Care Home: Seaton Lodge Residential Home

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well Seaton Lodge supports staff training and development ensuring that people who live at the home receive the best possible service. The home continues to update and maintain the decoration of the home and upgrade the environment for the comfort of the people who live at the home taken into consideration. One relative said, "Everything here is wonderful" and went onto say, "My relative is always praising the staff in the home". What has improved since the last inspection? Mr Briddick continues to invest in the home to improve the environment for the benefit of the people living in the home and one downstairs lounge area was being decorated during the inspection. There is ongoing work in two of the bathrooms that are currently being converted into two wet rooms for the comfort of people living in the home. What the care home could do better: All radiators must be covered to protect people from the risk of burns. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Seaton Lodge Residential Home 7/9 Seaton Avenue Mutley Plymouth Devon PL4 6QJ     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: Kim Fowler     Date: 2 1 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Seaton Lodge Residential Home 7/9 Seaton Avenue Mutley Plymouth Devon PL4 6QJ 01752667077 01752667077 seatonlodge@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Louise Catherine Evans Type of registration: Number of places registered: Mr Geoffrey Briddick care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 18 The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) Date of last inspection Brief description of the care home Seaton Lodge is located in the Mutley area of Plymouth. It is a medium sized care home situated in a residential area on the edge of Mutley Plain shopping precinct. The home provides accommodation and personal care for up to 18 older people from the age of 60yrs, some of who may have dementia. Accommodation is provided over 3 floors with a passenger lift and stair lifts providing access to the 1st and 2nd floor, Care Homes for Older People Page 4 of 29 Over 65 0 18 18 0 Brief description of the care home although there are some steps linking mezzanine floors. There are 2 lounge rooms on the ground floor, one of which is made available for residents who wish to smoke. The home endeavours to create an environment to meet the individual needs of each service user. The home has a family atmosphere due to the efforts of the owner, Registered Manager and staff to ensure a non-institutional atmosphere. The Registered Manager is Mrs Louise Evans who is in charge of the day-to-day care of residents. The current weekly fees for the home range from 295 pound to 335 pounds. Information about the services provided at Seaton Lodge can be obtained directly from Mrs Evans. Care Homes for Older People Page 5 of 29 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 quality rating for this service is 2 star. This means the people who use this service experience good outcomes. The unannounced inspection took place over 1 day and started at 9:30am and finished at 3:20pm. The homes Registered Manager and Mr Geoffrey Briddick the Registered Provider were both available throughout the inspection. The inspector made a tour of the building and spoke to most the people living at the home and one visitor visiting at the time of the inspection. Documentation relating to the care planning process and the management of the home were examined. Surveys were sent to people living in the home and seven surveys were returned to the Care Homes for Older People Page 6 of 29 Commission. Any comments are in the relevant section of the report. 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 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 8 of 29 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 9 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Pre-admission assessments are not routinely undertaken therefore, new admissions cannot be certain that their needs can be fully met at Seaton Lodge. Evidence: Of the files examined two of them held showed evidence that a pre-admission assessment of individual care needs had not been documented before their admission to Seaton Lodge. Other files of people living in the home, who had been at the home for some time, did have pre-admission assessments completed. The manager did confirm that information was obtained verbally prior to any admission but on this occasion she was not available to complete the forms before admission. Admission is a particularly difficult time for new admissions. If the assessment has not been carried out before admission, the care staff may not be fully aware of individual needs. This information is vital if the new admission is to feel safe and secure in a new Care Homes for Older People Page 10 of 29 Evidence: environment. One fairly new admission confirmed that the manager had visited them before they had moved into the home and had also had the opportunity to visit the home before they moved in. Other people living at the home were spoken with about their admission. Several were able to confirm that they had received information prior to moving in and another said, I visited with my family before I moved in. The homes AQAA states, Ensure all prospective service users spend time here and that the brochure gets updated and ensure all service users have a pre assessment check carried out. Seaton Lodge does not offer intermediate care. Care Homes for Older People Page 11 of 29 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. The staff and manager provide good personal and health care support to people who live at the home. Ensuring the promotion of privacy and dignity at all times. Evidence: Most files examined held a completed assessment, giving clear details and information on meeting individual care needs and comprehensive care plans supported this information. One care plan