Inspection on 30/04/07 for Sandhurst Lodge

This inspection was carried out on 30th April 2007.

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

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

Other inspections for this house

Sandhurst Lodge 29/04/10

Sandhurst Lodge 01/04/10

Sandhurst Lodge 01/12/09

Sandhurst Lodge 05/11/09

Sandhurst Lodge 23/10/09

Sandhurst Lodge 13/10/09

Sandhurst Lodge 02/10/09

Sandhurst Lodge 22/04/09

Sandhurst Lodge 23/04/08

Sandhurst Lodge 20/09/06

Sandhurst Lodge 27/06/06

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOMES FOR OLDER PEOPLE Sandhurst Lodge 58 Ampthill Road Bedford Bedfordshire MK42 9HL Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 30th April 2007 01:35 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 Sandhurst Lodge DS0000064699.V337556.R02.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. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandhurst Lodge Address 58 Ampthill Road Bedford Bedfordshire MK42 9HL 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) 01234 352051 F/P 01234 352051 Dr Surinder Kumar Gulati Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Physical disability over 65 years of age (10) Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2007 Brief Description of the Service: Sandhurst Lodge was registered to provide residential care to 10 older people who may have dementia and or physical disabilities. The homes condition of registration included one service user under 65 with mental health needs. The building was converted from its original purpose of a large Victorian style dwelling to its current state. It was located in a busy main road in the heart of Bedford town within close proximity to the local hospital and amenities. The accommodation was distributed over three floors that were accessible via a staircase and a shaft lift. All service users had single room occupancy and the lounge and dining rooms were situated on the ground floor. The fee was in the range of £425 - £504. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 30/04/07 over 5 hours 10 minutes by Pursotamraj Hirekar. The manager and the proprietor coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager, proprietor, staff, 2 visitors of a service user, conversation with service users’ and partial tour of the building. This inspection report also includes information from the service users’ survey carried out by the commission and preinspection information provided by the home. What the service does well: What has improved since the last inspection? A new manager was appointed. The responsible individual and the manager have made good efforts to comply with the outstanding requirements from the previous key inspection and random inspection reports and this had resulted in significant improvements as required. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 6 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. Sandhurst Lodge DS0000064699.V337556.R02.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 Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for the assessment of needs of the service users’ and the service users’ were aware of the care and services they would receive from the home prior to their admission. EVIDENCE: The home had reviewed and updated the statement of purpose and service user guide to cover all aspects of care delivery that would enable the potential service users’ to take an informed decision. The statement of purpose and the service user guide were displayed on the notice board in the hallway. The home had made arrangements for pre-admissions assessments of service users. There was evidence included within the records of the service users whose lives were tracked, which supported that the home had undertaken a full assessment of needs. The home had developed service user care plan from the assessment of needs. For example, the home had a new admission in the month of January 2007; the potential service user has had a 2-week trial period. Needs and risk were assessed including fire, fall, pressures, electricity Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 9 equipment, radiators burns, hot taps, going out wandering out the house by the then manager and the proprietor. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. A pre-inspection questionnaire was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. 10 service users’ have responded to the service users’ survey undertaken by the commission, of which 9 service users have said that they had prior information about the home, before they moved in and all the 10 service users’ have signed the contract of services. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements to meet the personal and health care needs of the service users’. EVIDENCE: The home had made arrangements to access the following support services to meet the personal and health care needs of the service users’. The support services that were accessed included; GP, district nurse, CPN, dentist, optician visit, and chiropodist. However, occupational therapist visit was wait listed, the proprietor informed the inspector. Trained staff administered medication, mars sheet seen and found that the record of medication was maintained. It was observed on this inspection that the staffs treated service users with respect and had good working relation; this was confirmed from the interaction with the service users’ and responses recorded in their survey forms. The care plans of service users’ were reviewed in the month of October and November 2006 and were regularly reviewed and updated as required every month. For example: Service user – 1 the care plan was reviewed and up dated in April 2007. She was unsettled and had problems with her sleeping Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 11 patterns, and was using the dinning or the lounge for night sleep. The home now moved her to a first floor bedroom from the second floor bedroom. Discussions were with her and the 2 visitors she has had on the day of this inspection. She appeared settled and was cheerful; the 2 visitors confirmed that the service user was happy with the care and the services she received at the home. The manager and the proprietor confirmed on this inspection that the service user no more use the lounge and the dinning for sleeping. The service user had cellulites on both the legs and she does not use the bed for sleeping and continues to sleep on the chair in her bedroom. The manager and staff with the help her son continues to work with her, to help her sleep on the bed, instead the chair, to avoid the cellulites on her legs. District nurse and the chiropodist support were also taken. Service user – 2-care plan was reviewed and updated in November 2006 and further revised in April 2007. Which covered areas such as life skills, communication, social interaction, use of communal facilities, health and hygiene, mobility, medication, safety with in the community, dietary requirements, sleeping, and memory loss. The manager was in the process of transferring on to the computer from the hand written record. Service user – 3 who was hospitalised and then was referred to the willows and following the discharge on the 12/04/07 a review was undertaken at the willows by the psychiatrist, district nurse, home manager, clinical nurse manager and the deputy manager from the willows on the 26/04/07. The care plan was reviewed and updated at two different points of time for various areas of care such as; on the 12/04/07 life skills, medication, dietary requirements, sleeping, memory loss, hair care, toileting and bowel management. And on the 16/04/07 areas of care covered were; use of community facilities, health and hygiene, mobility and safety with in the community. All the 10 service users’ who had provided response to the survey have said that they always received the care and support they need. When asked do they receive medical support they need, 10 service users’ said they received medical support always. Sandhurst Lodge DS0000064699.V337556.R02.