Care Home: Elmleigh Convent

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What the care home does well We were told that walking into Elmleigh is a `breath of fresh air`. Elmleigh is a `Home` of the best kind. "Dignity and respect was observed being given to the Sisters by staff been available and willing at all times to engage in conversation". The Sisters told us "there are no restrictions on how we live; we can choose our own routines, just like anyone can in their own home". One of the Sisters said "it is such a unique atmosphere here", another Sister said "it is a unique place to be". A staff member said "we make sure that the daily life revolves around the Sisters". Another staff said "I have the greatest admiration for the Sisters". The home provides staff with on going training and support to make sure they are able to carry out their job. There are good systems in place to make sure people are safe. The sisters are able to live the life they want with support and care from a dedicated staff team. People`s right and choice are respected. People live in a home that is kept well maintained and clean and tidy. What has improved since the last inspection? The complaint procedure has been updated so that it gives the information about the timescale within which a complaint received would be responded to. The home has realised that people in wheelchairs found it difficult to get through doors that have to be kept closed and did not have an appropriate door closure.The home have now fitted for easy access magnetic door closures to bedrooms of wheelchair users . What the care home could do better: The sharp corners of the shelves identified and the fire place hearth must be risk assessed with the action taken to resolve the risk. This would make sure that people are safe. The home should carry out risk assessments for all potential risks around the premises. This would make sure that people are safe at all times. The gate at the top of the narrow stairs that leads from the second to the first floor was unlocked. When unlocked this area is a potential hazard. Additionally, the height of this gate was below people`s waist line. This we felt could compromise people`s safety. Key inspection report Care homes for older people Name: Address: Elmleigh Convent Kings Road Ilkley West Yorkshire LS29 9AT     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Valerie Francis     Date: 1 2 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. that people have said are important to them: They reflect the things 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. Care Homes for Older People Page 2 of 26 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Elmleigh Convent Kings Road Ilkley West Yorkshire LS29 9AT 01943607003 01943604576 elmleigh@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sisters Of The Cross & Passion care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: As identified in the notice dated 31 October 2003 Date of last inspection Brief description of the care home Elmleigh Convent is conveniently located a short walk away from Ilkley town centre and a local bus route. It is registered as a care home and accommodates up to sixteen retired sisters of the Cross and Passion. Attached to the home is a chapel that is also open to the local community. This large detached building has extensive grounds including a boating lake no longer in use. There are ample parking facilities within the grounds including a convenient area in front of the home and chapel. There are a number of large communal rooms mostly located on the ground floor. A passenger lift provides access to all floors apart from the second floor where there is accommodation that visiting relatives and friends can use. Single bedrooms are available located on the ground and first floors. Many have en-suite facilities. Care Homes for Older People Page 4 of 26 Over 65 4 10 2 0 0 0 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: three star excellent 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 was an unannounced visit to the home by one inspector, which lasted about six hours. We were accompanied by an Expert by Experience from the organisation Help the Aged. An expert by experience is a person who, because of their shared experience of using services, is able to help us get a better picture of what it is actually like for people using services. During the inspection all of the key standards were looked at to assess the standard of care that people receive. An Annual Quality Assurance Assessment (AQAA) was completed by the home and this information was used as part of our findings of this inspection visit. Surveys were sent to people and staff. During the visit we looked around the home, spoke to people who live at the home, staff, visitors, manager and Sister Superior. Care plans, risk assessments, health care records, meeting minutes, staff recruitment, training records Care Homes for Older People Page 5 of 26 and the premises were looked at. Feedback was given to the manager. We were told that the weekly charge is paid by Sisters of the Cross and Passion. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use the service are not being put at significant risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 7 of 26 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 8 of 26 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. The home information is clear about the service they provide. Peoples needs are assessed before they move into the home. This is to make sure that everyone is quite clear that the home can meet their needs. Evidence: The homes statement of purpose and the service user guide is available to sisters wanting to move into the home. This gives them good information about the service provided at Elmleigh Convent. Most of the sisters living in the home had been aware of Elmleigh Convent and had chosen to live there. Any sister of the Sisters of the Cross and Passion wanting to live at the home, has an assessment of their care and support needs carried out by one of the homes manager. We saw that the assessment information accumulated by the home, had good details about peoples care and support needs. Care Homes for Older People Page 9 of 26 Evidence: We looked at the assessment information for the last sister who moved into the home. We found information about the persons psychological needs, reflecting their ability to make choices that affect their life. Care Homes for Older People Page 10 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a care service that meets peoples care and support needs. Evidence: From the information seen in the sisters care plans it was clear that their wishes and rights are respected, and they are involved in all aspect of their care and support. We saw that care is delivered by staff in a very sensitive way, thus ensuring that the support is delivered in a dignified and respectful way. We looked at three sisters care plans and found that all their identified care needs were in a plan that was specific to them and staff knew what action they must take to meet these needs. For example, one person who was receiving palliative care; their care plan clearly outlined how to assist them with their personal care and support needs. Pressure areas were cared for using pressure relieving equipment which was clearly identified in their care plan. When we spoke to staff they told us that they get enough information about people before they move into the home. We saw that care plans are evaluated monthly and reviewed annually or sooner if that was needed. Care Homes for Older People Page 11 of 26 Evidence: People are involved in their care planning, we were also told that Sister superior is involved in the care planning process for some sisters. This we were told depended on the sisters capacity. We saw that the home had involved professionals with regard to one sisters capacity to make choices about issues affecting her life. Information in care plans was clear and organised. It was clear from discussions with staff and from the record seen that staff make sure information is passed on. There is a handover record diary where any changes in relation to peoples care and support needs are recorded during each shift and passed on at handover and recorded in the individual file. This makes sure that all information is passed on and nothing gets missed. The home provides a care service that meets peoples identified needs. Care is delivered in a manner that respect people who live in the home. We observed that Sisters and staff alike have the greatest respect for one another. Records show that people receive the health care they need, there was evidence that GP and other health care professionals are consulted about peoples care. We spoke to a visiting health care worker who said staff always ask for help and guidance if they need it and follow instruction we give to them. Sisters were complementary about the staff they said they are good and they listen. We saw that some peoples care plan had a medication plan, for such as, covert medication which mean that the persons medication was added to food, which had been done in consultation with the GP and is kept under review. We looked at the way in which drugs were stored and we had no concern. We observed staff administering medication. This was carried out without any interruption from other staff. We saw and were told that all staff who administer medicines have had training on safe handling of medication. In the AQAA we were told that the medication policy has been reviewed and a procedure for handling controlled drugs had been implemented. A drug cabinet and medication trolley had been purchased. People have the opportunity to self medicate if this is what they wish. A risk assessment is carried out before this is agreed. The home also told us that they plan in the next twelve months to increase documentation to include Mental Capacity Act Deprivation Of Liberty. Care Homes for Older People Page 12 of 26 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. People living at Elmeigh Convent has a lifestyle that suits them, with staff supporting them to have choice and control over their lives. The home provide people with a varied and nutritious diet. Evidence: Elmleigh employs a part time activities coordinator. The Sisters told me they are very happy with this arrangement. The activities coordinator said she enjoys her job working with the Sisters. She is organising an Irish singer to come in for St. Patricks Day which is a big event at Elmleigh. She also takes the Sisters individually on shopping trips to Ilkley including outings to local countryside coffee shops. There is a computer for anyone interested in using it. An organised outing recently took place to Leeds Cathedral for those Sisters who were able to visit. Their spiritual needs are catered for as the Sisters have the advantage of attending their Chapel each day. An activity schedule is displayed in the hallway near the entrance and one is placed in each of the Sisters rooms. The activities displayed are Reminiscence therapy in the form of talking about past times, board games, flower arranging, card making and Care Homes for Older People Page 13 of 26 Evidence: chair exercises. Comments from the Sisters I live my life with my friends, I am very happy. We are all so lucky to live here. Everyone is so wonderful; they will do anything for you. We can keep ourselves occupied very happily. The Sisters said that all staff engage in some sort of activity with the Sisters, whether it is talking one to another, taking the Sisters