Inspection on 23/11/06 for Bishop Herbert House

This inspection was carried out on 23rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bishop Herbert House 18/01/06

Bishop Herbert House 03/05/05

Bishop Herbert House 15/11/04

Bishop Herbert House 16/06/04

Bishop Herbert House 24/02/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Bishop Herbert House 34 Globe Place Norwich Norfolk NR2 2SG Lead Inspector Mrs Lella Andrews Key Unannounced 23rd November 2006 09:45 Bishop Herbert House DS0000034848.V321548.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 Bishop Herbert House DS0000034848.V321548.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. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishop Herbert House Address 34 Globe Place Norwich Norfolk NR2 2SG 01603 620710 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) www.norfolk.gov.uk Norfolk County Council-Community Care Mr Roy Slater Care Home 14 Category(ies) of Physical disability (14) registration, with number of places Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The manager of the home is responsible for the care offered at Bishop Herbert House. The home can continue to accommodate the four service users aged over 65 years named in the home’s pre-inspection questionnaire dated 18th April 2005. The home can continue to offer respite care to the five service users aged over 65 years named in the home’s Action Plan dated 16th June 2005. The home will not offer respite care to any additional service users over 65 years of age. 18th January 2006 3. 4. Date of last inspection Brief Description of the Service: Bishop Herbert House is owned and managed by Norfolk Social Services. It provides accommodation for up to fourteen adults with a physical disability. There are currently twelve permanent places and two respite care places. The providers have informed the Commission that the Home will eventually be providing respite care only. The home is not admitting any new permanent residents. Accommodation is on the ground floor only and there is level access throughout the building. The home has recently undergone major refurbishment work. All service users in the home have en suite accommodation that is equipped and maintained to a high standard. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gathered about the Home since the last Inspection. This includes notifications made by the Home to the Commission, comment cards completed by relatives and residents and a visit to the Home. Four comment cards were completed by relatives and these were all positive with additional comments being made such as: “…always receives an excellent standard of care.” “…always made to feel welcome” “keep up the excellent work.” Nine comment cards were completed by residents and these also contained positive responses although two comments were made about there being too much reliance on agency staff at times. The visit to the Home took place on the 23rd November 2006 over approximately five hours. A tour of the building was undertaken, discussions took place with the manager, staff, visitors and residents and a selection of records were seen. In general, the Home provides a very good standard of care and the residents are supported to maintain and develop their independence. The refurbishment of the building means that the residents benefit from a high standard of accommodation. What the service does well: The views of the residents are routinely sought by staff and residents are encouraged to make their own decisions. The Home has systems in place for monitoring the quality of the service and continually strives for improvements. The Home is very well managed by a Manager who is well trained, enthusiastic and approachable. The staff are enthusiastic and work hard to meet the needs of the residents. The staff receive good training and support to carry out their roles effectively. The personal and health care needs of the residents are understood and met to a high standard. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 6 The Home provides a very high standard of accommodation. The staff team make visitors feel welcome and involve them in the residents care. 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. The summary of this inspection report can be made available in other formats on request. Bishop Herbert House DS0000034848.V321548.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 Bishop Herbert House DS0000034848.V321548.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. 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. The needs of prospective respite guests are assessed effectively prior to them staying at the Home. EVIDENCE: The Home has two respite beds and so there is a need for regular assessment of prospective residents using these rooms. The staff said that they always have good information about people prior to them coming in to stay. Several of the respite guests have stayed at the Home on more than one occasion. One of the care plans was seen for a respite guest and this was very detailed and provided good information to staff about how to meet the persons needs. Bishop Herbert House DS0000034848.V321548.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. 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. Residents are supported to make their own decisions about all matters affecting them. Care plans contain detailed information for staff about how to meet the needs of the residents Risks are assessed appropriately. EVIDENCE: All staff at the Home, including catering and domestic staff, work hard to ensure that the residents are supported to make their own choices in as many areas of their lives as possible. The Inspector saw examples of how this works Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 10 in practice and was impressed by the staffs commitment to finding alternative ways of communicating with residents who find speech difficult. All of the residents comment cards state that they are able to make choices about what they do and that the care staff listen and act upon what they say. Three of the care plans were seen and these contain a lot of information about the residents needs and how these should be met. The care plans contain information about seemingly minor issues but which are actually very important to each individual and ensure that the residents choices are respected. The care plans are currently being reviewed and a slightly different format being used which will be easier for staff to find information quickly. The assessment of risks is understood and recognised as an important part of ensuring that the residents are able to take part in the lifestyle of their choosing in a safe way. The care plans contain detailed risk assessments. The staff are aware of the content of the care plans and are involved in reviewing them on a monthly basis with the residents whom they are key workers to. Residents meetings are held on a regular basis and the minutes show that the residents are encouraged to contribute to discussions about a range of issues that affect them. The Manager also produces a newsletter which provides information about issues affecting the Home. Residents told the Inspector that they are able to make their own choices and that the staff listen to them. Staff receive training with regard to communication and sensory impairment which they feel is relevant and helpful. The Manager said that residents look after their own money, sometimes with the assistance of relatives and that staff provide support with this if required. Bishop Herbert House DS0000034848.V321548.