Care Home: Romans

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What the care home does well Romans care home provides a good quality of care in a homely environment. The housing association is planning to refurbish the home in the next twelve months. There are pleasant grounds including a sensory garden for people to use in good weather. The staff team are dedicated to providing a good quality of care and say that they work well as a team. The pre-admission assessments and care plans provide guidance for staff about the way care should be provided so they understand the care that people need. There is an activities programme and an activities coordinator works three days a week. The food is of a good standard and meals are taken in pleasant surroundings. People are encouraged to contribute to the development of the service and their views are listened to and acted upon. There is a thorough recruitment process to make sure that people are protected. Staff are provided with an induction and training programme and staff are supported to study for the National Vocational Qualification (NVQ) in care at level two and above. A health care professional who returned a survey said: "Friendly atmosphere at Romans. Staff are conscientious in communicating with the GP surgery regarding patient`s health concerns and administration of medication". Comments made by people about the care they receive included: "Staff are kind and I can`t fault the care here, nothing is too much trouble", "I am very happy with the home", " Food is of excellent quality and variety" and "I am perfectly happy here". Comments made by staff included: "Provides a good standard of care. Staff are well looked after", "I feel we are a very caring home- staff are very conscientious and care for overall wellbeing of service users", "I have no complaint re our manager she gives 100% to her job, is always ready to listen and discuss anything with staff" and "We are kept fully informed of changes. The home is run very professionally and we have an excellent team here". What has improved since the last inspection? The manager has made some changes in the home since she has been in post. A new care planning system is being introduced so that a more person centred approach is taken. New shift patterns have been introduced to better suit the needs of people in the home. All staff have attended training about the Mental Health Act so that they understand the implications for the people they care for. More activities are being provided. Some areas of the home have been decorated and further improvements are planned. What the care home could do better: The policy regarding supporting people who wish to self medicate must be reviewed to make sure that the guidance is clear. Risk assessments must be carried out with people who wish to administer their own medication to make sure that independence issupported and people are kept safe. These risk assessments must be kept under review. A requirement has been made regarding this matter. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Romans 1 Roman Road Southwick Shoreham-By-Sea West Sussex BN42 4TP     The quality rating for this care home is:   two star good 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: Annette Campbell-Currie     Date: 1 4 0 1 2 0 0 9 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 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) 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 27 Information about the care home Name of care home: Address: Romans 1 Roman Road Southwick Shoreham-By-Sea West Sussex BN42 4TP 01273270100 01903235770 julieveck.wshs@gmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) West Sussex Housing Ltd Type of registration: Number of places registered: care home 30 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Romans is registered with the Commission for Social Care Inspection to provide personal care for up to thirty older people. The establishment is a three storey detached building situated in the town of Southwick in West Sussex. A plaque in the hall shows that Romans has been operating as a care home since 1956. Romans is situated approximately quarter of a mile from Southwick Green, the main shopping centre of Southwick and all its amenities and half a mile from the sea front. Accommodation is provided in thirty single rooms. The rooms are arranged over three floors with a lift giving access to all but four of the rooms. A lounge, sun lounge and separate dining room provide the communal space. The responsible person is Mr Tony Matthews who represents West Sussex Housing Society Limited, a voluntary organisation who owns the service. The manager designate is in the process of submitting an application to become registered manager of the home. Care Homes for Older People Page 4 of 27 0 Over 65 30 Brief description of the care home Care Homes for Older People Page 5 of 27 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: two star good 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: The previous key unannounced inspection was carried out on 17th August 2006 and an Annual Service Review (ASR) was carried out on 29th February 2008. The current fees are from 402 to 539 pounds per week. Annette Campbell-Currie carried out the site visit over five and a quarter hours. The manager has been in post since April 2008 and is in the process of completing her application for registration with the Commission. The manager designate assisted with the inspection. The general manager for the organisation was also available for discussion and assistance. The information and documents required by us (the Commission) were available. There were twenty-six people living in the home at the Care Homes for Older People Page 6 of 27 time; one person was in hospital. The manager completed an annual quality assurance assessment form (AQAA) before the inspection. The AQAA provided information that was used to help plan the site visit. During the site visit most of the people staying in the home were seen and six people living in the home and a relative were spoken with. Time was spent with three members of staff and the cook. Surveys were sent out to people living in the home, staff and health and social care professionals, to find out what people think about the service. Two health care professionals, eleven staff and twelve people living in the home returned surveys. Comments were positive and have been taken into account in making an assessment of the service. A tour of the building included communal areas, the kitchen, laundry, bathroom and toilet facilities and a number of bedrooms. The following documents were read: the case records of four people living in the home, the complaints records, recruitment