out into the grounds for a walk or reading a newspaper and discussing its contents. A large activity room displayed all kinds of board games, crafts such as card making, sewing and knitting. Sisters seemed to be in charge of their own lives. We asked three of the Sisters about their daily life. They were all in unison stating that there are no restrictions on how we live; we can choose our own routines, just like anyone can in their own home One of the Sisters said it is such a unique atmosphere here another Sister said it is a unique place to be. Staff said we make sure that the daily life revolves around the Sisters. We have the greatest admiration for the Sisters. One Sister said of the staff they are my guardian angels. Another Sister told us that you would have to go a long long way to find somewhere as good as this. In the AQAA the home told us that they have a volunteer who comes in for a short time once a week, to hold Spanish conversation with one person, and play board games with other people. We saw that the menus were very flexible and adhere to the wishes, likes and dislikes of the Sisters themselves. The cook said we always prepare an alternative anything the Sisters wish to have we will it make for them. On Feast Days, birthdays, funerals and special occasions, the Sisters choose the menu for the lunchtime meal. We were told along with this, the cook always prepare three different puddings. On the day of the inspection a funeral was taking place of one of the Sisters. Because it was a special day the tables were set in the most colourful way with vases of tulips in memory of the Sister who had died and who originated from Holland. The Sisters said, we always have lovely food to eat, the kitchen staff are wonderful they will make anything that you want, we really appreciate their cooking, you cant get any better. The food served on the day of inspection was home made soup, choice of roast beef or turkey which was served on platters for people to help themselves, with a selection of Care Homes for Older People Page 14 of 26 Evidence: five vegetables served in tureens, followed by a sweet trolley with a choice of three sweets, which came round to every table. At the end of the meal, fresh fruit, cheese and biscuits, tea, coffee and mints were available. The cook had made a Dutch ginger cake in honour of the Sister whose funeral it was. During the meal orange juice and water was served. During the meal staff including kitchen staff, were most attentive to everyones needs; taking care to help or assist anyone who needed help. Three Sisters sat at one table required assistance in eating their meal. The staff were sat at the side of them and were being respectful and considerate in assisting them, without taking away their independence. People were given time to eat their meal, it was not rushed and was very relaxed. Three visitors were spoken to said we can always guarantee an excellent meal when visiting. The food is exceptional; the puddings are out of this world.Everything here is first class. At the end of the meal the kitchen staff were applauded for making such a wonderful meal. Care Homes for Older People Page 15 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel safe and are confident that their concerns will be listened to and dealt with. The robust procedures and staff training protects people from abuse. Evidence: The homes complaint procedure is available to the sisters and it displayed in the home, making it accessible to visitors. The Sisters have their own meetings once a month with the Sister Superior to discuss their daily life within the home, any concerns they have will be discussed then. The Sisters are able to rise and retire when they wish. Dignity and respect was observed being given to the Sisters by staff been available and willing at all times to engage in conversations, responding or asking if anyone required anything or needed help. Staff were attentive and helpful in their duty of care. The word unique came up in conversation many times when talking about living in Elmleigh. Staff have had training in Protection of Vulnerable Adults, this is updated yearly to make sure that staff knows what steps to take when a matter of abuse is brought to their attention. Speaking to staff it was evident that if they had any concern about any issue of abuse they would take the necessary steps, even it meant reporting their line manager to senior management to makes sure that the Sisters in Care Homes for Older People Page 16 of 26 Evidence: their care are safe. In the AQAA the home told us the views of Sisters are listened to and taken seriously and acted upon. They also said that in the next twelve months they hope to increase the number of staff meetings to improve their already high standard of communication to highlight any concerns. We were told that all new staff are introduced to the homes policy on adult protection and given training as part of their induction. Care Homes for Older People Page 17 of 26 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 provides people with a well maintained, pleasant and homely place to live. The home is kept very clean and tidy. Evidence: The home is a former convent and holiday home for the Sisters of the Cross and Passion. The Home has accommodation for 16 sisters, on the day of inspection there were 14 in residence. Bedrooms were highly personalised reflecting the occupant choice. The large downstairs lounge where we were told the majority of the Sisters like to sit, have comfortable easy chairs, coffee table and a television. The chairs were lined up side by side, we were told that the Sisters did not mind this arrangement. People live in a clean, tidy, safe and well maintained home which is suitable to meet their needs. The home told us that they had