Inspection on 18/07/07 for Downside House

This inspection was carried out on 18th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Downside House 04/12/06

Downside House 30/12/05

Downside House 10/02/05

Downside House 09/07/04

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

CARE HOMES FOR OLDER PEOPLE Downside House 3 - 4 St Boniface Terrace Ventnor Isle Of Wight PO38 1PJ Lead Inspector Annie Kentfield Unannounced Inspection 18th July 2007 11:45 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 DS0000044123.V341550.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. DS0000044123.V341550.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downside House Address 3 - 4 St Boniface Terrace Ventnor Isle Of Wight PO38 1PJ 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) 01983854525 01983 853606 Downside House Limited Mrs Keeley Groundsell Care Home 21 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (1) DS0000044123.V341550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate two named people over the age of 65 years in the MD(E) category One named person under the age of 65 years can be accommodated in the LD category 4th December 2006 Date of last inspection Brief Description of the Service: Downside House is situated on St Boniface Terrace, Ventnor, and has wide sweeping views across the English Channel and St Boniface Down. The home is a combination of two Victorian town houses joined to create one home and has recently been extended to increase the number of bedrooms to 21. Accommodation is split between three floors all serviced by a passenger lift. There is an additional top floor, accessed by stairs, with storage, office space and some staff accommodation. The home is fully accessible and there are steps and a ramp to the front entrance. The amenities of Ventnor are not easily accessed on foot, given the local geography, although public transport is accessible at the end of the road and the manager and staff often provide transport to the town if required. The home is currently registered to provide care and accommodation for up to 21 older people including up to 5 people over 65 years with additional physical disabilities, 3 people over 65 years with mental health problems and 1 person under the age of 65 with a learning disability (this condition is for a named person only). Weekly fees from: £355.11 - £435.05 with additional charges for hairdressing and chiropody. DS0000044123.V341550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is a summary of information received about Downside House since the last inspection of 4th December 2006 and includes information from the registered manager in the Annual Quality Assurance Assessment, and feedback from a visit to the home by one inspector on 18th July 2007 who was in the home between late morning and early evening. During the visit the inspector spoke to some residents, staff and the manager. Comment cards were also received from 12 residents, 2 relatives and 1 Social Services Care Manager. Comments about the home are generally positive and demonstrate a good level of satisfaction with the service provided by Downside House. Some of the comments are included below. What the service does well: What has improved since the last inspection? What they could do better: DS0000044123.V341550.R01.S.doc Version 5.2 Page 6 Improvement is needed to the home’s record keeping, however, the manager stated that a specialist computer programme has been purchased and it is hoped this will provide the manager and staff with an accurate record of all parts of the service and provide prompts to update records. It is anticipated this will be in operation within the next few months and it is planned for staff to have some training in computer skills to enable them to use it effectively. Risk assessments must be more detailed with clear plans of action for care staff where risks are identified. These must be recorded to ensure that residents’ care needs are not overlooked or missed. The home must have clear and written guidance for care staff about dispensing and recording medication that is prescribed to be given ‘as and when needed’ (PRN). This will demonstrate that residents’ are receiving their medicines at the right time and as prescribed. The home must develop a good system of quality assurance that measures how well the service is meeting the needs, choices, and preferences of the residents in the home. The new computer programme has a built in quality audit and the manager plans to use this to develop the home’s systems for quality assurance. 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. DS0000044123.V341550.R01.S.doc Version 5.2 Page 7 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 DS0000044123.V341550.R01.S.doc Version 5.2 Page 8 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): 2 and 3 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The process of moving into the home is well managed and prospective residents only move in after an assessment of their care needs and if the home is confident that those care needs can be met. The manager confirmed that residents or their representatives are given a copy of the terms and conditions of living in the home. However, the home must ensure that this information is up to date and regularly reviewed. The home does not offer intermediate care but does offer temporary or respite care if a room is available. EVIDENCE: The home has an assessment process that gathers all of the relevant information about a prospective resident’s care needs including health and personal care, social care needs and mobility. The home makes contact with DS0000044123.V341550.R01.S.doc Version 5.2 Page 9 community health and social care professionals if a particular health or care need is identified and requires further assessment or additional support. Since the last inspection, the manager has taken action to make sure that all residents or their representatives have a contract or copy of the home’s terms and conditions. In discussion with the manager it was agreed that some parts of this document could contain more detail, such as the room number to be occupied and details of the home’s insurance cover for individual