Inspection on 13/06/06 for Ashwood

This inspection was carried out on 13th June 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

Ashwood 28/06/07

Ashwood 11/01/06

Ashwood 03/08/05

Ashwood 21/03/05

Ashwood 10/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ashwood 12 Dudley Road Northbourne Bournemouth Dorset BH10 6BS Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 13th June 2006 09:30 DS0000004011.V300326.R01.S.doc Version 5.2 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 DS0000004011.V300326.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 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. DS0000004011.V300326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashwood Address 12 Dudley Road Northbourne Bournemouth Dorset BH10 6BS 01202 770242 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) Mr Jonathan Ashwood Van-Wyk Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000004011.V300326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service user to be accommodated in the second floor room must not be dependent on staff for means of their escape in the event of a fire. 11th January 2006 Date of last inspection Brief Description of the Service: Ashwood is a semi-detached family house situated in Northbourne, a suburb of Bournemouth. It is registered to provide personal care for three adults with learning disabilities and there were no vacancies at the time of the inspection. Details of current fee levels have been made available to CSCI, however, the provider does not wish these to be published. Fee levels would be discussed with individuals on application to the home. The home is located close to shops, bus routes and other local amenities. The homes statement of purpose includes the following aim; to support young adults to learn new skills and maintain and increase their independence. In pursuing this aim the registered person assists and supports service users to attend or undertake further education and employment opportunities as well as access the local community and its amenities. The building has no features that distinguish it from other similar properties in the street. The premises are spacious benefiting from a loft conversion and there is accommodation on three floors. The three service users have single bedrooms on the first and second floor. A bathroom and WC are easily accessible. Communal space is shared with the registered providers and this includes a lounge, kitchen/diner, conservatory, ground floor shower room and WC, utility area and gardens to the front and rear of the property. The registered providers work full time in the home and one has previous experience of working for a local authority in services for adults with learning disabilities. The domestic nature and character of the home enables service users to benefit from living in a family environment. DS0000004011.V300326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place over approximately 4 hours. It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. This inspection was a key inspection and therefore, assessed all identified key standards for care homes for adults. The inspector initially met with Mr Van Wyk (the registered person) and examined various records and documentation including care plans, risk assessments and health and safety records. The inspector also conducted a tour of the premises viewing all communal areas of the home and all service users bedrooms. The inspector returned to the home later in the evening and met will all three service users after they had returned from their day-time activities and spent approximately 1 hour talking to them. Additional information received by the inspector prior to the inspection was also taken into account. This included a pre-inspection questionnaire completed by the registered person, 2 service user surveys and 1 relative survey and any other information such as Regulation 37 notifications of significant events in the home. What the service does well: Ashwood offers a small family type environment providing a great deal of flexibility promoting individual choice. Observation during the inspection showed service users felt relaxed in the environment and were able to freely access all communal areas. Service users were able to fully participate in household routines such as washing up, hovering and helping in the garden and contribute ideas for the running of the home such as planning their annual holiday and taking on an allotment. The home aims “to support young adults to learn new skills and maintain and increase their independence” and there were plenty of opportunities for service users to do this. For example service users did their own laundry and ironing, they made their own breakfasts and lunches and helped themselves to drinks when they wanted, they were able to retain and administer their own medication and they were able to access public transport independently. All the care is provided by the registered proprietor and his wife which means they have a good knowledge and understanding of service users individual care needs and are able to offer an excellent consistency of care. Service users expressed a great deal of satisfaction about their care and felt there was a real family atmosphere in the home. DS0000004011.V300326.R01.S.doc Version 5.2 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. DS0000004011.V300326.R01.S.doc Version 5.2 Page 7 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 DS0000004011.V300326.R01.S.doc Version 5.2 Page 8 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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An admission procedure is in place that ensures prospective service users are only admitted on the basis of a proper assessment