Inspection on 28/01/09 for Shakespeare Way (4)

This inspection was carried out on 28th January 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

Shakespeare Way (4) 20/03/08

Shakespeare Way (4) 15/08/06

Shakespeare Way (4) 01/03/06

Shakespeare Way (4) 01/12/05

Shakespeare Way (4) 28/02/05

Shakespeare Way (4) 25/01/05

Shakespeare Way (4) 26/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Shakespeare Way (4) Aylesbury Bucks HP20 1JF two star good service The quality rating for this care home is: 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: Barbara Mulligan Date: 2 8 0 1 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. They reflect the things that people have said are important to them: 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 Adults (18-65 years) 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. 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. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Shakespeare Way (4) Aylesbury Bucks HP20 1JF 01296426332 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): jackieaklippel@yahoo.co.uk MacIntyre Care Name of registered manager (if applicable) Miss Jaqueline Klippel Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 6 0 care home 6 learning disability Additional conditions: The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - LD The maximum number of service users who can be accommodated is: 6 Date of last inspection 2 3 0 3 2 0 0 8 A bit about the care home 4 Shakespeare Way is situated a short distance from the town centre of Aylesbury, where a variety of shops and other local amenities can be found. The town is served by local public transport, including rail and bus links. Bus routes pass within walking distance of the home. 4 Shakespeare Way is run by MacIntyre Care who are a well established provider of a range of day and residential care services for adults and young people with learning disabilities. The home provides accommodation for up to six adults with learning disabilities. The home works with service users who have developed moderate levels of independent living skills so that the role of staff is essentially one of support and guidance, rather than direct provision of care. The home comprises two linked semi-detached properties that offer single bedrooms to each service user, along with communal lounge, kitchen, dining and laundry areas. At the time of this inspection there were five service users in residence. Fees for placements at the home currently ranged from £37,292 to £40,390. 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 Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home. This unannounced key inspection was conducted over the course of a day and covered the entire key National Minimum Standards for younger adults. Prior to the visit, a detailed selfassessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. Six CSCI surveys were received before the site visit was completed. The inspection officer was Barbara Mulligan. The inspection consisted of looking at some of the homes records, observation of practice, and discussions with the staff on duty and a tour of the home. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the acting head of service at the end of the inspection. The people who live in the home and the care staff on duty are thanked for their co-operation and hospitality during this unannounced visit. What the care home does well. The home is a nice and comfortable place to live. People who want to live at No 4 Shakespeare Way will have their needs assessed before they move in, to make sure the staff can meet the needs of the people who live there. Staff help people who live in the home to keep in contact with family and friends. The home provides good healthy meals for all the people who live there. There are safe recruitment practices are in place that protect the people living in the home. There are health and safety checks carried out regularly in the flats to keep the people who live there safe. The home deals with a number of diverse care needs and always makes sure the different needs of people living in the home are met. What has got better from the last inspection. Care plans are being updated and improved. All medicines which have a short shelf life, are dated when opened. Repairs have been completed in the bedroom and bathroom to provide more comfortable surroundings for people living at the home. The practice of sharing bars of soap has stopped. All risk assessments have been brought up to date so people are safe when they go out and take part in activities. . What the care home could do better. All care plans should be completed using the care plans. The organisation should recruit for the 2 staff vacancies at the home. If you want to read the full report of our inspection please ask the person in charge of the care home. If you want to speak to the inspector please contact Barbara Mulligan Burgner Ho, 4630 Kingsgate,Cascade Way Oxford Business Park Cowley Oxford OX4 2SU 018 6539 7750 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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 . Prospective service users are thoroughly assessed prior to admission and are given opportunity to visit the home beforehand to ensure it meets their needs. Evidence: There have not been any new admissions to the service in the past twelve months, according to information supplied prior to the inspection. At the last inspection, documents relating to the most recently admitted service user were examined and found to be in good order with a detailed and comprehensive needs assessment which indicated that the service user had been involved in the process. The home does not take emergency admissions and is not registered to provide intermediate care. People using the service who completed the CSCI surveys indicated that they had been involved in the decision to move into the home and had been given sufficient information about it beforehand. Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. 