CARE HOMES FOR OLDER PEOPLE
Bethany House Gamull Lane Ribbleton Preston Lancashire PR2 6TQ Lead Inspector
Ms Susan Dale Key Unannounced Inspection 6th November 2007 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 Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bethany House Address Gamull Lane Ribbleton Preston Lancashire PR2 6TQ 01772 792226 01772 792226 bethanyhouse2000@yahoo.co.uk 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) Preston Bethany Trust Mrs Gillian Whitfield Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home is registered for a maximum of 27 service users in the category of old age, not falling in any other category (OP) over 65 years of age The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 3rd October 2006 Date of last inspection Brief Description of the Service: Bethany House is a Residential Care Home for the Elderly, built and managed by Preston Bethany Trust, a Christian Charity (Registration No. 511535). The home provides personal care to older persons and is purpose built with the accommodation for service users all on the ground floor. The home has been extended and has the benefit of a large 2nd lounge and an easily accessible patio area. The home is situated within its own grounds, close to local shops and other community facilities. Accommodation is available for long term, short term and respite care for older persons with physical, medical, spiritual and social needs. Assistance is provided to enable each service user to follow their religious faith within the home and encouragement to participate in a local church of their particular denomination. Terminally ill Service Users needing nursing care or with Alzheimers disease are not accepted for accommodation, but should a Service Users condition deteriorate during their stay, every effort would be made to assist them using outside agencies. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The visit was unannounced and the focused mainly on key standards. Information was also gained from the Annual Quality Assurance Assessment completed by the manager. The inspector was able to speak to service users and staff and examine various records. Surveys were provided to service users, staff, relatives/friends and health professionals prior to the inspection. 4 surveys were returned from service users, 5 from relatives and 3 from staff. All the responses were very positive and the results were taken into account as part of the inspection. A tour of the premises took place. The inspector was joined by an ‘expert by experience’ for part of this visit. (An ‘expert by experience’ is a person who because of a shared experience of using or needing a service, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in the home.) The ‘expert by experience’ spent time in the communal areas of the home, talking to those living there and then provided feedback to the inspector. What the service does well:
The home has ‘family’ atmosphere and the emphasis is on the care of the service users with a person centred approach taken at all times for individual service users. There were many positive comments about the care provided and the manager and staff working within the home. The home is well supported by the local community with visitors from local churches and schools. Visitors are encouraged and can have a meal with service users. The home has a very welcoming atmosphere and the surroundings are pleasant with plenty of space for communal activities or for a quiet corner when preferred. A member of staff is responsible for co-ordinating activities and she has worked hard to ensure that different types of activities according to ability are on offer and how they have been appreciated. There are good staffing levels for the number and needs of the current service users. Five staff are on duty am and in the evening and 3 staff on duty after lunch when it is less busy plus the manager. Staff spoken to feel appreciated by management staff and well supported in their role. A team approach is taken over the care of service users and the wishes and care needs of the service users come first with regard to the policies and procedures operating within the home. Comments included:
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 6 “The staff look after you and are grand.” “Bethany House has provided care even beyond necessary needs on many occasions. No place is perfect but, they always give their best endeavour.” When asked what the home does well: “Provides a sense of continuity and security in pleasant surroundings and atmosphere.” “Excellent care, good food, homely atmosphere, sense of family.” “Bethany House has a good reputation for one to one care and the staff are excellent.” “Bethany House makes my mother in law feel loved and secure. All the staff are hand picked and it is rare that there is a change of staff. That in itself tells a lot.” From a member of staff: “I enjoy getting up and coming to work. I feel I could go to the manager and tell her anything either personal or work related and she would support me. All the care workers are a good bunch who generally care and take pride in their work. Bethany House is a lovely home.” What has improved since the last inspection?