and subsequent trial period ensuring the home is confident the service they provide will meet potential service users’ needs. EVIDENCE: There have been no new admissions to the home since January 2005. The home has an admission policy and previous inspections have provided evidence on the service users’ files that care management assessments and plans were in place for all service users admitted to the home. There was further evidence on service users’ files that all placements were subject to a 12 week trial period and a review was held after this with the service user, care manager and family if appropriate to make the place permanent if all parties were happy with the arrangements. Information is available to prospective new residents and there is a service user guide produced in an accessible format using clip art and simple text. Service users confirmed they were able to make introductory visits to the home prior to their placements and felt confident that the home would be able to meet their needs. DS0000004011.V300326.R01.S.doc Version 5.2 Page 9 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 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered providers have a detailed knowledge of all residents ensuring that their needs are well met and any changes to their care can quickly be incorporated into their plans. The small family type living environment offers service users a great deal of choice and flexibility allowing them freedom to make decisions about their lives. The home has appropriate policies and procedures in place for assessing and managing risks, which are based on enabling service users to take responsible risks rather than preventing them from doing so. DS0000004011.V300326.R01.S.doc Version 5.2 Page 10 EVIDENCE: All service users’ care plans were viewed. These provided comprehensive information about service users’ general health and mental health, finances, mobility, personal care, communication, family and friends, daily activities, eating and drinking and household tasks. Examples of likes and dislikes were recorded e.g. “likes to assist with preparation of meals” and “prefers a shower to a bath. Support needs were also clearly specified e.g. “verbal prompts are sufficient” and “requires supervision with cooking”. There was further evidence that plans were reviewed regularly with any amendments being signed and dated. Discussion with service users confirmed they felt their support needs were being met. They were able to make decisions about their lives and gave examples such as “going to bed when you want”, “showering when you want” and “getting our own breakfasts and packed lunches and being able to make drinks”. Any limitations to service users on service users choices were clearly evidenced on service users care plans and agreed with other professionals where appropriate such as placing boundaries on certain types of obsessive behaviours. All service users have their own banks accounts and are supported where necessary to manage their finances including support to use cash point machines and budgeting during the week. The use of advocacy was encouraged and one service user had an advocate to assist him during the transition period of moving into the home. There was evidence that the home was managing risks well with strategies in place to promote service users independence rather than restrict them. This included risk assessments to enable one service user to cycle to his work placement and to enable service users to use public transport. Other assessments ensured the safety of other activities such as cooking, bathing/showering and using cleaning materials. DS0000004011.V300326.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have good links to their local community offering them the opportunity to take part in a range of work, educational, social and leisure pursuits. Family visits and telephone contact are supported to ensure that personal relationships are appropriately maintained. Ashwood offers a small family type environment providing a great deal of flexibility and participation in the home’s daily routines promoting individual choice and independence. The meals in this home are good and ideas for increasing service users participation in meal planning and preparing have been explored providing further opportunities for service user involvement and choice. DS0000004011.V300326.R01.S.doc Version 5.2 Page 12 EVIDENCE: A record of service users daily activities was kept on each individual’s file. All service users had regular organised daytime activities including day centre attendance, college attendance and work experience. Discussion with service users indicated they were happy with their weekly programme of activities. They also told the inspector they regularly accessed the community and gave examples such as catching the bus to a club, going out for meals and going to the local shops. Service users were also included in family outings with the proprietors and the home has a MPV available to allow everyone to go out together. The service users told the inspector they were particularly looking forward to their holiday in September when they were going to Malta. Relatives details were recorded on service users’ files. Service users were able to keep in touch regularly with their families, one service user regularly stayed with relatives on weekend visits and the other two service users had regular visits from relatives who either visited them at the home or took them out for the day. There was a payphone in the hall to assist service users to make calls to family and friends and service users also had their own personal mobile phones. Discussion with service users showed they also had developed a strong sense of family within