Inspection on 12/06/08 for Croxley House

This is the latest available inspection report for this service, carried out on 12th June 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Croxley House 21/06/06

Croxley House 09/12/05

Croxley House 24/05/05

Croxley House 10/11/04

Croxley House 11/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Croxley House Croxley Green Rickmansworth Hertfordshire WD3 3JB Lead Inspector Julia Bradshaw Unannounced Inspection 12th June 2008 11:00 X10015.doc Version 1.40 Page 1 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000019318.V366243.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000019318.V366243.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Croxley House Address Croxley Green Rickmansworth Hertfordshire WD3 3JB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01923 775134 01923 897908 mike.sole@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Michael Sole Care Home 33 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (33) of places DS0000019318.V366243.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Room 21 (8.78 sq m) is to be used only for the purpose of short stay respite care. It will not be permitted for this use after 1.4.07 Rooms 15, 17 and 31 be designated as suitable for couples who through positive choice wish to share a room. A max. of 2 rooms to be used at one time. Room 22 (20.83. Sq m) will be altered to allow for the increase in size of Room 21 to meet the 12 sq m requirement. Alteration to Room 22 will not take place whilst the present occupant remains in that room. The home may accommodate five named service users who have a diagnosis of dementia. The manager must inform CSCI when any of the five service users permanently leaves the home for any reason. 12th and 13th June 2007 Date of last inspection Brief Description of the Service: Croxley House is a detached two-storey red brick Georgian dwelling house built about 1770 with several later additions. It has been extensively refurbished and converted for the residential care of older people. The home provides for up to 31 service users in single rooms, all of which have en-suite facilities. There are three rooms that are available for couples to share but only on a positive basis and with the maximum overall occupancy of 33 service users. One room is below the recommended minimum size standard and is used only by agreement for short stay respite care. The home has two main lounges and a separate dining room. The kitchen is completely stainless steel equipped with freezer and refrigerated food storage. The homes laundry is equipped to handle all the requirements of the home. Croxley House has its own access driveway across the green and stands in immaculately maintained grounds with beautiful views across the green and surrounding woodland and farm countryside. There is a working greenhouse and summerhouse at the rear of the home and the pathway around the garden has a single handrail for support. The garden houses an aviary and there is a fish tank, budgies and cats within the home. Whilst the home occupies a rural setting, it is but a few minutes drive from the towns of Watford and Rickmansworth. The home has a service user’s guide and statement of purpose that are provided to prospective service users. Copies of these and the latest report on the home from the Commission for Social Care Inspection (CSCI) are available in the home. The range of fees are from £495 - £565. DS0000019318.V366243.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This report draws on information obtained from: the recent Annual Quality Assurance Assessment (AQAA) completed by the manager, questionnaires completed by the people living at the home and from a full inspection visit carried out on the 12th June 2008.The inspection process included speaking to people living at the home, visitors, staff and a full inspection of records relating to care planning, medication, health and safety, staff records of training and the general management of the home. Surveys from people who use the service and from staff are part of the ongoing inspection of a service and any issues arising from these surveys and other relevant information received by the Commission could then inform further regulatory visits in respect of Croxley House. What the service does well: The care provided to people living at Croxley House is maintained to a high standard and confirmed by people using the service with comments that include “ I wouldn’t want to live any where else” “ They couldn’t do enough for us” and “ We have lovely sing–songs and the activities are always well organised and enjoyable”. The well-managed and effective staff team further evidences these comments. People living at the home can enjoy the extensive grounds surroundings the home that have been further enhanced by the introduction of a variety of wildlife, including two aviaries; free-range chickens (which provide eggs that people go and collect on a daily basis) and some rescue ducks. This is one example where the manager has taken great care to listen to people using the service and enhanced their lives by improving and increasing their opportunities and experiences both within the home and with the introduction more trips outside of the home. The general standard of the environment is good, with a variety of areas being decorated and upgraded since the last inspection was carried out. People’s bedrooms reflect their diverse range of interest and have been personalised to a high standard. DS0000019318.V366243.R01.S.doc Version 5.2 Page 6 The positive style of management of the home is also reflected by the satisfaction expressed by the staff team, many of who have been working within the home for several years and stated they feel supported