. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living within the home can be confident that they are in safe hands at all times. Staff are provided to meet peoples needs in suitable numbers and are effectively trained and supported to deliver care to people who use the service. Evidence: We looked at how the needs of people living at the home were met through the provision of appropriately skilled staff. We talked to people using the service and the staff working at the home, and looked at staff records, training records and duty rotas. The duty rotas show staffing levels at the home are good, and staff are deployed in numbers that effectively meet the needs of people using the service. Everybody that we spoke with on the day of our visit all commented favourably about the staff. People described staff as wonderful, excellent, very good, and one person went on to say you cant fault them, theyll do anything for you. Another person said that the staff always have time to listen, and this was confirmed by staff when we spoke with them. We observed staff interactions with people using the service. Everybody we saw were friendly, polite and respectful. Staff generated a warm, relaxed feel, and this, in turn, created humour. People said there are always enough staff on duty. Care Homes for Older People Page 21 of 28 Evidence: Staff receive training in a range of mandatory health and safety and care related subjects including moving and handling, fire safety, adult protection and dementia care. This means that staff are well equipped to provide care for the people using the service, and people using the service are reassured to know that they are in safe hands. The manager has developed a staff training programme, which sets out topics that staff will be trained in over the next 12 months. This helps the manager to coordinate and plan training, and also to see when, or if a member of staff is in need of training in a specific area of care or health and safety. Staff spoken to confirmed they attend courses and the manager keeps copies of their certificates in a file. Staff induction training is provided at the start of their employment, and records show the content of the induction - which is comprehensive and helps to equip new staff in delivering care to people using the service. Examples were seen of induction courses being signed off as completed with the specific date against individual topics and it was clear who the trainer was. There was supporting evidence of the course content kept with this record. The homes AQAA stated that 75 of staff have achieved or are working to achieve a National Vocational Qualification (NVQ) in care. This is highly commendable. We looked at how well people are protected through the homes recruitment process. Staff recruitment files for three staff were examined during our visit. The staff files we examined all proved that the home has taken the correct steps to ensure that only people who are suitable to work with vulnerable adults work at the home. People living at Haversham House are effectively protected by the homes recruitment process. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements ensure that the people living at Haversham House benefit from a well run home. The health, safety and welfare of the people living there is promoted and protected so ensuring their safety and well being. Evidence: Mrs Phillips is the manager of the service and is suitably qualified and experienced to manage the service. Mrs Phillips prides herself in having a very hands-on approach to care - this results in her being able to create and maintain close professional relationships with the people using the service. People using the service and staff rated Mrs Phillips management style as 9 out of 10, and staff described her as having an open, approachable style - someone you can talk to was how one staff member described her. The home has up-to-date records detailing how its responsibility to ensure the health and safety of people using the service has been met. Risk assessments are conducted Care Homes for Older People Page 23 of 28 Evidence: on a specific basis for each person using the service and there are generic risk assessments available within the home. All accidents and incidents are monitored closely and action is taken to prevent further accidental occurences happening when or should an accident occur. This helps to ensure that people are protected from avoidable harm, but they are also allowed and supported to take risks which promote their independence. The home has minimal involvement in the management of peoples personal finances; either people attend to this themselves, thus maintaining their independence, or relatives are asked to assist them. There is a framework for individual staff supervision, and there is a formal written agreement with staff about the content and format of supervision and written notes of meetings are kept. Representatives from Springlea Limited (the parent organisation) undertake unannounced visits to the home each month and look at how well the home is operating - taking into account the views of people using the service. A report is produced for the manager following each visit and any issues arising that need addressing are clearly specified within the report. There was no evidence of any residents meetings having taken place. These meetings provide a formal arena whereby people using the service can raise agenda items about anything they feel they want to discuss as part of the homes quality assurance system. Care Homes for Older People Page 24 of 28 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 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 A comprehensive assessment of peoples needs must be undertaken before a decision is made to offer accomodation to people. Any need identified within the assessment must generate a plan of care to address the identified need. To safeguard people using the service. 31/03/2009 2 7 15 Plans of care must be developed and implemented once a risk, potential risk or need is identified through assessment. This is to ensure that peoples needs are met and their safety and wellbeing is protected. 31/03/2009 Care Homes for Older People Page 26 of 28 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 Both the Statement of Purpose and the Service User Guide should be made available in alternative formats that promote understanding by people with sensory impairment. The range of fees charged by the home should be included within the Service User Guide. Up-to-date contact details for the CSCI should be included within the Statement of Purpose and Service User Guide. Care plans developed should be robust and comprehensive to help ensure that care staff working within the home deliver consistent care to people using the service. Wherever possible, and with the agreement of the person using the service, care records should be discussed and reviewed with the individual and/or their representative and the outcomes from the review documented. People with memory problems should be provided with more meaningful recreational, social and leisure activities that are designed to minimise the impact of their condition and maximise their quality of life. Consideration should be given to the development of forums (such as residents (and/or relatives) meetings) for people using the service and/or their representatives to raise issues and suggestions about how the service should operate and develop. 2 3 4 1 1 7 5 12 6 33 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or 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. 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