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 . Service user plans are in place, which outlines service users needs, however these would benefit from completion using the newly implemented care planning format. The way service users make choices and the management of risks promote continuity of care and service users well being. Evidence: Following the previous inspection a requirement was issued for details within all the service users files are accurate and kept up to date. Three care plans were examined during this inspection. The home is in the process of changing the care planning documentation to a new format. One care plan has so far been completed using the new format and this was examined. The file completed using the new format includes a photograph of the person, for easy identification, and a detailed care plan and accompanying risk assessments. This file is better organised and indexed. It contains essential information about the person, a detailed pen picture, details of people who support the person, intimate care guidelines including preferred gender of staff to give assistance, and an outline of the persons daily routines. The Acting Head of Service was asked how long it was expected to complete the remaining care plans in the new format. She has estimated this will be by the end of March 2009 and this is strongly recommended. The main new areas added to the care planning documentation details the support needs in relation to eating and drinking, cooking, personal space, domestic tasks and decision making and choices. This latter section outlines how people using the service make decisions and was divided into decisions the person can make for himself or Evidence: herself, those they need some support with and those they need full support with. The file contains the persons likes and dislikes, how the person communicates, their learning activities, support in managing finances and cultural and faith needs. The persons physical and mental health needs have been documented and include information about any other people involved in their care, such as a dietician and speech therapist. The individuals emotional care needs have been recorded as have behaviours causing concern, with information on how to support people in these areas. All information has been dated and shows evidence of regular review. The remaining two care plans seen were individualised and detail how the individual wishes to be supported, and the documents that had not been filled in and left blank at the previous inspection have been completed. There is good use of photographs and pictures to make the care plans more user friendly and the new format is written with a person centred approach. House meetings take place on a regular basis and minutes were in place to note discussions or actions agreed. Risk assessment documentation is in place and these are signed and dated. Examples of risk assessments seen include personal care, medical and health support needs, relationships and emotional support, finance, learning opportunities, domestic/life skills, leisure, transport, home safety and challenging behaviour. Missing person procedures were in place in the event of anyone being absent from the home without notice and for staff to refer to, if need be. House meetings take place on a regular basis and minutes were in place to note discussions or actions agreed. Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. 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 use the service have a varied and active lifestyle, which reflects their interests, and are supported to maintain family links and friendships inside and outside the home.Service users receive a balanced diet but should be more involved in the planning of the menu. Evidence: Service users are involved in a number of activities during the week, mainly based at the MacIntyre day care services in Great Holm in Milton Keynes. Care plans demonstrate involvement in the coffee shop, bakery, the garden centre taking part in craft, drama and computer classes. There is also opportunity for those who were interested to develop office skills and undertake a National Vocational Qualification working at the providers central headquarters. There is good regard for the diverse needs of the people living at the home and their requirements related to their disabilities, lifestyle choices and personal preferences. On the day of the visit all people living in the home were attending places of work. There is evidence of individuals interests recorded in their care plans for example, football,walking, shopping and reading magazine, listening to music and watching DVDs. The inspector was told that all people using the service have their own mobile telephones in addition to the homes phone. The new care plan format provides details of what individuals do during the week, social likes and dislikes and information about how they access the community. Family Evidence: and social contacts were seen recorded in all files. The weekly menu is put together by people using the service taking into account specific diets and an awareness of individuals likes and dislikes. The inspector noted that individuals dietary intake is recorded and the menus indicate an alternative meal. There is a menu on the wall in the kitchen which is also available in a picture format. The kitchen was well stocked with food with plenty of fresh fruit and vegetables available.The menus demonstrate that meals are well balanced and choices are available.The acting head of service said that individuals are weighed regularly and the inspector saw these recorded for each person. Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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 . The health and personal care needs of people living at the home are well met and improvements have been made to medication practices to further safeguard service users. Evidence: Each person using the service has a separate file which provides detailed information about the type of support and assistance people using the service need in relation to personal and healthcare. In each file there is an intimate care policy that details how personal care is to be delivered to each person in a way they prefer. In the new care plan format there are new documents called, My personal health profile and My health which detail the support needed to attend healthcare appointments. Peoples medication was also noted in their care plan files. Records are maintained of appointments attended by people using the service and the outcome. These show that staff support people using the service to see their local GP and other community healthcare services when needed, both within the home and in the local community. Care plans viewed during the visit contained evidence of healthcare treatment