identified that the door opening leading to the narrow stairs from the second to the first floor put people at risk of falling down the stairs. To eradicate the health and safety risk they have erected a safety gate with a bolt . However, during our inspection of the premises we found the gate open. This put people at risk. Additionally, the height of this gate was below peoples waist line. This we felt could compromise peoples safety. This was fedback to the manager and Sister Superior. The laundry rooms in the cellars below are large and well equipped for their purpose. Overall we found that the home provided the people who live there with a well maintained premises. In the AQAA the home told us since the last key inspection they have fitted magnetic release door closures to bedrooms of wheelchair Care Homes for Older People Page 18 of 26 Evidence: users to ease access. Care Homes for Older People Page 19 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a stable staff team who are well trained and conscientious in their work. Safe and through recruitment procedures make sure that staff are safe to work with vulnerable people. Evidence: We looked at the staff rota and found that the staffing level were adequate to meet the needs of the current people living in the home. Staff were observed as working in cooperation with one another, taking over tasks and responsibilities if their colleagues needed assistance. Staff on a one to one with a sister asked to be relieved of her duty to carry out another task, another member of staff came willingly to help. Each staff member had their job to do, but each one was flexible to one another in carrying out their duties of care to the Sisters. During our discussion with staff and in records seen we found that staff have had induction training and there is on going training for such as fire safety, food hygiene, manual handling, infection control and dementia. They are also encouraged to undertake National Vocational Qualification (NVQ) training Level 2. The home have over fifty percent of their staff with an NVQ level 2 or 3. Health care professionals who are involved in peoples care provide information to staff. We reviewed three staff files and looked at their recruitment and selection process. The records showed that staff Care Homes for Older People Page 20 of 26 Evidence: had gone through the homes robust recruitment and selection process including an enhanced CRB ( Criminal Records Bureau ) check which also included a POVA ( Protection of Vulnerable Adults ) first check and two written references. Staff spoken to said, I wouldnt want to work anywhere else.I have worked here so long now it feels like my home.I enjoy coming to work every day.To work at Elmleigh is a unique experience. Many of the staff had worked in Elmleigh for several years. Care Homes for Older People Page 21 of 26 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. The home is well managed and run in the best interest of the people living there. Evidence: The home is managed by two registered manager, they both have the appropriate qualifications and experience to meet the needs of the people in their care and the management of staff. Staff said they are approachable and helpful. From information seen and our discussion with people it would appear that the home is well run and organised. There are systems in place for the home to get feedback about their performance. Sister Superior has monthly meeting with the sisters for them to discuss their life and any concerns they may have. Questionnaires are also distributed and the outcome is feedback to people and all involved with the home. There are good policies and procedures in place to assist staff to carry out their job. Staff told us that they are well supported by the managers. Both managers have undertaken the Mental Capacity Act Deprivation Of Liberty course. Although we found that the home was well maintained to a high standard and there Care Homes for Older People Page 22 of 26 Evidence: were systems in place to make sure all the required check to the premises are carried out, there were no records to show that the home carries out risk assessments for any potential health and safety hazards around the building and the grounds. During our inspection of the building we saw in the Parlour low shelves which have sharp edges, and the fire place marble hearth which was a potential trip hazard. These were brought to the attention of the maintenance person and the manager. We saw that the home had put systems in place, such as the magnetic door stops, to make sure people are safe at all times. The sisters finances are handled by the sister Superior and the Order. The sisters were complementary about the managers, they said they are very good and you can talk to them, they are always available to talk to. We observed the managers interaction with the Sisters to be helpful caring, respectful, and friendly. Care Homes for Older People Page 23 of 26 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 24 of 26 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 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 26 Some consideration should be given to discuss with the West Yorkshire Fire Service the issue regarding the gate to the top of the stairs identified in this report .To make sure people are safe at all times. Some consideration should be given to carry out risk assessments for any potential risks identified around the premises. This would make sure people are safe. The sharp corners of the shelves and the fire place hearth identified must be risk assessed with an action plan in place to manage the risk. This would make sure that people are safe. 2 38 3 38 Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. 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