The pro-forma used for recording the initial assessment leading to the care plan has been improved and takes into account any requirements under the Mental Capacity Act (MCA). The manager has improved the current pro-forma for recording the care plan together with staff; a person centred care planning approach is taken. One of the staff is in charge of activities and the level of activities has been increased to 6 days a week. The staff member responsible is due to attend a course on activities and is keen to expand her knowledge on the subject. The manager has recently increased the hours of the cook and kitchen assistant and this has freed up the care staff so that they can spend more time with service users. The cook is also able to provide extra baking and assist with tea. The role of the key worker is going to be extended with a senior and junior member of staff on each shift. Currently seniors are key workers and in the future juniors are going to be more involved in the key worker role. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 7 Since the last inspection, all the rooms in the original part of the home have been refurbished including new sink units and wardrobe doors. Fourteen bedroom doors have been replaced with self-closing fire doors, which are connected to the fire alarm system; self-closing fire doors have also been installed in the kitchen. Five bedrooms have been painted and had new carpets. Laundry room and adjacent corridor have been painted. The short wing corridor has been painted. Seven new commodes have been purchased. All bedrooms are refurbished as they become vacant. A PA system has been installed in the main lounge and this includes a hearing aid loop system. Music can be played through the loop system. Once the budget has been approved, the sluice room is to be re-developed and new sluice machines purchased. The number of qualified staff has significantly increased, there are currently 25 care staff and 18 have obtained an NVQ qualification in Care; one other staff is in the process of obtaining the qualification. A staff comment included “We have a list of all types of courses which are available to all staff in the staff room. All staff are encouraged to update their training.” The manager has successfully completed an NVQ level 4 in Health and Social Care and the NVQ level 4 Registered Managers Award top up programme. 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. The summary of this inspection report can be made available in other formats on request. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 The quality in this outcome group was good. Up to date written information about the home is available and each service user is provided with the terms and conditions/contract when they commence. Prospective service users are assessed in order to ensure that the services provided meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full assessment is undertaken before service users are admitted to the home; a visit is undertaken to the prospective service user at home or in hospital to confirm whether they will be able to meet their needs. The pro-forma used for recording the initial assessment leading to the care plan has been improved and the manager is ensuring that any assessment takes into account any requirements under the Mental Capacity Act (MCA). The manager is undertaking training in the MCA and has purchased a toolkit from the National Care Association; all staff are also to receive training.
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 10 The assessment is comprehensive and looks at any particular physical requirements such as the need for specialised equipment or whether there are any risks connected with their care needs. Every effort is made to ensure that the room is suitable and the records included a checklist for preparing the new service user’s room. Any new service user is able to stay at the home for a maximum of 4 weeks before making a decision about a permanent stay and they are all issued with a contract. Advance notice is given of any changes regarding payments. The home does not provide Intermediate Care. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome group was good. A comprehensive care plan is produced that meets all physical/health and emotional requirements and appropriate medication policies and procedures are in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has improved the current pro-forma for recording the care plan together with staff. A person centred care planning approach is taken and the records seen were well laid out and divided into sections covering the assessment, risk assessment and care plan. General Practitioners/District Nurses etc visits, hospital appointments and telephone calls were recorded in a separate section and were very detailed showing that good liaison was in place with all health practitioners. Every effort is being made to determine and record the background/history of service users that will assist in compiling an effective care plan. The service user or their representative had signed the records seen and a review of the care plan had been completed once a month. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 12 A recommendation was made that the section recording social activities could be expanded upon and added to the checklist where areas of potential risk had been recorded. The strategy to meet any aims and objectives to meet any hobbies and interests could be recorded and any background, social history should assist in the process. Appropriate medication policies and procedures are in place for the storage, handling and administration of Medicines. There is a dedicated storage area for medication, which is kept secure at all times. The manager provides oversight to ensure that medication records are complete and signed for at the time of administration. 