and valued by the current manager. The home is in the process of further developing the care planning system and once completed this will provided an excellent profile and working document for individuals living at the home. To ensure peoples safety risk assessments are in place and are reviewed on a regular basis. Health and safety practices are carried out effectively and monitored by the manager, maintenance person and senior members of the staff team. The home creates a welcoming and inclusive atmosphere to everyone who lives at the home or who is visiting. This is truly reflected by the comments received from people using the service, staff, visiting professionals and families. The home is well established within the local community and holds annual fete’s to promote itself and to help fundraise for further projects. The inspector would like to thank everyone who took part in this inspection and helped make the process both enjoyable and rewarding. Also to extend those thanks to the two residents who invited her for lunch and who were able to give a great insight into what its like for someone living at Croxley House. What has improved since the last inspection? What they could do better: The home currently provides a high standard of care. There is very little that needs to be done to improve the current service. Although, there are areas of the home’s environment that still require updating, including modernising some of the bathing facilities and general areas of the home. DS0000019318.V366243.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000019318.V366243.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000019318.V366243.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering Croxley House, as their home can be confident that they have the necessary information to enable them to make a well informed decision. Assessments made before admission provide assurance to people considering Croxley House as their home, or as home for someone they are responsible for, that only people whose care needs are understood and can be fully met will be admitted. EVIDENCE: Relatives and people living in the home spoken to on the day of this inspection confirmed that they had opportunity to visit the home prior to admission in order to help them decide if it was somewhere they thought they could be happy and well cared for. DS0000019318.V366243.R01.S.doc Version 5.2 Page 10 Care plans for people who had been recently admitted into the home were seen to contain a detailed assessment of need and how these needs were going to be met. People living in the home or those responsible for them were involved in the assessment process, which should provide confidence in its accuracy and thoroughness. DS0000019318.V366243.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service can be assured that they will receive effective personal and healthcare support that respects them as an individual, with their personal healthcare needs clearly recorded, reviewed and updated in their person centred care plan. People living in the home are protected by an effective and robust medication process that ensures that they receive the support they need with their medication in order to maintain their wellbeing. EVIDENCE: During this inspection four care plans were inspected in detail and were found to provide a good insight into the individual needs of each person living at the home. There is a new and improved care planning system that is part way through completion and the manager hopes to finish this process within the next three months. The care plans contained all the required information, including life history, health and personal care needs, activity planner, risk DS0000019318.V366243.R01.S.doc Version 5.2 Page 12 assessments, likes and dislikes. The new care plans provide a better working document for both staff and for the person living in the home. There was also evidence to confirm that people had been involved in their care planning with signatures from either the person using the service or their representative. People spoken to on the day of the inspection and comments received by way of surveys carried out by the home were all positive about the way that care is received in terms of preserving their rights and dignity. 100 of the surveys returned agreed that care staff listen and act on what people living in the home say. People we spoke with to stated “staff are always very kind when they are helping me with my personal care”. There is community health care support from the visiting district nurse and the home has access to all other health care agencies if required. The home uses to main G.P. surgeries. Medication records were spot-checked and found to be accurate. The medication is held within a large locked cupboard on the ground floor of the home. All medication is dispensed from the main drugs trolley. The home has a rigorous medication procedure in place. There are nominated members of the senior staff team who have responsibility for ordering and the disposal of medication. The home has a contract with a local pharmacy for supplying the monthly dosette system of medication. There was an up to date temperature record for the drugs fridge in place. One person self medicates and there is a current risk assessment in place for this to ensure that they are kept safe. DS0000019318.V366243.