Inspection on 21/10/08 for Woodlands

This inspection was carried out on 21st October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands 09/11/06

Woodlands 24/01/06

Woodlands 09/08/05

Woodlands 03/03/05

Woodlands 11/11/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Woodlands 69 Queens Road Oldham OL8 2BA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Fiona Bryan     Date: 2 1 1 0 2 0 0 8 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. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Woodlands 69 Queens Road Oldham OL8 2BA 01616249344 F/P01616249344 woodlandsltd@tiscali.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Woodlands Residential Care Home Limited care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category sensory impairment Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Mental disorder, excluding learning disability or dementia - Code MD Sensory Impairment - Code SI (maximum number of places: 1) The maximum number of service users who can be accommodated is: 18 Date of last inspection Brief description of the care home Woodlands is a detached Victorian property situated one mile from Oldham town centre, close to local amenities and public transport. Accommodation is provided in 16 single rooms, 15 of which have ensuite. Of these, two bedrooms share an adjoining ensuite. One of the bedrooms is below the minimum 10 square metres required by the Care Homes for Older People Page 4 of 30 Over 65 0 0 18 0 18 18 0 1 Brief description of the care home National Minimum Standards. Communal areas consist of two lounges and a dining room, which leads onto a small conservatory area providing additional seating and a smoking area for residents. There are garden and patio areas to the front of the property, which are accessible to residents through the provision of ramps and handrails. There is a car park to the rear of the home. Residents gain information on the service through a service user guide, which is given to them prior to admission. The last inspection report is situated in the hallway of the home. The weekly scale of charges within the home range from £350 to £440. Additional extras not covered by the fees include hairdressing, chiropody and holidays. Care Homes for Older People Page 5 of 30 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: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection, which included a visit to the home, took place on Tuesday 21st October 2008. The staff at the home did not know that this visit was going to take place. All the key standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with residents, the manager and other members of the staff team. Key standards refers to those standards we feel are particularly important in ensuring the health, safety, welfare and quality of life of people living at the home. The care and services provided to three residents were looked at in detail, looking at Care Homes for Older People Page 6 of 30 their experience of the home from their admission to the present day. A selection of staff and care records was examined, including medication records, training records and staff duty rotas. Before the inspection, we asked for surveys to be sent out to residents and staff asking what they thought about care at the home. Five residents and five staff returned their surveys. Comments from these questionnaires are included in the report. We also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we see the service. The manager completed the form well and showed that she had a good understanding of what parts of the service could still be developed. What the care home does well: What has improved since the last inspection? What they could do better: Although standards of care provided at the home seemed to be good and the outcomes for residents in terms of their quality of life were good, inadequate procedures in respect of adult protection and record keeping has lowered the overall quality rating for the home. Care Homes for Older People Page 8 of 30 We saw from the records that a number of residents had some behavioural problems that at times impacted on other residents. Daily reports were not always written so an accurate record of residents behaviours and response to staff interventions was not always available and the manager could not clearly assess when potential risks to other residents needed the input of other health care professionals. Care plans and risk assessments were not always updated to take into account new events relating to individual residents. This meant there was a risk that actions stated in the care plans may no longer be appropriate or reflective of how staff were dealing with residents in practice. Where residents had displayed challenging behaviour there was no record that other appropriate agencies, such as the residents social worker or GP had been informed or contacted for advice. The manager must make sure that any incidents in the home that potentially put residents at risk are referred to the appropriate agencies so that safe guarding decisions can be made. 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. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were assessed before coming into the home to make sure staff were able to deliver the right care for them. Evidence: Information about the home was provided in the form of a service user guide, which was displayed in the reception area of the home and also provided in each residents room. The information was generally relevant but does need some updating, as the contact details for the CSCI have changed and some information was not entirely accurate, for example it stated that a dessert was offered at each teatime meal but this was no longer the case. The care for three residents was looked at in detail. Each person had been assessed before they came into the home. One of the staff said that the manager always went and visited a prospective new resident before they came in and started to write a care Care Homes for Older People Page 11 of 30 Evidence: plan, which was added to as they got to know the person and their routines and preferences. Staff said they were told about any person being admitted to the home as an emergency straight away and also were informed about significant changes in the health or well being of all residents so they knew what care they needed to provide. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although record keeping needs improvement the staff had a good understanding of residents support needs, which meant that in the main residents were well cared for. Evidence: The care of three residents was looked at in detail and we also looked at several other care files to check information about specific issues we identified relating to other residents. Care plans had been written for all the residents that addressed care needs that were identified during their assessment. Care plans often provided detailed information about residents individual needs and had been reviewed monthly, but some care plans for residents with behavioural disorders needed to be more detailed to provide information about any triggers staff had identified that made their behaviour worse, or techniques that helped staff diffuse situations where residents started to become agitated. Care Homes for Older People Page 13 of 30 Evidence: Risk assessments had been undertaken to assess the risk to residents in respect of pressure ulcers, nutrition and moving and handling. Specific risk assessments had also been carried out for some residents to assess the risk of harm to themselves or other residents or staff at the home. However not all risk assessments had been reviewed monthly even when an increased risk to the resident had been identified. For example the nutritional risk assessment for one person who had lost weight had only been reviewed in April, July and September 2008. The person had lost 5lbs in weight between April and July but had not been weighed again until September and they had lost a total of 1 stone in weight by October. The care plan for this resident stated that they should be weighed monthly but monthly weights were not recorded. The manager had contacted the GP about the residents weight loss in October 2008 but the details of treatment ordered by the GP were only written in the daily record and the care plan had not been updated. Care plans should always be updated with advice or instructions by other health care professionals to make sure all staff can clearly see the most up to date advice about the care to be provided. There were numerous gaps in the daily records for a number of residents and some entries were undated. Detailed daily records are good practice as they help the manager check the care being provided and ensure staff are following the guidelines in the care plans. Daily records show what staff have done and provide the evidence on which to base the monthly review of care plans. The daily records for one resident showed that their mental health was unstable but the gaps in the records were not helpful in providing accurate information about potential triggers for aggressive behaviour and ways in which staff could deal with this. Some of the care being provided to this resident was in contradiction to the actions stated in their care plan but there was no evidence that changes to the management of the resident had been discussed with other members of the multi-disciplinary team. The manager said the changes had been discussed with the residents doctor and family but this should have been recorded. The manager understood the reasons why record keeping needed improving and said she would take steps to rectify this. Records showed that residents had seen GPs, dentists, opticians, podiatrists and nurses. The manager said that it was her policy to always send staff to escort residents if they had to attend hospital for any reason. A 24 hour on call system was in Care Homes for Older People Page 14 of 30 Evidence: place so that staff could ask for help in an emergency and someone would be available to accompany residents. Procedures for managing medicines in the home were satisfactory and ensured the safety of residents. Residents looked clean and smart and appeared comfortable and relaxed. Residents said staff were kind and treated them well. One resident said staff tended to shout but thought this was because they were used to raising their voices to speak to residents that had hearing impairments. Of 5 residents that returned surveys, 4 said they always received the care and support they needed and 1 said they usually did. Four residents said staff listened and acted on what they said and 1 said they usually did. One resident commented The staff are always very kind and caring. Staff that were spoken to were able to describe residents usual abilities and preferences and explained what care each person required. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a developing range of opportunities available for residents to participate in activities that met their abilities and expectations. Evidence: Since the last inspection an activities organiser has been appointed who spends a couple of hours once or twice a week taking residents out or engaging in activities such as baking or arts and crafts. The manager is committed to offering residents as much choice as possible and the emphasis is on developing interests and social activities that meet individual needs. Residents are encouraged to take part in household tasks such a weekly food shopping and will have coffee or lunch while they are out and about. Some residents do not enjoy group activities and the activities organiser will spend one to one time with them perhaps doing a jigsaw or helping with a crossword. There are several animals at the home including a cat, 4 chickens and some koi fish. Some residents help in the care of the animals. One resident had brought her own budgie with her to live at the home. Residents said they could get up and go to bed when they wanted. Several residents Care Homes for Older People Page 16 of 30 Evidence: were having a lie in on the day of our visit. The manager said a number of residents liked to have a sherry or a lager in the evenings and this was arranged. The manager and staff took six residents on a 5 day holiday to Filey over the summer. Photographs were displayed in the reception area and all the residents who went said they had a great time