6 staff are responsible for the provision of medication and have received training. The storage area for medication is to have new cupboards and dedicated fridge installed for medication when required. The surveys indicated that a relative and one service user would prefer a matron to oversee medical matters; this is because the previous manager was a registered nurse however, the majority of service users have every confidence in the staff with regard to their health. Evidence was provided from observation, comment cards and talking to service users and staff that privacy and dignity are respected at all times. Surveys indicated that service users felt well cared for and were treated well by the staff. Service users confirmed that they receive their mail unopened and a public telephone is available for use as well as one within the office to ensure privacy. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome group was good. Appropriate activities are in place according to the needs and capabilities of the service users. Contact is maintained with family, friends and the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The lifestyle of the service user prior to entering the home is taken into account and facilities are in place to ensure that their expectations and preferences are met as much as possible in all aspects of their lives. Evidence was provided from talking to service users that the routines of daily living are flexible and varied according to individual needs. Service users interests are recorded and there are ample opportunities for religious interests, leisure and recreational activities both inside and outside the home. Information about activities is circulated verbally as well as documented on a notice board. One of the staff is in charge of activities and the level of activities has been increased to 6 days a week. The staff member responsible is due to attend a course and is enthusiastic and keen to expand her knowledge on the subject. A file is created that records the activities and feed
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 14 back from individual service users. Activities include, dominoes, music and movement, reminiscence, nail salon, basketball or quoits and videos or DVD’s. There has been a recent trip to the illuminations and wheelchair users were accommodated. The home had a party on the 5th November with fireworks that was a great success. The ‘expert by experience’ spent time in the lounge and observations during this time included; that service users could not praise the standard of living high enough. The variety of food, staff attentiveness, privacy and dignity were all respected. Service users confirmed that at all times they felt respected and were friends with other service users. Confirmation was provided about how important a service user felt about the assistance provided by the home to follow her religious beliefs and how comforting this was. Another service user commented on how she was separated from her husband who was in another care home and how this was not a problem as staff had ensured that contact was maintained whenever it was needed. Comments included: The staff “looked after you and are grand.” “Couldn’t be happier.” “Look at my room my dining facilities, what more could anyone want.” The manager has recently increased the hours of the cook and kitchen assistant and this has freed up the care staff so that they can spend more time with service users. This has only taken place very recently and the manager and staff are going to review the impact of the changes however, staff spoken with were very happy with the change and how it had helped them to spend quality time with service users. The cook is also able to provide extra baking and assist with tea. The role of the key worker is going to be extended with a senior and junior member of staff on each shift. Currently seniors are key workers and in the future juniors are going to be more involved in the key worker role. Good contact is maintained with family and friends and representatives from local churches, usually every Tuesday, undertake regular visits. Service users confirmed that meals offered variety and choice and that they are provided at regular intervals. Menus are planned on a six weekly rota and cater for any service user on a specialised diet. Mealtimes were seen to be unhurried and assistance provided discreetly.
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 15 Comments included: “Bethany House has a good reputation for one to one care and the staff are excellent.” “Bethany House makes my mother in law feel loved and secure. All the staff are hand picked and it is rare that there is a change of staff. That in itself tells a lot.” “If the meal is not what I like they will change it for something.” “I feel that the home is nice and friendly that all staff do their work well and with a lot of care when helping residents in their daily activities.” Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome group was good. There is an appropriate procedure for dealing and recording any concerns about the care and facilities of the home. Polices and procedures are in place for protecting service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an appropriate complaints procedure and Complaints, Compliments and Comments leaflets are freely available. There has been one complaint received by the Commission for Social Care Inspection; the home investigated and the complaint about infection control was not upheld. Comments include: “I never need to complain.” “I am very rarely unhappy here.” The home has comprehensive procedures in relation to dealing with allegations of abuse. Staff policies include the need for the non-involvement of staff with regard to legal documents/wills and the non-acceptance of gifts. All staff are made aware of these policies during their induction period and are asked to sign documentation confirming they have read and understood the content of the policies. Some staff have received training on the subject of Adult Abuse
