Inspection on 13/06/08 for Doneraile

This inspection was carried out on 13th June 2008.

CSCI found this care home to be providing an Good service.

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

Doneraile 30/11/06

Doneraile 05/01/06

Doneraile 12/07/05

Doneraile 18/01/05

Doneraile 15/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Doneraile 24 College Road Newton Abbot Devon TQ12 1EQ Lead Inspector Sue Dewis Unannounced Inspection 13 June 2008 09:10 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 Doneraile DS0000003691.V365260.R02.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. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Doneraile Address 24 College Road Newton Abbot Devon TQ12 1EQ 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) 01626 354540 01626 354540 jones.karen4@sky.com Graham Paul Jones Karen Jones Graham Paul Jones Care Home 25 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (25), Physical disability over 65 of places years of age (25) Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: Doneraile is a privately owned care home registered to provide accommodation and care for up to twenty-five older people (OP) who may also have physical disability (PD(E)) and/or dementia (DE(E)). The Registered Service Providers are Mrs Karen and Mr Graham Jones. Doneraile is situated in a quiet, attractive residential area about a mile from Newton Abbot town centre. All but one of the bedrooms are single rooms, and there is a lounge and separate dining room. More than half of the bedrooms have en suite facilities, and there is adequate bathing and communal toilets facilities. A shaft lift as well as a stair lift provide access to the upper floors. There are attractive views from some rooms, including the lounge. There is a large sun terrace and garden. Access from the road to the home is via a fairly steep drive. The current fees for Doneraile range from £301 to £436 per week according to the assessment of individual care needs and the room in which the person is accommodated. Extra costs include hairdressing, chiropody, and other sundry items. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . A copy of the CSCI inspection report on the home is available on request from the office. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced visit took place over 10 hours, one day in the middle of June 2008. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at people’s individual plans of care and, where possible speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We gave questionnaires to the home on the day of inspection for them to distribute to interested parties. At the time of writing the report, responses had been received from 6 staff and one person living at the home. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 3 people living at the home were spoken with individually and 4 in a group setting, as well as one representative. We also spent time observing staff and people living at the home throughout the day. We spoke with 3 staff and the owner. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There were no major requirements or recommendations made at the last visit. However, the owner now writes to people prior to them moving into the home to confirm their needs can be met. The home has obtained 1:1 funding for an individual so that more time can be spent with them to enrich their lives. A hoist has been purchased in case it is needed to meet the needs of individuals who may develop mobility problems. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 7 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. Doneraile DS0000003691.V365260.R02.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 Doneraile DS0000003691.V365260.R02.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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures at the home ensure people have sufficient information on which to base a decision and assessment procedures ensure that their care needs can be met. EVIDENCE: The home has a Statement of Purpose and Service Users’ Guide that is available to people thinking of moving into the home. The document clearly sets out the types of needs that the home can cater for, and although the home has recently purchased a hoist, it will not normally admit anyone who requires the use of a hoist on a day to day basis. There is also a copy of the Service Users’ Guide in all bedrooms. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 10 Three people’s files were looked at, including that of the most recently admitted person, all of which contained pre-admission assessments. The owner told us that they now write to people before their admission, to confirm that the home can meet their needs. We were told by the owner, that people and their representatives are always invited to visit the home before their admission. The most recently admitted person had moved to the home from out of the area and their relatives had visited the home on their behalf. One person confirmed on their survey form that ‘A lady came from the home to visit. Then I came in for a day visit’. The home does not provide intermediate care. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to produce a new website and continually review processes. Doneraile DS0000003691.V365260.R02.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and generally give clear information. However, more detail would ensure consistency of care is maintained. Medicines are stored securely and administered appropriately to ensure the safety of people living at the home. EVIDENCE: Three care plans were looked at. They had been regularly reviewed and showed evidence of some involvement of the person and/or their representatives. Care plans are produced from detailed assessments made following admission and adjusted as people’s needs change. Care plans contain a checklist for risks Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 12 that indicates whether the person is at risk in a particular area. However, there is no further in-depth assessment, showing any control measures in place or that may be needed, when a risk has been identified as medium or high. The care plans generally set out the personal care needs and preferences of the individual and how these are to be met. However, the plans do not give specific instructions to staff on how to meet the daily needs of the individual. Positive comments were received from staff on their survey forms and included ‘All the care staff are very good at supporting and caring for the residents…we are told regularly if any needs of any resident changes’. Although it was clear that staff are aware of people’s needs, clear written information would ensure the consistency