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Croxley House can be very confident that they will be able to be involved in meaningful activities of their choice, reflecting wherever possible their personal tastes and preferences EVIDENCE: The range and opportunities for people living at the home to enjoy a fulfilling and meaningful social and leisure is extensive. The home should be congratulated on achieving a true reflection of the diverse needs and wishes of everyone at the home. During this inspection the manager and people living at the home took the opportunity of demonstrating the activity planner where daily events are recorded .The programme is drawn up from the questionnaire/survey that is sent around to everyone to complete in order to ensure everyone has an opportunity to become involved. Since the last inspection was carried out the home has obtained some rescue chickens from the RSPCA and has created a large chicken coup in which people living at the home can go out each morning and collect their eggs for breakfast/supper. This is one example where the manager and staff have DS0000019318.V366243.R01.S.doc Version 5.2 Page 14 excelled at giving people alternative experiences to enjoy and become involved in. The home also has two aviaries, in the extensive grounds to the back of the home, which house budgerigars (bred at the home) and also some “love” birds, also home bred. Various people living at the home have the responsibility of feeding these birds daily. Another new addition to the home are two rescue ducks. The home has a large minibus, which is used every week to take people on trips to the seaside, garden centres, pub lunches and local places of interest. Every Thursday there is also a ‘mystery’ tour for people to enjoy. Several people we spoke to confirmed the social and leisure opportunities that are provided by the home and particularly enjoy the monthly entertainment provided. There are two activities workers who provide 32 hours per week for activities. It is encouraging to see that Greensleeves Home Trust see activities as an essential part of people’s well-being and provide a generous annual budget in which the manager can allocate on a monthly allowance. The home also has a committed and loyal staff team who are involved in supporting the various fundraising activities inside and outside of the home. Activities are recorded on people’s individual care plans and also a running record is kept in order for the manager to monitor the programme on a regular basis. The people spoken to stated that “ I love living here, there is always something to do”. “ I love the trips out and its nice that the manager comes out with us sometimes too”. “ I like my nails and hair done every week, which the staff always organise for me.” The inspector joined two people for lunch and found the main meal of steamed fish, fresh vegetables and creamed potato to be both flavoursome and substantial. Comments heard during the lunchtime meal were all very positive. There is one main cook during the week and another cook who covers the weekends. Also there is a kitchen assistant covering every day of the week. The manager has re-arranged the staffing at mealtimes in order to ensure there is adequate staffing to assist people with eating their lunch, in a dignified and unhurried manner as well as ensuring there are adequate staff to assist people with leaving the dining room and with their personal care. The whole experience of mealtimes for people living at the home, appears to be relaxed, informal and a socially enjoyable. DS0000019318.V366243.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this service can be assured that they will be protected from abuse and that they will be listened to if they raise any concerns or make a complaint about any aspect of their care. EVIDENCE: All staff spoken to were aware of the different kinds of abuse and had a good understanding of the home’s policies and procedures for safeguarding people who live in the home from abuse. People living in the home said that they felt safe and well cared for. “You couldn’t find a better home than this” was one comment recorded. Training records and staff spoken to show that staff are given the knowledge and skills they need to be able to recognise abuse if they see it and what to do if it is seen or suspected. This can provide people living in the home, and those responsible for them with confidence that any abuse will be recognised and appropriate action taken to deal with it. People living in the home indicated that they felt comfortable with expressing their views and that they would have no hesitation in approaching the manager or their key worker if they did want to raise any concerns or make a formal complaint. DS0000019318.V366243.R01.S.doc Version 5.2 Page 16 There is material about advocacy services available to people living in the home available, which means that independent assistance can be provided to people living in the home if they feel that they need it or have no one else to act on their behalf. Age Concern also visits the home every six weeks to carry out informal chats with people. One safeguarding issue was referred by the home since the last inspection and this has been resolved to a satisfactory conclusion. The home has received no other complaints since the last inspection. DS0000019318.V366243.