Care Home: The Old Vicarage

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What the care home does well People live in a safe and comfortable environment and well-trained and enthusiastic staff care for the people living at the home. Staff form good relationships with the people living there. Comments from people using the service included: `Always someone available to listen or act. This is always done with smiles and kind words` and `Nothing is too much trouble for the staff`. People living at the home and their relatives find the management and staff approachable and they are encouraged to express their views. A person replying to our surveys said: `Always someone available to listen or act`, and another said `Management are always available to discuss matters and to explain or resolve them`. There are also quality assurance and quality monitoring systems in place, which help to ensure that the safety and welfare of people is promoted. People who use the service tell us that they feel well supported living at the home and that they receive the care that they require. Health, personal and social needs are set out in comprehensive plans of care, and these are regularly reviewed to ensure that they remain up to date. Comments from people that we spoke with included: `The staff are very good`, `Smashing staff` and `Staff bend over backwards to help you`. People tell us that they enjoy the food at the home. Comments about the food included: `The food is good here` and `The food is lovely`. What has improved since the last inspection? This is the first key inspection of this service since the change of ownership. What the care home could do better: It has not been necessary to make any requirements at this inspection Recommendations have been made to further develop some aspects of the care planning recording and review processes. A recommendation has also been made for an up to date written risk assessment for the preventive checks on the water system. Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Old Vicarage White House Road Bircotes Nr Doncaster DN11 8EQ     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: Andrew Bailey     Date: 1 9 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. 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: The Old Vicarage White House Road Bircotes Nr Doncaster DN11 8EQ 01302745707 01302745707 oldvicaragecarehome@hotmail.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) : Care People Private Ltd care home 28 Number of places (if applicable): Under 65 Over 65 0 28 dementia old age, not falling within any other category Additional conditions: 28 0 The Registered person may provide the following categories of service only: Care home only - Code PC To Service users of the following gender: Either 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 The maximum number of service users who can be accommodated is 28. Date of last inspection Brief description of the care home The Old Vicarage is a care home registered for the residential care of twenty-eight older people, and is also registered to admit people with dementia care needs. Care People Private Limited became the registered provider of this service from March 2008. The care home is an extended and converted vicarage and is set in its own private grounds. Two lounge areas and a dining room are situated on the ground floor of the building. There are seven bedrooms on the ground floor, with a further eighteen bedrooms on the first floor. All bedrooms are currently utilised as single occupancy. Seven of the bedrooms have en-suite facilities. The range of fees as of 19 January Care Homes for Older People Page 4 of 27 Brief description of the care home 2009 was from £294 to £385 per week. Further details about this service are available by contacting the care home directly. 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: This is the first inspection of this new service. Care People Private Limited became the registered provider of this service from March 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for the people who use the service. The process of inspection considers the homes capacity to meet regulations and minimum standards of practice, and looks at any aspects of service provision that may need further development. The inspection visit was unannounced and took place over a 7 hour period. For the purposes of inspection we have taken into account information that we hold Care Homes for Older People Page 6 of 27 about this service. This includes information provided in the Annual Quality Assurance Assessment (AQAA) questionnaire completed by the home. The service has also told us about things that have happened at the home and these are called Notifications. We have considered the eight surveys that have been returned to us by people using the service and their views have been included in this report. At the time of the inspection there were twenty-two people living at the home. Five residents, five relatives, two staff, the registered manager and a director of the company were spoken with during the visit. We also spent some time observing the interaction of staff with people who use the service. Records were examined during the inspection, including the care records of three of the people who were living at the home. This was part of the process called case tracking. Where possible we spoke with these people, or with a member of their family, during the inspection visit. 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 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 receive information to help them decide whether the service can meet their needs, and they have the opportunity to visit the home before choosing to live there. Evidence: Prior to this visit to The Old Vicarage we received the homes Annual Quality Assurance Assessment (AQAA), a self-assessment document telling us about the service. The home told us that there is a Statement of Purpose (a written document describing the services that the home provides) and that people living at the home have a contract, or a statement of terms and conditions. They said that pre-admission assessments take place with people who are considering living at the home, with family input, where this is appropriate. The home does not provide formal intermediate care. Care Homes for Older People Page 10 of 27 Evidence: The home is registered to admit older people, and people under the category of dementia. The manager told us that the staff training programme includes training about dementia. Staff that we spoke with confirmed that they had undertaken training to assist them with meeting the needs of people with dementia. We case