records for three members of staff, training records, a sample of medication records, quality assurance documents and Regulation 26 reports. Time was spent in the dining room at lunchtime and the medication round was observed. The outcomes for people living in the home have been assessed in relation to twentytwo of the thirty-eight National Minimum Standards for Care Homes for Older People; including those considered to be key standards to ensure the welfare of people living in the home. What the care home does well: What has improved since the last inspection? What they could do better: The policy regarding supporting people who wish to self medicate must be reviewed to make sure that the guidance is clear. Risk assessments must be carried out with people who wish to administer their own medication to make sure that independence is Care Homes for Older People Page 8 of 27 supported and people are kept safe. These risk assessments must be kept under review. A requirement has been made regarding this matter. 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 27 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 27 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. People have their needs assessed before they move to the home to make sure they will receive the care that they need. Intermediate care is not provided at Romans Evidence: People are provided with information about the home before they move in. The service user guide has been updated to include recent changes in management. This document includes a copy of the complaints policy. The manager takes a brochure about the home when she goes to carry out a pre-admission assessment so that people have a better understanding about the services provided at Romans. People are encouraged to visit the home before they make a decision about moving. Respite care is provided and the manager said that this helps people to make a Care Homes for Older People Page 11 of 27 Evidence: decision about moving to a care home on a more permanent basis. The manager said in the annual quality assurance assessment form (AQAA) that families and people living in the home have said they find the admission process relaxed and friendly. The manager visits people at home or in hospital to carry out a pre-admission assessment with the person and their relatives if appropriate. The manager said that she tries to make this a relaxed process so that people feel comfortable to chat and ask questions. Information is also gathered from relatives and other professionals involved in the persons care. Copies of completed pre-admission assessments were seen and included key information about the person. Information about their medical history, medication taken and mobility and personal care needs were noted. There was some information about peoples spiritual or religious needs. Care Homes for Older People Page 12 of 27 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. Peoples health and personal care needs are set out in a plan of care that is kept under review to make sure that people are receiving the care that they need. Most of the medication policies and practices in the home protect people however the policy and practice regarding supporting people who are self-medicating needs to be improved to make sure that people are kept safe. People are treated with respect and their right to privacy upheld. Evidence: There is a care planning and review system in place. The manager is beginning to change the documentation for care plans and risk assessments because she feels that the system previously used did not include sufficient detail or guidance for staff. People are involved in drawing up their care plans when they move to the home. A training session in person-centred care planning has been set up for senior staff so that they understand the new care planning process. The case records of four people were seen; two case records included the new Care Homes for Older People Page 13 of 27 Evidence: paperwork. Care plans covered all aspects of each persons personal, healthcare and emotional needs and guidance was provided to staff, for example: Xs mobility is restricted at times, staff to offer a wheelchair, staff to make sure that room is not full of clutter, ensure X uses the correct hoist assisted bathroom and that a member of staff stays with her and X is bed bathed daily and has a bath weekly at his request. People who returned surveys indicated that they have the care that they need and that staff listen and act on what they say. People living in the home spoke highly of the staff and said that they receive the care they need. Each person has a mental capacity assessment so that it is clear to staff when people are able to make decisions for themselves. Independence is encouraged and there was a note on one persons case records that: X would like a pot of tea delivered to her room in the evening; a risk assessment had been carried out to make sure that this request would not present a risk to the persons safety. Peoples healthcare needs were noted and it was clear that staff monitor peoples health and that they are referred for further input from healthcare professionals when required. One persons records included a note that an occupational therapy assessment was needed. A record is kept of visits from the persons GP or other healthcare professional with the outcome and any guidance given to staff. The surveys that were returned by GPs said that they are called when appropriate and that care staff follow their guidance. The manager said that there is good communication with the local primary care team. One person spoken with said she gets to see her GP when she needs to. A standard format has been used for risk assessment and a more detailed system is being introduced including the Waterlow system to monitor skin integrity and the M.U.S.T. system for monitoring nutritional risks. General risk assessments have been carried out and provide policy guidance for staff, for example the procedure to be followed when taking people for outings. Some people had individual risk assessments where a need had been identified; the manager was advised to make sure that all areas of risk should be documented for example when people go out independently. Daily records are kept of people progress; some records were recorded in detail where a particular need had been identified. The manager said that she is encouraging staff to make clear records of daily events and care provided for every person living in the home to make sure that it is clear that people are receiving the care that they need on a daily basis. Care plans and risk assessments are kept under review and it was clear that changes of need had been noted with additional input provided if