their home environment and they spoke about the close relationships they had developed with the other residents and the proprietors. One resident said, “I feel like part of a family.” Discussion with the registered person indicated routines in the home were flexible accommodating individual’s needs. For example service users helped themselves to their own breakfasts and evening meals were generally eaten together but times could be adjusted to enable service users to attend evening activities. Service users confirmed routines were adjusted to suit their needs and felt their rights were respected, e.g. they could spend time in the privacy of their rooms, bath and shower when they choose and go to bed when they wanted. Observation on the day showed that service users had freedom of movement around the premises and were able to help themselves to drinks when they wanted. The proprietor said service users were responsible for keeping their own bedrooms clean and also participated in household tasks such as washing and drying up, hovering and cleaning bathrooms. They each had an identified day when they could do their laundry and ironing. Discussion with service users confirmed they took part in all these tasks. A sample of menus was viewed as part of the inspection. This showed service users were offered a varied and nutritious diet and supported to follow a healthy eating plan. Service users usually helped themselves to their own breakfasts and made their own packed lunches. The evening meal was generally cooked by the registered person mainly because service users were out at their daytime activities, however, the registered person has been DS0000004011.V300326.R01.S.doc Version 5.2 Page 13 working on giving service users more opportunities to participate in meal preparation and one service users said “I’ve started to cook” and was clearly enjoying been more involved in this activity. DS0000004011.V300326.R01.S.doc Version 5.2 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in a way that promotes the service users’ privacy and independence. The physical and emotional health needs of service users are well met with multi disciplinary working taking place as appropriate. The home encouraged service users abilities to retain, administer and control their own medication whilst ensuring appropriate systems were in place to minimise any risk or harm to them. EVIDENCE: There was evidence that service users were receiving the personal support they needed. Support needs were clearly recorded on care plans, although all 3 service users were fairly independent and the majority of care needed was verbal prompts to ensure residents had washed, shaved and taken showers as appropriate. Service users said their privacy was respected and felt they were “treated like adults”. DS0000004011.V300326.R01.S.doc Version 5.2 Page 15 All service users were registered with a local G.P. Any health care needs were clearly recorded and allergies were noted on service users’ files. Records of all appointments were kept such as visits to the G.P., dentist or optician. Other health conditions were monitored such as epilepsy or mild compulsive/obsessive behaviours with support from other professionals where appropriate e.g. consultant psychiatrist. Only one of the residents is currently taking medication. This service user is currently self-medicating and the inspector was shown a copy of the risk assessment ensuring an appropriate management framework was in place. For example a dosage box is used that is filled once a week, which is monitored by the registered person. The remainder of medication is kept in a locked cupboard and the number of tablets is recorded so there is a clear audit trail. The home has satisfactory policies and procedures for administering medication and the registered person confirmed an awareness of these. A record was kept of any homely medication taken and the inspector viewed a sample of these records. DS0000004011.V300326.R01.S.doc Version 5.2 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the way that complaints are dealt with in the home and residents feel much more confident that their views will be listened to and acted upon. Adult protection procedures have been updated to reflect current practice ensuring the registered person is aware of local procedures and residents are appropriately safeguarded. EVIDENCE: The home has a written complaints policy and procedure. Service users were aware of the procedure and were able to tell the inspector whom they could talk to apart from the registered person, e.g. family, advocate, social worker and the inspector. Residents told the inspector they could talk to the registered person and he would listen to them and take necessary action such as “ringing up the social worker”. The home has policies and procedures in place concerning the protection of vulnerable adults. These included challenging behaviour, physical intervention and management of residents’ monies. The Abuse policy has been updated since the last inspection to clarify local procedures and ensure these are correctly followed. Mrs Van Wyk has undertaken training in the protection of vulnerable adults. A copy of the Department of Health guidance “No Secrets” was available in the home. DS0000004011.V300326.R01.S.doc Version 5.2 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashwood maintains a good standard of décor and furnishings that provides the residents with an attractive, comfortable, homely environment. The home is clean and hygienic with satisfactory procedures in place for controlling infection. EVIDENCE: A tour of the premises was carried out as part of the inspection. All communal rooms were seen including the lounge, dining area, kitchen and laundry