tracked three of the twenty-two people who were living at the home on the day of the inspection. The process included looking at the care plan and assessment documentation held at the care home. Detailed pre-admission assessments had been completed in all the cases that we examined. The manager told us that where appropriate, social service assessments are received before people are admitted to the care home. In the care plans that we looked at during case tracking social service assessments had been received and taken into account during the admission process. We spoke with people using the service, and their relatives, and they confirmed that there had been the opportunity to visit the home to help make the decision as to whether they wished to live there. People felt that they had received suitable verbal and written information to help them make their decisions. Two of the people spoken with had received personal recommendations about the care home prior to them making initial enquiries at The Old Vicarage. Relatives had arranged the admissions in the cases of two of the people that we spoke with, after visiting the home on their behalf. Speaking about a pre-admission visit on behalf of their relative, one visitor told us: I was made welcome, invited to look all around the home and to speak to the staff. One of the written survey responses said: All the information was readily available and clearly explained in advance. 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. Peoples care needs are met and the principles of privacy and dignity are upheld by staff. The needs of people using the service are documented in their care plans, ensuring that staff have detailed guidance to follow in caring for people. Evidence: In the AQAA self-assessment information that we received before the inspection the service told us that the privacy and dignity of people is preserved at all times, and that they have policies and procedures for equal opportunities, and equality and diversity. They also told us that care plans are reviewed on an on-going basis, with the input of the person living at the home, and the next of kin, where appropriate. Preferences and choices are recorded and each person has a keyworker allocated. The care records of three people who use the service were examined as part of the case tracking process. The care plans that we examined had been developed from the assessment information and we found evidence of relevant risk assessments, including risk of falls, nutrition and risk of developing pressure ulcers. The manager had Care Homes for Older People Page 12 of 27 Evidence: reviewed the care plans monthly and updated them where this was necessary. This involved a written monthly report on each individual area of need that had been identified in the persons care plans. We discussed with the manager about ensuring that each persons risk assessment scoring tool e.g. nutritional assessment, has a revised monthly score entered and she has agreed to action this. Relatives told us that staff are very good at keeping them informed about any changes in the condition of their relative and always notify them if a doctor has been called to see the person living at the home. A relative said Staff always keep me up to date about any changes. There was evidence within care plans of acknowledgement of where people had decreased ability to make decisions for themselves. The manager has identified that more detailed and specific recording of competency may be required in future, in line with the principles of the Mental Capacity Act 2005. She has attended seminars and obtained resource information about the Act in order to review this area of care planning and recording. The relatives of people living at the home had signed the care records that we looked at, indicating that they were aware of the content and had agreed to the plans of care. Relatives had signed on behalf of the person living at home because they had been unable to sign for themselves. The manager told us that where appropriate, the person living at the home is encouraged to sign the records in person to signify their agreement with them. Summary sheets listing an overview of care needs and personal details have been introduced and are used where a person needs to be admitted to hospital, in order to ensure that the hospital has relevant information about the person. A keyworker (a member of care staff) is allocated to each person living at the home. The manager told us that the keyworker has a particular role in ensuring that individuals are having their personal needs met, such as ensuring that there are sufficient toiletries and specifically liaising with relatives. A keyworker is allocated within six weeks of admission so that the manager has time to match staff to the individual, taking into account where a particularly positive relationship may have developed. Notwithstanding the keyworker role, the manager and other staff are on hand to assist any of the people living at the home at any time. The manager also told us that one of the care staff has recently become the Dignity Champion. This is a developing role, but demonstrates that the service recognises the importance of dignity issues and now has a person to champion the cause by promoting and raising the profile of dignity issues among the care team. People who Care Homes for Older People Page 13 of 27 Evidence: use the service and their relatives who were spoken with at inspection were able to confirm that the care needs of people are met at the home. People said that staff treat them with respect and have regard to their privacy and dignity. One person stated: Staff always knock on the bedroom door before they enter. Staff use a range of means to promote privacy and dignity. They record and abide by the preferences of people, including washing and bathing. People that we spoke with were very satisfied with the care staff, both in terms of their competence and their approach. Comments included: The staff are very good, Smashing staff and Staff bend over backwards to help you. Written survey responses said: Always someone available to listen or act. This is always done with smiles and kind words, Staff are like an extended family and Nothing is too much trouble for the staff. The home is able to admit people with dementia needs and staff have received training on this condition to help them meet the needs of the people using the service. When we spoke with some of the staff they explained that they had undertaken a specific National Vocational Qualification (NVQ) Level 2 about dementia care to ensure that they had the knowledge and skills to care for people with this condition. We