necessary. Care Homes for Older People Page 14 of 27 Evidence: The policy on self-administration of medication should provide more detail and clear guidance for staff. Some people are supported to administer their own medication and lockable facilities are provided for people in their rooms. A disclaimer is signed, however the manager must ensure that a risk assessment is carried out for each person and kept under review so that people are protected. A requirement has been made regarding this matter. The medication storage and samples of records were seen. The records have photographs of each person to avoid any errors in medication. Staff who administer medication have all attended training so that they are competent to do so. A medication round was observed. The local pharmacy carries out an audit once a year and provides advice to the home if required. Staff are given guidance about the way to provide personal care as part of their induction. During the day staff were seen to be communicating well with people and providing support in a respectful and sensitive manner. Those spoken with said that care staff are very good and one person said: I couldnt fault the care here. Care Homes for Older People Page 15 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the lifestyle that they choose in the home. People are supported to maintain contacts with family and friends and the local community. People are able to make some choices about their lives in the home. A healthy diet is provided and meals are taken in a pleasant environment. Evidence: An activities coordinator is employed to work three days a week in the home. There is a weekly programme of activities and people are given a list so that they can choose what they wish to take part in. Planned activities include; card games, a movie afternoon, a poetry session, quizzes, a musical hour and one to one time. There were some comments in care plans about peoples interests and a list is kept of the activities that people join in with. The manager said she would look at including more information about peoples interests and life experiences in the care plans so that a more person centred approach could be taken to activities planning and one to one sessions. The manager said that sometimes people put forward ideas for new activities at resident meetings. Care Homes for Older People Page 16 of 27 Evidence: The manager has established links with a local school. People living in the home are invited to events arranged at the school and visits from the children are also arranged to the home. The school held a carol concert in the home at Christmas that people enjoyed. The home also has links with local churches and religious services are held in the home for people who wish to join in. Outings are also arranged and special events including birthdays are celebrated. One person was being supported to go out clothes shopping during the morning. The manager said in the AQAA that there are plans to provide activities for people to join in with seven days of the week. Relatives and friends are encouraged to visit the home and are welcome to stay for a meal. The relative spoken with said that she is always made welcome in the home and that she is kept well informed of her mothers wellbeing. People are supported in their independence and people are encouraged to go out independently or with the support of staff if they wish to. People are supported and encouraged to make choices in their daily lives. People are able to get up when they wish to and breakfast could be served in their room. People spoken with said that they could choose when they go to bed and are free to spend time in the lounge or in their rooms. There is an advocacy service available for people who may wish to use it. The food provided at Romans is of a good standard. Fresh produce is used as often as possible and all food is home cooked. People are provided with a printed menu each week and there are choices available if they wish. The cook provides a four weekly menu and she said that people give her ideas for new things to try. People spoken with said that the food is very good and there is always a choice; one person said that the food is wonderful. Special diets are catered for and information about allergies, likes and dislikes is kept in the kitchen as well as in care plans. The dining room is pleasant and attractively laid for meals and lunchtime was a relaxed occasion. People were being assisted at the mealtime in a sensitive manner and were not being rushed. Care Homes for Older People Page 17 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their complaints will be listened to and acted upon. There are measures in place to keep people safe from harm. Evidence: There is a complaints policy that is provided to everyone in the home. People can also raise concerns through the regular residents meetings or through the quality assurance process that is carried out once a year. There is a system for recording complaints. One complaint had been made in the past twelve months and the records showed that this had been appropriately investigated. The home follows the West Sussex multi agency policy and procedure for safeguarding vulnerable adults. All staff have attended training about adult abuse and reporting procedures; this training is repeated every year so that staff are kept up to date. The manager is due to attend a workshop on safeguarding adults that is being run by social services staff. The manager was clear about her responsibilities to report any safeguarding matters. Care Homes for Older People Page 18 of 27 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. People live in a safe and well-maintained home with good levels of cleanliness and hygiene. Evidence: Romans provides a homely environment with two communal lounges and a dining room. There are plans to refurbish and upgrade the building in the next twelve months. Several ensuite bedrooms will be provided and additional sluice rooms and storage space. The manager and general manager will draw up plans to make sure that the building work will not have too much of an impact on people living in the home and they will be kept informed and involved in the process. There is a member of staff who is responsible for maintenance of the building and he is currently working part time at the home; the manager said that he would soon be available in the home full time. The manager said in the annual quality assurance assessment (AQAA) form that the home fully complies with fire and health and safety regulations. The gardens are attractive and well maintained. There is a ramp from the front door so that it is easier for people to access the garden. A sensory garden was developed last year and the manager