Inspection on 29/11/06 for Margaret Clitherow House

This inspection was carried out on 29th November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Margaret Clitherow House 07/10/08

Margaret Clitherow House 16/08/07

Margaret Clitherow House 09/03/06

Margaret Clitherow House 19/07/05

Margaret Clitherow House 17/11/04

Margaret Clitherow House 29/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Margaret Clitherow House Priory Road Torquay Devon TQ1 4NY Lead Inspector Stella Lindsay Key Inspection (unannounced) 29th November 2006 9:30 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 Margaret Clitherow House DS0000018395.V307461.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. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Margaret Clitherow House Address Priory Road Torquay Devon TQ1 4NY 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) 01803 326056 01803 315066 margaretclitherow@btconnect.com Margaret Clitherow Housing Association Mrs Margaret Parsons Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2006 Brief Description of the Service: The Margaret Clitherow House provides residential care for up to 41 older people. There are 38 bedrooms, of which three could be double if required. All but one room has en suite facilities, and that one has an adjacent wc. Most of the Home is accessible via the shaft lifts, with a short flight of steps to some rooms. There is a dining room large enough to seat all the residents while providing quiet corners. There are two shared sitting rooms, a gazebo and a conservatory. There is a kitchenette where residents may make hot drinks or snacks, if assessment shows this to be safe. The Home has extensive gardens, which are accessible to residents. There is suitable garden furniture and shade provided. Vegetables are grown for the kitchen. The Home is adjoining the Catholic Church, and is close to the St. Marychurch precinct with all its amenities and services. Transport is provided for medical appointments and social activities. There is a Residents Social Fund, which pays for entertainments. Current fees range from £295 to £400 per week. The Manager will supply a copy of the latest CSCI report on request. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in November 2006. It involved a partial tour of the premises, examination of care records, staff files, the medication system and health and safety documents. The inspector met with twelve residents, four staff on duty, the Registered Manager, Mrs Margaret Parsons, and the Responsible Individual for the Margaret Clitherow Housing Association, Mrs Eileen Martin. Comment cards and surveys were received from staff and relatives, and their views will be represented in the text. The Manager provided supporting information prior to the inspection. As part of this inspection, the quality of information given to people about the care home was looked at, and the Complaints Procedure. Discussions with recently admitted residents considered whether they could understand this information, and if it helped them make choices. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this will be found on our website www.csci.org.uk. What the service does well: The Margaret Clitherow House has an air of formality and respect, which is appreciated by residents living at the home. Residents are encouraged to retain their independence and to exercise choice and control over their daily lives. Excellent information has been produced for prospective residents, including a video portraying life at the home. Residents expressed satisfaction with the care they received. ‘Most impressed’, said one who had experience of care work in their professional life, ‘personal and individual care is so good, anything you ask for will be dealt with’. Another complimented the staff on their ability to help motivate people to mobilize. The home always sends a member of staff, often one of the managers, to medical appointments and hospital admissions, even during the night in the event of an emergency, if family are unable to attend. Social activities are provided regularly in the home. Many residents are pleased to maintain their links with the adjoining Roman Catholic Church, and with other Churches in the neighbourhood. The meals are very good, with choices available and care taken in the presentation. There are utility rooms on the first and second floors, where residents can make hot drinks and snacks. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 6 The complaints procedure is on display in the home, and residents have found that when they have brought something to the attention of the Manager, it is dealt with promptly, without any difficulty. The house is well-maintained, and accessible throughout. It is attractive and comfortable. It is well staffed and well managed. 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. Margaret Clitherow House DS0000018395.V307461.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 Margaret Clitherow House DS0000018395.V307461.