and intervention. Evidence was seen in the files of hearing tests, visits to the psychologist, physiotherapist, occupational therapist, and dietician. Medication practices were examined during this visit to the home.Medication was stored safely and medication administration records were in good order with staff signatures alongside prescribed dose times. During the previous inspection it was identified that prescribed creams, which have a short shelf life after opening, did not alert staff to the date of opening and a requirement was issued for all medication, which has a short shelf life, is dated when opened to ensure the health safety and Evidence: welfare of the service users. It is pleasing to see that this has been complied with. There are guidelines in place for the administration of as required medicines, which were available in the medication administration records and individual, care plans. Records of medicines disposed of were in good order. Training records for staff expected to administer medicines were examined and it was noted that staff have completed a distance-learning course via Aylesbury college. The acting Head of Service told the inspector that she had recently completed a medication training course facilitated by the organisation and this will allow her to train care staff in-house to undertake the safe administration of medicines. It is the responsibility of the organisation to ensure that all medication training completed by care staff is accredited. Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. 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 . Procedures for managing complaints and adult protection are in place and people using the service and those close to them know how to complain if the need should arise. Their concern is looked into and appropriate actions are taken. Evidence: Most people completing comment cards were aware of how to make a complaint about the service. Those who had needed to raise issues added that the service had responded appropriately. The organisation are presently revising and updating the complaints procedure. The Annual Quality Assurance document indicates that the home has had one complaint in the last twelve months and this was seen recorded in the homes complaints log. This has been responded to within the stated timescales. Each user of the service has an individual book in which any concerns or complaints are logged and appropriate actions are taken. These demonstrate that concerns raised by people using the service are listened to and record the actions taken by the home. This is recognised as good practice. The Commission has not received any direct complaints or concerns during the last 12 months. The Annual Quality Assurance document indicates that there has been two safeguarding of vulnerable adults referrals in the last twelve months. However the care staff informed the inspector that there have not been any safeguarding referrals and the Commission has not been notified of any referrals. This may be a mistake on the AQAA and the acting Head of Service is requested to clarify this and inform the Commission for Social Care Inspection of the outcome. Training records show that staff completed Safeguarding training in 2008. The home has an up to date copy of the Buckinghamshires multi agency policy and procedures for the protection of vulnerable adults. Evidence: 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People using the service benefit from living in a comfortable, homely environment, which is clean and hygienic. Evidence: The home is situated in a residential area of Aylesbury and blends in with the surrounding houses. It comprises of two linked semi-detached properties that offer single bedrooms to each service user, with a bathroom and toilet upstairs on each side and a toilet downstairs. There is a communal lounge and dining area and a good-sized kitchen which has been refurbished since the last inspection. Access to the garden is through patio doors in the dining area. The garden is well maintained by people who use the service and are supported to do this by the staff team. During the previous inspection it was identified that the the seating arrangements in the lounge did not provide comfortably for all those living there. There were two-2 seater settees for the 6 residents, which if all wished to use the lounge left some with no choice but to sit in the dining room adjacent to the lounge, or go to their bedrooms. An extra chair had been provided in the lounge so there was adequate seating observed during this visit. Each service user has their own bedroom; none of which are shared and all are lockable to allow for privacy. All people who use the service were out at work on the day of the inspection and so the bedrooms were not observed during this visit.At the previous inspection however, it was identified that repairs were required to one particular bedroom in which there was damage to the wardrobe, one of the doors had a large hole in it and damage was also apparent to part of the wall. The acting head of service said that these repairs had been completed. At the previous inspection it was noted that there was a hole in one of the communal toilet doors and this has been Evidence: repaired. The home is not readily accessible to wheelchair users, there are no ramps to enable easy access and there is no lift. People who use the service and visitors to the home have to be able to use the stairs to access the upstairs bedrooms. A requirement was issued following the previous inspection for the practice of sharing bars of soap to cease to ensure that people are not at placed at risk from cross infection. The staff informed the inspector that service users have their own toiletries and dont share these. Staff support service users to undertake the cleaning at the home and cleaning schedules and records are in place to support this. On the day of the inspection the home was clean, homely and nicely presented. The laundry is separate from the kitchen and is spacious, clean and tidy. 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. 