Inspection on 25/03/09 for Pelsall Hall

This inspection was carried out on 25th March 2009.

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

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

Pelsall Hall 22/12/06

Pelsall Hall 03/03/06

Pelsall Hall 28/09/05

Pelsall Hall 04/03/05

Pelsall Hall 24/08/04

Pelsall Hall 22/03/04

Pelsall Hall 17/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 10/07/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Pelsall Hall Paradise Lane Pelsall Walsall West Midlands WS3 4JW     The quality rating for this care home is:   two star good 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: Pam Grace     Date: 2 5 0 3 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: Pelsall Hall Paradise Lane Pelsall Walsall West Midlands WS3 4JW 01922693399 01922685525 pelsall@greensleeves.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Greensleeves Homes Trust Name of registered manager (if applicable) Ms Rosanna O`Mara Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 41. 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 -Code OP maximum number of places 41. Dementia-Code DE maximum number of places 41 Date of last inspection Brief description of the care home Pelsall Hall is a large detached property within in its own extensive grounds. The house has been converted to provide residential care for up to twenty-nine older people. The home has a large lounge/dining room with a small quiet lounge and conservatory off it. Laundry and kitchen facilities are provided within the home. Care Homes for Older People Page 4 of 28 41 0 Over 65 0 41 care home 41 Brief description of the care home The home has recently undergone major refurbishment and a large extension. This now provides people with better facilities, and a unit dedicated to the provision of care for people with dementia. The fees charged for the service at Pelsall Hall, are from 353.01 up to 595. 00 pounds per week. The fee information included in this report applied at the time of inspection, the reader may wish to obtain more up to date information from the care service. Top up fees may apply, dependent upon individual financial circumstances. Items such as hairdressing, chiropody and newspapers are not included in these charges. 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: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection for this service was 21 December 2006. This inspection visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over eight hours by one inspector who used the National Minimum Standards and outcomes for people who use the service as the basis for the inspection. Prior to the inspection, the registered care manager completed an Annual Quality Assurance Assessment for us. On the day of the inspection, the home was accommodating 32 people. Care Homes for Older People Page 6 of 28 We spoke with staff and the people using the service. We also examined records, carried out indirect observation of six people who use the service, and the four staff on duty. Three plans of care and three staff records were examined, we also directly observed daily events. We looked at five bedrooms, the communal lounge areas, the dining area, kitchen, laundry, toilet and bathing facilities. We inspected the system of medication administration and storage. What the care home does well: What has improved since the last inspection? What they could do better: Risk assessments in individual care records need to be dated. Care Homes for Older People Page 8 of 28 Quality Assurance surveys should include other stakeholders, for example the General Practitioner, District Nurse, Pharmacist, Dentist and Chiropodist. 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 9 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 10 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and their representatives have up to date information, in order to choose a home that will meet their needs. Evidence: The Annual Quality Assurance Assessment (AQAA), which was completed by the care manager told us: Enquiries are received into the home through various methods including telephone, internet, walk ins, and professional or family referrals. Information is recorded for every enquiry. The home manager and or deputy manager meet and or speak with every enquirer, to provide all the information they may require. This is supported by a comprehensive information pack, which also gives details about obtaining further information about the home from inspection reports from CQC. Prospective residents are offered to visit the home unannounced, and further information is available about funding arrangements and advocacy services. There is a Statement of Purpose which includes information as per schedule 1, Care Homes for Older People Page 11 of 28 Evidence: Schedule 5 and NMS 1. These are available in large print and braille if requested. Prospective residents receive a detailed pre admission assessment from the Home Manager to ensure that the home can meet their physical and social care needs. Comments received on the day, from people using the service, confirmed that they had received enough information, and had been given a contract. Comments received included the following, we were shown around by the owner, and liked the home, its really good here. We looked at three pre-admission assessments. These had been undertaken either by the local authority or the manager of the service, and had been comprehensively completed. The Statement of Purpose and information pack were readily available for us to view, these had been reviewed and updated to include the change of address for the Care Quality Commission (CQC), and the details in regard to the current fees charged. We were assured by the care manager that