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): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users’ were offered choice of menu and timings. The introduction of nutritional assessments of all the service users’ regarding their specific dietary needs and provision of meals based on the nutritional assessment would be beneficial to the service users’. EVIDENCE: The home had made arrangements to engage service users in various social activities and maintain good relations with their family members and friends. For example: service user – 1 participated in general discussion with the staff on the current issues picked up from the TV news, plays dominoes and cross word. Service user – 2 assisted staff in laundry work, has a bird (pet) in her bedroom, plays dominoes, snake and ladder, and bingo. Sometimes she goes out for a walk and with the support of CPN visit town centre once a week to help build her confidence to go on her own. Service user – 3 started with a day care centre from the 30/04/07 expected to attend 3 days a week, participates in indoor game with the help of staff support. Service user – 4 goes for a walk, attend volunteers from out reach twice a week, and attend day care once a week. Over weekends, the proprietor take at least 4 service users’ on a car ride and have a stop at the country side, garden centre embankment, have an ice cream or a cup of tea and sometime engage in shopping. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 13 The home had appointed a new cook-cum-domestic in February 2007 who works from Monday to Friday during 9.00am to 12.00noon. However, over weekends the home continues to use the care staff for kitchen responsibilities and some times the support of the cook-cum-domestic help was sought as well. The home had made clear arrangements that the care staff working in the kitchen over weekends do not engage in care work on the same shift. Food menu was prepared on weekly basis and in consultations with the service users’ choice. However, the home was in the process of revisiting the nutritional assessments of all service users’ and plans to update care plans and revise the food menu where ever the changes need to be made with specific reference to the service user’s nutritional needs. The proprietor and the manager in their letter of 10/05/07 have confirmed that the home now uses the derby nutritional tool and continue to have consultations with the dietician at the Bedford general hospital for advice. Sandhurst Lodge DS0000064699.V337556.R02.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ were aware of the complaints procedure and were confident to use the same when necessary. EVIDENCE: The home had written complaints policy and procedure and the staff, service users’ and their family members had access to the same. The information provided in the pre-inspection questionnaire indicated that the home had 1 complaint in the past 12 months and has dealt with satisfactorily. Pova issue that was reported regarding staffing levels and their impact on care delivery is now resolved. A random inspection was carried out on the 14/03/07 and found that the requirements with regard to staff deployment were complied with. In the follow-up meeting of 11/04/07 at the Bedfordshire social services, it was acknowledged that it is the proprietor‘s openness, co-operation and commitment that has helped to turn the situation around and the group thanked her for it and stated that this now put closure on recent events from Bedfordshire social services point of view. Of the 10 service users who responded to the commission’s survey, of which 8 service users’ have said that they always speak to if they were not happy with any of the service at the home and 10 service users’ said they were aware how to make a complaint. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was maintained clean and tidy and the service users’ were happy about it. However, the recommendation of fire authority personnel needed implementation and the water pipes under the washbasin of a service user bedroom need covering. EVIDENCE: On this inspection partial tour of the premises was undertaken and found that the home was maintained clean and tidy without any offensive odours. The pre-inspection questionnaire provided by the home indicated that, the home had carried out the maintenance and completed the associated records of fire equipment, fire drill, fire alarm test, central heating system, water temperature checks, emergency lighting, hoist/adaptation, emergency call system, environmental health officer visit, gas engineer, lift engineer, and disposal of soiled waste. However, fire officers visit report of 30/10/2006 was not available on this inspection. The proprietor and the manager had written to the commission in their letter dated 10/05/07 that they had contacted the fire officer and found out that the report went to a wrong address and a fax copy Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 16 of the same was obtained. The home had also confirmed in writing that the fire audit would be completed by the end of May 2007. Laundry room in the first floor was converted to a bedroom for a service user who was unsettled on the second floor but now feels at ease with her new bedroom on the first floor, which was also a convenient location for staff member to monitor her. This change had resulted in positive outcomes for a service user. The bedroom had a chair, bed, and emergency call system, washbasin and a chair commode. However, the water pipes under the washbasin needed covering. The home was registered for 10 beds and the conversion had not resulted in change of number of bedrooms. However, the ground floor bathroom was now converted into a laundry room for ease of operations, which resulted in the reduction of 1 bathroom. The home currently had 2 shower rooms and 4 toilets. The notice of change, information was provided in the pre-inspection questionnaire after the alteration to the premises had taken place. The home has the responsibility to inform the commission prior to the proposed changes to the premises are significantly altered under regulation 39(h). The commission expects the home to take note of this observation and not repeat in future. The home now had replaced the dinning furniture with the new, the pay phone has been now removed from the dinning room, arrangements have been made in the lounge with a cordless phone with a system and procedure of recording any personal out going calls for staffs. The home was in the process of arranging OT audit; the proprietor informed that the home was waitlisted. The proprietor and the manager had updated their diary to follow-up. Of the total 10 service users’ those who have responded to the service users’ survey, all of them have said that the home is always fresh and clean. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s policy on staff recruitment was comprehensive and the home had improved staff ratio with appropriate skill mix, to match with the current and changing needs of the service users’. However, the home must complete statutory checks of all the staffs working at the home. EVIDENCE: The new management had inherited the staff already working at the home and on search of their personnel records found that the 2 staff members CRB was missing. The inspector advised the manager and proprietor on this inspection to carry out a thorough search again and in the event of not being able to locate, the home need to make a CRB application. The commission had received a letter dated 10/05/07 from the home which mentioned that applications have been submitted for re-check of CRB for the 2 staff members whose original CRB’s were missing. The home had carried out the statutory checks of the 2 new care staffs and a manager appointed recently. A random inspection was carried out on the 14/03/07 and found that the requirements relating to the staffing levels and deployment were complied with and this was confirmed with staff rota and staff deployment seen on this inspection. The staff now do not have extended hours of work and operate on an 8 hour shift. There were 3 staff members on the morning and afternoon shift and 2 staff members on the night shift. The home had carried out staff need assessments and developed a staff-training calendar. Some of the Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 18 trainings the home plan to provide to their staff include; diabetes awareness, fire safety awareness, POVA, report writing, infection control, emergency aid, administration of medication, and understanding mental health. The staffs’ appeared to have good working relations with the service users’, service users families, and external professionals. 10 service users’ those who have responded to the commissions’ survey all of them have said that the staff listen and act to what the service users’ say and are usually available when they need them. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had maintained good standards of care delivery and good working relations with the service users’ and their family members, staffs and relevant professionals which had been useful for appropriate care delivery and in meeting the service users’ assessed needs. EVIDENCE: The home had produced an improvement plan in response to the previous key inspection and made significant improvements in quality of care since then and continued to improve further. The home as part of the quality assurance system and practice had developed service users’ comment card and has received comments from 6 service users’. The home also had received letters of satisfaction from the family members of the 5 service users’. On the 30/11/06 the home was in receipt of a letter from Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 20 assessment network ltd congratulating on successfully completing recent investors in people review. The home had made progress with social services for the change of authorised signatories, as the authorised signatories were the previous owner of the home. Currently, the Houghton lodge, Bedfordshire social services was managing money of a service user, the proprietor informed on this inspection. The home had now devised a procedure to supervise staff once a quarter and in any special circumstances the supervision would happen in less than 3 months time. 2 staffs supervision dated 23/11/07 and 14/12/07 was seen on this inspection. The fire officer visited on the 30/10/07 and confirmed the present arrangement of wedged open doors was fine the provider mentioned on the inspection. The home now informs the commission of any notifiable incidents/accidents that take place. The home had provided information to the commission with regard to various policies, procedures, and codes of practice that would impact upon the life of the service users’. They included adult protection, administration of medication, fire safety, equal opportunities, food safety, and nutrition, racial harassment, record keeping, recruitment, privacy, quality assurance - investor in people, and dignity at work place. The management had terminated the services of the previous manager on the basis of irregularities found in her reference and a completed form was sent to the POVA Register and reported the matter of the false references to the police. The management, on completion of statutory checks had appointed a new manager who reported to duty on the 11/04/2007. The manager was observed to communicate effectively with both service users, staff and appeared approachable. The manager of the home had provided effective leadership and managed the home professionally with the support of the proprietor. The key to good management of this home was having good working relations with the staff, service users’ and their family members, and relevant professionals and the proprietor. Service users and staff who were spoken to supported this view. The home had an inclusive atmosphere. The new manager is a registered nurse since 1978 and gave evidence of substantial experience working in hospitals and with care of the elderly in short term rehabilitation and now undertaking RMA. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 22 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 OP19 Regulation 23 (4) Requirement The home must after consultations with the fire authorities implement all recommendation made in their report. The home must carry out an audit of the home with the help of an occupational therapist and implement the recommendations made in the report of the occupational therapist. (Previous time line 30/09/06, 30/11/06) The home must satisfactorily complete all the statutory checks of all the staff working at the home. Timescale for action 31/05/07 2. OP19 23 15/06/07 3. OP29 19 15/06/07 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 Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 23 1. 2. OP24 OP15 The home should cover the water pipes under the washbasin in a service user bedroom. The home should carry out nutritional assessments of all service users’ and update care plans, and revise the food menu where ever the changes need to be made with specific reference to the service user’s nutritional needs. Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Sandhurst Lodge DS0000064699.V337556.R02.S.doc Version 5.2 Page 25 - 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!