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 home provides staff cover to meet the needs of people using the service. Thorough recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. Evidence: The staff who were met during the inspection were knowledgeable and presented as good advocates for service users. At the time of the visit the registered manager was on maternity leave and the senior support worker was acting as head of service. There is one full time permanent support worker and three relief workers. The acting head of service said that they are about to commence recruitment for two full time support workers. This was also the case at the previous inspection and it would appear that this has not yet been undertaken. The organisation need to ensure this is addressed as soon as possible and is strongly recommended. This is a significant number of vacancies for a small team and the inspector enquired how the team have been managing to staff the home adequately. The inspector was told that there are three regular relief staff who have been working at the home on a regular basis. The Annual Quality Assurance Assessment (AQAA)tells us that the home has not used any agency staff. It is noted that the organisation has a formal agreement with the Commission for it to hold centrally some specific staff recruitment documentation and maintain a signed checklist within the home. Two staff recruitment files were viewed at this inspection including those new to the service. These show that all necessary clearances have been received. The AQAA tells us that two staff have recently had their CRB checks repeated as they have been in post for a long period of time. This is recognised as good practice. All newly recruited members of staff receive a structured induction training including shadowing more experienced carers until both parties feel confident and comfortable. Evidence: Copies of certificates from courses attended have been collated for each person working at the service. These demonstrate that overall the staff are up to date with first aid training, fire safety training and moving and handling training. The acting head of service needs to updated her basic food hygiene training. Further training undertaken by staff includes positive handling strategies, person centered care planning and communication. Feedback from staff was positive and they felt that the training was good and they were supported by the manager who provides them with regular formal supervision. There are regular staff meetings held and minutes are kept of these which the inspector observed. The staff on duty said they they felt involved in the home and that their views were respected. Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. 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 home has a registered manager ensuring continuity of care and there are systems in place within the home that are used to ensure that health, safety and welfare of the people who use the service are protected and promoted. Evidence: At the time of the inspection the registered manager was on maternity leave.The AQAA tells us that the registered manager has commenced the Registered Managers Award. The registered manager reports to an external line manager who carries out her supervision monthly and undertakes monitoring visits on behalf of the provider. In the absence of the registered manager a senior carer is acting as head of service for the home. She is being supported by the registered manager of another nearby home. The home has some quality assurance systems in place. Regular monthly visits are undertaken by the operational manager and these were looked at by the inspector. The most recent of these visits took place on 16th December 2008 and they follow a detailed format that shows speaking with staff and people who use the service is a regular feature of the visits, plus good practices such as examining a sample of individuals money and staff training records. During the visit the inspector observed service satisfaction questionnaires that had been sent out to individuals who use the service. These were sent out in 2006 by the organisation. The inspector was told that this has not been repeated since then. Although there is a residents forum that is held twice a week and facilitated by an independent person, service users using this service do not attend this. There are regular house meetings and Listen to me books which are systems used by the home to gather feedback from service users. Following the previous inspection a requirement was issued for all generic and Evidence: individual risk assessments to be brought up to date to ensure the health safety and welfare of those using the service. It is pleasing to see that that this has been complied with. Staff mandatory training is up to date with the exception of basic food hygiene training that needs to be completed by the acting head of service. A range of health and safety checks are in place at the service, carried out on a daily, weekly or monthly basis. Portable electrical appliances had been checked on 10/03/2008, electrical hardwiring was checked on March 2008 and a Gas service certificate was dated 14/01/2009. There are service certificates for fire equipment and emergency lighting and the home maintains records of weekly fire alarm testing. Fire drills are carried out with the full involvement of the service users and these are recorded in the homes fire safety records. There is evidence of water temperature recording, work placement risk assessments, accident and incident reports and health and safety risk assessments. Are there any outstanding requirements from the last inspection? Yes  No  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 1 6 15(1) That the manager ensures all 11/05/2008 care plans and other related individual care needs information in brought up to date for all service users. Repeated requirement 2 19 12 No information supplied 11/05/2008 3 20 13(2) No information supplied 11/05/2008 4 24 23(2)b No information supplied 31/05/2008 5 27 13(4) No information supplied 11/05/2008 6 42 13(4) No information supplied 11/05/2008 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 Description 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 Description 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 6 It is strongly recommended that all care plans are completed using the newly implemented care planning format. It is strongly recommended that the organisation undertake recruitment for the staff vacancies at the home. 2 33 Helpline: 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 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). 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