of good quality care is maintained. The plans also include a detailed social history and details of hobbies or interests. Daily recordings are usually made by senior staff from reports given to them by care staff. The recordings were generally objective and descriptive. Staff said that they receive a good handover each time they came on duty. However, staff were not generally aware of the detail on people’s care plans, saying that they got all the information they needed at the handover. Good records are maintained showing the involvement of healthcare professionals and it was possible to see where they had been called in for advice. The home currently uses a ‘NOMAD’ system for administration of medicines, but will shortly be changing to a ‘blister pack’ system, as the home feels this will better suit their needs. Only senior staff administer medicines and they have received appropriate training that tested their knowledge. Administration records were well maintained and all medicines were stored securely. There was no sample list of the signatures and initials of staff who administer medicines, so it was not easy to identify who administered any one dose. However, during the visit the owner produced a spreadsheet to address this matter. Some people are able to self administer inhalers that aid their breathing, and eye drops. Staff were seen offering personal care in a discreet manner, they spoke with people in a friendly and respectful way, and always knocked on doors before entering. Staff were also seen spending time comforting and reassuring one person who was a little confused about where they were. All bedrooms, toilets and bathrooms have suitable locks fitted to the doors to ensure people’s privacy is maintained. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 13 The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continually monitor and update care plans. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a suitable range of activities and entertainments to stimulate and occupy people. Links with visitors and the community are good, giving opportunities to support and enrich people’s social life. Meals provide nutritious variety and choice for individuals. EVIDENCE: Three people were spoken with in private and several others were observed and spoken with in the lounge. All appeared happy and relaxed, and good interaction that promoted wellbeing was seen between staff and individuals. Regular activities are on offer, including art classes, entertainments and discussion groups. People commented how much they enjoyed these, and having staff spend time with them individually. One person proudly showed us some of their art work that had been done in one of the classes. Staff told us about the discussion groups and how most people joined in. They are currently using a ‘problem page’ article to stimulate their discussion. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 15 We spoke with one representative who said that they were always made to feel welcome at the home. They said that they felt their relative was very well cared for and that they often praised the staff to them and never had any complaints. We were told by staff and also observed through the visit, that people are regularly offered choices. Choices include what time people get up and go to bed, what they want to eat and where they sit. Staff were heard offering choices of where to sit and what was wanted to eat and drink throughout the visit. People told us that the food was very good. There is a choice for breakfast and tea and an alternative is offered when people do not want the main lunch. We were told that staff know the likes and dislikes of individuals very well and that if they do not like something on the menu an alternative is always available. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to install a new kitchen and to review all existing and new individuals at the home. Doneraile DS0000003691.V365260.R02.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone is confident that any complaints would be dealt with appropriately. People are protected by staff that are able to recognise abuse and know their duty to report poor practice. EVIDENCE: There is a simple complaints procedure contained in the ‘Service Users’ Guide’, and displayed on the notice-board in the hallway. Although people were generally not able to tell us anything about the ‘complaints procedure’, they were able to say who they would talk to if they had any concerns, and felt that if they did they would be dealt with immediately. One person commented on their survey form that if they were unhappy about anything ‘I know I can speak to any of the seniors on shift’. The representative that was spoken with said that they had never had to raise any serious concerns and that any small issue they had raised had been dealt with immediately. One complaint had been received by CSCI, since the last key inspection. This related to the home not having a hoist. The home has always been explicit Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 17 about there not being a hoist at the home as they did not want to admit people who had this level of need. The home has since purchased a hoist, although they do not wish to change their admission criteria, so that it is available if a need arises. Staff said that they have received training in recognising and dealing with abuse. Staff were able to describe a variety of differing kinds of abuse, including shouting at people who may be hard of hearing, or ignoring someone who is asking for help. Staff were aware of the correct procedures for reporting any suspicions to someone within the home and said that they would involve other agencies such as the police if they felt they needed to. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue to update training. Doneraile DS0000003691.V365260.R02.