said that people enjoyed using it in good weather. Care Homes for Older People Page 19 of 27 Evidence: People have the equipment they need in the home. There is a call bell system in all bedrooms. The sluice and laundry facilities are suitable for the home and there are infection control measures in place. There are three domestic staff who keep the home clean and free from offensive odours. People spoken with said they are very happy with their rooms and the accommodation in general. All staff have attended infection control training and their are facilities in the home to prevent the risk of cross infection. Care Homes for Older People Page 20 of 27 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. Peoples needs are met by the numbers and skill mix of staff. People are protected by the homes recruitment policy and procedure. Staff are trained and competent to do their jobs. Evidence: Samples of rotas were seen and showed that there are sufficient numbers of staff on duty to meet the needs of people living in the home. The current manager has changed the shift patterns so that there is more consistency and to ensure that sufficient numbers of staff are available at key times. Staff are now allocated to work on one floor so that people get used to the staff providing their care throughout the day. In the mornings there are four or five care staff with a senior carer on duty, in the afternoons there are two or three carers and a senior carer or a manager available. At night there are two or three waking night staff; at times when there are two staff on duty at night there is a designated person on call. The home does not use agency staff and the manager said that she is able to provide additional staff if people living in the home have increased needs. The management team support staff to register for a National Vocational Qualification Care Homes for Older People Page 21 of 27 Evidence: (NVQ) award. Eleven of the twenty-five permanent staff have achieved an NVQ award at level two or above. All senior staff have achieved an NVQ at level three and all managers have achieved the NVQ level four in care. Five care staff are due to start the NVQ two and two are being supported to study for the level three award. The recruitment policy and process is thorough. A sample of recruitment records showed that people complete an application form and the manager said that gaps in employment would be explored at interview. The manager interviews all prospective staff and there is a standard format for questions to be explored during the interview. The outcome of the interview is recorded. Three written references are requested on the application form and an enhanced Criminal Records Bureau (CRB) check is carried out. People do not begin work until at least two references and a full CRB check have been received, to make sure that people living in the home are protected. Records seen have shown that this is the case. Staff who returned surveys also said the recruitment process had been thorough. There is an induction and training programme to make sure that staff have the knowledge and skills they need to do their job. The induction programme meets the Skills for Care standards and includes a workbook that staff complete with the support of their supervisor. The training programme is comprehensive and all staff have recently attended training days that included fire training, food hygiene, infection control, first aid, safeguarding vulnerable adults and medication policies and procedures. The manager supports staff through carrying out annual appraisals that help to identify peoples training needs. There is an ongoing programme of supervision where training needs would also be identified. Staff who returned surveys said that they receive the training and support that they need. Care Homes for Older People Page 22 of 27 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 manager is not yet registered with the Commission. She has the qualifications and experience to make sure the home is well run. Peoples views are listened to and taken into account in the running of the home. Peoples financial interests are safeguarded. The health, safety and welfare of people living in the home and of staff are promoted and protected. Evidence: The current manager has been in post since April 2008 and has not yet registered with the Commission. The manager said that she is now in the process of completing her application form. The general manager was advised that it is a legal requirement to ensure that a care home is run by a manager registered with the Commission. The manager is well qualified and has experience of managing care homes; she has achieved the Registered Managers Award (RMA) and is committed to her ongoing training and development. Care Homes for Older People Page 23 of 27 Evidence: There are quality-monitoring systems in place. The general manager carries out Regulation 26 visits each month to make sure the home is running efficiently and a written report is provided. Samples of these were seen and showed that staff and people living in the home are spoken with during these visits. Questionnaires are sent out every year to find out what people think about the service. It was clear that concerns and ideas are listened to and acted upon. The manager said that she makes sure she speaks with everyone living in the home on a regular basis and that she works alongside staff so that she keeps up to date with any issues or problems as they arise. Some people are supported with their day-to-day finances and there is a system in place to ensure that their money is kept safe. Receipts are kept and the accounts are checked by the manager on a regular basis. The manager said in the AQAA that the equipment in the home is serviced as required. A fire risk assessment has been carried out and the home complies with fire regulations. Staff have attended mandatory training. Incidents and accidents are responded to and recorded as required. The manager has systems in place to monitor health and safety in the home to make sure that people are protected. Care Homes for Older People Page 24 of 27 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 25 of 27 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 9 13 The policy regarding supporting people who are self medicating must be reviewed and risk assessments must be carried out with people who wish to administer their own medication to ensure that people are kept safe from harm. 28/02/2009 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 Care Homes for Older People Page 26 of 27 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 © (2009) Commission for Social Care Inspection (CSCI). 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