Contracts/Terms and Conditions of service had been reviewed and updated for each individual. Intermediate care is not provided in this home. Care Homes for Older People Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples individual health and personal care needs are appropriately met. The principles of respect, dignity and privacy are upheld. Evidence: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager told us: The pre-admission form and the Resident Profile forms the basis for each residents individualised care plan. Contributions are made by the resident, family members and support specialists. The care plan reflects the personal care, social and spiritual needs, and risk management of the resident. This is a working document which is reviewed formally after the initial 6 week trial period, but can be updated at any time on an ongoing basis as needs change. Monthly reviews are completed, and resident/family reviews are held every 6 months. Residents have access to a wide range of additional healthcare services through the community, these include: Registered Chiropodist, Incontinence Specialist, Nutritional Specialist, Community Psychiatric Nurse, Optician, Dentist, Physiotherapist, Occupational Therapist. The home operates a series of policies and procedures to ensure that all Care Homes for Older People Page 13 of 28 Evidence: residents are protected with regard to the administration of medications. Risk assessments are completed for all residents. Medication is audited twice weekly, and staff who dispense medication are audited weekly. We undertake Waterlow assessments, MUST assessments, Initial Wound/Bruise assessments. We examined three care plan records, these contained a variety of assessments, for example nutrition, continence, mobility and pressure area care. These were clear, comprehensively completed, and contained appropriate individual risk assessments. However, review dates were missing from some of the records seen, dates would highlight the need for review, and staff would then know that these are the most up to date and would use them for instruction to prevent risk to people. This was discussed at the time with the care manager. Records and the daily diary also showed evidence of health professionals involvement, for example District Nurse and General Practitioner visits, and health appointments for individuals. We spoke with staff and people who use the service. Staff spoken with could tell us exactly how each of these people were to be cared for. We spoke with people using the service, they confirmed that they do receive the support and care they need. They also said that staff listen and act upon what they say, and that they receive the medical support they need. Comments received included we get looked after here, the staff do a really good job, I like it here , we get lovely food . One person described how their room had been adapted to suit their needs, for example, a recliner chair and a pressure cushion had been provided, and furnishings had been arranged to enable them to freely and safely mobilise. We examined the homes administration of medication, which is provided by the pharmacist in a monitored dosage system. Medication Administration Sheets (MAR) evidenced that there were no anomalies, and medication given was all signed for. There was a system in place for the return of medication, which is witnessed and signed as received by the pharmacist, thus providing an auditable trail. This ensures the health, safety and welfare of people using the service. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are satisfied with their chosen lifestyles, meals and activities in the home. Individual social, recreational and religious needs are met. Contacts with family and friends are encouraged and maintained. Evidence: The Annual Quality Assurance Assessment (AQAA) which was completed by the care manager told us: Routines within the home are flexible, the residents can choose when they want to get up and when to go to bed, and where they want to take their meals. A monthly activities programme is displayed on the notice board detailing the activities or entertainment offered to our residents, this is then recorded on our record of social activities, as to who participated, and their enjoyment of it. Resident care plans detail past and current activities enjoyed. Visiting is flexible. Residents meetings include discussion about food and activities. There is a monthly visiting Pastoral service. The main meal of the day was served during our visit, people spoken with said the meals are lovely, sometimes theres too much to eat. The care manager and people spoken with confirmed that there is always a choice of main meal for people. Care Homes for Older People Page 15 of 28 Evidence: Comments received from people using the service and staff, confirmed that there are activities arranged by the home that they can take part in. People spoken with confirmed that activities include games and crafts, outside entertainment coming in, music and singing. Comments received included the following: we see the minister regularly, we sometimes go for trips out if the weather is good, I like doing puzzles and quizzes, I stay in my room sometimes. Activities take into account peoples age, and abilities. The home has a variety of communal areas, and a dining area, which are well used by the people using the service, their visitors and friends. Visitors can also be seen in private if people so wish. Bedrooms seen evidenced that people can bring in their own furnishings and personal effects. We were told that visitors and relatives can visit at any reasonable time. There is a family room which can be utilised by people using the service and their families. 