Inspection on 17/01/06 for Ashcroft

This inspection was carried out on 17th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Ashcroft 21/11/06

Ashcroft 04/07/05

Ashcroft 22/02/05

Ashcroft 10/10/04

Ashcroft 05/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ashcroft 48/50 London Lane Bromley Kent BR1 4HE Lead Inspector Mrs Susan Hall Unannounced Inspection 17th January 2006 09:30 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 Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 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. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashcroft Address 48/50 London Lane Bromley Kent BR1 4HE 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) 020 8460 0424 020 8402 5640 www.care-providers.co.uk Care Providers (UK) Limited Mrs Stella Martine Barnes Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 21 July 1999 Date of last inspection 4th July 2005 Brief Description of the Service: Ashcroft is an older, detached building, situated in a quiet residential area in Bromley. It is conveniently placed for public transport, and is near to local shops and other facilities. It is part of a family run business, and the Providers have another residential care home nearby, and run a separate domiciliary care agency. Ashcroft is registered to provide nursing care, and provides accommodation in a mixture of single and shared rooms, on 3 floors - ground, first and second. All rooms can be reached via a passenger lift. Communal areas are situated on the ground floor, with a spacious dining room leading to a lounge. There is a well-maintained garden at the rear, with a patio for use in good weather. Off road parking is available at the front. The Providers have planning permission to extend the property at the rear, to include another six en-suite single rooms, and a larger garden. Nursing care is provided over 24 hours, with one nurse covering each shift. The Registered Manager is also a trained nurse, and is on duty throughout the week. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out from 09.30 – 14.45, and the Inspector was able to talk with 9 Service Users, the visiting hairdresser and 7 staff, as well as the Manager and the Provider. The Deputy Manager was the nurse on duty, and she discussed medication and nursing practices with the Inspector. A senior carer showed the Inspector around the building, and she was very helpful, providing lots of information about how care is carried out, staff training, activities for Service Users, and staff supervision. The usual cook was off sick, and cooking was carried out by a carer who is trained in basic food hygiene, and is able to cover cooking duties when needed. A kitchen assistant assists the cook each day. The Inspector talked with the laundry assistant, and observed other staff carrying out their care and domestic duties calmly and efficiently. Two Administrators assist with the general running of the whole business, and the Inspector met these as well. The Inspector viewed documentation, including: care plans, medication charts, training records, servicing records, satisfaction surveys, relatives and resident meetings, pocket money accounts, complaints record, kitchen records and accident records. The Provider said that the Company hope the building work for an extension will be carried out during this year, and Service Users and relatives will be fully informed before this is commenced. There will be minimal disruption to the existing premises during this time. What the service does well: The home provides good personal and nursing care, and staff have a commitment to ensuring that Service Users have as full a life as possible, within the confines of their nursing needs. Service Users all gave positive comments about their care, such as “ everyone is lovely here”, and “they are all good, and look after us very well.” A good range of activities and outings are provided by the home, with outings such as pantomime and theatre visits, and seaside outings. Information about forthcoming activities and any changes in the home are included in a bimonthly newsletter, which is available for all friends and relatives as well as Service Users. There were detailed records for staff training, and all care staff have been trained to a minimum of NVQ level 2. This is exemplary, as the recommended minimum number for care staff trained to this level is 50 , and the home is achieving 100 . Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 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. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 7 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 Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 The home supplies detailed information to assist Service Users in making a decision about moving into the home. Pre-admission assessments are sufficiently detailed to ensure that staff are able to meet the needs of Service Users. EVIDENCE: The Inspector read the Statement of Purpose and the Service Users’ Guide. These included all required information, such as the Provider’s and Manager’s experience, staffing information, medical arrangements, visiting arrangements, terms and conditions of residency, and complaints procedure. Further detailed information includes items such as bringing in personal possessions, pets in the home, insurance cover, public transport available, and church services. Terms and conditions clearly state the room to be occupied, and the weekly fee payable. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 9 A summary of the last inspection report is provided, and the whole report is available on request. Service Users are admitted for an initial trial period of 4 weeks, and a review is held at the end of this time. The Manager carries out all pre-admission assessments, and these are recorded on a specific form. The Inspector saw that information was taken about personal care needs, medical data, medication, mobility, continence, nutrition needs, falls assessment, communication (sight, hearing, speech), mental state, and pressure areas and any wounds. The Manager obtains as much information as possible from other sources, such as relatives, care manager, GP, or hospital staff. Service Users are then re-assessed on admission, and have nursing checks for weight, temperature and blood pressure. Any necessary equipment (such as a pressure-relieving mattress, or bedrails), would be put in place prior to admission. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 There is a good care planning system in place, which provides staff with the necessary information to give effective care. Health needs are met, and there is good evidence for involving other health professionals. Medication practices and procedures are well managed. Staff treat Service Users with respect and dignity. EVIDENCE: The Inspector examined 4 care plans. These are presented in individual A4 folders, and set out in sections for easy access of information. Admission details include assessments for all aspects of care, and care plans are individually formulated according to the initial assessments. These include plans for meeting personal hygiene needs, continence care, medication, nutrition, mobility and hoisting needs, pressure area care, social needs, communication, and sleep pattern. Risk assessments are completed for items such as use of bed rails, or use of wheelchair, and a falls risk assessment is completed when indicated by the Service User’s previous medical history. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 11 Care plans and assessments are reviewed and updated every month. Service Users are weighed monthly, and recordings of temperature and blood pressure are taken monthly. Specific care plans were seen for such things as foot care, diabetes, oral care, visual impairment, constipation. These showed that specific care plans are drawn up for individual needs. The nurse on duty completes daily records after each shift, and good communication is maintained between care staff and nurses to ensure that all details are included. Service Users are fortunate to have a GP visiting the home each week, and this doctor is therefore able to build up a relationship with each Service User, and an awareness of their different medical needs. There were good records for visits from other health professionals such as the Tissue Viability Nurse (to help assess individual wounds); dentist, chiropodist, optician and speech therapist. The Manager randomly audits care plans each month. The Inspector noted that most wound care records were good, showing the progress of the wound whenever a dressing is changed, and specifying the type of dressing to be applied. However, it was noted that where there was more than one wound these had sometimes been documented together, and it is therefore difficult to assess progress if one wound heals faster than the other. There is a recommendation to address this. Medication is administered via a monitored dosage system, and is stored in a locked medicine trolley. Other medication is stored in suitable metal cupboards in a locked clinical room. There was no overstocking of medication, and no items were found to be out of date. Medication Administration Records (MAR charts) were accurately completed, and had 2 signatures for handwritten entries. A controlled drugs cupboard had been more securely attached to the wall, in line with storage regulations. The Manager carries out medication audits to check for staff competency, ordering, and medication procedures. Service Users were well groomed, with attention paid to suitable clothing, hair styles, clean teeth and glasses. The hairdresser visits every 2 weeks, and Service Users clearly enjoyed her attention. Staff ensure that Service Users are kept clean and comfortable when they are ill in bed, and visitors are welcomed at any time. Several staff – including the Manager and Deputy Manager – have experience in palliative care, and in giving additional comfort and care when Service Users are dying. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 Service Users are provided with a good range of activities, and staff help them to maintain cultural and social interests. They are enabled to make choices according to their individual preferences. The menus are suitably varied to provide good nutrition, and there is provision for different choices, and additional snacks if required. EVIDENCE: A range of activities is provided each week, and includes armchair exercises, bingo, singing, indoor games (such as skittles), quizzes and reminiscence. Service Users are free to join in or not as they choose, and some prefer to stay in their own rooms. A record is maintained in each Service User’s care plan, showing the daily activities they take part in. Library books with large print are available, and the mobile library visits to change these books at regular intervals. Notices of forthcoming activities and outings are pinned to a public notice board, and relatives are invited to join in when visiting. The home is excellent at enabling close friends or relatives to join Service Users for meals (at a reasonable charge). Service Users are able to bring in their