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Clear and illustrated information about the service gives prospective residents the opportunity to make an informed choice about their move, and careful pre-admission assessment is carried out. 1,2,3 Standard 6 is not applicable. EVIDENCE: The Margaret Clitherow House has a newly produced Resident Information Guide, including photos of the home, inside and out. The statement of purpose is held on file and available for visitors and prospective residents. A video has been produced, showing daily life at the Margaret Clitherow house. It has been useful for prospective residents who live too far away to visit. It has also been used to promote the service and gain supporters. The Home has produced a ‘Client Agreement’ to clarify terms and conditions, and these were seen on residents’ files, signed by themselves. The inspector spoke with four recently admitted residents to gather information for the CSCI study. One remembered being given a brochure. The second said their relative had entirely dealt with the process. A third said the Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 9 home’s reputation had gone before it. They found the home’s telephone number in the directory, phoned up, and were sent information. The fourth was convinced that they had bought the ‘flat’, and had found it in the normal way, through an estate agent. In general the inspector found that they did not remember details about decision-making. With the move and the problems that accompany becoming frail, this slipped from their memory. Two of the residents, quite independently of each other, said that ‘it is a miracle’ that they are at Margaret Clitherow House. Another said, ‘I couldn’t have chosen a better home’. Two of the four were aware that they had a contract. The inspector can confirm that all had been given one, copies seen on file. All had their needs assessed. They were not aware of this, though they knew they had met staff from the home, and had visited. Two had assessments by Social Workers, and one by a Nurse and a Social Worker. The Manager of the home had completed a brief but comprehensive summary for each, showing that all their care needs had been considered, and concluding with the judgement that their needs were well within the capability of the home to meet. This is good practice. Margaret Clitherow House DS0000018395.V307461.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care provided are very good, but the care plans had not been reviewed or shared with residents. Residents’ dignity is highly respected. 7,8,9,10 EVIDENCE: Each resident has a care plan. The inspector examined a sample of five. There was no evidence that they had been drawn up in consultation with the resident concerned, or that they had been reviewed monthly by staff in the home. There was a brief social history. This could be developed, to enhance staff understanding of new residents, and to retrieve family information for those whose memory is failing. Residents expressed satisfaction with the care they received. ‘Most impressed’, said one who had experience of care work in their professional life, ‘personal and individual care is so good, anything you ask for will be dealt with’. Another complimented the staff on their ability to help motivate people to mobilize – ‘they are good at getting them out of their wheelchairs’. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 11 During this inspection an Intermediate care worker was visiting to help a resident with their mobility. Another was taken for an appointment with a dietician. The home always sends a member of staff, often one of the managers, to medical appointments and hospital admissions, even during the night in the event of an emergency. The home has a sound procedure for the safe administration of medication. Residents are enabled to administer their own medicines if they are competent to do this. A good self-medication assessment record was seen on a resident’s file, showing that this judgement had been made with suitable care. A trolley has been purchased, to make administration safer and easier. Records are properly kept, with the exception of one occasion when the records had been written after the giving of the medication, instead of at the time, which is the home’s policy, and this had lead to gaps. The Controlled Drugs register was properly kept, and improved storage was being arranged. There is a fridge for insulin, creams, eye drops and anti-biotics, beside the other fridges in the kitchen area. Care staff keep these records. District Nurses call weekly to oversee the care of the resident with diabetes, and draw up the doses of insulin for the resident to administer with staff supervision. The Assistant Manager has drawn up a care plan specifically for diabetes care. Residents told the inspector that they appreciate being addressed formally, as Mr or Mrs, rather than by their Christian name. They consider that it maintains a sense of respect from the staff. Most residents have their own telephone line. There is a room called the ‘domiciliary’ where residents can go for the hairdresser and the chiropodist. The home has gone to considerable trouble and expense to fit locks to all bedroom doors. The new locks provide for residents’ privacy, they can secure their possessions when they are out, but staff can gain access in an emergency. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities that suit residents’ interests are provided, links with the community are very good, and the meals are of good quality and offer both choice and variety. 