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 17 and Whistle Blowing as part of their NVQ training. All staff are due to receive training on Abuse in January 2008. The recruitment procedure ensures that prospective staff are checked as to whether they are on the Protection of Vulnerable Adults Register (POVA) as well as police clearance via the Criminal Records Bureau. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome group was excellent. The home provides luxurious accommodation. All areas of the home including service users’ personal accommodation are safe, clean and comfortable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home and grounds are safe, accessible, and well designed for the needs of the service users. Every effort has been made to ensure that the decor is of a high standard. The building complies with the requirements of the fire service and environmental health department. A tour of the premises took place and the home was found to be warm, clean and free from any obvious hazards. The home has recently been inspected by the local fire service. Since the last inspection, all the rooms in the original part of the home have been refurbished including new sink units and wardrobe doors. Fourteen
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 19 bedroom doors have been replaced with self-closing fire doors, which are connected to the fire alarm system; self-closing fire doors have also been installed in the kitchen. Five bedrooms have been painted and had new carpets. Laundry room and adjacent corridor have been painted. The short wing corridor has been painted. Seven new commodes have been purchased. All bedrooms are refurbished as they become vacant. A PA system has been installed in the main lounge and this includes a hearing aid loop system. Music can be played through the loop system. Once the budget has been approved, the sluice room is to be re-developed and new sluice machines purchased. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome group was excellent. There are sufficient numbers of staff on duty for the needs of the service users. A suitable recruitment procedure is in operation that ensures the protection of vulnerable people and training is provided to staff that ensures they are competent and able to meet the needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new staff appointed since the last inspection; one of the strengths of the home is that continuity of staff is maintained as they enjoy working at the home so much. All appropriate checks have been undertaken prior to the commencement of new staff. Two written references had been received prior to commencement and clearance had been obtained from the Criminal Records Bureau and a check undertaken of the Protection of Vulnerable Adults Register (POVA). All staff have to abide by a Code of Conduct that is in accordance with the code set by the General Social Care Council. There are good staffing levels for the number and needs of the current service users. Five staff are on duty am and in the evening and 3 staff on duty after lunch when it is less busy plus the manager. The manager is seeking to recruit an additional bank staff member. Most of the staff work part time and are
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 21 available for additional hours as required. Staff, service users and relatives had no concerns about staffing levels. There are currently 25 care staff and 18 have obtained an NVQ qualification in Care; one other staff is in the process of obtaining the qualification. According to the manager, induction training is being altered to meet the new Skills for Care Training programme. Ongoing training includes, First Aid, Food Hygiene, Health & Safety, Fire Safety and Moving and Handling. Comments included “We have a list of all types of courses which are available to all staff in the staff room. All staff are encouraged to update their training.” Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome group was good. The home is well run and service users benefit from the services provided by the staff. Service users are also protected by the policies and procedures operating within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has successfully completed an NVQ level 4 in Health and Social Care and the NVQ level 4 Registered Managers Award top up programme. Staff meetings are held on a regular basis at which minutes are taken and daily meetings are held to discuss any issues that have arisen. The chairman of the home’s board of trustees visits the home on regular basis and speaks to service users and staff and the information gathered is then fed back to the staff within the home. The staff have encouraged service users to hold their own meetings but without success.
Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 23 When service users cannot look after their own finances, assistance is provided with the best interests of the service users in mind. The manager recommends all service users appoint a lasting power of attorney. There was evidence that all staff receive one to one supervision with the manager supervising senior staff and seniors supervising the junior staff. Prior to the supervision, staff record any issues they wish to be discussed and so does the supervisee. Staff confirmed that the manager is very supportive and service users spoken with were very happy with the attention they received from both manager and staff. Comments included: “I enjoy getting up and coming to work. I feel I could go to the manager and tell her anything either personal or work related and she would support me. All the care workers are a good bunch that generally care and take pride in their work. Bethany House is a lovely home.” “Management very receptive and willing.” “Staff support is excellent.” Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 25 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 OP7 Good Practice Recommendations The care plan should be expanded upon in the area of hobbies and interests with a strategy to meet any aims in this particular area. Bethany House DS0000009839.V346755.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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