personal belongings. This would ensure that residents and their representatives have clear and accurate information about the service they will be receiving. It is recommended that the terms and conditions be reviewed on a regular basis to make sure that the information is up to date and correct. One relative was not sure if they had received a copy of the terms and conditions and queried why the care fees had risen twice in one year. This was discussed with the manager who agreed to ensure that the information in the home’s terms and conditions clearly sets out and informs residents and their representatives what is included in the care fees and how increases in fees are agreed and when. DS0000044123.V341550.R01.S.doc Version 5.2 Page 10 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. Residents have their health care needs met and receive the medicines that are prescribed for them. Care is provided that respects privacy and dignity. EVIDENCE: Each resident has a care plan that sets out what their care needs are and how staff will meet the care needs. The home employs both male and female care staff and some of the residents told the inspector that their choice of who provides their care is always respected. Comments from other residents confirmed that the care in the home is always given that respects privacy and dignity. The home has improved their care plans and make sure that care is regularly reviewed. The care plan records show that residents have access to a GP, see a Community Nurse, or are able to access other specialist health care services when required. Comments from a care manager said that the home are good at seeking advice or further assessment if the home are concerned about the DS0000044123.V341550.R01.S.doc Version 5.2 Page 11 health or welfare of a resident. A relative commented that the home is good at meeting changing care needs. The manager and staff are aware that they must assess any risks to residents such as the risk of falling, or developing pressure sores. The manager explained what steps they had recently taken to protect a resident who was at serious risk of falling and the consultation they had made with health care professionals to protect the resident. This demonstrated that residents’ care needs are always considered. It would be good practice for the risk assessment and risk management plan to be recorded in the care plan so this can be regularly reviewed and changes in care needs monitored. Good recording would ensure that care needs are not overlooked or missed. Medication for residents is dispensed by staff that have been trained in safe medication procedures. The storage and recording of medicines was satisfactory, although the systems for checking medicines in could be made clearer and for all staff to follow the same procedure. Residents who want to manage their own medicines have a signed agreement with the home and all residents have a lockable wall medicine cabinet in their rooms if it is agreed that they are safe to have their medicines in their room. Some residents need eye drops and the home should seek advice that they are storing the eye drops according to the prescriber’s instructions. Staff confirmed that they have a procedure for safely giving eye drops and it would be good practice for this to be written down, to ensure that residents receive their eye drops safely and as prescribed and this should be regularly reviewed. Some medicines are given by staff ‘as and when needed’. It was evident that staff are following the instructions as prescribed but it would be good practice to have a written procedure so that all staff are clear when PRN medicine should be offered. This would clearly demonstrate that residents are getting the medicine they need at the right time. DS0000044123.V341550.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The manager and staff are committed to respecting residents’ choices and preferences about the daily life in the home. Care is taken to make sure that residents are offered a choice of healthy, attractive and nutritious meals that they like. The home could be more pro-active in offering residents the opportunity to use the garden, or take trips outside of the home. EVIDENCE: All but one of the comment cards from residents said that there were daily activities arranged that they liked doing. One resident said, “I like all the activities, it’s good fun”. Since the last inspection, an activities programme has been printed and is on display in the hallway, this shows that there is an activity every day covering a wide range of interests and for all abilities. A lot of the residents prefer to stay in their room and listen to radio, read or watch TV. It was evident that the manager and staff respect residents’ choices and preferences about daily life. The manager also stated in the Annual Quality Assurance Assessment that the home will help residents to fulfil their religious or spiritual needs as much as they are able. Visitors are welcome in the home and relatives and friends often visit and stay for a meal or refreshments. DS0000044123.V341550.R01.S.doc Version 5.2 Page 13 One resident said they would like to be more involved in the garden. The garden is still being landscaped and made safe following the recent building work and the manager hopes that residents will be able to make use of the garden soon. There is a balcony on the front of the house and this offers residents good views across the Channel and will provide a pleasant seating area. At the moment residents cannot use this as it is awaiting the installation of special non-slip flooring. One relative and one resident expressed concern that residents had not been able to get out into the garden for nearly two years while the building work was in progress and were upset that the delay in providing hand rails in the garden was overlong. Following the inspection visit, the manager confirmed that the garden was now fully accessible for residents and visitors. One resident commented that they did not like the new fencing in the garden. Comments from residents and relatives indicated that the home could do more to offer residents the opportunity to go on trips outside of the home. This