Care Home: Downshaw Lodge Nursing Home

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What the care home does well A robust system of assessment, involving prospective residents and their representatives, ensures that individuals can be confident the home will be able to meet their needs. Similarly, person-centred care plans set out in detail the tasks that staff will undertake in meeting personal and healthcare needs. Needs assessments and care plans are reviewed regularly and updated to reflect the current support that people need from the staff team. People living in the home and visiting relatives told us that staff are good at providing support in a private, dignified and respectful way. One of the relatives said, `I was particularly worried about mum coming to live in a home, but from what I`ve seen, staff really care here and it`s reassuring.` Daily routines in the home are flexible in order to meet residents` preferences and choice of lifestyles. We were pleased to find that particular attention was being paid to provide stimulating and interesting activities for people living with dementia and those who were confined to bed. This person-centred approach had been extended to meeting the dietary needs and preferences of the people accommodated. Outcomes in the area of catering exceeded the National Minimum Standard and this was commended as an area of best practice.We found that the views of people using the service and their representatives were important to management and staff. Records provided evidence that complaints and concerns had been managed well. The people we spoke to said they felt safe in the home. Staff were skilled and knowledgeable in the action they needed to take to keep people safe from harm. The home`s maintenance and development programme was consistent with developing a therapeutic environment for people living with dementia. Regular satisfaction surveys had been undertaken and action taken to respond to suggestions for improvements to the environment. This service received a second commendation for exceeding the National Minimum Standard in relation to training and development. The manager`s commitment to developing the staff team had resulted in person-centred outcomes for people living in the home. What has improved since the last inspection? We found that the manager and staff had worked hard to ensure that people living in the home received a good standard of care. At the last inspection two requirements and five good practice recommendations had been made. These had been met at the time of this visit. Significant improvements were found in the way staff recorded medicine administration, recruitment procedures, staff training records and written information in care plans. What the care home could do better: We made two good practice recommendations during this visit. Incoming medication had generally been checked and signed for as correct, although this had not been done for one person. This should be consistently recorded to ensure that an accurate record of medication is held for all people living in the home. A system should be devised to record the outcome of residents` experiences of activities provided in the home. This will provide evidence of how the service is meeting the social, cultural and religious needs of the people accommodated. CARE HOMES FOR OLDER PEOPLE Downshaw Lodge Nursing Home Downshaw Road Ashton-under-Lyne Tameside OL7 9QL Lead Inspector Val Bell Unannounced Inspection 10:00 16 and 24th July 2008 th 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 Downshaw Lodge Nursing Home DS0000025432.V363443.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. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downshaw Lodge Nursing Home Address Downshaw Road Ashton-under-Lyne Tameside OL7 9QL 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) 0161 330 7059 0161 339 4112 downshawlodge@schealthcare.co.uk Exceler Health Care Group Limited Mrs Kim Beverley Langford Care Home 45 Category(ies) of Dementia (45), Dementia - over 65 years of age registration, with number (45) of places Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 45 service users to include: *up to 45 service users in the category of DE (Dementia under 65 years of age). * up to 45 service users in the category of DE(E) (Dementia over 65 years of age). No service user under the age of 55 years to be admitted to the establishment. 2 registered nurses on duty 24 hours; The Home Manager shall be a First Level Registered Mental Nurse and be supernumerary to the stated staffing levels for 37.5 hours per week. 18th July 2007 2. 3. Date of last inspection Brief Description of the Service: Downshaw Lodge is a purpose built, two-storey building that accommodates up to 45 service users from the age of 55 years with dementia, who require nursing care. The home is owned by Exceler Health Care Group plc, which is a subsidiary company of Southern Cross Health Care, and is under the control of a general manager who is also a qualified nurse. Fees for accommodation and care at the home range from £465.35 to £475.35 per week. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. Details of the facilities provided by the home are contained in the service user guide, which is displayed in the reception area of the home. Service users are accommodated in single rooms, 26 of the rooms having ensuite facilities. Rooms without en-suite facilities are provided with vanity units incorporating washbasins. Within the home there are six communal rooms offering a variety of settings for service users to socialise, entertain family or friends and participate in activities. A pleasant garden is designed to ensure that service users can enjoy being outdoors whilst maintaining their safety and security. The home has access to a mini-bus and service users who are able to, are taken for trips out to a number of local destinations. The home is located on the main Oldham Road with good access by public transport. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key inspection, which included a site visit to the home. The visit was unannounced which means the manager was not informed beforehand that we were coming to inspect. During the visit we spent time talking to people living in the home, a number of visiting relatives and healthcare professionals, nursing and care staff on duty, the registered manager, administrator, cook and the activity coordinator. An Annual Quality Assurance Assessment (AQAA), which is a self-assessment document had been completed by the manager and returned to the Commission prior to our visit. Four staff surveys were also completed. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well: A robust system of assessment, involving prospective residents and their representatives, ensures that individuals can be confident the home will be able to meet their needs. Similarly, person-centred care plans set out in detail the tasks that staff will undertake in meeting personal and healthcare needs. Needs assessments and care plans are reviewed regularly and updated to reflect the current support that people need from the staff team. People living in the home and visiting relatives told us that staff are good at providing support in a private, dignified and respectful way. One of the relatives said, ‘I was particularly worried about mum coming to live in a home, but from what I’ve seen, staff really care here and it’s reassuring.’ Daily routines in the home are flexible in order to meet residents’ preferences and choice of lifestyles. We were pleased to find that particular attention was being paid to provide stimulating and interesting activities for people living with dementia and those who were confined to bed. This person-centred approach had been extended to meeting the dietary needs and preferences of the people accommodated. Outcomes in the area of catering exceeded the National Minimum Standard and this was commended as an area of best practice. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 6 We found that the views of people using the service and their representatives were important to management and staff. Records provided evidence that complaints and concerns had been managed well. The people we spoke to said they felt safe in the home. Staff were skilled and knowledgeable in the action they needed to take to keep people safe from harm. The home’s maintenance and development programme was consistent with developing a therapeutic environment for people living with dementia. Regular satisfaction surveys had been undertaken and action taken to respond to suggestions for improvements to the environment. This service received a second commendation for exceeding the National Minimum Standard in relation to training and development. The manager’s commitment to developing the staff team had resulted in person-centred outcomes for people living in the home. 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. Downshaw Lodge Nursing Home DS0000025432.V363443.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 Downshaw Lodge Nursing Home DS0000025432.V363443.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 and 6 Quality in this outcome area is good. People can be confident that their needs will be thoroughly assessed and recorded to determine if the home will be the right place for them to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care records for four people living in the home to see if their needs had been suitably assessed prior to admission. Needs assessments had been obtained from care managers and the home had used its own assessment tool. This ensured that care and accommodation was only offered to people whose needs the service could meet. The relatives of two people confirmed that they had been fully involved in the assessment process. They both agreed that this reassured them that they had made the right choice. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 9 The home did not offer an intermediate care service. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. People living in the home receive a good standard of person-centred care that respects their rights to privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The four care records that we looked at contained up to date plans of care that provided staff with structured guidance on how to meet the individuals’ specific health and social care needs. Risks had been carefully assessed and included written instructions on what staff needed to do to keep people safe from harm. Care plans had been signed by the individual, or their representative, providing evidence that a person-centred approach was taken in meeting needs. Two visiting relatives said that they often looked at care plans and that staff always made themselves available for discussion about the care being provided. One person added, ‘Mum recently had a fall and the family were Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 11 happy that additional monitoring had been put in place to keep her safe. All the family say that staff are good at promoting mum’s independence, always treat her with respect and maintain her right to privacy and dignity. I was particularly worried about mum coming to live in a home, but from what I’ve seen, staff really care here and it’s reassuring.’ Care plans provided written evidence that staff take prompt action to refer people to the relevant health professionals when they are concerned about their welfare. Comprehensive daily recording had been made in monitoring the outcome of the care being provided. We examined medication records for the four people being case-tracked and these appeared to be accurate and up to date. Incoming medication had generally been checked and signed for as correct, although this had not been done for one person. We asked the nurse on duty about this. The nurse was aware that she should maintain a consistent audit trail for all medication, which suggested that this was a genuine oversight. The requirement made at the last inspection to keep accurate records of medication administered to residents had been met and fridge temperatures in the first-floor clinic we visited had been recorded daily. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. People living in the home are treated as individuals by providing a service that meets their choices and preferred lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We assessed daily routines in the home and the type of activities that were provided. Routines were flexible with attention paid to meeting individuals’ preferences as recorded in care plans. An activity co-ordinator was new in post. He told us that he was spending time getting to know the people living in the home so that he could develop person-centred activity programmes in addition to group activities that would offer stimulation and interest. A resident told us that he was a keen domino player and that the activity coordinator had organised a domino school. Residents were observed to engage in this activity during the afternoon. It was pleasing to be told that the activity co-ordinator was also keen to develop one-to-one activities with people living with dementia and those residents who were confined to bed. We were told Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 13 that a system for recording individual experiences of these activities had not yet been agreed. The manager said that she would look into the best way of doing this. The home has shared use of a minibus and residents are able to go on weekly trips to places of interest. Links were being developed with local schools and churches and services were held weekly in the home. Residents were also able to attend local churches with staff support on Sundays. Relatives were observed to visit throughout the day and we took the opportunity to speak to several of them. They told us that they are made welcome in the home and are encouraged to express their views on the quality of the service provided. They also confirmed that staff were good at encouraging residents to be as independent as possible by making choices that affected their daily lives. We joined two residents for the lunchtime meal. There were two choices of hot main course and dessert and the meals were attractively presented and nutritious. The two residents we were seated with praised the standard of catering provided. One person commented, ‘It’s good home-cooked food. Staff always ask if you want any more and if you don’t fancy what’s on the menu you can ask for something else.’ We noticed that staff were on hand to assist people to eat where needed and the mealtime was relaxed and unhurried. The cook was knowledgeable about the specific assessed needs of people living in the home and was providing a large range of special diets to meet the specific dietary needs of individuals. Fresh fruit and vegetables were always available and the cakes and desserts provided were baked daily. This was commended as an area of best practice. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. The rights and views of people living in the home are respected and robust policies and procedures afford protection to the welfare of individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A comprehensive complaints procedure was accessible to residents and visitors and the manager held fortnightly surgeries as advertised in the reception area. Staff were trained in customer care and had been issued with complaints forms so that out of hours complaints could be swiftly recorded and dealt with. Ten complaints had been recorded since the last inspection and all had been dealt with within the specified time limits. Full details of the complaint and the investigation had been written down. For complaints that needed to be escalated to Southern Cross management, written responses were provided to complainants. There was a particularly strong focus on providing independent advocacy for people living in the home to promote their right to be autonomous. It was very pleasing to find that staff worked on the assumption that people have capacity to make decisions unless proven otherwise. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 15 Staff had been trained in how to recognise, report and manage abuse. The manager had promptly informed the Commission of any suspicions or allegations of abuse as soon as they occurred. There had been a high number of such notifications on the male only unit in the previous months. This had been managed well by taking action to minimise the risk of further occurrences. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 16 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 and 26 Quality in this outcome area is good. People living in the home are provided with a clean, safe and pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We toured the home to assess health and safety and the quality of the environment. The home was found to be safe, clean and hygienic and no unpleasant odours were detected. The home’s maintenance and development programme included the provision of therapeutic environments for people living with dementia, such as a reproduction bar lounge and potting shed. This was identified as an area of good practice and progress will be reassessed the next time the home is inspected. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 17 It was pleasing to note that prospective residents had been encouraged and supported to personalise their bedrooms prior to admission. This resulted in positive outcomes for people by enabling them to settle in their new environment more easily. Residents were given the opportunity to have a key to their bedroom door and lockable space in their bedrooms, although bringing valuables into the home was discouraged. The home used a capital grant allocation at the end of 2007 to purchase bedroom furniture and chairs for the lounges. A high proportion of bedrooms had been decorated in the previous twelve months and a shed and greenhouse were to be provided in response to suggestions from residents. It was pleasing to see residents participating in a therapeutic outdoor gardening programme facilitated by the activity coordinator. Suitable laundry facilities were provided and staff had access to a rolling programme of weekly health and safety training including infection control. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. The management and staff team’s commitment to training and development ensures that they have the necessary knowledge and skills to meet residents’ needs in a person-centred way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Suitable numbers of staff had been deployed to meet the assessed needs of people living in the home. Staffing had recently been increased to meet the specific needs of people accommodated on the first floor male unit. In addition to qualified nurses, twelve care assistants had achieved a National Vocational Qualification at level 2 or above. We examined two personnel files to assess the checks made during the recruitment process. These records contained evidence that the full range of pre-employment checks had been undertaken before staff were appointed. This affords protection to the welfare of people living in the home. The manager had introduced a weekly rolling programme of staff training to cover mandatory health and safety and the care and nutrition of people with Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 19 dementia. Application had also been made for specific dementia training for the nurses. Alongside this the manager was in the process of applying to Bradford University to study the Diploma in Dementia. From conversations with the manager it was evident that she considered staff training and development to be crucial in maintaining and further improving the quality of positive outcomes experienced by people living in the home. This commitment to continuing professional development was commended as an area of best practice. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is good. The management and staff team value the views of the people using this service and use this information to manage the home in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had over sixteen years professional nursing experience and had achieved a National Vocational Qualification in management at level 4. She was about to undertake further study to achieve a Diploma in Dementia. It was evident that the manager and staff team had worked hard over the Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 21 previous twelve months to improve the service provided and it was pleasing that all the standards assessed during this inspection had been met. A robust quality assurance system was in place and this included regular auditing of systems, staff and management meetings. The manager planned to increase the number of residents’ meetings and was looking at how these could promote improved information sharing in view of the high numbers of people living with dementia that the home accommodated. The most recent meeting had been held the month previous to this visit. An evening meeting had been arranged to afford relatives, who worked during the day, the opportunity to attend. This was identified as an area of good practice. Questionnaires had been issued regularly to residents and their relatives, the most recent being a reminiscence survey to capture historical information about individuals’ lives. The annual quality assurance satisfaction survey was issued in June 2008, although results were not available at the time of our visit. Data from the previous survey in 2007 revealed that more activities were needed and it was pleasing that action had been taken to meet this request. The manager had also applied for the Investors in People assessment and this was due to take place in the near future. Staff had received regular supervision and annual appraisals and new staff were inducted to skills for care specifications. Health and safety audits had recently been carried out and it was planned to continue these on a regular basis. The Primary Care Trust carried out a control of infection inspection in February 2008 and the home achieved 83 compliance. Similarly, a positive result was achieved when the environmental health department inspected the home in March 2008. The certificate of registration and PLI certificate were displayed in the home. We examined a sample of records relating to health and safety and residents personal finances and found these to be accurate and up to date. No health and safety issues were found during this inspection. Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 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 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 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 3 X 3 X X 3 Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Medicines brought into the home should be consistently recorded to ensure that accurate records held for all people living in the home. A system should be devised to record the outcome of residents’ experiences of activities provided in the home. This will provide evidence of how the service is meeting the social, cultural and religious needs of the people accommodated. 2. OP12 Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Downshaw Lodge Nursing Home DS0000025432.V363443.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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