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 are listened to and can feel assured that the home will act in their best interests and protect them from harm. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the care manager told us: The complaints procedure is detailed in the Statement of Purpose, and a copy is given to all new residents on admission. The complaints procedure is displayed in the reception area. Written information on how to contact CQC at any stage of the complaint is detailed on the complaints policy with full contact details. Residents are protected from abuse through rigorous training of all staff members, and a no tolerance/whistleblowing culture is promoted. We now include POVA as part of our induction for new staff as well as the Mental Capacity Act and Deprivation of Liberty Safeguards. The care manager told us that the service had received two complaints, and had made one Safeguarding referral since our last visit. We saw that the complaints had been dealt with in a timely way by the care manager, and that these had been appropriately documented and recorded. The complaints had been upheld, and appropriate action had been taken by the service. Comments received from people using the service included, I have no complaints, but Care Homes for Older People Page 17 of 28 Evidence: if I did, I could always speak to any of the staff, I tell my daughter. We spoke with staff and the care manager about safeguarding, and their role in keeping people safe from harm. They said that they understand their role, and their responsibilities in relation to this. We looked at three staff records. We did this to see if the home is fulfilling its obligation in completing safety checks against the Protection of Vulnerable Adults (POVA) list and Criminal Records Bureau disclosures. The service must do this to prevent unsuitable people from working with vulnerable adults. We found that appropriate security checks had been undertaken prior to their employment at the home. The care manager confirmed that people using the service manage their own finances. The service does not hold monies for individuals. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well maintained and comfortable environment, which encourages independence. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the care manager told us: Pelsall Hall offers a safe, comfortable and homely environment set in extensive grounds in a quiet area of Pelsall. Our residents have new bedrooms, and these are furnished to an exceptionally high standard. All rooms are en-suite and have walk in wet room showers. All rooms have new carpets, curtains, blinds, furniture and beds. Communal areas are furnished in a stylish and contemporary manner. There is a passenger lift to access all floors, a second lift will be installed shortly. There are two mobile lifting hoists, and a stand aid, as well as a rotary turn stand. Communal bathrooms are equipped with bath hoists. A state of the art Aid call system has been installed, and all care staff carry DECT phones programmed into the system. There is a re-decoration programme, and the buildings are maintained by a full time maintenance person. Systems are in place to keep the home safe and hazard free. The building and grounds were maintained to a very high level, and were safe for people to use. Care Homes for Older People Page 19 of 28 Evidence: Communal areas were clean and comfortably furnished to a very high standard. These were well used by people using the service, their visitors and relatives. Bedrooms seen had been personalised and adapted to suit the individual. Aids and equipment were in place for people needing them, these had been appropriately and safely maintained. Furnishings and fittings were to a very high standard. Wheelchairs and a hoist were seen to be blocking a corridor, which was also a fire exit. This was rectified straight away, and was thought to be due to the maintenance person needing to access a cupboard. The kitchen and laundry areas were clean and tidy. All equipment was in good working order. Infection control measures were in place, ensuring the health and safety of the people using the service. The AQAA listed the maintenance checks of equipment made since the previous inspection, however the dates for when these had been serviced were missing from the documentation. This was subsequently highlighted, and we requested that the dates are forwarded to CQC for our records. The care manager later confirmed that the Fire recommendations made by the Fire Officer had been met. Environmental recommendations and requirements made by the Care Quality Commission at the previous inspection had also been met. 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. Staff are in sufficient numbers to meet peoples needs, they receive update and refresher training according to their role and responsibility. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the care manager told us: We operate a thorough and rigorous recruitment and selection process that ensures that all staff members have background checks and two references before starting work including POVA and CRB checks. The manager holds the NVQ4 Registered Managers Award, and NVQ 5 in Management, with the deputy Manager holding the NVQ4 in Care, and is currently working towards NVQ4 Leadership and Management. Staffing levels are set with the number of residents and their care needs in mind. Our induction programme is in line with Skills for Care and Greensleeves Homes Trusts policies and procedures. Additional training is given to staff on a variety of topics including dementia care, managing challenging behaviour, pressure ulcer care, communication, death, dying and bereavement. This is as well as mandatory training which includes, moving and