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. 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. Residents are supported to take part in a range of educational and leisure activities. The rights and responsibilities of the residents are respected. The residents enjoy their meals and individual dietary needs are met. EVIDENCE: The Home is situated very close to the city centre and to the local day centre where several of the residents attend for appointments such as physiotherapy. The Home no longer has a mini bus but residents and staff said that this has not been too much of a problem as taxis and trains are used if necessary. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 12 Three of the residents have a member of staff working with them on a 1:1 basis for several hours a day to enable them to access a variety of leisure and educational activities as well as providing support with communication. Staff and residents described a large variety of social and educational activities that residents take part in within the local community and farther afield. Residents said that their visitors are made to feel welcome and this was observed to be true during the visit to the Home. The Inspector spoke to two visitors during the visit to the Home and four comment cards were received at the Commission. All of the information provided to the Inspector was positive about the care that their relatives receive and about the support that they, as visitors, are given. Residents said that they are able to make choices about their daily routines and how they spend their time. Residents were seen to make use of the communal areas of the Home and their own bedrooms as they wished. Residents have a key to their rooms if they wish to. All bedrooms have a post box outside the door where external mail and any internal information, such as newsletters, are delivered. The staff are very aware of the need to respect the privacy and dignity of the residents when supporting them. Staff were seen to knock on doors prior to entering rooms and the Inspector was not shown any bedrooms unless the resident had given permission for the Manager to do so. Residents said that the meals have improved since the last Inspection due to a change in personnel in the kitchen. The minutes of the last two residents meetings included residents asking for praise for the meals to be passed on to the kitchen staff. Residents said that they are provided with a choice and that the cook knows what they like and don’t like. There is a water cooler and squash available in the dining room as well as fruit on the servery hatch which residents can help themselves to. The cook said that there is always food available for snacks in the servery which staff and residents have access to at all times. The menus are not put together by the cook or the residents but the cook said that there is flexibility within the menus to provide what the residents would like. The cook has information about the dietary needs of the residents and has a good knowledge of what individual residents need with regard to special diets. The cook talks to the residents on an individual basis about their personal choices and preferences. The care plans contain information about the residents dietary needs and the support that they require at mealtimes. One of the residents comment cards states that there are not always enough staff at tea time to assist everyone. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 13 Discussions with staff and the Manager show that arrangements are in place to ensure that all residents who need 1:1 support at this time can receive it. Bishop Herbert House DS0000034848.V321548.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The physical and emotional health needs of the residents are met. Medication is managed effectively and safely Residents receive very good care at times of ill health EVIDENCE: The care plans contain detailed information about the residents physical and emotional health needs and how these are to be met. There is evidence of a variety of health professionals being involved in the residents support such as physiotherapists, speech and language therapists, dietician. The staff support the residents to attend some appointments whilst some professionals visit the Home to see the residents. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 15 The residents are all registered with a GP and also have regular optician and dental appointments. The relatives comment cards state that they are kept informed about the care that their relative receives if appropriate. One of the relatives particularly commented on the fact that the staff give very good personal care and ensure that the individual is always assisted to wear appropriate clothes and to maintain their own personal standards of cleanliness as they had prior to moving to the Home. Examples were given to the Inspector that showed the efforts that the Manager and staff have made to ensure that one of the residents receives the health care that they choose for themselves. Additional support has been provided to the resident and to the staff team. The medication system was looked at. All staff receive appropriate training so as to be able to administer medication safely. Medication is stored securely and appropriate records are kept. The management team are building up a library of information about medication, disabilities and illness for the staff to use for reference. Bishop Herbert House DS0000034848.V321548.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. 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. Residents are encouraged to raise any concerns that they may have and there are procedures in place to deal with any complaints that may be made. Procedures and staff training are in place to provide protection for the residents from abuse of any kind. EVIDENCE: All of the residents and the relatives comment cards state that they are aware of who to complaint to if they needed to. The Home has a suitable complaints procedure and the Manager deals with any complaints appropriately. The Commission has not received any complaints about the Home and the Manager has dealt with one, minor, issue through the complaints procedure. Residents are encouraged to discuss any concerns that they have with their key worker, Manager or any member of the staff team. The minutes of the residents meetings show that residents are encouraged to raise any issues that they may have and are reminded that they are able to talk to someone privately if they prefer. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 17 The staff work hard to improve communication between themselves and residents and this will further enable residents to be able to raise any concerns/complaints that they may have. The staff all receive training with regard to Safeguarding Adults (from abuse). Staff are aware of the whistle blowing policy and are confident that any concerns that they raise with the Manager will be dealt with appropriately. The staff are very clear that they are there to support the residents and they were seen to show respect and kindness towards residents. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The Home provides a very good standard of accommodation for the residents which meets their needs. EVIDENCE: The Home has recently undergone a long period of refurbishment. The result is a very much improved standard of accommodation for the residents. The residents told the Inspector that they appreciate the improvements and really like having their own bathrooms ensuite to their bedrooms. All bedrooms are now ensuite, the majority of which have showers, toilets and hand basins but two of the rooms have a bath instead of a shower as that is what the residents requested. One of the residents showed the Inspector their room and this showed that residents have been encouraged to personalise their rooms as they wish. Residents have also been supported to purchase additional items of furniture if they wish to. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 19 The Home also has communal bathrooms which have assisted baths or level access showers. There is overhead tracking in the bathrooms. Since the residents have started to use the overhead tracking it has been discovered that, in two cases, this would be better if it, or the bath, was positioned slightly differently. The Manager said that this situation has been passed to the appropriate department within Social Services. A recommendation is made that this work takes place. All of the bathrooms, including en suites, have hand soap, hand towels, gloves and aprons for staff and residents to use as appropriate and reduce the risk of infection. There is a separate toilet and shower area for staff to use as well as a toilet for visitors to use. The Home has communal lounges situated around the Home as well as a large dining room. Both the dining room and one of the smaller lounges has a kitchenette area. There are plans in place to improve the tiles in the kitchenette area in the dining room and a recommendation is made that this is carried out soon. There is a small “smokers” lounge but as there are currently no residents who smoke at the Home this is only used by staff. The Manager said that room will shortly become a non-smoking lounge and staff will smoke outside the Home. The Home has several, small, secluded patio areas for residents to use and a larger patio area which is a very pleasant area with a pond as well as space for several people to sit at any one time. The Home has a laundry room with washing machines and tumble dryers. The linen and towels go to an external laundry and so staff are only responsible for the residents personal linen and clothes. The Home employs domestic staff and there are procedures in place to reduce the risk of infection. The Home was clean and free from offensive odours on the day of the visit. The residents comment cards all state that the Home is ALWAYS fresh and clean. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive good training and supervision which enables them to carry out their roles effectively. The staff team are enthusiastic about their roles and have a good understanding of the residents needs. EVIDENCE: The residents spoke highly of the staff and the fact that they are kind and work very hard. The residents comment cards all state that the staff listen and act on what they say and that they treat them well. All of the relatives comment cards state that they are satisfied with the care provided at the Home with additional comments made about staff “…keep up the excellent work.” Staff all receive mandatory training provided by Social Services and 65 of staff have completed NVQ Level 2 with some planning to complete Level 3 also. Staff have also undertaken distance learning courses in subjects such as Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 21 Advanced Medication, Provision of Craft and Activities, Infection Control. Other training provided has included Communication, Working with people with Sensory Disabilities. Further communication training is planned. Staff who spoke to the Inspector were enthusiastic about training and the skills and confidence that this provides for them. Norfolk Social Services have been carrying out a staffing review at the Home for over two years and this has caused some difficulties within the team and with morale in general due to the length of time that it has taken to resolve. However, this process is now coming to a conclusion and the staff team can become familiar with new roles and titles. As recruitment was suspended whilst the staffing review was ongoing there have been a lot of agency staff working at the Home. Residents and staff told the Inspector that the agency staff are mostly people who have worked at the Home before and who know the residents. One of the agency staff confirmed that they receive a good induction when they first arrive at the Home and that the staff team are supportive to them. A selection of recruitment files were seen and these contain the necessary records. The Manager follows the social services recruitment procedures and receives support from the personnel department. Staff said that they receive regular formal supervision from either the Manager or one of the assistant managers. Records show that this takes place on a regular basis. Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The Manager is enthusiastic, approachable and manages the Home well The Home has systems in place for continually monitoring the service that the residents receive. Health and safety issues are given a high priority EVIDENCE: The Manager of the Home, Roy Slater, has completed the training expected of managers as well as the training that is provided to the rest of the staff team Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 23 to assist them in supporting the residents. In addition, he has completed further management training at a high level and is currently undergoing another NVQ course. Roy Slaters management approach is positive and inclusive. He provides a good role model for the staff team. He ensures that the residents are involved in decisions affecting their lives and that the staff team focus on meeting the needs of the residents. Visitors, residents and staff all told the Inspector that the Manager is supportive and approachable. The Manager has systems in place for monitoring all aspects of the service provided at the Home and has plans in place for continuous improvements. He has produced a development plan for this year which is based on the results of the quality assurance system and has plans for improving the format of this for next year. The health and safety of residents, staff and visitors is given a high priority. Regular monitoring of aspects of health and safety take place and action is taken to address issues as they arise. A selection of maintenance records were seen and these are up to date. A fire risk assessment has been carried out with an additional one having been recently carried out as one of the fire escapes is currently not in use. On the day of the visit work was being carried out to the front of the Home to provide additional car parking spaces and to improve wheelchair access from one of the fire escapes. The work on the fire escape was a requirement made during the last Inspection. Bishop Herbert House DS0000034848.V321548.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 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 4 25 4 26 4 27 3 28 3 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 4 3 X X 3 X Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 25 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 Refer to Standard YA27 YA30 Good Practice Recommendations It is recommended that the work is carried out in the bathrooms to improve the location of the baths/overhead tracking It is recommended that the work to improve the servery is carried out Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bishop Herbert House DS0000034848.V321548.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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