Care Home: Southmead

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What the care home does well We found Southmead to be a relaxed and friendly home. The home is small and there is a homely atmosphere, where residents and staff know each other well. Mrs Fletcher is experienced and provides a hands on management approach shows great commitment to residents, which was acknowledged by them. The supportive staff team were seen to be happy and alert to residents needs. Residents made it very clear that they feel well supported by staff and their company enhances their lives. One member of staff said that in other homes, where they have worked, there is little or no time to talk to residents and that at Southmead, this is a very important part of the life of the home. The home has a beautiful garden, which is used and enjoyed by residents. What has improved since the last inspection? The environment has been improved with decoration, the upgrading of two bathrooms and installation of specialist baths. Staff have worked hard to gain national Vocational Qualifications and further training has been undertaken. Improvements to the medication system have been made. The importance of notifying the Commission for Social Inspection of any occurrence, which may affect the well being of a resident has been understood and notifications have been made. What the care home could do better: The formal care plan file and recording system could be improved so that there is a clear and straightforward care plan for each resident, providing immediate information on all aspects important to residents. A key worker system could support improvements for residents. An activities coordinator could help to ensure all residents and those with differing needs can achieve a more fulfilled lifestyle and that their wishes can be explored with increased opportunities. There should be a review of the environment to check that it remains a good and safe place for residents to live. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Southmead 159 York Road Broadstone Poole Dorset BH18 8ES     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: Peter Still     Date: 1 9 0 3 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. 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. 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: Southmead 159 York Road Broadstone Poole Dorset BH18 8ES 01202694726 01202659495 robert@southmead.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Penelope Anne Fletcher care home 16 Number of places (if applicable): Under 65 Over 65 16 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 Southmead is registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of 16 older people. The home is owned by Mr and Mrs Fletcher and Mrs Fletcher is in day-to-day charge of the home. Mr and Mrs Fletcher live on the premises. The home is in a quiet, residential area of Broadstone, which has a wide range of shops and local amenities. The premises consist of a lounge and dining room and 4 bedrooms on the ground floor, and 8 bedrooms on the first floor. 3 of the bedrooms are double rooms. All areas on the first floor can be reached by the stair lift. The home is very well maintained and has a particularly attractive garden. At the time of the inspection fees ranged from three hundred and sixty nine pounds to five hundred and forty pounds per week. Care Homes for Older People Page 4 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: This inspection was carried out by one inspector but throughout the report the term we is used, to show that the report is the view of the Commission for Social care Inspection. Prior to the inspection, we considered information, which had been sent to the Commission. We spoke with one health care professional and we read the responses to surveys we had sent out; we received responses from ten residents, ten staff and four healthcare professionals. The inspection was unannounced and we spoke with residents, and staff. We examined files, including care plans and used three files in particular to track the care of Care Homes for Older People Page 5 of 27 residents. We made a tour of the building and garden. 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 7 of 27 Care Homes for Older People Page 8 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 9 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 considering living at the home are provided with information to assist their decision making. A pre admission process including assessment, ensures the home can meet peoples needs. The home does not provide intermediate care. Evidence: We reviewed the Statement of Purpose and Service User Guide, which gave detail concerning all key aspects about the home. We noted that the section concerning how to make a complaint, had been revised with the new contact details of the Commission for Social Care Inspection. These documents had been recently updated and were well laid out, easy to read and contained pictures. The Annual Quality Assurance Care Homes for Older People Page 10 of 27 Evidence: Assessment document produced by the home said that there are plans to produce the Service User Guide in large print and to enhance their current web site with additional pre-placement information. We reviewed the care files of three people as part of our case tracking approach to this inspection. We found that each file contained a local authority single assessment, setting out the needs for the individual and including risk areas. One file also included a personal history, which provided carers with important background information. Files contained an admission plan and there was evidence of family involvement. A separate file contained detail about financial matters including up to date contracts of residency. Southmead does not provide a specialist intermediate care service, solely to help people to return home. Care Homes for Older People Page 11 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. Care plan files include important information so that staff are aware of individual needs. Improvement to the file system, which the provider is aware of, will make access easier for staff. Healthcare professionals provide support when required. Input from external agencies supports good administration of medication. People living at the home are treated with respect and dignity. Staff are respectful and sensitive during end of life care. Evidence: We examined the files of four residents and found information to show that their needs were known and reviewed. Each file contained a photograph of the resident, which also made it clear who the information related to. The files we