own personal possessions or furniture (in agreement with the Manager), and are encouraged to pursue any chosen Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 13 hobbies, and preferred lifestyles. One Service User does not like to get up and dressed until mid-morning, and care staff ensure that this wish is met. Some Service Users do not have close family, and advocacy services are sometimes required. The Manager has arranged for an independent advocacy clinic to be held in the home each month, by Bromley Advocacy Alliance, so that an independent advocate is available for Service Users or relatives for assistance. The Inspector viewed the kitchens and noted that the area was clean and well organised – even though it was viewed immediately after lunch was served. The cooks work to a 4 weekly menu, and this is discussed and altered with Service Users and relatives to reflect different choices and seasonal changes. An alternative to the main dish at lunch and tea time is always available, and additional snacks or drinks are provided on request – including night times. A kitchen cleaning programme is carried out on a daily, weekly and monthly basis for different tasks, mostly by the kitchen assistant, and some tasks by the maintenance man. Fridge, freezer and food temperatures are recorded, and food temperatures of van deliveries. The Inspector saw that food was appropriately stored, and opened items in the fridge were covered and dated. There were suitable measures in place for infection control. A record is kept for each Service User’s main meals, so any concerns about food related illnesses can easily be traced. Service Users are assisted as necessary with eating meals, and food was seen to be satisfactorily presented and according to choice. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 There is a good complaints process in place, enabling Service Users and relatives to voice any concerns. Service Users are assisted with access to legal services. Staff have satisfactory knowledge and training in the prevention of adult abuse. EVIDENCE: A record of any complaints is retained in the home, and details of any relevant investigations or letters. The Inspector noted that complaints are taken seriously, and properly investigated and followed through. There had been no complaints received since the last CSCI inspection. Service Users are able to access advocacy services within the home every month, and relatives are also able to access this service for advice. Some Service Users still wish to take part in legal processes such as elections, and the Manager arranges postal votes for these Service Users. Staff training includes recognition and understanding of different types of abuse, and all staff are trained in preventing this. Staff had been given updated training in December 2005. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,26 The premises provide a homely environment, with satisfactory décor and furnishings. These have been suitably adapted to meet the nursing needs of Service Users. The home is clean and hygienic, and has suitable sluicing and laundry facilities. EVIDENCE: Although the home is an old building, corridors are large enough for the use of wheelchairs, and there is a good sized passenger lift for access to all floors. The home was clean throughout, and there were no offensive smells. Communal areas were satisfactorily decorated, but could benefit from some upgrading in due course. The lounge overlooks the rear garden and patio, but the new building plans will change the aspect of the lounge. The plans include extending the rear garden, as well as providing 6 new en-suite bedrooms. The home currently has 7 shared rooms, and pre-admission assessments include discussions with Service Users regarding their preference for a single or a shared room. Plans also include altering some shared rooms into large, Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 16 single, en-suite rooms, but retaining some shared rooms for those who prefer this. Service Users and relatives will be fully informed when building work is to take place, and as this will be mostly at the rear of the premises, it will be carried out with minimal disruption. Additional nursing equipment was seen in the home, and this includes 3 mobile hoists, grab rails, disabled toilet areas, and pressure-relieving mattresses and cushions. Bed rails are used for some Service Users, and risk assessments were in place for these. Padded sides are used with bedrails to minimise the possibility of accident or injury. There are 2 assisted baths, and a walk in shower room. The Inspector noticed that the side of the shower unit needed repair or replacement, but as this had already been noted, and put forward for maintenance, the Inspector has not made this a requirement or recommendation. Some bedrooms were viewed and these had satisfactory décor and furnishings. Some rooms included personal furniture items, or pictures and ornaments. All laundry is carried out on the premises, and there is a laundry assistant on duty each day to manage this. The laundry assistants ensure that clothes are marked clearly, and check that bed linen and towels are of good quality – and replaced as needed. There is a large commercial washing machine and a commercial tumble dryer. The washing machine is set up with a chemical system which is automatically fed into the machines, and cleans and disinfects clothes even at low temperatures. A red alginate bag system is used for any soiled items. The laundry was seen to be well organised. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Staffing levels are suitable to meet the needs of Service Users. Good recruitment procedures are in place, and there are good staff training programmes arranged. The home is commended for having 100 of care staff trained to a minimum of NVQ level 2. EVIDENCE: The home is staffed with one nurse for every shift; 4 additional care staff in the mornings, 3 in the afternoons, and 1 at night. This provides sufficient staff numbers to treat Service Users as individuals, enabling time to get up and go to bed when they wish, and for carers to take part in assisting them with meals and activities. There are 2 domestic staff on duty on week days, (when all rooms are thoroughly cleaned each day), and 1 on duty at weekends. A laundry assistant is employed each day, and a cook and kitchen assistant. All care staff have trained to NVQ level 2, and some have trained – or commenced training – for NVQ level 3. The home also takes on nurses from abroad for adaptation training. The Inspector examined 4 staff files, and found that these met the requirements. All staff files included a photograph of the employee, proof of identity, a well-completed application form, signed confidentiality form, 2 written references, and a health declaration. Criminal Record Bureau (CRB) checks and POVA First checks are carried out for all staff prior to employment, and the Inspector viewed these documents as well. Staff from overseas had up Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 18 to date work permits on file, and nurses’ PIN numbers had been verified with the Nursing and Midwifery Council. Staff files contained copies of training certificates, and a signed copy of terms and conditions of employment. The Manager showed the Inspector the staff training record, and this verified that staff receive mandatory training after induction, and have updated training in these subjects as required. Other training given includes adult protection training and prevention of abuse; medication awareness (for care staff as well as nurses); dementia training; understanding older people; diabetes; stroke awareness; wound care; and report writing. All care staff have a first aid certificate, and food awareness training. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. The Manager has clear strategies in place for leading the home, and is well supported by senior staff. There is good communication between staff, Service Users and relatives, and the opportunity for them to take part in discussing changes in the home. Records are well maintained, and there is satisfactory attention to health and safety issues. EVIDENCE: The Manager has many years experience in caring for older people, and has completed NVQ 4 in management and the Registered Managers’ Award. She is also an NVQ Assessor, and has certificates for elderly and palliative care. She meets with staff at handovers and throughout the week, as well as holding staff meetings where all staff have the opportunity to share concerns and ideas. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 20 Relatives and Service Users are invited to meet with the Manager and staff, and are asked to complete short customer satisfaction surveys several times per year. These usually relate to specific subjects such as activities, food, or quality of facilities. The Manager writes a bi-monthly newsletter, which is made available to all friends and relatives, and includes forthcoming activities and outings, specific news (such as birthdays, new staff), and planned changes in the home. The Inspector examined a variety of records, including how Service Users’ pocket monies are managed. These are stored in a locked safe, in individual wallets, and each transaction is clearly identified and signed for by 2 people (usually the Manager and an administrator, if the Service User is unable to sign). All receipts are retained, and given to the Service User or next of kin as appropriate. Staff supervision records showed that one-to-one supervision is carried out monthly, and uses a format which assists with discussion about the staff member’s performance, and any training needs identified. Records were generally well completed, and up to date. Accident records were viewed, and the Inspector noted that an audit of accidents is carried out each month to note any patterns of behaviour. Fire risk assessments had been completed, and fire extinguishers and emergency lighting had been checked and serviced appropriately. Hot water temperatures are checked before each bath or shower, and the Manager checks that hot water is delivered at correct temperatures into the system. COSHH leaflets are provided for all chemicals used in the home, and these were available in the cleaners’ cupboard, as well as in the office. The Inspector noted that a fire exit in the lounge had become obstructed by a Service User’s armchair, and a recommendation was given to ensure that staff do not allow any fire exits to become obstructed in any way. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 21 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? 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 2 Refer to Standard OP8 OP38 Good Practice Recommendations To ensure that wounds are documented separately from each other, and show the progress of each individual wound. To ensure that fire exits do not become obstructed in any way. Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 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 Ashcroft DS0000010126.V278180.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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