Inspection on 15/09/05 for Spring Mount

This inspection was carried out on 15th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Spring Mount 05/01/07

Spring Mount 15/02/06

Spring Mount 16/11/04

Spring Mount 29/06/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Spring Mount Parsons Road Heaton Bradford West Yorkshire BD9 4DW Lead Inspector Barbara Grell Unannounced Inspection 15th September 2005 9:00am X10029.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 Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 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 and Care Homes for Adults 18 – 65*. 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. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Spring Mount Address Parsons Road Heaton Bradford West Yorkshire BD9 4DW 01274 541239 01274 772000 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) Mrs Janet Bell Mrs Jacqueline Taylor Smith Mrs Janet Bell Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24) of places Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16.11.04 Brief Description of the Service: Spring Mount was established and first registered in 1987. Janet Bell and Jacqueline Taylor Smith are the registered providers and also manage the home. It is an impressive detached house situated in it’s own half acre of well maintained garden. The grounds are secure in order to ensure the safety of the service users whilst enabling free movement. Spring Mount aim at providing a homely, family type environment for individuals of all ages suffering from memory disorder and dementia. Accommodation is provided on three floors. Those with mobility needs have rooms on the ground floor, as there is no lift installed. The local area features shops, bus routes, pubs and the Lister Park. The overall philosophy at Spring Mount is to care for people with dementia without the effects created by the administration of sedating medication. Staff in the home use a holistic, psychotherapeutic approach toward problems associated with dementia, enabling the person to come to terms with, and learn to live with their dementia in a positive way, regaining dignity and selfrespect. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken unannounced by one inspector on 15 September 2005 between 9:00 and 15:00. The inspection was completed on 20 October 2005 and all materials received back by this date helped to inform the findings. Previous inspection reports and information on other social care services are available on the Internet www.csci.org.uk. The following methods were used during this inspection. Survey materials were provided for completion. Five relatives/visitors and two professional visitors completed and returned surveys. The inspector had discussions with both provider/managers and ten of the staff. Service users were observed in their activities and fourteen service users were able to make comment about the care in the home. Additionally three of the service users visitors were able make comment about the standard of care and services at Spring Mount. Three of the service users case files were inspected. Medical administration and record keeping was observed and inspected. Materials were looked at pertaining to staff training and supervision. What the service does well: Service users and visitors take advantage of the various communal rooms and gardens. The gardens allow for free movement outside and many of the service users go out regularly for a walk or a rest using the garden furniture provided. Service users are able to use their own rooms at any time. The surveys returned showed that visitors are generally satisfied with the care and services provided at Spring Mount. One professional complemented the home in respect of it’s holistic and person centred approach and this was apparent during the inspection. The service users spoken to did not feel that they were restricted in their lifestyle or movement and use of the communal rooms at Spring Mount. Service users had good relationships with the staff assisting them. Staff are described as helpful. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 & 6 The assessment process ensures that service users needs are met. The service users benefit from good partnership working with other agencies. EVIDENCE: Spring Mount has devised a statement of purpose/service user guide that gives the required information. Specific detail about the philosophy and aims of the home are made clear. A copy is available in the general office and visitors and service users are able to access this. An assessment is undertaken and recorded within an appropriate format that covers all areas. In many instances an assessment is provided via the care management process and this forms the basis of the assessment continued Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 9 and recorded by staff in the home. This service has got specific admission criteria that must be met. Service users must have a diagnosis of Dementia or similar. A number of service users with additional physical disabilities can be accommodated on the ground floor. One placing officer commented that the home works in partnership with other agencies and is “very impressed with the person centred approach”. Prospective service users and their relatives or other representatives are invited to visit the home prior to admission. A relative spoken to visited the home prior to admission. The home was chosen for the philosophy. This is a good example that information is provided to a good level and service users and their representatives are informed and hence able to make informed choices about this service. Spring Mount does not provide intermediate care. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The service user plans are in need of update when service users have deteriorated and more staff assistance is needed. Monthly reviews must be undertaken by staff and recorded. The service users health care needs are well monitored with the involvement of NHS professionals. The medical administration system and practices ensure the safe administration and storage of medicines. Service users are encouraged to practice their daily living skills and assistance provided by staff is provided sensitively and in a way that ensures service users dignity and privacy. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 11 EVIDENCE: The care plans are based on the assessments undertaken. It was noted during the previous inspection that not all care plans reflect the changing needs of service users. Reviews must be undertaken by staff monthly and a record kept. Changes must be made to the care plan when needed. The care plan must lay out in detail the action to be taken by care staff in order to meet the identified and assessed needs. Two of the three service user plans inspected had no monthly reviews recorded. The care plan did no longer reflect the needs of the service users as both had clearly deteriorated since the recording of the assessment. One care plan had not been updated since March 2003. Previous requirements made must be urgently implemented. It is additionally recommended the registered person undertakes an audit of the quality of recording and updating service user files. Staff spoken to were clear about what assistance they needed to provide in order to meet the needs of the service users. Their knowledge and practices was not reflected in the records kept. The management aims at involving service users and their representative on a formal, annual basis in the review. One file included good evidence of this process. The case record included details of any medical needs, check-ups, observations, appointments and treatments. NHS nurses provide any nursing treatments. The nurses commented positively on the care and services provided at Spring Mount. They are appropriately assisted by staff and interactions showed good relationships and communication. The treatment of service users is undertaken in private. Case records showed regular and ongoing treatments. Policies are applicable and implemented when service users are unable to give consent to treatments. The medical administration record is well recorded by staff. Medicines are kept safe and only appropriately trained staff administer medication. The philosophy of the home is to keep intervention by medication to a minimum. There are few examples of service users requiring medication that might be seen as modifying extreme behaviour. Service users have access to NHS services via the usual referral processes. All service users are registered with a local GP. Service users are accompanied by a relative or member of staff when attending outpatient appointments. Community Psychiatric Nurses are involved in the treatment and monitoring of some of the service users. Assessments are undertaken in respect of the risk of falls, nutrition and skin viability. The service users spoken to were clear that they follow their own chosen routine. Service users were able to mix with others or stay in their room if Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 12 they wished. Many of the service users are independent and only need prompts from staff to enable tasks of daily living. A few help in the garden or with other domestic tasks. More dependant service users are assisted by staff to be comfortable, eat a meal or to meet their personal needs. Some service users have become friends and value the friendships with people in the home. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15 The staff ensure that practices do not restrict the lifestyle choices of service users and take into account their preferences. Service users were seen to engage in meaningful activities when able. The service users dietary needs are ascertained and addressed and there is a choice of food provided. Service users spoken to describe the standard of food as good. EVIDENCE: Service users were free to rise and have breakfast throughout the morning. Service users were able to walk freely and use communal areas, own bedroom or the gardens as they wished. Some were watching a show on TV and got quite involved in the discussion and had fun laughing about various topics. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 14 Those who smoke do so outside and a small outbuilding provides for shelter in case of rain. The smokers did not mind smoking outside and some were able to state health risks and passive smoking to be a problem. Daily records kept show that service users go out with staff to local pubs, for walks and to the park for example. Several service users commented that they enjoyed going to the pub especially. Many activities are lead by the service users needs and wishes at any time. Two service users had visitors. One visitor had lunch with her relative. Both described the care and services to be of a good standard. The two visitors and total of seven surveys returned stated that the visiting arrangements in the home are flexible and allowed for normal activities such as meals to be shared. Visitors said that they could use the service users bedroom for private conversations. Both were kept informed of the important issues in the service users life during visits and by phone. Contacts are maintained as much as possible with family and friends. The homes staff and managers arrange parties and relatives are invited. Pictures are displayed of events. The food is prepared by a cook and kitchen assistant in the main kitchen situated in the lower ground floor. The menus include daily choices and provide for soft & vegetarian options. The meal is served from a cafeteriastyle hot counter that allows service users a visual choice of the items available. Service users benefit from visuals. The menu plan takes account of the service users preference and waste is monitored to ascertain likes and dislikes for those who are no longer able to state their choice. Diabetic choices are provided to those who need it. Care plans comment on specific needs. Several service users are assisted by staff giving verbal prompts or assisting. The meal was well conducted and service users were able to eat their food unrushed. Service users said that there is always plenty of food and drink and meals are usually good. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not inspected on this occasion. EVIDENCE: Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 The home provides for good indoor and outdoor communal facilities. management ensure good maintenance ongoing improvement EVIDENCE: Spring Mount is situated in the Heaton area of Bradford in a converted and extended period property. The home is situated close to local amenities allowing. Main bus services are situated close by and there is parking within the ground or on road. The home is accessed via a secure system and any visitors have to ring a bell to gain access to the grounds and home. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 17 The There is an ongoing programme of refurbishment and the communal rooms have recently benefited from refurbishment. The home employs a full time gardener and handy person to provide for ongoing and prompt maintenance. There are four communal areas including a conservatory. The views offer sight of the large gardens from all windows. Many residents enjoy watching or going into the garden. Garden furniture is provided. The house has no lift installed at the present time limiting the access to the first and second floors for those with a disability. Service users benefit from the ongoing use of the staircase in respect of their mobility skills. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30 The numbers and skill level of staff on duty was in line with current requirements and sufficient in meeting the needs of the service users. EVIDENCE: During this inspection a senior care assistant lead a team of four care assistants, two cooks, laundry assistant, two domestic assistants and one handy person/gardener. This is in line with the current requirements for the home. The senior care assistant acts as shift leader. Several newly appointed staff were on duty during this inspection. Employees undertook their work unrushed. Both provider/managers were on duty during this inspection. The survey material returned by professionals showed that there is always a senior member of staff is on duty to confer with. Four out of five visitors stated in the surveys returned that there are always sufficient staff on duty. One felt this not to be the case. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 19 The new employees confirmed that they were in the process of undertaking induction training or had completed this. Staff receive appropriate training in line with the Sector Skills Council requirements. The induction training process commences with a two-week plan and the worker working alongside an experienced member of staff. The training plan shows that staff receive a minimum of five days paid training each year. The homes managers provide dementia training that includes the homes aims and philosophy. Two staff on duty have completed NVQ level 2 or 3 training. Support is provided from the organisation both financial and practical for staff to complete professional and NVQ training. Foreign conversion nurses are supported and work at the home whilst undertaking further training outside of Spring Mount. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 35 The managers exceed the standard in respect of qualifications. Their qualifications, experience and skill level ensures that the homes is managed to a good standard and staff supported in their roles. EVIDENCE: Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 21 The two registered providers manage the home. They share the duties of a registered manager and provide some of the training and supervision. They are involved in the management of the ongoing care of the service users and assessment and admission of new service users. The managers also take a lead during joint care reviews. The managers are both qualified nurses and have undertaken management and degree level training. This exceeds the required standard. Staff meetings are held several times annually and staff spoken to state that they are encouraged to attend. Annual appraisals are undertaken and recorded. The staffs training needs are ascertained and recorded during this process. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 X 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X ENVIRONMENT Standard No Score 19 3 20 3 21 X 22 X 23 X 24 X 25 X 26 X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 X 33 X 34 X 35 3 36 X 37 X 38 X Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 & 17 Requirement Service user plans must be updated in line with their changing needs. Staff must review the service user plans every month. A record must be kept. (Item outstanding from previous inspection.) Timescale for action 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33OP7 Good Practice Recommendations It is recommended that the registered person undertake ongoing review of the quality of recording of the service user plans. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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. Spring Mount DS0000001147.V267489.R01.S.doc Version 5.0 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. 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