was not completed in full and the manager stated that the person was admitted for respite in the first instance and she was not available to complete the form in its entirety. But confirmed this would be completed. These care plans give detailed instructions to all staff to ensure intimate personal care is being provided in a manner that meets with peoples approval. This is particularly important if the people living at the home have limited communication skills. All peoples assessment and daily care plans are easy assessable for staff on duty and risk assessments are held on individual files for the protection of all people living at the Care Homes for Older People Page 12 of 29 Evidence: home. The manager stated that the risk assessments are reviewed regularly and updated as and when needed. All people living at the home have access to all health care services and information was recorded onto a medical visit record sheet in each persons file that there was input from other professionals including GPs, District Nurse, chiropodist and consultants based at the local hospital. Most people living in the home were spoken with and some were able to confirm that their health care needs were met and one person said, I see the District Nurse. A survey returned to the Commission when asked whether they receive medical support they ticked yes and wrote, Especially at the moment. and went onto say this was due to a recent injury. The manager and staff of the home talked through the medication procedure for the home. The home uses the blister pack system for administration. The manager confirmed that the staff had attended medication training. It was evident from these discussions that the manager and staff spoken with understood the medication procedure that included administration, storage and disposal of medication. Any changes in medication were recorded, signed and dated onto the medication recording sheets. However the MAR (Medication Record Sheet) sheets were checked and some administrations of medications had not been signed for. One person is currently self-medicating and this information is recorded into their individual plan, however no risk assessment is completed to support this. The manager confirmed that this would be completed and that the home has received a new Policy and Procedure on medication from the pharmacist that holds information on self-medication risk assessments. One staff file examined held a medication training course certificate. Most people living at the home were spoken with during this inspection and all that were able to confirm that the staff respects their privacy and dignity at all times. Observed during the inspection were staff knocking on peoples doors to promote privacy and shutting the bedroom door when attending to a person personal care needs. The homes AQAA returned states, We need to ensure our care plans are updated regularly. One person living in the home said, the staff shut my door and another stated, The bathroom door is shut when Im having a bath. Care Homes for Older People Page 13 of 29 Care Homes for Older People Page 14 of 29 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 Seaton Lodge can be confident that the home offers good wholesome meals and the home welcomes and encourages families and friends to visit. Regular activities and trips out are arranged by the home for peoples enjoyment. Evidence: People were observed moving freely around the home. Some people remained in their individual bedrooms and one person said, I like to stay in my room some days. Staff were seen interacting with people and discussing everyday topics and included assisting individuals when needed showing staff were aware of the needs of people living in the home. All activities people enjoy is recorded into individual care plans and the home organises activities such as bingo and an Occupational Therapist visits to carry out armchair aerobics. The home also organises fortnightly trip out for a lunchtime meal and many people spoken with spoke enthusiastically about these lunches. One person said, We have a great time and the food is lovely. The manager also stated that a Care Homes for Older People Page 15 of 29 Evidence: group of people living in the home had visited France on a ferry trip planned by the home. The home is fortunate to be situated near a small shopping centre and observation showed several people accessing the local community independently. It was also observed that staff were taking people living in the home out during the day. All family visits and contact is recorded into individual files and daily records examined showed recent family visits for several people living in the home. One visitor was spoken with during the inspection and spoke very highly of the home and the staff. All bedrooms visited contained personal possessions and items and one person living at the home said that the home encouraged them to bring in items from home. And all rooms are single to maintain privacy. All people who were able to made positive comments about the food provided. The homes 3 weekly menus was displayed for all to see and showed a varied and nutritional diet. It was evident from the food seen served at lunch time, Roast Pork, roast potatoes and fresh vegetables followed by home made summer fruit pudding, that the food was home cooked using fresh products. The meal was well presented and freshly prepared. Observation showed staff assisting people with their meals including providing assistance with cutting and eating. It was observed that this staff member was patient and did not rush the person eating the meal. The homes AQAA states, Encourage more service users to participate in activities. The comments received from people living at the home about the food provided included, Food is good. One person said of the lunch observed being served, The food is fresh and very good. All people spoken with confirmed that food was plentiful and very good, and that drinks and snacks were available at