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, 20, 22 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides people with an excellent place in which to live, being clean, safe, comfortable and homely. EVIDENCE: We made a full tour of the communal areas of the home and saw that the home is safe, comfortable and well maintained. There are several communal areas around the home for the use of everyone. The communal areas are homely, with many ornaments and pictures around Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 19 them. They are decorated and furnished in a very comfortable and pleasant manner that meets the needs of individuals. There is level access to the front of the home and seating all around the front terrace. Further seating is available down a rather steep drive to a pleasant lawned, level area. Some bedrooms were looked at, each had personal possessions displayed and reflected the personalities of the occupant. The rooms contained all the items that individuals require in order to have their needs satisfactorily met and had suitable locks fitted to the doors to ensure their privacy. The home has recently acquired a hoist to enable staff to meet the needs of those individuals who may develop mobility difficulties. The laundry is well equipped to deal with the washing from people living there. However, it does not have an impervious floor covering and this may lead to cross infection from soiled laundry. Staff confirmed that they have access to disposable gloves and aprons, and were aware of good basic hygiene procedures. Staff were seen to be wearing disposable gloves and aprons where necessary. The home was clean, tidy and well maintained throughout, and there were no unpleasant odours. We were told that there is a regular programme of maintenance and upgrading. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to redecorate the dining room and install a new kitchen. Doneraile DS0000003691.V365260.R02.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of well trained staff available throughout the day and night are sufficient to meet the needs and numbers of the people currently living at the home. The procedures for the recruitment of staff are robust and offer full protection to people living at the home. EVIDENCE: During the morning of the visit there were 4 care staff on duty, including a senior, plus a cook, 2 cleaners and the owner. During the afternoon there are usually 3 staff on duty, one of which is responsible for activities. At night there is one staff awake and another sleeping in. People and their representatives that were spoken with said that they felt there were always sufficient staff on duty to meet their needs. The care staff said that they did not feel rushed at any time and had time to spend chatting to individuals. People living at the home told us that there were always staff available if they wanted anything, and that they did not have to wait for help. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 21 The owner told us that they had recently had extra funding approved so that an individual could have 1:1 staffing for a few hours each week that will enable them to get out and about more, to enrich their lives. There was a relaxed and unhurried atmosphere around the home, with staff meeting the needs of individuals in a quiet and competent manner. Staff were well aware of the individual care needs of people living at the home and were able to describe these and how they are met on a day to day basis. Staff spoke with enthusiasm about the individuals and their work with them. There were many positive comments received from staff on their survey forms including, ‘plenty of training on offer, always enough staff on duty’, ‘Good team of staff’, ‘Good staffing levels and low staff turnover, good training’ and ‘everyone at Doneraile works as part of a team. It is a friendly place to work’. Staff files were available for inspection and six staff files were looked at. All contained proof of identity, recent photographs of the staff member, and evidence that satisfactory police checks had been obtained. One file for a member of staff that had been employed several years ago contained only one reference. All files for recently employed staff contained two references. One person confirmed on their survey form that all required documentation had been obtained before they started work. Staff told the inspector (certificates were seen) that they had received training in POVA (Protection of Vulnerable Adults), Moving and Handling, Basic Food Hygiene, Infection Control and Fire Precautions. Six staff have obtained NVQ (National Vocational Qualification) level 2 or above and a further three are working towards NVQ level 2 or above. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue with the current ongoing training programme. Doneraile DS0000003691.V365260.R02.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 and 38 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 managed resulting in practices that promote and safeguard the health, safety and welfare of people living and working at the home. EVIDENCE: Mr and Mrs Jones have worked with older people for many years. They are supported by an assistant manager, who has also worked at the home for many years and is working for their NVQ level 4. Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 23 Many positive comments were received from staff on their survey forms, about the support they receive from the owners. These included ‘feel part of a happy and secure team with a very nice boss’, ‘The home is run smoothly’ and ‘Both proprietors are approachable’. The owners have recently purchased a system for ensuring the quality of care provided at the home. This system allows for consultation with people living at the home as well as other interested parties. The owners should send any reports produced from this consultation to the Commission. There was a discussion with Mrs Jones about the importance of providing more detailed information on the AQAA (Annual Quality Assurance Assessment) that is required each year, as this helps us form a judgement about how the quality of care has been managed throughout the year. The AQAA that was submitted this year prior to the visit, contained little information and did not reflect the quality of care provided at the home. The home manages some money on behalf of individuals. The systems for recording transactions are good, helping to ensure their financial interests are safeguarded. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Doneraile complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. Staff confirmed that they receive regular training in fire precautions as well as Health and Safety. So that the risk of burning from hot surfaces is minimised, radiators within the home are covered. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. So that the risk of burning from hot water is minimised temperature controls are fitted to bath taps. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to continue with their ongoing commitment to staff supervision and training. Doneraile DS0000003691.V365260.R02.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 3 X X 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 4 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Doneraile DS0000003691.V365260.R02.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. Refer to Standard Good Practice Recommendations Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Doneraile DS0000003691.V365260.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!