looked at the medication storage and administration systems. There were no issues of concern. The community pharmacist had undertaken a full audit of the systems in November 2008 and the manager had addressed the findings of the report. This included obtaining a maximum/minimum thermometer for recording the medication refrigerator temperatures. Staff receive periodic medication training and staff that we spoke with confirmed that this training had taken place. Relevant written information about medicines is available for staff to refer to when needed. Care Homes for Older People Page 14 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. The activities on offer and the standard of food are good, which meets the needs and wishes of the people living at the home. Evidence: In the self-assessment the home told us about the activities at the home, including arts and crafts and chair based exercises. They told us that there are entertainers who visit the home, two of whom are volunteers. A Strawberry Fair is held annually and each year there is a day trip to Skegness arranged, with as many of the people taking part in the trip as are able, or wish to. Relatives and friends are invited to take part in the trip. The home said that the preferences and choices of each person are recorded and observed by staff. When we examined the care records we saw examples of completed personal preference documents for the three people that we case tracked. We also spoke with people living at the home and they confirmed that they choose how they spend their time, for example, choosing what time they get up in the morning. When we undertook the inspection we spoke to people about the social and leisure programme and there was positive feedback from them. The activities are arranged to Care Homes for Older People Page 15 of 27 Evidence: be inclusive, taking account of the range of abilities and preferences of the people living at the home. Care staff deliver the activities programme and on the day of the visit activities included chair based exercises and a quiz. Some of the people living at the home prefer to use the quiet lounge and on the day of the inspection there were two people using this lounge. We spoke with these residents and they told us that they particularly enjoyed the coach trip to Skegness each year. The manager and staff that we spoke with told us that there is usually a church service held at the home, but they were waiting for this to resume following a recent change of the local clergy. Over the festive period there had been a Christmas and a New Year party held for the people living at the care home. The manager spoke about the use of the garden area. She told us that it is a private and secure area that many of the people living at the home enjoy using during the better weather. The grounds of the home are extensive and are level, therefore providing a safe environment for the people living there. Most of the people living at the home choose to eat in the main dining area on the ground floor. We observed the midday mealtime and it was clear that staff were on hand to assist people if required. The mealtime was unhurried and people seemed to enjoy their meal. The cook ascertains the preferences from people during the morning and the displayed menus offer a choice to select from. Alternatives are available in addition to the menu items and special diets are catered for. Staff have received food hygiene training as part of a rolling programme of training provided by an external training company. The catering facilities had been routinely inspected by Environmental Health last November and there were no outstanding matters for the home to address following this visit. We received good feedback from people that we spoke with about the food at the home. Comments included: The food is good here and The food is lovely. One of the written survey responses said: We get very good meals and a choice. Care Homes for Older People Page 16 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 systems for dealing with concerns and complaints and aims to protect people from harm. Evidence: The AQAA self-assessment that we received prior to the inspection told us that staff have received training in the protection of adults (safeguarding training) and whistle blowing. The dataset information indicated that there had not been any complaints made in the last twelve months. There have not been any safeguarding adults or Protection of Vulnerable Adults (POVA) referrals made in this period. The home confirmed that there is a written policy and procedure for dealing with any complaints. We noted that the complaints procedure was prominently displayed in the entrance area of the home. When we spoke to people living at the home, or to their relatives, none of those spoken with had any complaints about the service. They told us that they always felt able to raise any minor day-to-day concerns with the manager and staff and that things always got resolved satisfactorily and quickly. One of the written survey responses said: Management are always available to discuss matters and to explain or resolve them. We spoke with staff and they confirmed that they had received training about safeguarding adults, complaints and whistle blowing. Training had also been provided Care Homes for Older People Page 17 of 27 Evidence: on dealing with challenging behaviour, whilst staff stated that currently none of the people living at the home presented with such behaviour. 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 comfortable, clean and well-maintained home. Evidence: The AQAA self-assessment told us that the home had been completely redecorated in 2007. New blinds, pelmets had been provided, and some carpets had been replaced. There are also plans to replace further floor coverings. They told us that staff had received training in infection control. We undertook a tour of the building and it was evident that the standard of decoration and fittings was generally good and the building incorporates features such as radiator covers and thermostatic valves on taps for the safety of the people living at the home. Some areas of the home await refurbishment, such as some toilet and bathroom areas, but there is a maintenance plan to address this. The manager and other staff that we spoke with felt that there had been positive developments with the ongoing maintenance of the home since the new owners had taken over the running of the home last year. The ground floor facilities include a dining room and two lounge areas. One of the lounges is utilised for activities, whilst the smaller lounge is a designated area for those who prefer a