all times. Also that alternative to the menu is available upon request and one spoken said, Will always give me something different if I dont like what is on offer this was confirmed through observation on the meal time observed as one person was eating a cottage pie. One survey returned stated, There are alternatives available if I dont like what is on the menu. Care Homes for Older People Page 16 of 29 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 living at the home can be confident that any complaints or concerns raised will be listened to, acted upon and well managed by the home, which protects the welfare of all. Evidence: The homes complaints procedure was displayed for all to access and the complaints file was available in the main office. This showed no complaints made to the home and the Commission has not received any complaints. Most of the people living at the home were spoken with and some were aware of the homes complaints procedure and a few stated that they had never had any need to use it. One person wrote in the survey returned to the Commission, I have never had to complain. Most of the staff members on duty were interviewed during this inspection. The discussion with these staff members confirmed that many had completed the Adult Protection training. This training was carried out by a local training provider and it was clear from the information given to the inspector from some staff they had a clear knowledge and understanding of the Adult Protection process. A Safe Guarding training pack is given to all staff and completed. This is then returned to the training company before a certificate is provided confirmation training is complete. Care Homes for Older People Page 17 of 29 Evidence: Many of the people living in the home were able to confirm that the Registered Provider, Mr Geoffrey Briddick, the registered manager and the care staff are very approachable and they were confident that any issues of concern would be dealt with promptly. Neither the Commission nor the home has received any complaints since the last inspection. The one relative spoken with felt the communication between themselves and the home was very good and had never needed to complain. Care Homes for Older People Page 18 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Seaton Lodge is a warm and comfortable home. The unguarded radiators place people living in the home at risk. Evidence: A full tour of the premises found the home to be clean, tidy and free from offensive odours. Some areas of the home were observed to be under improvement including the converting of two bathrooms into wet rooms for the comfort of people living in the home. One of the downstairs lounge areas was being painted on the day of the inspection. A previous inspection report made a requirement that all radiators in rooms accessible to people living in the home must be covered or have a guaranteed low temperature surface to protect them from the risk of burns has not been completed. Mr Briddick confirmed that this job was due to be undertaken several week ago however due to a unforeseen circumstance the radiator cover were now not available but gave assurances this Requirement would be completed soon. The Registered Manager confirmed that the requirement to seal the laundry room floor had been completed. As had the recommendation that the Registered Provider should give consideration to controlling the temperature of all hot water accessible to people Care Homes for Older People Page 19 of 29 Evidence: living in the home to protect them from scolds. Having controls fitted to all taps has completed this recommendation. People living in the home that were able to confirm that they found the home comfortable, clean and warm. One person spoken to said, Would recommend the home to anyone and one survey returned said, Happy at home. The Kitchen floor requires re-sealing to prevent any food particles or spills of liquid from soaking into the floor and to make it more easily cleaned, reducing the risk of cross infection. Mr Briddick, the Registered Provider, stated that this work had already been priced up and the home was waiting for new tiles to be delivered and fitted. The homes AQAA under improvements for the next 12 months states, Radiators to be covered. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff training is encouraged and this enables people who live at the home to receive the best possible service. People living at the home are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Evidence: On day one of the inspection there were 17 people living in the home and 3 care staff supported these people with the registered manager, handyman, cook and cleaning staff also on duty. The duty rota was examined and it shows sufficient numbers of staff for the amount of people living in the home and their dependency. The staff interviewed felt that the home had sufficient staff on duty and observation of staff throughout the inspection showed them to be relaxed, patient and helpful when assisting people. One staff interviewed said that when people are sick it could leave them short of staff. Some of the people living at the home were able to state that the care received is very good. Care Homes for Older People Page 21 of 29 Evidence: Currently 9 of the 13 care staff holds an NVQ qualification at level 2 or above this is a nationally recognised care qualification for which staff have had their work performance and knowledge evaluated by an external training organisation. Through this training staff received further training in first aid and health and safety ensuring they have the knowledge to deal with emergencies. Examination of staff files showed that all staff had the required pre-employment checks, including CRB (Criminal Record Bureau Disclosure) in place ensuring as far as possible unsuitable staff are not employed. Staff confirmed that the home holds staff meetings and these staff interviewed felt that they were able to express their view at