examined had recent review Care Homes for Older People Page 12 of 27 Evidence: dates and detail was found on the files. Whilst the care plan files we examined contained key information, it was not easy to find. Some information was set out as an account of an incident or points that had occurred. It will be helpful for the format to be revised so that the formal care plan includes the key areas of need, such as: personal care and physical well being; diet; communication; oral health and foot care; mobility; history of falls; continence; medication mental state and cognition; interests and activities; risk assessments; detail about those people important to the individual. The care plan should include a daily living plan with goals. Where people share a bedroom, detail concerning residents agreements, should also be set out and reviewed along with all the other points within the care plan. Only one of the four files we examined contained risk assessments, which had been completed where necessary and using headings, which represented good practice. The other files did contain abuse and vulnerability assessments. Risks had been outlined within the single assessments, when people had been admitted. We spoke with a member of staff about care plans and were told that because staff know residents so well, it was felt the current system was satisfactory. However we consider it would be helpful to review the current system and in discussion with the provider/manager, it was agreed it is an important task to respond to. An index and headings to care files would be also be helpful. We considered the responses to surveys we had sent out to healthcare professionals and spoke directly to one professional. The four responses were positive and one professional spoken with, said: It is a valuable local service and I would be happy for my relative to live at the home. Positive points were also made about the hands on approach of the provider manager, her commitment and that of her staff team. Another professional said, in terms of whether individuals health care needs are met by the care service: Carers are careful to follow instructions and Staff are always kind and support the wishes of the patients. We spoke with seven residents who were all very positive in relation to their comments about the way staff provide care, show commitment and kindness. One resident said that if a resident calls out from the lounge, staff immediately respond, using the residents name, since staff know residents so well. The resident added that the way staff respond, gives reassurance. We considered the use of double rooms at the home and found that one was being used as a single bedroom. A survey response we received from staff had said: We Care Homes for Older People Page 13 of 27 Evidence: have problems with shared rooms because some clients are very noisy at night, which also raised a staffing issue. We spoke with residents about this and one person said they really did hope they could move into a single room soon. We talked with the providers about this and the difficulty was understood and options would be consider. The home does not use a key worker system to support residents and the merits of this approach were discussed. If introduced, it would mean that each resident would have a named member of staff who would have a specific responsibility for one or more residents to ensure their needs and wishes are supported to improve their lives. This task does not take away responsibility from the provider/manager but it supports good communication and helps to ensure agreed action is undertaken. A key worker will spend time regularly talking to the resident and will usually produce a monthly report, which will be linked to changes and review of the care plan. Policies and procedures were in place concerning medication and we examined a recent review undertaken by the Primary Care Team of the Southmead medication administration system. A form following the visit had been completed and given to Mrs Fletcher. A number of points were made and Mrs Fletcher confirmed that she had addressed the issues. A senior member of staff is now supporting the medication process and also checks and double signs medication delivered to the home each month. The form given to the home had a section called Action Plan and this contained one point, which read: Update homely remedies and audit. The home uses the services of a large pharmacy, who provide a blister pack medication system. This was checked for the day of inspection and it was seen that medication had been given and signed for. The Annual Quality Assurance Assessment also noted that the pharmacy undertakes annual audits of the homes medication system. The home had needed to provided a secure medication cabinet, which was seen at the home, it had not been securely fixed to a wall, however this task was completed immediately following the inspection. Staff were observed to be respectful of residents during the day and maintaining privacy and dignity. One person was being supported in bed during the inspection and we observed staff being with this person frequently. One member of staff was seen to be gently helping the person with their food at lunch time. We were shown a sign, which is put onto the door of a residents room, when staff are engaged in giving personal care to promote privacy and dignity. Care files reviewed, included information important for staff to be aware of, during end of life care. The provider is considering the introduction of the palliative care Gold Standards Framework. Care Homes for Older People Page 14 of 27 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. Residents are offered choices of activity to enhance daily life. Families and friends are encouraged to visit. Balanced meals and choice is offered to meet residents tastes and needs. Evidence: Residents are provided with opportunities for activity. Trips out are arranged and some people choose to go out frequently. Residents enjoy the activities of the local church and local community. One resident spoken with said that Mrs Fletcher often takes residents out shopping. Entertainers visit the home regularly, including a violinist and shows are performed. The home has a memory box, though recently this has not been used much. The weather was good on the day of inspection and staff spent time in the attractive garden with residents. Two staff spoken with said that residents really enjoy having conversation and said they do have time to chat to residents. Surveys and discussion with staff found that whilst there was activity provided, there could be more emphasis, Care Homes for Older People Page 16 of 27 