quieter communal area. Televisions are provided in both lounge Care Homes for Older People Page 19 of 27 Evidence: areas. The garden area is private and secluded, with an appropriate level of security. The home has satisfactory infection control procedures and the staff training programme includes infection control practice and safeguards. Staff confirmed to us that they had received infection control training. Domestic staff are employed and on the day of the inspection we found the home to be clean and tidy. When we spoke to people living at the home they commented that staff keep the home very clean. One person living at the home said: My bedroom and the rest of the home is always kept clean. A visiting relative that we spoke with praised the laundry service at the home and said that their parent always had: A fresh clean change of clothes every day. People living at the home told us that they had been able to personalise their bedrooms with their own possessions. All of the bedrooms are now utilised as single occupancy. Therefore, whilst the registration remains at twenty-eight persons, a maximum of twenty-five persons are currently accommodated at the care home. 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. Staff training and recruitment practices promote the safety of people living at the home. Evidence: In the AQAA self-assessment the service told us that staff are well-trained and morale is good. They told us that the turnover of staff is low and that a high percentage of the staff have undertaken recognised training (National Vocational Qualifications). They told us that there has not been any use of agency staff. The service told us that they undertake proper recruitment checks and have an annual staff training plan. During the inspection we looked at training records and spoke with staff about the training at the home. Routine training is organised on a rolling programme, mainly through an external training company. Training includes first-aid, infection control, health and safety, manual handling and fire safety. Training planned for the early part of this year includes risk assessment and a safeguarding adults update. Most of the staff have completed National Vocational Qualification (NVQ) training Level 2, with many having completed or undertaking Level 3/4. The level of training indicates that a well trained group of staff deliver care to the people living at the care home. We asked staff about the recruitment and induction processes at the home and their Care Homes for Older People Page 21 of 27 Evidence: responses backed up the information that we were given when we spoke with the manager. The manager showed us examples of completed training records and explained how the induction process has been developed to ensure that it fully meets with recognised standards (Common Induction Standards). We looked at the recruitment files of two of the staff and we found that all the necessary preemployment checks had been completed for these staff members. We spoke with staff and with people living at the home (or their relatives). They told us that feel that there is sufficient staff on duty to meet the needs of people. Staff described how the home continues to improve, for example, repairs and maintenance are dealt with more speedily. They feel that the manager and the new owners are very approachable. Comments from people that we spoke with included: Staff brilliant - all very kind, Smashing staff. If they are short, then they bring someone in and Staff are good at their jobs. 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 health, safety and welfare of people living at the home are protected by the management systems in place. Evidence: In the annual self-assessment the service told us that they listen to the views and opinions of people living at the home and their relatives. They told us that there is a quality assurance system in place and that periodic meetings are held with the people living at the home, visitors and staff. They report that they regularly receive positive feedback about the service. One of the written survey responses said: The staff do listen and act on what I say. An experienced registered manager leads the service. She has the required qualifications and staff, people living at the home and their relatives told us that she is approachable and effective in the management of the care home. Care Homes for Older People Page 23 of 27 Evidence: We spoke with the manager and she told us about the quality assurance and quality monitoring systems in place at the home. These include audits of the recording systems at the home, for example, medication administration records. There is an annual satisfaction survey of the views and opinions of relatives and people living at the home, with the latest results on display in the reception area. We were able to confirm at inspection that the mandatory monthly visits and reports by the registered provider are taking place. These regulatory visits are part of the quality monitoring processes, which act in the interests of people who use the service. The recording system for the management of personal money held by the home on behalf of people living at the home was examined and was satisfactory. The system is a dual-signature system with receipts issued for transactions. We looked at a sample of the maintenance and servicing documentation held at the home. It was clear that there is a robust and conscientious approach to ensuring that services and equipment are maintained and examined on an appropriate basis. Regular preventive measure are undertaken to guard against the risk of Legionella. The manager told us that she would ensure that an up to date written Legionella risk assessment is completed by a competent person in support of the measures already in place. All other service and maintenance records examined at this inspection were satisfactory. 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 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 Individuals risk assessment scoring tools should be recalculated each month as part of the routine monthly care plan review system in place at the home. The homes care plan documentation processes should be further developed to demonstrate that the service fully considers individual capacity to take decisions, in accordance with the Mental Capacity Act 2005. An up to date written risk assessment should be completed in support of the measures already in place, which guard against the risk of Legionella. 2 8 3 38 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). 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. 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