these meetings. Regular consultation with staff ensures staff can contribute to the running of the home and are aware of the homes aims and objectives, philosophies of care and promotes consistency and improvement. Some staff spoken with confirmed that they held a NVQ certificate and other are hoping to start this qualification soon. Staff training files showed staff had completed training in a variety of training including fire safety, protection of vulnerable adults and moving and handling. The manager said that an outside training company provides much of the training. Currently the medication training is completed via a correspondence course for all staff. A new Policy and Procedure of administration of medication is to being introduced by the pharmacist and further training will be provided soon. The home AQAA states, Much better supervision for staff. One staff member confirmed they had completed a staff Induction provided by the training company the home uses for all its training. One survey returned said, The service is brilliant and one person spoken with said, Commendable and another said, The staff are lovely. One staff member said of the staff team, Brilliant. Many of the people spoken with during the inspection spoke highly of the staff and said they were kind and caring and confirmed they responded promptly to requests for assistance indicating that there are sufficient staff on duty to meet the needs of those currently living in the home. One relative wrote on a survey returned to the home, All staff appear polite, professional and caring. Care Homes for Older People Page 22 of 29 Care Homes for Older People Page 23 of 29 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 owner, manager and their staff team strive to provide a homely, stimulating environment that respects and protects people who live at the home. Evidence: The Registered Provider, Mr Briddick and the Registered Manager, Mrs Evans is in dayto-day charge of the home. Mrs Evans is the Registered Manager and has been at Seaton Lodge for many years and is also a Registered Nurse and holds the NVQ4 in Management certificate. A discussion was held with the manager on quality assurance. The manager confirmed that these had been completed within the last year. The results were looked at and were all positive. One relative wrote, The care and love you have given my relative is excellent and another said, I am happy with the care my relative receives. The manager said she would continue to do quality assurance audits like this on a regular basis so that ongoing improvement can be measured. Care Homes for Older People Page 24 of 29 Evidence: The manager confirmed that a small amount of personal money is held for each person. This money comes via the placing authority in a form of a cheque and Mr Briddick collects this money. All the money is paid into a Residents Account at the bank and held their until needed. The manager confirmed that some people have their money held by family members and others is held under the placing authorities Receivership. Two balances were randomly checked and were found to be correct with a clear audit trail of income; expenditure and receipts were held for money spent. Mrs Evans has completed a training course in ant-discriminatory practices and the promotion of equality and diversity, and confirmed that the home was in a position to meet the needs of residents from different faiths and cultures. The staff spoken with confirmed that they receive regular supervision and the manager produced records to show this is carried out regularly and recorded. Sampling of records indicated equipment is serviced regularly and maintained in good order. Health and Safety is a priority in the home and records examined showed fire safety training and fire protection is in place and up to date. The accident records were accurate and files examined showed that information is recorded onto accident forms and also written into peoples daily records with appropriate action taken when needed. One staff member working at the home said, Enjoyable place to work and another said, Couldnt work anywhere better! Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 25 Reg. 13(4)(a) The registered person shall 31/03/2007 ensure that (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (All radiators in rooms accessible to service users must be covered or have a guaranteed low temperature surface to protect them from the risk of burns). The previous timescale of 31/08/06 has not been met. Reg. 13(3) The registered person shall 31/12/2006 make suitable arrangements to prevent infection, toxic conditions, and the spread of infection at the care home. (The laundry room floor must be sealed). The previous timescales of 31/12/05 and 01/03/06 have not been met. (1) The registered person 31/03/2007 shall establish and maintain a system for - (a) reviewing at appropriate intervals; and(b) improving, the quality of care provided at the care home, including the quality of nursing where nursing is provided at the care home. Page 26 of 29 2 26 3 33 Reg. 24 Care Homes for Older People (2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. (3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. (The Registered Provider must introduce a quality assurance and quality monitoring system). The previous timescale of 01/06/06 has not been met. Care Homes for Older People Page 27 of 29 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 25 13 The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety.All radiators must be covered as discussed at the inspection. All radiators in rooms accessible to service users must be covered or have a guaranteed low temperature surface to protect them from the risk of burns. 31/01/2009 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 1 2 3 19 All pre admission assessments should be completed prior to admission. The kitchen floor should be replaced as discussed at the inspection. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!