Evidence: in particular because the home has residents with distinctly differing needs. This was discussed with the provider manager, who agreed this was an area that needed renewed effort; staff had already raised it with her. We discussed the merits of having one member of staff with delegated responsibility to coordinate activities and provide an overview to promote all residents wishes for a fulfilling life. We spoke with one resident who enjoys their Talking Book service and a resident who said they enjoy listening to classical music. We shared information about the British Wireless for the Blind Fund, which is a registered charity and may be of some interest. Three residents spoken with talked particularly about their relatives and how they enjoy their visits and this showed that the home encourages and helps families and friends with their visits to the home. One relative, within their survey response to us, gave the following list of activities: Good variety of visiting musicians and singers; gentle exercises class fortnightly; occasional special trips out: panto, river trip, garden centre; summer garden party; monthly communion and monthly service. One resident who answered our survey question about activities they could take part in said: Sometimes. This indicated there could be more emphasis on activity. The home has their own chef,who was enthusiastic about their work and was aware of the importance of diet and good food for residents. The menu was discussed and there was evidence of choices. Likes and dislikes were recorded as well as specific dietary needs. The main meal of the day was roast lamb and residents, both on the day of inspection and in their survey responses, gave high praise for their food. One resident in their survey response said they could eat another roast potato, but only because they were so tasty and another said: Food is plentiful and there is always a choice. Chef is a very good cook. We asked the chef where food was sourced and found that local butchers were used, with suppliers from: Bridport, Scotland and the New Forest. 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. The home has a complaints and adult protection system to ensure residents can be protected and supported if there are concerns. Evidence: Since the last inspection, anonymous concerns had been raised about medication and points concerning residents. These were looked into by the Local Authority and the home was informed the matters were unfounded. We spoke with three staff about adult protection training and abuse. They knew the steps to take if they had a concern, which included whistle blowing. Staff also knew they could contact the Commission for Social Care Inspection or other agencies if they wished. Staff talked about their National Vocational Qualification training and that adult protection was covered in their learning programme. One resident in their survey response to us about who they would talk to if they had a concern, said: Mrs Fletcher or any member of her staff. 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. Residents live in a home, which is generally well-maintained, decorated and furnished, however some areas are tired and in need of up-grading. Residents enjoy a homely atmosphere and have access to a pleasant garden area. Specialist bath equipment helps people to maintain dignity, whilst supporting their personal care needs. The home was fresh and clean. Evidence: Whilst much of the home was in good decorative order, the kitchen in particular requires up-grading. A part of the floor was stained and work surfaces needed replacing. A recent Environmental Health report also found that upgrading was needed. The providers said they have plans to carry out this work. The providers have a maintenance programme for the home and some redecoration had taken place since the last inspection. Extensive works had also been completed to upgrade two bathrooms, providing specialist baths. The bathrooms were tiled in a homely way and were pleasant for residents to use. A new specialist washer unit had Care Homes for Older People Page 19 of 27 Evidence: also been installed in the laundry. Windows in the home have been replaced and window restrictors were in place; a member of staff demonstrated how they work. Some furniture in bedrooms was seen to be worn and needed replacement, for example a table and a chest of drawers. One carpet was also seen to be rucked slightly and may cause a tripping hazard. The provider manager said furniture and carpets would be replaced or attended to where necessary. A section of ceiling paper had come away in a bedroom and needed attention. Staff in their survey response had drawn attention to the difficulties posed by the building and lack of space to care for people as they become more dependant. Concern was also raised about a step in the downstairs toilet, where residents had fallen. It was said that a standing hoist should be used but this was not enforced by the manager. We viewed the hoist and the provider manager said that currently it was not needed for residents. Residents were seen visiting the toilet and no difficulties were observed. However it is clearly necessary to continue to risk assess this potential hazard for each resident. Two healthcare professionals also made reference to the building. One said: constrained by way out of building, another said: The building is adapted and not purpose built. However the staff manage well within the constraints of the building. Seven residents spoken with about the building, were all positive in their responses. Some talked about having been at the home for a long time and feel it is very much their home and are happy with the way it is for them. One said that because the home is quite small, staff are never far away. The home was seen to be fresh, clean and tidy and we found no unpleasant odours. Antibacterial hand gel was available for staff to use. The garden area was considered to be excellent, it was attractively planted and included water features. There was a variety of places for people to sit and shade was provided. A resident was sitting in the garden as we arrived and during the day, many residents enjoyed the garden environment. One resident talked about how the owners are seen tending the garden they are out there every evening. There was appreciation for the way the garden is kept for residents to enjoy. 