12,13,14,15 EVIDENCE: The residents are pleased with the laundry system. There are no more complaints about clothes going missing, due to the introduction of a more accountable system of recording which staff carried out these duties. Bingo is a regular and popular activity on Tuesdays, lead by a staff member. Musical exercises are lead by a visiting activity organiser every Wednesday morning, and this was seen during the inspection to have a lively following. During the summer trips out are arranged. A theatre trip was being arranged for Christmas week, and a zither player was booked for the week following this inspection – an annual event. A Catholic Communion service is held in the little lounge every Sunday. The Catholic Church adjoins the home and is accessed through an internal door. The proximity of the church to the home is a very important aspect of the Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 13 homes facilities offered to residents. Several residents attend mass daily, and support other church functions and social activity. Some residents attend other Churches, and some are able to walk to the nearby St. Marychurch precinct. Links with the community are enabled to suit the wishes of the residents. A recently admitted resident is a member of the Freeman’s Society, and the home now provides a room for their 3 monthly meetings, which enables the member to continue attending. There is always a choice at mealtimes. On the day of the inspection roast lamb was offered or a savoury pancake, suitable for vegetarians. There are always two puddings, including a milk pudding. Residents were looking forward to egg on waffles at teatime. Staff and residents often discuss the best method of serving meals and hot drinks. All is carefully considered, as there is a large group to be served, who do not like waiting, and some need assistance. A new improvement was the serving of soup from thermos flasks, which gets the soup to the diner quicker and hotter. Meals are liquidised for those with swallowing problems, and food supplements obtained as necessary. Sugar-free options are available. Vegetables from the garden are enjoyed. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures were in place, and the Manager is open to comment, so that people are enabled to voice any concern. 16,18 EVIDENCE: The complaints policy is displayed in the home, and given to prospective residents. There is also a suggestions box, and well as residents’ meetings, and questionnaires. A file is kept to record any complaints or suggestions made, and action taken. There have been no official complaints, and no complaints had been received by the CSCI. The inspector spoke to four residents to gather information for the CSCI study. Three said that they were aware of the home’s complaints procedure, one said they could not remember. One knew that is was on the wall in the dining room. One said that the management deal immediately with anything that is brought to their attention. Another said that they ‘would go to the office – they have sorted out problems. You never feel you are causing a ruckus.’ The fourth said they would discuss any anxiety with their relative. The home has a policy on the protection of vulnerable adults which includes the local reporting arrangements, called the ‘Alerters’ Guidance’, so that the Manager knows what to do in the event of any allegation of abuse being made. Staff all knew that they must report any concern to the Manager. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 15 Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in comfortable surroundings, which are regularly well maintained. 19,24,26 EVIDENCE: The Margaret Clitherow House was purpose built for communal living, having previously been a convent. There are 38 bedrooms, three of which are large enough to be used as double rooms if required. The corridors are wide, and there are two shaft lifts. Rooms had been redecorated and re-carpeted as required. The appearance of the house was smart, safe and comfortable throughout. New flooring had been laid in the servery, and all surfaces were sound and easily cleanable. The conservatory along the side of the building had been rebuilt, and is in regular use. Residents said they really liked this sunny and comfortable space, with its outlook on to the garden. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 17 Residents had many personal items in their rooms. One was pleased to have a room with a sitting room separated by an archway, and was pleased to tell the inspector that the Manager had at her request arranged for curtains to be made to fit this space and separate the two parts of the room. Some rooms have wonderful views. The management have been trying to replace windows. This is an on-going and difficult building problem, as the sash windows are set in shaped stone spaces, and a way of providing a completely draft-free fit has not yet been found. Efforts are continuing. Work had been done to make the laundry floor hygienic. New flooring had been laid along the corridor between the kitchen and the servery, and stainless steel surfaces are fitted in the servery. All surfaces were seen to be sound and easily cleanable. The ‘Safer Food, Better Business’ system of kitchen management has been introduced. Cleaning was observed in progress during the inspection. The house was clean and sweet smelling throughout. A disinfecting system has been installed to assure the disinfection of all laundry and bed linen. Stocks of disposable gloves and aprons are kept in the bedrooms of residents who have on-going personal care needs. There is a system in place for ensuring that soiled laundry does not contaminate other items, and a suitable place for sterilising commode pots. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff morale is high, resulting in an enthusiastic workforce that works with residents to provide a good quality of life. 27,28,29,30 EVIDENCE: There are four or five care staff in the mornings and four in the afternoons, and two by night. This was seen to be sufficient to meet the needs of the current residents. Four separate rotas are kept. The Manager’s rota ensures that at least one of the management team are on duty 24 hours per day, with sleep-in cover by night in case of illness or emergency. Care staff are lead by a dedicated and highly competent Head Carer. Care assistant meetings are held every month, to make sure all are up to date with any changes, and to give appreciation of work done. Residents were very complimentary about the staff. ‘They are observant – and act upon what they see’. They are able to think of ways around problems of daily life. The experienced staff are willing and capable, and the new staff are eager to learn. Domestics work in pairs, partly for their protection from any allegation if objects go missing, and partly for safe and efficient working practice. There are no cleaning staff at the weekend. Night staff clean toilets, and there have been no complaints with regard to standards of cleanliness at weekends. There is a dedicated laundry worker, Monday to Friday. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 19 A head cook and two assistant cooks are employed, and a team of dining room staff. Junior staff start in the dining room, until they have the age, maturity and experience to move on to care. Staff told the inspector they love their work. Some have worked at the Margaret Clitherow House for many years. One said they appreciate the serenity of the house. Of the 20 carers employed, 12 were qualified to at least NVQ2. This shows excellent progress towards achieving a qualified workforce. The Manager adheres to a sound system of recruitment, to ensure protection for the residents. CRB clearances had been obtained, and proof of identity retained. Some references needed to be chased up. A recently recruited carer had completed induction training and was moving on NVQ. As well as mandatory health and safety training (see standard 38) there had been training in stroke care. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear leadership and guidance from management ensures that residents receive a high standard of care. 31,33,35,38 EVIDENCE: The Registered Manager, Mrs Margaret Parsons, has achieved NVQ4 and the Registered Managers’ Award, and is experienced and competent in the management of residential care. She is supported by the Committee, who have appointed a new Chairperson, Mrs Eileen Martin, who has taken on the role of Responsible Individual for the organisation. The Manager had been collecting feedback from resident, their relatives, and other visitors to the home. The Manager reviews maintenance requirements periodically with the maintenance worker. The home needs to develop a system of quality assurance, to ensure accountability and progress in consultation with residents. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 21 The home is appointee for three residents. The Accounts Clerk collects their pension weekly, gives their personal allowance to them, and pays the fee element into the home’s account. All transactions are documented. She keeps small amounts of cash in the safe on the request of twenty residents. All are kept separately, with records kept. A sample was checked and found to be accurate. The inspector was assured that this money is covered by the home’s insurance policy. The fire precaution system had been serviced professionally. Moving and handling training had been provided in May and October of this year. Infection control training was given on 17/11/06. Twenty-seven staff had attended fire safety training, and a chart was kept showing that all staff had benefited except for two night carers who had not been able to attend because of their work pattern. They will be accommodated at the next training session. Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 22 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 4 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 3 Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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. 1. Standard OP7 Regulation 15(2) Requirement ‘The Registered Person shall make the service user’s plan available to the service user, keep the plan under review...’ A plan of care should be drawn up with the involvement of each resident, agreed and signed by them (or their representative), setting out in detail action which needs to be taken by care staff to ensure that all aspects of their health, personal and social care are met, and reviewed by care staff in the home at least once a month. Previous timescale 30/04/06 The registered Person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home, and shall supply to the Commission a report… and make a copy of the report available to service users. Timescale for action 31/01/07 2. OP33 24 30/06/07 Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Margaret Clitherow House DS0000018395.V307461.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Margaret Clitherow House DS0000018395.V307461.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!