room and all service users bedrooms. The inspector was also shown the outside garden by the registered person. The premises were well maintained and decorated in a comfortable, homely way that was suitable for its stated purpose, i.e. providing care and support to adults with learning disabilities. Since the previous inspection the lounge and dining area had been redecorated and new carpets had been laid. The registered person had also moved all the paperwork to a vacant room, which DS0000004011.V300326.R01.S.doc Version 5.2 Page 18 increased the security of storing information and documentation of a confidential nature. Service users bedrooms were observed to be personalised to each individuals taste with plenty of space for personal possessions. Service user spoke positively about their bedrooms and their living environment. One resident was particularly pleased that he had now got ‘freeview’ in his bedroom. On the day of the inspection the home was observed to be clean, tidy and hygienic. The registered person is aware of procedures to control the spread of infection and an appropriate policy was seen during the inspection. The laundry room is accessed by the hall ensuring any soiled articles do not need to be carried through the kitchen. Separate hand washing facilities are provided and gloves are available for dealing with bodily fluids. DS0000004011.V300326.R01.S.doc Version 5.2 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): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered person and his wife currently provide all the care to the residents and do not employ any staff. Occasional cover is provided by the same relief worker who has been appropriately vetted by the home to ensure consistency of care to the residents and safeguard their welfare. EVIDENCE: The home does not currently employ any staff but is owned and managed by the registered person and his wife who provide 24 hour care to the residents. When it has been necessary for them to have a break, a regular relief worker provides cover in the home. The registered person has obtained all the information and documents specified in paragraphs 1 – 7 of Schedule 2 of the Care Homes Regulations 2001 in respect of this person and these were shown to the inspector. Details of current training courses attended by the registered person are recorded under standard 37. DS0000004011.V300326.R01.S.doc Version 5.2 Page 20 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and enables service users to meet its stated aim “to support young adults to learn new skills and maintain and increase their independence.” The home encourages feedback about the quality of service from the residents and these are included in a formal plan setting out aims and objectives for future service development. Practices in the home promoted and safeguarded the health, safety and welfare of the people using the services. DS0000004011.V300326.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home is managed by the registered person and his wife. Both have previous experience of working with people with learning disabilities and prior to running a registered care home, they had been registered as adult placement carers. Mr Van Wyk had also undertaken voluntary work with adults with learning disabilities and Mrs Van Wyk worked for a local authority managing a service for adults with learning disabilities. Mrs Van Wyk has the Registered Managers award and Level 4 NVQ in care, Mr Van Wyk has undertaken NVQ Level 3 in ‘Promoting Independence’. There was further evidence that Mr Van Wyk had recently undertaking further training in managing challenging behaviour, risk assessments for care and dementia. He is also booked to attend a course on medication. The home has developed a system to monitor the quality of the service. This is based on the views of residents, which are sought on a regular 6 weekly basis at house meetings. These are recorded so residents’ views can be incorporated in to the annual development plan. The registered person has produced a plan for 2006 – 2007 and this includes improvements to be made to the environment, service user plans such as cinema trips, working on an allotment and planning an annual holiday. The plan also included care plan goals such as help with budgeting to save money for outings service users have chosen to go on throughout the year. The registered person demonstrated a commitment to working with CSCI and all the requirements and recommendations made at the previous inspection have been met. Health and safety matters were generally well managed in the home. A fire risk assessment had been completed for the building, however, this needed to be updated to include an additional resident living in the home. Records showed that checks and drills were carried out on a regular basis. Service users confirmed they knew what to do in a fire drill and were able to describe the procedure to the inspector. The registered person was aware of legislation regarded health and safety and policies and procedures reflected this. Both Mr and Mrs Van Wyk have undertaken courses in safe working topics including fire training, food hygiene, manual handling and the administration of medication. There was further evidence that facilities and equipment was being serviced at regular intervals. DS0000004011.V300326.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X DS0000004011.V300326.R01.S.doc Version 5.2 Page 23 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 YA42 Good Practice Recommendations It is recommended that the fire risk assessment of the building be updated to include an additional resident as the home is now registered for 3 service users instead of 2. 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