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. Residents can be confident that they are supported by competent staff, in sufficient numbers to meet their needs. Recruitment practice, including policies and procedures, ensures residents are protected. The staff team take advantage of training opportunities to ensure they have the skills to care for residents. Evidence: As we arrived at the home, the staff team were being provided with a training event by an external trainer in fire prevention and procedures. Staff were engaged in fire scenarios and were observed to be a happy team of staff, used to working together and enjoying their training. It was noted that extra staff were available during the training to care for residents. We spoke with a number of staff during the day, they were experienced and highly motivated, clearly enjoying their work and knew the needs of residents well. One member of staff commented that they like to work at Southmead because they enjoy caring for residents they have known for a long time and working with the staff and Care Homes for Older People Page 21 of 27 Evidence: the owner/manager. Commitment and positive feedback was given by all staff spoken with and residents spoken with too, emphasised the importance of the caring staff team to their happiness. Other comments from staff included: Because it is a small home you get to know the residents very well; The owner manager is very approachable; The last staff meeting was on 09/03/09 and I can make any points I want and am listened to; I have regular supervision, it is supportive; Staff all support each other; Further training concerning dementia and individual needs could be helpful. We were told that all staff have been provided with training in relation to dementia, recently, however this importantly remains a key point for staff. Other comments made by staff within their survey responses to us included: The staff are very friendly both to one another and to residents. The residents are treated to the highest standards and all their needs are met. It is a really lovely place to work, as an employee, I put my heart and sole into my work because I really do enjoy the work and the workplace. One member of staff responding to our survey about staffing levels, said: There are enough staff, unless somebody is ill. The manager always steps in and helps anyway so we are never without help. Concerning communication between staff, survey responses included: There could be better communication. The homes Annual Quality Assurance Assessment drew some attention to this by stating that there would be consideration of team building exercises to encourage employees to work together. We reviewed well recorded minutes of the recent staff meeting. The home employed fourteen staff and seventy three percent had achieved National Vocational Qualification at level two or higher; there are five senior staff, who all have the level three award. We examined the personal files for two staff and found good recruitment practice, which included: Application with career history; Criminal Records Bureau checks; two references; and photograph of the individual. We reviewed staff supervision notes and found them to be well recorded and with evidence of regular supervision. 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. Residents can be assured the home is run by an experienced and competent person, who residents and staff find is approachable and provides supportive leadership. The home has financial procedures in place to safeguard residents. Residents health and safety is promoted and protected by policies and procedures. Evidence: Mrs Fletcher owns and runs the home with her husband and provides a very hands on approach, working at the home on a daily basis. They have run the home for many years and have significant experience. Mrs Fletcher has completed the National Vocational Qualification at level four in management of care. Residents gave high praise for the care provided by Mrs Fletcher and one resident said It is wonderful that the Fletchers live here. This gave an indication that residents Care Homes for Older People Page 23 of 27 Evidence: feel well supported by owners who show commitment to their care and needs. One resident said: Any little query, we can put to Mrs Fletcher and it is responded to. Another resident said: It is homely - a first class home - nothing could be better and the staff are kindly. One relative said in their survey response to us: Southmead is quite simply an excellent care home. Its small size and friendly caring atmosphere make it feel as close to a family as is possible for such establishments. The environment is enhanced by fresh flowers and a lovely garden. They deserve to be highly commended!. Many other residents or relatives made similar references. Another relative said: Very nice and friendly home and I feel my relative is very lucky to be here - we rate Southmead very highly and would recommend it to anyone. One health care professional responding to our survey said: The home is a small well managed residential care home meeting individual needs, friendly staff - a very well run home. Annual quality assurance had been undertaken by the providers, with analysis and points emerging responded to. Questionnaires are sent out to residents, staff and to external agencies and families. The survey in relation to food was seen and responses were positive. It was noted that the chef had worked hard to produce a thorough analysis of the surveys. A residents meeting was due to take place the week after this inspection. The home has policies and procedures in place to protect the health and safety of residents and risk assessments support practice. Care Homes for Older People Page 24 of 27 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 38 Schedule 4 12 You are required to record (a) any accidents that occur in the home. 04/07/2008 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 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 A review of the care plan file system and introduction of headings and an index to the files would help staff to find necessary information swiftly. This would also ensure greater clarity for the monthly review of care plans, including risk assessments. Further consideration of ways of encouraging activity could improve the lives of residents. A member of staff with specific responsibility to coordinate and provide an overview, may be helpful. The providers should undertake work to upgrade the kitchen as directed by the local Environmental Health Services, following their recent visit to the home. There should be a review of furniture and fittings at the home to ensure items are repaired or replaced as necessary. This particularly related to a rucked carpet and to a worn table and chest of drawers. 2 12 3 19 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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