was discussed with the manager who explained that the home does not have it’s own transport but could use community transport from time to time. The mini-bus has been out of action but the manager hoped that more trips would be offered to residents in the near future. All comments from residents and relatives confirmed that the meals in the home are good. There are two dining areas on the ground and first floor although residents prefer to use the ground floor sitting/dining room, or have meals in their room. Care staff were seen carrying lunch trays to rooms. It was recommended as good practice for meal plates to be covered as staff carry trays around, this would keep the meals hot for the residents and also be more hygienic. DS0000044123.V341550.R01.S.doc Version 5.2 Page 14 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. Residents in the home are protected from the risk of harm or abuse. The views of the residents are listened to and taken seriously. EVIDENCE: Since the last inspection the home have improved their staff recruitment procedures, this is one way that the home can make sure that residents are protected from the risk of harm or abuse. Discussion with some of the care staff demonstrated that they were aware of their responsibilities to protect vulnerable residents and said they would speak to the manager if they had any concerns. Some of the care staff have recently done some training in ways to safeguard vulnerable residents and the manager is aware of the agreed procedures for reporting any allegations or suspicions of abuse to the Local Authority Social Services Department. Comment cards completed by residents confirmed that mostly they were aware of their right to make a complaint. Some residents said they did not have anything to complain about but would speak to the manager if they needed to. The manager explained that she would like to develop residents meetings as a way of giving residents the opportunity to air their views about the home. One meeting has been held and it is hoped to hold these on a regular basis. Some DS0000044123.V341550.R01.S.doc Version 5.2 Page 15 of the residents are not able to express their views easily and the manager tries to ensure that these residents either have a relative or other representative to act in their best interests, or seek further support from Social Services. One relative wrote that the home had changed the basin and taps in a residents’ bedroom because of difficulty in using the taps. This is an example of good practice where the home has clearly considered the needs of the resident and taken action for the benefit of the resident. DS0000044123.V341550.R01.S.doc Version 5.2 Page 16 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 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Downside House provides residents with a clean, comfortable and wellmaintained environment that is suitable for their needs. The home is pleasant and safe and all residents have their own room with en-suite facilities. EVIDENCE: During the previous inspection a number of areas were highlighted that were in need of repair or remedial work. With one exception all of these have been addressed. In one bedroom, an electrical socket was still loose and the manager confirmed that this would be addressed as a matter of urgency. The home has undergone considerable expansion and building work to increase the number of bedrooms and additional sitting rooms. The work is almost completed and during the visit, work was being done to build a separate shower room for residents. The manager confirmed that all windows on the upper floors have had restrictors fitted to the openings for the safety of the DS0000044123.V341550.R01.S.doc Version 5.2 Page 17 residents. Work is still needed to make the garden and balcony safe for the residents. Replacement of the stair and hallway carpets is planned. The home was clean and tidy and free from unpleasant odours. Comments from residents and relatives confirmed the home as “always very clean”. Some of the bedroom carpets were in need of a good clean where they had become stained and the manager confirmed that this would be addressed. Many of the residents prefer to spend time in their bedrooms and the inspector was able to meet some of the residents in their rooms. These were personalised as residents choose and comfortable, with space for tables and chairs and other furniture belonging to residents. It was noted that the windows in the home are in need of cleaning and had collected a lot of dust from the building work. This was pointed out to the manager who agreed to arrange for them to be cleaned. Staff are aware of good practice in the control of infection and there are hand washing facilities (liquid soap and paper towels) provided and gloves and aprons supplied. The home has a sluice and separate laundry. Some dirty washing was seen left on the floor and the manager said that usually staff know that laundry must be kept in designated baskets as part of good practice in infection control. The new extension has provided residents with a large new sitting/dining room. At the moment this room is rarely used, as residents prefer to use the ground floor sitting room. However, residents do enjoy using this room for special occasions or parties, and it can be used if residents want to talk to visitors in private. DS0000044123.V341550.