and really enjoyed themselves. Several residents said they went out of the home with relatives and that their visitors were made welcome. Residents said they liked the food provided at the home. The manager said they did not have a set menu as she felt this was too regimented. The cook wrote on a memo board in the hallway each day, what she planned to make for lunch and tea. Residents that were able could check the board and request alternatives if they wished. The cook or one of the staff would explain to the less able residents what food was on offer. The main meal of the day was served at teatime and a light meal was served at lunchtime. On the day of our visit lunch was pea and ham soup with dumplings followed by ice cream. Tea was lamb chops, mashed potatoes and mixed vegetables. The manager said dessert was no longer served after tea, as a number of residents were putting on too much weight. However, this should be assessed on an individual basis, as some residents may need a dessert if they are losing weight. A record of all the meals served each day was kept in the kitchen. This showed that typical food for the main meals was liver and onion, battered fish, ham chips and peas, roast dinners, steak pudding and gravy, lamb chops and corned beef hash. Food for the lighter meals included spam and cheese toasties, sausage and beans or scrambled eggs on toast, sausage bacon and apple roll, cheese and Stilton soup and salads. Efforts were made to seek the residents views about what food they liked and where they expressed preferences these were accommodated, for example one resident said she liked kippers and was able to have them for breakfast a few times a week. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures for recording and reporting potential safe guarding incidents are not strong enough to fully protect residents living at the home. Evidence: The complaints procedure was provided in the service user guide, which was available in all residents bedrooms. It was also displayed in the reception area but did need updating, as the contact details for us were incorrect. All the residents that returned surveys said they knew how to make a complaint and all the staff returning surveys confirmed they knew the procedure to follow should a complaint be made to them. Several residents spoken to on the day of our visit were unsure about who to speak to saying they could not remember but one resident said they would speak to the manager and felt any issues would probably be resolved. The manager said no complaints had been made to her since the last inspection and the CSCI have received no complaints. One member of staff was aware of the procedures to follow if they had concerns that residents were at risk of harm. Another staff member was newly employed and had not yet received the training but had been directed to where the policies for the home were kept and asked to read them. This staff member was due to attend formal Care Homes for Older People Page 18 of 30 Evidence: induction training, which covers adult protection. Since the last inspection the manager has reported one incident to the CSCI, which she also referred to the Safe Guarding team. We were satisfied that the manager acted in a timely manner and cooperated with the relevant agencies to investigate the incident and take appropriate action. However, from reading some of the care files we could see that there had been a number of incidents in the home where the challenging behaviour of different residents had resulted in some physical contact between residents or residents being frightened by the behavior of others. It was not clear that the manager had taken steps to involve other members of the multi-disciplinary team to address these issues and care plans and risk assessments had not always been updated to reflect what was happening and did not give staff enough information about how to deal with individual residents. Incidents were not recorded separately outside of individual care files (there were forms available to record accidents, but staff did not use these to also record untoward incidents). This made it more difficult for the manager to properly audit the nature and frequency of incidents and would not highlight the need to take appropriate action. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained and provided a comfortable and homely environment for the residents. Evidence: A partial tour of the home was undertaken, which included the lounges, dining room and a selection of residents bedrooms. The home was clean and tidy when we visited and smelled fresh. Residents rooms were homely and comfortable. Many residents had personalised their rooms with photographs, ornaments and small items of furniture. Two of the residents had brought their own bedroom furniture. Since the last inspection ongoing maintenance and refurbishment had taken place. New armchairs had been bought for one of the lounges and both lounges had new curtains and blinds and were awaiting new carpets. The hallways had been re carpeted. One of the bathrooms had been refitted and looked very appealing and attractive for residents to use. The adjacent toilet had also been refitted. At the time of our visit work was taking place outside to create a decking area for Care Homes for Older People Page 20 of 30 Evidence: residents wanting to sit outside. The front garden was well maintained and included a koi fish pond and a coop for the chickens. The manager had a plan for the rest of the year for ongoing improvements to the environment. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were available at the home in sufficient numbers and with the experience and qualifications to meet residents needs. Evidence: Staff and residents spoken to during our visit said they felt that staffing levels were satisfactory. All 5 staff that returned surveys said there were always enough staff on duty to meet residents needs. Three of the 5 residents that returned surveys said there were always enough staff on duty and 2 said there usually were. At the time of our visit there were 18 residents living at the home. It was reported that there were 3 carers on duty between 8am and 10pm, including a deputy manager, and two carers on duty all night. Examination of duty rotas for the weeks from 6/10/08 until 26/10/08 confirmed this. In addition the manger was available at the home from 8am-4pm Monday to Friday and an on call system was in operation to ensure that at all times a senior member of staff, either the manager or one of her deputies was contactable for advice or practical support. A full time cook, a part time cleaner and an activities organiser for 2 hours 2-3 times Care Homes for Older People Page 22 of 30 Evidence: per week was also employed. In the AQAA the manager showed that she was aware of and took the needs of residents living at the home into account when planning recruitment, as she had actively tried to recruit a male carer (and had just been successful), as she had seen that this would benefit the male residents and give them more choice about who delivered their care. All of the staff except the two newest members, had successfully achieved NVQs. The 3 deputy managers had NVQ 3 qualifications. The manager said that all new staff completed induction training that met Skills For Care specifications, run by Oldham MBC. Examination of staff personnel files showed that staff had been recruited using robust procedures that ensured that all the necessary checks were in place before new people started working at the home. This meant that the manager could be sure that the staff she employed were suitable to work in the care home. Training records showed that ongoing training was taking place and staff had refresher training in health and safety topics such as fire safety and moving and handling. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Procedures were in place for residents to make their wishes known but there were shortfalls in record keeping that meant the manager could not always check that the care for residents met their needs appropriately. Evidence: The manager, who is also the owner of the home has over 20 years of experience and holds general and mental health nursing qualifications, a diploma in health education, a research and management qualification and an NVQ level 4 in care. She has nearly completed an NVQ level 4 in management. Staff said that the manager was approachable and supportive, and that they had regular team meetings with her. One person said, She is a good boss - she gets involved. Residents said there had been residents meetings and the minutes of these showed Care Homes for Older People Page 24 of 30 Evidence: that residents had been asked for suggestions about the types of meals they would like and the activities they wanted. The manager had undertaken a resident satisfaction survey in November 2007 and had analysed the results. Examination of this showed that the majority of comments and feedback about the home were positive. The manager had also sent surveys to visiting professionals such as GPs, nurses and social workers to gain their feedback about the home. The manager could further develop the quality monitoring system she has in place by auditing records in the home such as care plans and risk assessments. These were not always as up to date or complete as they should have been and the manager recognised that she had relied on other staff to keep documentation updated without checking if it was done herself. The system for managing and safe keeping residents money seemed satisfactory, in that separate ledger sheets were held for each resident and receipts were kept for all transactions. However, the manager said the safe had been burgled and she was waiting for the insurance company to settle the claim she had made for the reimbursement of money to residents so we could not make any checks in detail. The manager did not notify us about the theft and was not aware that this type of incident was reportable. We directed her to the Care Homes Regulations 2001 so that she can ensure that notifications about relevant events in the home are made in the future. As stated previously, there was no formal system in place for the recording of adverse incidents that happened in the home. Although staff kept a record of accidents, incidents that involved the residents were only recorded in their individual care files. Records of accidents and incidents should be used to analyse potential risks to residents and ways to minimise them. The manager confirmed that regular weekly checks in respect of health and safety were made in the home and on equipment and that all equipment was serviced and maintained appropriately. The manager completed the AQAA well and we felt the information she provided gave us a good insight into how the home was running and her plans for future development. Care Homes for Older People Page 25 of 30 Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 18 12 The manager must ensure that appropriate agencies are always informed when incidents occur within the home that potentially place residents at risk. In alerting relevant agencies the manager can ensure that appropriate action is taken to protect people living at the home. 28/11/2008 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 7 Daily records of the care given to residents should be written, to show what care the person has needed and to use when reviewing the care plans. Risk assessments should be reviewed and updated to take into account any changes to a residents health or personal care needs. Corresponding care plans should be written and followed. Detailed records should be kept of all incidents that occur in the home which are detrimental to the health or welfare of residents so the manager can properly assess the potential Page 28 of 30 2 7 3 18 Care Homes for Older People risk to residents and the need for further action to minimise the risk to themselves or other residents. 4 33 The manager should develop an audit system to check that documentation has been completed to the required standards. The manager should ensure that the CSCI is notified about any incidents that occur in the home that are detailed in Regulation 37 of the Care Homes Regulations 2001. 5 38 Care Homes for Older People Page 29 of 30 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 © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!