Inspection on 06/03/08 for Firgrove House

This inspection was carried out on 6th March 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

Firgrove House 05/01/07

Firgrove House 19/12/05

Firgrove House 27/06/05

Firgrove House 06/01/05

Firgrove House 11/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Firgrove House Station Road Yate South Glos BS37 4AH Lead Inspector Andrew Pollard Unannounced Inspection 6th March 2008 10:00 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 Firgrove House DS0000003323.V360012.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. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firgrove House Address Station Road Yate South Glos BS37 4AH 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) 01454 310636 01454 310636 Mr Kenneth Roberts Mrs Jennifer Roberts Lorraine Sarah Beer Care Home 20 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (18) of places Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2007 Brief Description of the Service: Firgrove House is situated in Station Road at Yate. It is within walking distance of local amenities including shops, post office and public house. The home is made up of the Main House and smaller Coach House, and provides care for up to twenty older people including two with Dementia. The Main House is on three floors and offers places for fourteen older people while the Coach House has room for six. The house is decorated in a homely way with comfortable furnishings. In the Main House there is a lounge with adjacent conservatory and separate dining room. The Coach House has a lounge/dining room. All of the bedrooms are for single occupancy other than two with the potential to be double rooms. There are ample bathrooms and WCs, the Coach House having some rooms with en-suite and the Main House with 3 ensuite facilities. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection focused on outcomes for the individual’s. This is evidenced through inspecting key standards and surveying and case tracking approach that included talking with individuals who live at the home and any visitors and staff. A high number of surveys were received prior to the inspection, 12 were from residents, and 3 were from relatives of those who live at the home, 3 from general practitioners who visit individuals at the home. All comments were positive no complaints were made Comments made were reviewed during the inspection visit and comments, maintaining individuals confidentiality were shared with the registered manager and registered provider and these have been incorporated within this inspection report. A tour of the premises was made. Various records were sampled these included care plans and maintenance records. Inspection feedback was given and the visit was concluded. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. We came to this quality rating at the last key inspection. What the service does well: Residents, relatives, visitors and health professionals were consulted on the services and evidenced positive results for residents. The residents/relatives consider the quality of food to be good. The activities provide a regular, varied and stimulating programme to suit individual preferences. The impression of the home is that it is a friendly comfortable and safe place to live and the staff respectful and caring. The environment is of a good standard and clean. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Firgrove House DS0000003323.V360012.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 Firgrove House DS0000003323.V360012.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): 1, 3, 4. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is clear and a thorough assessment of prospective residents needs is carried out. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 9 EVIDENCE: A statement of purpose and a home guide is made available at the initial stage of enquiry to prospective residents/families. This provides useful information of the services available and includes the terms and conditions. The statement of purpose is being expanded to fully reflect the range of needs and admission criteria that the home can accommodate. All the residents’ surveys returned stated that they had received adequate information to help them decide if Firgrove was somewhere they would like to live. They also confirmed that they had received a contract on admission to the home. The manager fully demonstrated a clear understanding of the admission process for individuals to the home. Ms Beer told the inspector about the admission process for recently admitted residents to the home. Visits to the home are encouraged either for the day or perhaps for lunch dependent on their wishes. For those residents who are funded by the local authority the inspector saw that the home had in place a comprehensive care management assessment in order to make a decision on whether the home and the skills of the staff team are able to meet the individual’s needs. A review takes place after one month’s placement at the home, at this meeting the residents and their representatives are present and make their views known, these are recorded and appropriate action is taken. Staff spoken with said that all of those living at the home are treated as individuals, all with different needs and likes. A number of resident’s relatives wrote positively in survey forms about the staff and their helpful attitude when assisting residents with their needs. There are residents living at the home with specialist cognitive impairments and healthcare needs; these are being met by staff at the home and other professionals. The support from these services are clearly recorded, they’re recommended actions are shared with the staff team in order that continuity of care is maintained. Firgrove House DS0000003323.V360012.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): 7,8,9,10 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Care plans detail residents care needs and are clearly written and give clear directions to staff. The staff provide appropriate personal care to maintain residents’ health and well being and dignity. Proper arrangements are in place for residents to access primary healthcare services. The staff properly store, administer and record medication on behalf of residents. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 11 EVIDENCE: Several individuals care records were reviewed at this inspection and it was found that the plans in place had been generated from a manager and care management assessment. Information contained within care records included: an individual’s profile containing information about the reason for admission, health care support services involved, next of kin, family contact details and medical history. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling, the correct use of bed rails and how to reduce the risk of falls. Each resident also had records of health professionals visiting, daily records of individuals routines and a care plan. A more person centred/holistic approach is recommended in the management of care and documentation which the manager supports and will take forward. It is intended that each resident has a brief biography written and a person centred assessments where their wishes, likes and dislikes are put at the centre of the care provided. It is intended that people’s health and social needs including, psychological, emotional, and cultural needs will be detailed to demonstrates that the home takes a holistic approach to the provision of care. A care review meeting takes place regularly for each resident where possible with the involvement of the resident, family members and key worker. The reviews allow opportunity to discuss and evaluate residents’ care plans and any issues or concerns they may have. End of life Care Plans are becoming established and be in more depth whereby residents are encouraged to think ahead about the care they would like to receive if their health deteriorates. Each resident was referred to a GP on admission to the home and an initial first visit was then set up. Although the GP does not conduct weekly visits to the home, good working relationships with the GP’s have been formed and the GP’s visit on request. General Practitioner (GP) and Para-medical visits and their outcomes were well documented. Returned comment cards that indicated their satisfaction with the home with comments such as, ”The staff have always looked after my patients well” and “I think this is a good home where the residents are well cared for, all the staff are extremely caring towards the residents”. Residents said that ‘they always get the doctor to me if I am not well’. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 12 Policies and procedures for receiving, storing, administering and disposing of medications are in place and meet with current legislation. The receipt, administration, disposal and controlled drug records were up to date and in order. The pharmacist who supplies the medication also receives unwanted medication for disposal. None of the current residents is able to self medicate at present but appropriate policies and risk assessments are in place if the need arises. Staff are properly trained in administration of medicines. There was appropriate storage and recording for controlled medications. The home has a pharmaceutical storage fridge the temperature of this is checked daily. Throughout the inspection all of the staff on duty were observed helping residents with their needs in a polite way. Staff knocked on resident’s bedroom doors and spoke to residents respectfully. Comments from residents were very complimentary of the staff and the care they provided. All the residents spoken with said, “They were satisfied with the overall level of care being provided”. They spoke highly of the staff saying they were, “Friendly and caring”. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. A range of social and recreational activities is arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives and are able to maintain close contact with families and friends. The food is of a high standard and provides a balanced diet for residents. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home has an open policy related to resident’s friends or family visiting the Home. The staff are to undertake developing a more detailed residents biography and social profile which will provide interesting facts and life history information about each resident. And is beneficial in enhancing person centred care. Regular entertainment is provided in the afternoons including singers, guest games and passive exercises and beauty therapy. Special events are arranged throughout the year and residents and visitors are sent invitations to attend. Special events are arranged such as visiting theatre groups, summer fetes and themed events. Residents enjoy a craft group. The residents have free use of a community mini bus for trips and outings. A programme of events is set out and the manager issues a quarterly new letter to residents and relative to keep people up to date about all aspects of life and news in the home. Individuals have records of their social and activity choices and record of participation in their files. An Easter fete and garden party are being organised. There are photos on displays of social and special events on show in the home. There are annual fund raising events organised and all proceeds go to the residents’ funds. The grounds staff have done a good job in the gardens and the flower boarders were pretty and well stocked and the lawns laid. The local parish priest conducts services and communion on a regular basis and makes pastoral visits on request. One resident attends church. At present there are no residents from other faith backgrounds. The rotational menu offers traditional food and choice is available at each meal. The menus are reviewed in response to residents views expressed in meetings and surveys. Special menus are provided for birthdays and other occasions. Fresh fruit and vegetables are available and bowls of fruit are on offer in the home. Lunch was served in the dining areas, the tables were attractively laid and the meals nicely served. Residents can eat in their rooms if they choose to. Surveys confirmed that residents were satisfied with the meals provided people indicated they always liked the meals. Comments included,” The home is blessed with good cook” and “The meals are excellent”. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to protect residents investigate complaints or manage allegations of abuse. There are good arrangements in place for staff training and awareness of Protection Of Vulnerable Adults matters. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 16 EVIDENCE: A copy of the complaints procedure is on display and is part of the information provided to people on admission. Resident and relative surveys indicated people knew how to complain. The complaints policy and procedure contains all the required information. There have been no formal complaints received since the last inspection. One minor issue was properly dealt with and resolved to the satisfaction of the complainant. All residents who completed a survey indicated that they knew who to talk if they were not happy and how to make a complaint. Comments included, “I’ve never had cause to complain “. Residents also said they would speak to their key workers or the manager to discuss any concerns they may have. The home has written procedures for adult protection, whistle blowing and the management of challenging behaviour. The Local Authority ‘No Secrets’ document was available. The manager actively promotes staff training and education in adult protection issues on induction and by regular updates. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of safeguarding adults from abuse. The General Social Care Council code of practice has been distributed to the care staff. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 17 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): 19,20,21,25,26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The standard of furnishing and décor is good to the benefit of residents. The home provides a safe and well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. The standard of cleanliness is high. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 18 EVIDENCE: Firgrove is a large detached building, with a coach House accommodating six residents set within the grounds of the main house. The whole exterior on the home has been painted, the car park has been extended and re shingled, the rear garden has been re planted. The Home is situated in Yate and is close to private houses and a short distance from the local village of Chipping Sodbury and nearby to bus stops. This helps ensure residents can be a part of the community. The home is a three-storey building, and residents have access to all areas there is a stair lift servicing the upper floor. It is furnished to a high standard. There are adaptations in place throughout the Home and specialist equipment including mobility aid, sensory aids, and specially adapted baths. Bathrooms include specially adapted baths to assist residents who may have reduced mobility. Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. There are two dining areas a conservatory and comfortable lounge areas. The Home looked clean and tidy in all areas. Residents were observed sitting in the lounges, the conservatory and going into their rooms, looking relaxed and comfortable in their environment. Residents’ surveys confirmed that the home is and clean and one resident stated, “ they are always cleaning” and another “the decoration is nice”. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and records are in good order. The home is well staffed with appropriately trained and experienced staff for the number of residents. Good progress is being made training care staff for the benefit of residents. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 20 EVIDENCE: Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear from surveys and discussions that staff have developed relationships with individuals and support people appropriately. Many favourable comments were received about staff at the home from both residents and visitors to the home; comments included: ‘Staff are very kind’, ‘all of the staff are caring and cheerful’. There were sufficient numbers of staff on duty to meet the needs of the residents. The staff team is very stable with high morale. There have been no staff recruited since the last inspection. No agency staff are required. The last inspection found the recruitment procedure was based on equal opportunities, was robust and proper procedures and records were kept. The deputy manager assists with administrative duties. The manager has supernumerary hours each week to deal with administerial and management duties. An admin assisstant helps Mrs Roberts with office duties relating to both the homes. The induction programme is comprehensive and based on the Skills for Care standards. After completion of the commence foundation training care staff enrol on the National Vocational Qualification (NVQ) programme level 2/3 Three of the staff are NVQ assessors. A training matrix has been developed to show that all mandatory training including fire safety, food hygiene, first aid, load handling, medication and adult protection were undertaken and course dates that have been organised for staff such as dementia awareness and infection control. All staff have an annual appraisal, which identifies learning needs, and the manager provides regular one to one supervision. Residents’ surveys agreed that staff were always available when they needed them and always listened and acted upon what the residents had to say. Staff that were observed to be supporting and caring for the residents, they were patient and encouraged residents to make choices. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home is well managed and run taking into account the views and wishes of the relatives and residents and as they are able. There are good arrangements in place to maintain and service the equipment and facilities in the home. The Home protects the health and safety of residents and staff. The policy for protection of residents valuable needs expanding. The staff supervision and appraisal arrangements are good. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 22 EVIDENCE: Lorraine Beer is the registered manager. Mrs Beer has 17 years experience in the caring profession, and achieved the NVQ level 2 and 3 in care during her career. Her continual professional development includes achievement in the following subjects: NVQ Level 4 and Registered Managers Award, NVQ Assessor Award, Manual Handling Trainer and Appointed First Aider Mrs Beer was able to demonstrate a good understanding of the requirements of the registered manager post and staff found her supportive and flexible. Continuing support and guidance from Mrs Roberts one of the providers has encouraged Mrs Beer to develop her management skills. Mrs Beer and Mrs Roberts have high visibility in the home and give strong leadership and direction. The home has a Health and Safety policy and audits and relevant training takes place. Generic and individual risk assessments are in place and kept under review. Manual handling risk assessments are completed for all residents; a review of these documents at the home found that these had been fully completed and identified areas of potential risk and how individuals would be supported in line with their assessed needs. Health and safety records showed that relevant inspections and maintenance has been carried out at the required intervals for the fire alarms and equipment, gas and electrical services, hoists and stair lift. The kitchens have been awarded a 5 star rating by the Local Authority. The fire logbook records showed fire alarm tests are being carried out. There are also fire drills carried out on a regular basis to help protect the health and safety of residents and staff. Additional fire door closers have been installed in the home. The home has comprehensive policies and procedures in place in order to support and provide a service for older people who have a varied range of needs. The manager reviews all of the policy documents including; policy on the code of conduct for staff, confidentiality, policy on the management ethos of the home and equal opportunities. All documents had been signed by the manager and are freely available for staff. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 23 The manager has developed a future development/business plan for Firgrove, which includes information about staff training, supervision, recording and meeting needs of residents. This document links in well with the quality assurance audit that the home have implemented this seeks and records the wishes of residents and relatives with written responses in place recording how issues raised had been dealt with. Resident surveys are carried out on a regular basis the most recent of which showed 99 of residents rating services between good and excellent. Regular residents and staff meeting are held at the home and provide an opportunity for open discussion, to raise concerns, ideas and suggestions and to plan for the future. The policy relating to the management of money/valuables needs to be expanded and contain much more detail and a single location and ledger identified for all valuables and lost property held in safekeeping. Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 3 X X X 3 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 2 3 X 3 Firgrove House DS0000003323.V360012.R01.S.doc Version 5.2 Page 25 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 OP7 OP35 Good Practice Recommendations Firgrove House DS0000003323.V360012.R01.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. 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