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The home recognises the importance of staff training in providing residents with a good quality of care. There is evidence of training but there are some gaps and a planned programme of training and development could address this. Staffing rotas take into account the needs and routines of the residents. EVIDENCE: Comments from residents and relatives reported that usually there is enough care staff to meet the needs of the residents. Two residents said that sometimes “staff are very busy and don’t have time to talk”. The manager explained that she tries to take into account residents’ needs and routines when planning the staff rota so that there is more staff on duty during the morning and afternoon. There is two waking staff on duty at night. The member of staff who is responsible for staff training, development, and supervision was not on duty at the time of the inspector’s visit. The manager was able to find some of the training records but not all of them. It is evident from talking to staff and from looking at some of the training certificates that staff are receiving training. There are some gaps and there was not enough information in the home’s Annual Quality Assurance Assessment to demonstrate that the home has a training and development plan in place. This would be good practice and confirm the home’s stated commitment to providing training that gives care staff the skills and confidence to meet all of DS0000044123.V341550.R01.S.doc Version 5.2 Page 19 the needs of the residents in the home. The home need to ensure that staff preparing and serving food have the appropriate food hygiene certificate and that domestic staff have received appropriate training in health and safety and safe working practice. The manager agreed that this would be addressed. At the last inspection, it was found that staff had not been receiving any formal supervision, this has been addressed and records were seen of supervision and annual appraisals. It would be good practice for supervision records to also include how practice in the home is monitored at regular intervals. This would demonstrate the home’s commitment to making sure that staff are working in a way that is safe for the residents and staff at all times. The home does not have a system for regular staff meetings, these happen occasionally. The manager said that she is aware that regular staff meetings would improve staff and manager communication about daily issues in the home and plans to address this. The home has improved their staff recruitment procedures. One new member of staff is awaiting satisfactory employment checks before they start working in the home. The manager is aware that this is a regulatory requirement to make sure that residents are protected from the risk of harm or abuse. The manager confirmed that the home has a new induction programme that includes the nationally agreed Core Induction Standards for all care staff. New staff will follow this induction programme that will lead onto further training and the National Vocational Qualification (NVQ) in care. DS0000044123.V341550.R01.S.doc Version 5.2 Page 20 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. There is lots of evidence to show that the home is run in the best interests of the residents and that residents’ care needs are always considered and health care needs are being met. This could be more clearly demonstrated if the home develops a good system of quality assurance that measures at regular intervals how well the service is meetings residents’ needs and choices. A good quality assurance system should also measure how well the service is meeting the National Minimum Care Standards and the legal requirements of the Care Homes Regulations 2001. EVIDENCE: Issues of health and safety and making the home safe for the residents are taken seriously and there are systems and procedures and checks in place to meet health and safety legal requirements. The home employs outside DS0000044123.V341550.R01.S.doc Version 5.2 Page 21 consultants to undertake risk assessments and maintain checks on the fire alarm and fire safety equipment. It was noted that all doors in the home have self-closing devices so that if residents prefer to keep their bedroom doors open, the doors will automatically close when the fire alarm is activated. The home was recently inspected by the Environmental Health Department and given a four star rating for food safety and hygiene. The manager confirmed during the inspection that a loose electrical wall socket in a residents’ bedroom would be repaired immediately. The registered manager is experienced and qualified and is committed to providing a service for residents that is safe, welcoming and comfortable. This was confirmed by comments from residents, relatives, staff and health and social care professionals who visit the home. The policy of the home is for residents to manage their own financial affairs or with the help of someone independent of the home. The manager has agreed to one exception and these financial records were looked at and found to be up to date and correct. The manager is aware that the home needs to develop a good quality assurance system. This is happening in parts with monthly care plan reviews, the setting up of residents’ meetings, staff supervision and health and safety checks. These systems could be developed to provide a clear and accessible way of demonstrating how well the service is doing, where changes have been made and demonstrate that the home is seeking regular feedback from residents, staff, relatives and others who visit the home. The manager is confident that the new computer programme that the home has purchased will assist the home to develop a good system of customer satisfaction and quality assurance. The manager is also aware that the home needs to have systems in place to check how well the service is meeting the National Minimum Care Standards and meeting the home’s legal requirements to comply with the Care Homes Regulations 2001. The Annual Quality Assurance Assessment that registered homes are required to complete and return every year was not received before the inspection visit. A copy was obtained during the visit. The manager had completed most of the document but more information should have been provided, along with more detailed evidence of those areas where the service plans to improve. DS0000044123.V341550.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 DS0000044123.V341550.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 24 (1) (2) (3) Timescale for action The home must develop effective 30/09/07 systems for reviewing and measuring the quality of the service provided by the home. The systems must include regular consultation with residents, their representatives, and others involved in the service. Requirement 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 DS0000044123.V341550.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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