Inspection on 23/01/07 for The Martins

This inspection was carried out on 23rd January 2007.

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 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

The Martins 14/01/09

The Martins 20/01/06

The Martins 17/08/05

The Martins 24/02/05

The Martins 01/09/04

The Martins 26/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Martins The Vinefields Bury St Edmunds Suffolk IP33 1YA Lead Inspector Jane Offord Unannounced Inspection 23rd January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Martins Address The Vinefields Bury St Edmunds Suffolk IP33 1YA 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) 01284 753467 01284 725807 home.bur@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Wendy Tomlinson Care Home 42 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (20) of places The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 Brief Description of the Service: The Martins was rebuilt in l998, to an extremely high standard. The Martins stands in its own beautifully kept grounds, which are frequently used by residents. The main view from the Home is towards Bury St. Edmunds town centre. Many rooms look on to the historic Abbey Garden ruins and the cathedral, with the River Lark running between the ruins and the home. All community facilities are available in the town centre. The purpose built home is constructed on an incline, therefore has a lower ground floor, which is Lark Close, a ground and first floor that are the main part of the home. The Home has 42 single rooms, each with en-suite WC facilities. Communal areas in the main home comprise a large sitting room and dining room, both of which have entrances onto the veranda and a second lounge on the ground floor. There is an additional sitting room on the first floor equipped with tea making facilities. There is a purpose built hairdressing salon and a small courtyard in the middle of the Home. Lark Close is more compact, designed in a simple L shape. It has a kitchen/diner and two lounges for communal space as well as individual bedrooms. It also benefits from a secure sensory garden containing sculptures, seating and scented plants. The home offers accommodation to twenty older people requiring residential care and is registered to support a further twenty-two people with dementia. People with dementia are accommodated in Swallow Close and Lark Close. The fees range between £437.00 and £550.00 per week and do not include the cost of hairdressing, chiropody, newspapers and toiletries. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place between 9.30 and 16.00 on a weekday. The manager was present during the day and assisted with the inspection process. This report has been compiled using information available and evidence found during the inspection. Three new residents’ files, care plans and daily records, three new staff files, the policy folder, some maintenance records and minutes of meetings were all inspected in the course of the day. A number of staff, residents and relatives were spoken with and part of a medication administration round was followed. The medication administration records (MAR sheets) and the controlled drugs (CD) register were seen. A tour of the home was undertaken with the manager but all areas of the home were revisited in the course of the day. The weather on the day of inspection was cold and wintry but the home felt warm and welcoming. Everywhere was clean and tidy with no unpleasant odours. Residents were using all areas of the home and looked comfortable and relaxed. The meal served at lunchtime looked appetising and residents spoken with said they had enjoyed it. Interactions observed between residents and staff were respectful and friendly. What the service does well: The service offers individual care to residents with a range of abilities in excellent surroundings. The décor in the home is attractive and maintained to a high standard. The service has a Christian philosophy underpinning the care it offers and there are regular services and prayer meetings for residents to take part in if they wish. There is also a wide range of other activities available and residents clearly enjoyed the challenges of seated exercises and the newspaper crossword on the day of inspection. There is a commitment to staff training with a full programme of varied training sessions for staff throughout the year. New staff have an induction programme before being encouraged to achieve NVQ awards at level 2 and 3. The home holds regular meetings for residents and relatives to inform them about any changes in the home and offer them the opportunity to express ideas and suggestions for improving the service. There is also a monthly magazine produced that includes activities and services that have taken place and those that are planned for the coming month. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. People who use this service can expect to have their needs assessed and an assurance given that they can be met before moving into the home. This service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of three new residents were seen and each contained a pre-admission assessment completed by a senior member of staff before the resident came to the home. The assessment covered aspects of daily care that the resident may need some support with such as personal hygiene, mobility, continence, nutrition and communication. Other areas considered were orientation, night needs, religious wishes, health promotion and medication. The terms and conditions seen showed that if a resident was offered a place at The Martins there was a trial period of eight weeks and a review of the placement. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 9 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, 10. Quality in this outcome area is good. People who use this service can expect to be treated with respect, have their health needs met and have a care plan to help carers support them in their daily life. They can also expect to be protected by the home’s medication administration policy and practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were inspected and showed individual interventions for the residents’ needs. Areas covered included personal hygiene, dressing/undressing mobility, night needs and nutrition. One care plan had a note that the resident wanted support for personal care from a same gender carer. There were comments from residents on their emotional and mental well-being included. One resident had said, ‘living here reminds me of boarding school, which I loved, I am so content and happy here’. The files had risk assessments for moving and handling and one had a risk assessment for the resident to bath alone. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 10 The Waterlow scores for tissue viability were completed but did not always generate an intervention if the score indicated the resident was at risk. The categories of risk would have been more useful with an action flow chart to accompany them. This was raised with the manager who later said that the company were in the process of developing one for use in all their homes. There was evidence that residents’ final wishes were discussed and recorded together with their chosen resuscitation status. ‘I have discussed this decision with my son’. The daily records seen were not very informative and restricted reporting generally to physical care given. Mood, emotion and activities were rarely commented on so there was no real feel for the overall experience of the resident. There was evidence that the care plans were discussed with residents who could understand and evaluated monthly. The medication policy was seen and had guidance on ordering, storing, administering and disposing of medicines. The medication administration records (MAR sheets) seen were all correctly completed. Each MAR sheet had an identification photograph of the resident attached and the folder contained a list of signatures and initials of the staff qualified to administer medicines. The carer doing the lunchtime round said they had had medication administration training twice and had an annual competency assessment from the manager. Their practice was safe on the day of inspection. Records of the temperature in the clinic room and the drugs refrigerator showed they were both within safe limits for storing medication. The controlled drugs (CD) register was seen and stocks checked against the entries. They tallied with the records. A quality assurance audit done in November 2006 that covered dignity, respect and independence showed that residents were satisfied with the way staff worked with them. They felt that staff upheld their privacy but did request some ‘Do not disturb’ notices. The manager said these had been bought for the residents’ use. One resident asked about bathing alone and was told a risk assessment could be done for that. As noted earlier in the report this was done. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 11 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, 15. Quality in this outcome area is excellent. People who use this service can expect to be encouraged to maintain contact with family, friends and the community, offered meaningful pastimes and receive a well-balanced and varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ files seen all contained details of the next of kin, the resident’s religion and a life history. One recorded, ‘XXXX goes to the Cathedral for a service every Sunday’. In one care plan under living/working/recreation a resident had said, ‘Make sure I have an up to date calendar of activities so I can join in’, another one said, ‘I have led a fulfilled life and continue to enjoy my later years’. The home employs an activities co-ordinator who divides their time between the different units. On the day of inspection there was a sing along in Lark Close with some old songs on a compact disc, a group of residents organised their own seated exercises in the dining room and in the afternoon the coordinator did a newspaper crossword with some residents before tea. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 12 An activity programme run by the staff and the activities co-ordinator for residents in the special needs units offers a variety of pastimes including cooking, gardening, carpet bowls, exercises, reminiscence therapy and Sonas activity, which is an activity developed for helping communication with people with dementia. The home also has a number of volunteers who assist with activities doing poetry sessions, craft and art sessions and spending time chatting with residents. A number of ‘have your say’ comment cards were received by CSCI prior to this inspection and all were positive in their comments about the activities and entertainments arranged in the home. One said, ‘There is a member of staff dedicated to activities. They are popular and hard working’. Another one said, ‘We have an excellent activities co-ordinator. The time flies here as we have so much to do’. The home has morning prayers each day with a service on Sundays and Wednesdays. Although the home is owned by a Methodist organisation other denominations are welcomed and Anglican Holy Communion is celebrated monthly for any resident who wishes to participate. Visitors were seen to come and go during the day. Staff welcomed them and made them comfortable with their relative or friend. Fifteen relatives/visitors comment cards were received by CSCI prior to this inspection and without exception they say they are made welcome by the staff. The lunchtime meal was seen served after Grace had been said. Dishes of vegetables were placed on each table for residents to help themselves if they were able. Carers helped residents who could not manage alone asking which vegetables they wanted and how much. The main meal choice was pork steak or broccoli pasta bake followed by Bakewell tart and custard or fresh fruit, yoghurt or ice cream. The meal looked appetising and well served. One resident spoken with afterwards said, ‘Lunch was lovely. I always clear my plate’. In the ‘have your say’ comment cards residents have written, ‘Good, wholesome, tasty meals. Plenty of choice every day’, and, ‘Meals are well cooked and served in an excellent dining room’. The kitchens were visited and found to be clean and tidy with dry foods correctly stored. Food in the refrigerators was clearly dated and labelled. The records of temperatures of the refrigerators and freezers showed they were all functioning within safe limits for food storage. The cook has only been in post for a couple of weeks but has a wide experience in the food industry. They said they plan to consult with the residents at the monthly meetings about the menus and look at making changes to the choices offered if the residents wish that. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 13 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, 18. Quality in this outcome area is excellent. People who use this service can expect to have any complaint taken seriously and investigated and be protected from abuse by staff training and knowledge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Thirteen ‘have your say’ and fifteen relatives/visitors comment cards received prior to this inspection all record that they are aware of the complaints policy of the home and are quite clear about who they would approach if they had a concern. CSCI has not received any complaints about this service since the last inspection. The home has received three concerns that were actioned following the policy. Two concerns were about changes to the menu and these were done, the third was for stable shower chairs and these were purchased. The compliments folder was seen and showed a large number of comments about the high standards in the home. One said, ‘A big thank you to you all for all you did to give the residents a really Happy Christmas. All the hard work and planning were appreciated’. The Protection of Vulnerable Adults (POVA) policy was seen and offered guidance based on the guidelines issued by the Suffolk POVA committee and was cross-referenced to them. The home has a whistle blowing policy to protect staff if they report a colleague. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 14 The annual staff training plan supplied to CSCI with the pre-inspection questionnaire (PIQ) showed an objective for all staff to be updated on ‘abuse in care homes’ by January 2007. Staff spoken with, including ancillary staff, said they had had the training and found it interesting and helpful. They were clear about their duty of care and knew what to do if they had any concerns about the residents. The Martins DS0000024443.V328129.R01.