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, clean and well-maintained environment for those who live and work there and people who live in the home can be assured that they can personalise their rooms to reflect their own tastes and personalities. EVIDENCE: There has been some major improvements in the environment since the last inspection took place. The entrance hall is now light, airy and welcoming. The replacement of new fire doors throughout the home is now complete. Several areas of the home have been re-carpeted. The dining room has been refurnished and careful attention has been made to create an environment that is both welcoming and bright. Pictures throughout have also been chosen to reflect the interest and generation of the people who live in the home. DS0000019318.V366243.R01.S.doc Version 5.2 Page 18 Those rooms seen, with the permission of the people whose rooms they were, showed evidence of personalisation with pieces of furniture, equipment, pictures and ornaments that reflected their life history, interests and personalities. Throughout the home there was evidence of a variety of events and activities that have been held over the past year and also a photograph in the main entrance hall of the whole resident group. These personal touches create an individual impression when you enter the home. There has been a programme of decoration since the last inspection drew attention to some shortcomings and the home’s AQAA states that this is to continue. The manager is planning to improve and further develop the bathing facilities throughout the home with the installation of new showers/baths. The manager and staff should be congratulated on their hard work and commitment to create and maintain a pleasant and homely environment in which people can be assured that their health and safety needs are protected and maintained. All fire records were up to date on the day of this inspection. There were no mal odours on the day of the inspection. DS0000019318.V366243.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a very effective management team, which supports all staff by providing the necessary supervision and training to ensure an effective staff team are able to support people living at the home to lead safe and fulfilling lives. EVIDENCE: The manager has made some effective and important changes to the home since being appointed in 2007. The staff team are provided with monthly supervision and staff meetings are held every three months, or sooner if necessary. All staff spoken to stated that they feel supported and valued by both the management team and the Company and have felt the new manager has been a great asset to the home. The home provides adequate staffing for both the morning and evening shifts. However the manager should keep under review the current staffing arrangements for waking night care, which are currently 2 staff per night. These levels of staffing could prove ineffective if the home had to be evacuated in an emergency. This situation should be reviewed and if necessary, should be increased to three waking night care to ensure the people living at Croxley House are safe, at all times. DS0000019318.V366243.R01.S.doc Version 5.2 Page 20 Training records were inspected and confirmed that all staff are provided with the necessary training to carry out their roles effectively. All recruitment procedures are carried out in line with the Company’s recruitment and selection procedure and confirmed by the manager with the information provided in the recent AQQA completed by the manager. There is also an effective systems in place to monitor all staff who are required working visa’s/work permits and these are carried out effectively by the manager. DS0000019318.V366243.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at Croxley House can feel confident that they are living in a home that is well managed, is run with their best interest and they are safeguarded from harm by effective policies, procedures and accurate record keeping. EVIDENCE: The manager should be congratulated on all his hard work since being appointed into the permanent post in 2007. He has worked extremely hard to improve and develop various aspects of the service and opportunities for people living at the home. The environment of the home has greatly improved, policies and procedures have been further developed. The manager ensures that supervisions and staff DS0000019318.V366243.R01.S.doc Version 5.2 Page 22 training are held regularly and staff confirmed that they feel supported and respected by the current manager. The manager is currently studying for his RMA and is due to complete this within the next three months. People are safeguarded from harm by the homes recruitment procedures, safeguarding training and the complaints procedure. People spoken to stated, “If ever I have a problem I can talk to any of the staff, they are always there to listen” and “The manager comes around to talk to us every day and if there’s a problem he gets it sorted”. People living at the home were aware of the complaints procedure and staff spoken to also confirmed that they were aware of the whistle blowing policies and also had received training on safeguarding. Everyone living at Croxley House has a small safe in their room for holding their monies, where appropriate. The home has an administration assistant who manages some people’s monies and prepares and maintains individual ledgers for accounting purposes. All records relating to health and safety standards are maintained and carried out effectively by the maintenance person, the manager and senior staff. To ensure the continued safety of the people living in the home the staff should monitor the hot water temperatures closely as there is a tendency in the records for the some temperatures to fluctuate. Quality assurance systems are in place and carried out by the manager and senior staff. A senior member of staff from Greensleeves Homes trust carries Regulation 26 visits out monthly and provides supervision to the manager. DS0000019318.V366243.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 3 DS0000019318.V366243.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations To ensure residents continued safety the staffing levels must be kept under review and increased to meet the needs of service users, in particular during the nighttime hours. DS0000019318.V366243.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000019318.V366243.R01.S.doc Version 5.2 Page 26 - 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. 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