handling, fire, food hygiene, adult protection and first aid. New staff are given an induction booklet to work through with the support of the management team. Staff have regular supervision sessions to promote good practice, and as revision practice for the homes policies and procedures. The GSCC code of conduct and staff handbook is issued upon appointment. Care Homes for Older People Page 21 of 28 Evidence: The service has a good recruitment procedure that meets statutory requirements and the National Minimum Standards (NMS). Records were clear and uniformly kept, and there is a Greensleeves induction pack issued to all new employees. Staff spoken with confirmed that they had received regular supervision and appropriate training. For example, Adult Protection, First Aid, Dementia, Managing Challenging Behaviour, Advocacy Matters, Infection Control, Moving and Handling and Food Hygiene. The staff training matrix confirmed this, and showed the training undertaken and the training planned for the next year. The staff rota for May 2009 evidenced that staffing levels had been maintained. Staff confirmed their system of handover, and instructions and support given to staff to enable the smooth day to day running of the service. We saw that this was reflected in the qood quality of care that people receive. Comments received from people using the service included, Staff are available when you need them, they do as much as they can, I really like it here. 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 of the home is based on openness and respect. Quality assurance systems have been established. The administration and record keeping of the home is clear and up to date. Evidence: The Annual Quality Assurance Assessment (AQAA) completed by the care manager told us: The registered manager has introduced several staff, resident and family meetings, and has a clear vision for the future of the newly refurbished and redeveloped Pelsall Hall. The manager is supported by the operations manager and the support team at head office who carry out monthly Regulation 26 visits. Documentation is in place to carry out monthly internal audits, to ensure all record keeping and health and safety checks are carried out prior to Regulation 26 visits. The Annual Quality Assurance Assessment (AQAA) was well completed and returned to us on time by the registered care manager/provider. The AQAA gives us good Care Homes for Older People Page 23 of 28 Evidence: information about the areas where they need to improve, and the ways that they are planning to achieve this are briefly explained. We are kept informed via Regulation 37 Notifications of incidents in the home which affect the people using the service. This helps to ensure the safety of individuals using the service. There had been two complaints, which had both been upheld, and one Safeguarding referral made since the previous inspection. Staff spoken with and records seen evidenced that up to date training, formal supervision, and appraisals had taken place. Recruitment files were clear and uniformly kept, making it easy to see evidence that individuals had been safely recruited, inducted and trained. The environment is safe for people and staff because appropriate health and safety practices are in place. Care plans and risk assessments, in regard to how staff are to safely care for individuals, were in place. Individual risk assessments were kept up to date, and included the measures taken to minimise the risk. Thus ensuring the safety of the people using the service. We noted that the quality of the care received is good, and people were very complimentary about this, I like it here, I can go to my room, or just watch the television if I want to. I sometimes need to ask for help, and I have no problem getting it. The staff are marvellous. We looked at the homes medication systems. Medication Administration Records (MAR), storage and disposal of medication, this revealed that there are safe practices being followed by staff, and there were no shortfalls in regard to this. We were told in the AQAA that the registered manager/provider had reviewed records, policies and procedures in the light of new legislation and current good practice. However, the information as to when these were reviewed was missing from the paperwork. This was discussed with the care manager, and we requested that this information is forwarded to us. The home does not hold monies for people using the service. People using the service were complimentary of the staff and management, and positive comments were received in regard to the commitment, care and support that they received. Comment cards and letters received by the service since our previous Care Homes for Older People Page 24 of 28 Evidence: inspection confirmed this. Quality assurance systems are in place, and Regulation 26 visits are undertaken regularly by the provider to monitor the service, however, other stakeholders should be included in surveys sent out. For example the General Practitioner, District Nurse, Dentist, Pharmacist, Optician, Chiropodist. Care Homes for Older People Page 25 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 26 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 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 2 7 33 Individual risk assessments should be dated to ensure that they are kept up to date. Thus ensuring peoples safety. Quality Assurance surveys should include other stakeholders for example the General Practitioner, Pharmacist, District Nurse, Optician, Dentist and Chiropodist. 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. 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. Care Homes for Older People Page 28 of 28 - 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!