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, 25, 26. Quality in this outcome area is excellent. People who use this service can expect to live in a clean, safe, attractive home that is well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection everywhere in the home was clean and tidy with no unpleasant odours. The atmosphere was welcoming with vases of fresh flowers and bowls of fruit in some of the communal areas. As well as the main lounges there are small seating areas throughout the home that can be used for private meetings or just to be quiet. The décor is attractive with a selection of interesting pictures in the wide corridors that give a feeling of spaciousness to the building. A large number of the rooms look out over the ruined abbey and Abbey Gardens with the Cathedral on the skyline. Residents spoken with commented on the inspiring views from the windows. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 16 There is a rolling programme of redecoration and the upstairs corridors have recently been re-carpeted. During the better weather last year the external paintwork was done and major repairs to the boiler for the heating and hot water systems were undertaken. The home employs a full time maintenance person who is responsible for the day-to-day repairs and regular checks on hot water, electrical equipment and external hazards such as irregular paving or blocked guttering. Residents’ rooms seen were all individualised with personal pieces of furniture, ornaments and pictures. The special needs units had memory boxes outside each resident’s room that contained items of specific significance for that resident chosen by the resident or their representative. The home throughout was light and airy with all radiators covered to prevent harm. The laundry was clean and tidy. Hand washing facilities in the home were all equipped with liquid soap and paper towels. Staff spoken with were able to explain universal precautions for prevention of cross infection and there was protective clothing available for use. The Martins DS0000024443.V328129.R01.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, 30. Quality in this outcome area is excellent. People who use this service can expect to be supported by adequate numbers of correctly recruited and well-trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that during the day there were eight carers rostered supported by domestic and laundry workers, a maintenance person and an activities co-ordinator. The kitchen has a cook and kitchen assistant and the home has two part time administrators. The registered manager is in the home most days and is supernumerary. The nights are covered by a senior carer and three care assistants. The files for three new staff were seen and contained a recent photograph of the person, a complete work history and evidence of the interview questions and responses. There was documentary evidence that identification checks had been made and POVA 1st and criminal records bureau (CRB) checks had been received prior to commencing work. Each file contained two references and the copy of a contract stating terms and conditions of employment. There was evidence that on the first day staff received training in moving and handling methods followed by and induction over the next few weeks. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 18 Some of the induction took the form of videos with question and answer sheets to ensure the member of staff had understood the content of the video. Areas covered included fire awareness, health and safety, 1st aid, delivering personal care, residents’ privacy, choice and rights. Ongoing training included food hygiene, POVA, care planning and control of substances hazardous to health (COSHH) regulations. Staff spoken with confirmed they had regular training sessions that included more specialised areas of care such as managing medication, dementia awareness, stoma care and care of the dying. The home employs thirty-two carers of which twenty have achieved an NVQ level 2, or above, award with a further ten starting the training in January 2007. This means the workforce is above the standard of 50 of carers holding an NVQ 2, or above, recommended in the National Minimum Standards (NMS). The Martins DS0000024443.V328129.R01.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, 38. Quality in this outcome area is excellent. People who use this service can expect to have their opinions sought and their financial interests and welfare protected. They can also expect that the home is run by a responsible manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for two years and has a wide experience in the field of caring for older people. They showed strong leadership skills and staff spoken with said they were approachable and fair. One ‘have your say’ comment says, ‘The manager….. is accessible and helpful’ and one relative/visitors comment card says, ‘The manager’s care and skills are exemplary’. The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 20 One resident in their ‘have your say’ card has put, ‘I now truly feel this is my home. There is a great deal of laughter and good humour here, which is a good sign of a well-run establishment’. There is a residents’ meeting held monthly and a relatives’ meeting held two monthly. Minutes of the meetings are made available and show that a wide range of issues are discussed from information about the boiler repairs to recruitment of staff, the new care plans and arrangements for Christmas. The concerns noted in a previous section of this report about food changes and the shower chairs were issues raised at the residents’ meetings. The administrator explained the system for managing residents’ personal monies. Individual transactions are recorded and receipts are kept. There is a separate wallet for each resident’s money and a number were checked at random. The contents all tallied with the records. The home had a visit from the fire officer in August 2006 and their report stated that they, ‘confirmed that the outcome (of the visit) was considered to be satisfactory’. A number of general risk assessments for the environment were seen and covered areas of risk such as hot water, upstairs windows, the coffee machine for the use of residents, visitors and staff that stands in the entrance hall, the use of the kitchen in the special needs unit and COSHH requirements. There were also assessments covering access to the gardens, residents’ outings and residents who wished to go to the town unaccompanied. The Martins DS0000024443.V328129.R01.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 X X 3 X X 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 The Martins DS0000024443.V328129.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NONE 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 (1) Requirement The registered manager must ensure that residents who have an assessment that indicates they are at risk have a care plan intervention generated to manage the risk. Timescale for action 23/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered manager should encourage fuller daily records to cover areas of residents’ experience apart from just physical care. 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