Inspection on 07/12/05 for Ashley Close 1 & 2

This inspection was carried out on 7th December 2005.

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

Ashley Close 1 & 2 29/06/07

Ashley Close 1 & 2 07/07/05

Ashley Close 1 & 2 28/10/04

Ashley Close 1 & 2 28/05/04

Ashley Close 1 & 2 29/01/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Ashley Close (2) 2 Ashley Close Bennetts End Hemel Hempstead Hertfordshire HP3 8EH Lead Inspector Tom Cooper Unannounced Inspection 15.00 7 December 2005 th Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 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 Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 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 Adults 18-65. 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. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ashley Close (2) Address 2 Ashley Close Bennetts End Hemel Hempstead Hertfordshire HP3 8EH 01442 258226 01442 258226 Ashleyclose2@walsingham.com 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) Walsingham Ms Pat May Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (6) of places Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: First opened in 1996, 2 Ashley Close is a two-storey, purpose-built care home providing personal care and accommodation for six people with learning disabilities, owned and operated by the voluntary organisation Walsingham. The home is part of a modern development in a very quiet cul-de-sac in a residential area in the Bennetts End district of Hemel Hempstead, next door to another Walsingham home and close to local shops and amenities and two day centres. The home has six single bedrooms for service users, domestic style accommodation and suitable equipment to meet any special needs. The house and garden are fully accessible for the current residents. Staffing is provided twenty four hours per day. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the current inspection year and took place on a weekday in the late afternoon and early evening. The main focus of the inspection was to evaluate the service users’ experience of living in the home. In addition to observing and talking with the service users, discussions were held with the registered manager and members of staff on duty. Documentation checked included two service users’ care plans, records of activities, risk assessments, fridge/freezer temperature records, medication records and the complaints procedure. A tour was made of the premises, with two residents happily showing the inspector their bedrooms. The inspection indicated that the home was running smoothly with the service users enjoying their lives in the home and receiving consistent support from highly motivated staff. What the service does well: Staff recognise and promote the principle that this is the residents’ home and see their prime task as assisting them to live their lives as they wish. The service users clearly enjoy stimulating lifestyles and have great opportunities to experience a wide range of activities, supported by staff as appropriate. Very positive relationships were observed between staff and residents and staff obviously know the individual needs and personal preferences of residents and strive to meet them. Detailed care planning files have been created in consultation with the residents. These provide comprehensive information on the personal and healthcare needs of all the residents as well as their individual aspirations and the actions planned to achieve the goals set. The staff team is stable and experienced and Walsingham provides regular relevant training. The home operates a very safe system for the storage, administration and recording of medication. The premises are well maintained and clean, providing a comfortable, safe and homely environment for the residents. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: None of the residents or staff spoken with made any suggestions for improvements to the service, all those who expressed views confirming their satisfaction with the home. With respect to the quality of care provided little needs to be done. However the paperwork in the service users’ files is bulky and somewhat confusing and should be reviewed and collated to produce more accessible information. Also all care plan documents should be dated as a matter of course and obsolete items clearly separated from current information to aid clarity. The kitchen worktops are worn and should be replaced to ensure proper hygiene can be maintained. The manager said that she was in the process of obtaining quoted for a new fitted kitchen (which would obviously include worktops) to resolve this issue. As at the previous inspection staff files were not inspected. However on previous occasions not all the staff records and information required by the Care Homes Regulations 2001 have been kept in the home, due to Walsingham’s policy of holding such records centrally. As a result it is impossible to assess the rigour of the home’s recruitment practices in the context of the Regulations and National Minimum Standards. Negotiations have taken place between Walsingham and the CSCI at a senior level however the matter remains unresolved. A further statutory requirement has not been made in this report however it remains an issue of concern and detracts from what is otherwise a very good service. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 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. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Adequate information is available to prospective residents to facilitate an informed decision about moving into the home. Admissions are made following thorough assessments of needs and prospective service users are able to visit the home to experience the atmosphere and assess the quality of the service before moving in. Each service user has a statement of terms and conditions of occupancy. EVIDENCE: No new service users had been admitted since the last inspection. However any prospective service users or their representatives can access the home’s statement of purpose and service user’s guide to obtain adequate information about the service philosophy and care to be provided. Any future admission would be subject to a full needs assessment and a series of introductory visits would be arranged to enable the prospective resident to become familiar with the operation of the home. A trial period would follow the initial admission to allow both the resident and staff to evaluate the suitability of the placement. At the end of the trial period the placement would be confirmed at a review meeting, assuming it was deemed to be appropriate. Each resident has a tenancy agreement, drawn up in a personalised format using pictures and photographs. This style makes it easier for residents to have some understanding of the agreement. Parents and other representatives are involved in the process as necessary. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Each service user’s needs are documented in individual care plan files that contain comprehensive details of their needs and aspirations. Staff consult closely with service users about the content of their care plans and empower them to make decisions and choices for themselves, participating in activities and taking risks that are evaluated and documented. Therefore service users can lead reasonably independent lives with staff support provided as necessary. EVIDENCE: For each resident a personal file, a communication file and an individual planner are maintained. The files relating to two residents were examined in detail. These contained personal details, comprehensive assessments for social, health and personal care as well as information on current approaches agreed for behaviour management, activities and risk assessments covering a wide range of identified risks. Referrals to and contacts with outside professionals were also recorded. The individual planner has been produced in a “person centred planning” format. Entries are written in the first person and are complemented by photographs, pictures and symbols illustrating the person’s personal preferences, methods of decision making and assistance Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 11 required from staff. The resident sets his or her own goals over specific timescales. The communication file contains written and pictorial representations of activities undertaken and the resident’s comments, for example regarding the choice of bedroom wallpaper, a Christmas meal out being planned and comments on the day care timetable. Each resident has a daily diary, completed by the staff on shift, detailing activities occurring and any incidents. A commendable amount of work has gone into the care planning process and there is no doubt that the “person-centred” format allows individual service users to be placed at the centre of the life planning process, assuming they are able to communicate their views effectively. For less able individuals who lack such communication skills, inevitably staff have to make and record subjective judgements on their behalf and in such cases the pure PCP format is of questionable value as it is hard to demonstrate genuine service user involvement in the planning process even with input from representatives outside the home. The residents make decisions about their daily routines in the home, activities and holidays and these are reflected in their care plan goals. Staff encourage and negotiate with them about taking part in household tasks such as cleaning their rooms, shopping and meal preparation. Risk assessments are filed separately. Those seen in respect of service users included topics such as wandering off, room clutter, bath safety, allegations against staff, behaviour management and medical issues. The two files seen were bulky and contained many undated documents that may have been obsolete. It was also hard to locate the most recent updates, although it was evident that regular reviews had taken place. It is recommended that all service users’ files be reviewed and old information either clearly separated from current material or archived to facilitate access. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Staff assist and encourage service users to make decisions for themselves and choose their activities. Service users use community services and amenities. Service users have appropriate relationships with each other, with relatives and with others outside the home. Staff respect and promote individual rights and encourage service users to take responsibilities in some areas. Service users have well balanced diets with any special requirements catered for appropriately. EVIDENCE: On the afternoon of the inspection four of the residents and supporting staff went out to attend a local carol service, which they evidently enjoyed a great deal. Extra staff had been rostered to provide adequate cover for this event. Two residents stayed behind and spent time following their own pursuits and having dinner with the remaining member of staff. Each resident has an individual daily timetable, detailed in his or her care plan. Some days they go out to day centres, on others they stay at home and choose what they want to do. One resident does not attend a day centre and extra staffing has been provided to allow her to go out into the community Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 13 without taking staff time away from the other residents. All of the residents enjoy a wide range of stimulating activities and as they take place staff record details in their communication files. Typical activities include shopping, bowling, meals out, visiting garden centres and cinemas and attending the Gateway Club. All the residents are involved in choosing their annual holidays, with staff presenting and discussing options with them. Family relationships are supported and relatives are encouraged to be involved in the home, including invitations to social events through the year. Most of the residents receive regular visits from relatives and also visit their families. The residents have a well balanced diet and there are adequate stocks of food held in the kitchen. They choose their meals and take part in menu planning and shopping on a weekly basis. The evening meal produced on the day of the inspection was well presented and looked appetising. One resident has phenylketonuria (PKU) and requires a special diet. Staff are aware of the implications of this condition and she has a supply of special low protein food and milk. Residents asked said they were very happy with the food provided. Staff indicated that residents would certainly complain if they were not happy. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Staff provide a good standard of personal care and treat residents with sensitivity and respect. Staff have excellent knowledge of the residents’ healthcare needs and personal preferences and act accordingly. The home has thorough procedures for ensuring the safe handling, storage and recording of medication that protect service users’ interests. EVIDENCE: The care plans examined contained a good level of detail regarding the personal and healthcare needs of the residents. Staff demonstrated excellent knowledge of the residents’ individual circumstances and the actions agreed to meet their needs. Very positive relationships were observed between staff and residents, with staff treating residents with respect and discouraging inappropriate behaviour in a measured and constructive way that corresponded closely to the behaviour management guidelines noted in care plans. The healthcare records seen included references to hospital visits, contact with GPs and other health professionals, appropriate monitoring of epilepsy and regular weight checks. The home follows sound medication procedures, using the Boots Monitored Dosage System that features pills supplied by the pharmacist in blister packs. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 15 No residents are able to self-manage medication, although one signs the medication administration record (MAR) sheet when she has taken her medicines. Medication is stored in a locked cabinet in the office. The stocks and records were checked. Dates of opening were recorded on packets and bottles of medication not in the blister packs and all administration was correctly recorded, with no gaps noted on MAR sheets. Two staff administer medication and carry out a check of the system at each round. Very clear instructions to staff on how to administer items to individual residents were held in the MAR file. The system is effective and minimises the risk of mistakes. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users and their relatives/representatives are encouraged and enabled to make their concerns and complaints known. Adequate policies and procedures are in place to ensure that service users are protected from abuse. EVIDENCE: The ethos of the home is to empower the residents to express their opinions, including concerns and complaints about the service provided. In support of ideal the home has a satisfactory complaint procedure in place that contains the required information on how to complain that is available to all residents and their relatives. A simplified version has been produced using pictorial symbols designed to be easier for residents to understand. Staff have explained the complaint process to residents. One complaint from a member of staff had been recorded since the last inspection in respect of allegedly inadequate bathing equipment for one resident. This had not been resolved at the time of the inspection, although the manager stated that the matter had been referred to an occupational therapist for assessment. The home has up to date policies concerning adult protection that follow the Hertfordshire inter-agency guidelines and a copy of the guidelines is kept in the office. All staff have had training in the prevention of abuse, and the subject is covered in the new staff induction programme. Staff spoken with were aware of the general principles involved including the company’s whistleblowing policy. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 The home provides a safe, comfortable and well maintained environment well suited to the service users’ needs. Service users’ single bedrooms are individually arranged to suit their needs and preferences. Adequate toilets and bathrooms are provided for six residents. Specialist equipment is provided to assist service users with restricted mobility, although the adequacy of bathing provision has been questioned and is being reassessed. Staff maintain a good standard of cleanliness and hygiene, involving service users in cleaning tasks as appropriate. EVIDENCE: The building is a spacious purpose-built chalet bungalow, with three bedrooms and communal rooms on the ground floor and three bedrooms upstairs. The home is well maintained, with good quality domestic style furnishings, fittings and décor. The lounge, and dining room are very smart and comfortable. The home is spacious and easy to move about in. Residents’ bedrooms are nicely Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 18 decorated, with all but one redecorated in recent months, and personalised with many items such as pictures, electrical equipment and furniture. The large kitchen is modern and well equipped with suitable domestic appliances, although the worktops are worn and should be replaced in the interests of good hygiene. The manager said that she was obtaining quotes for a new fitted kitchen and when fitted this problem would be resolved. Bathing facilities are adequate, although the facilities in the main bathroom will be re-evaluated following a complaint made by a member of staff. The laundry is well equipped to cope with the workload generated by six residents. The garden is fully accessible and provides a useful facility for service users. All areas seen were clean, tidy and hygienic. Staff are aware of good infection control procedures. Service users asked said they really liked the home. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 33, 35 The home is staffed by adequate numbers of experienced and competent support workers who are appropriately trained to meet the service users’ needs. The company provides regular relevant training for staff that ensures they are well equipped to assist service users to lead safe and fulfilled lives in accordance with the home’s statement of purpose. EVIDENCE: At the time of the inspection four staff were on duty, including the manager to support the six service users and provide sufficient cover for a trip out to a carol service attended by four residents. Staff numbers are varied depending on the need identified by reference to the planned activities taking place. All staff felt that numbers were adequate as indicated by the staff rotas. Agency staff are used when necessary, usually individuals who know the residents well and understand the routines of the home. All the staff are clear about their roles and responsibilities and understand and support the aims of the home. Team meetings are held frequently and staff spoken with rated teamwork and communications in the home as good. Walsingham provides comprehensive training for staff that covers all mandatory training in first aid, moving and handling, fire safety, food hygiene, Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 20 etc. and training to meet special needs the residents have such as epilepsy, and behavioural problems. All the staff have either completed or are currently undertaking NVQ2 or NVQ3 qualifications and the manager has recently completed the Registered Manager’s Award. Staff confirmed that they had ready access to relevant training opportunities. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 The home is well run in accordance with its stated aims and provides a stimulating and friendly environment for service users. The manager is experienced and qualified. Appropriate health and safety measures and safe working practices are followed to ensure that the home is a safe place to live and work in EVIDENCE: The manager has considerable relevant experience of working with adults with learning disabilities and has recently completed the course leading to the Registered Manager’s Award. She sets the tone for the home and clearly enjoys a positive relationship with both service users and staff. Equipment examined during the inspection such as the fire extinguishers and parker bath had been serviced within the last year. Fridge and freezer temperatures were recorded daily and regulated within safe limits. The COSHH Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 22 cabinet was locked. Hot water delivery was regulated close to 43 degrees centigrade by thermostatic mixer valves. Risk assessments and other records relating to health and safety matters were available for inspection. These are maintained in accordance with the home’s health and safety policy. Mandatory training is given to new staff as part of the induction programme. No health and safety hazards were noted during this inspection. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ashley Close (2) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 x DS0000019270.V265229.R01.S.doc Version 5.0 Page 24 No 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. 3. Refer to Standard YA6 YA6 YA24 Good Practice Recommendations All care plan documents should be dated and obsolete records clearly separated from current information. The PCP format should be refined to meet the needs of service users who cannot communicate their views. The worn kitchen worktops should be replaced in the interests of good hygiene. Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Ashley Close (2) DS0000019270.V265229.R01.S.doc Version 5.0 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. 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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