Inspection on 08/12/06 for Fraryhurst

This inspection was carried out on 8th December 2006.

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

Fraryhurst 30/05/06

Fraryhurst 17/01/06

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

CARE HOMES FOR OLDER PEOPLE Fraryhurst Prinsted Lane Prinsted Emsworth Hampshire PO10 8HR Lead Inspector Mrs A Peace Key Unannounced Inspection 8th December 2006 08:00 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 Fraryhurst DS0000065077.V315149.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. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fraryhurst Address Prinsted Lane Prinsted Emsworth Hampshire PO10 8HR 01243 372024 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) Springfield Health Services Limited Manager post vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 27 male and/or female service users in the category Old Age, not falling within any other category, may be admitted/accommodated. No persons under the age of 65 years may be admitted. Date of last inspection 30th May 2006 Brief Description of the Service: Fraryhurst is a care home with nursing registered to provide services for up to twenty-seven residents in the category OP, Old Age not falling into any other category. The property is a large detached extended building sitting in it’s own grounds in the village of Southbourne. The home is situated in a residential area close to local shops. Bus and train services are close by. Accommodation is provided on ground and first floor level; the first floor is accessed via a vertical lift. The majority of rooms are for single occupancy however there are a number of double rooms. The weekly fees range from £580 to £650. Extras include hairdressing, chiropody and newspapers. Fraryhurst is owned by Springfield Healthcare Services Limited. The responsible individual on behalf of the company is Mr Matthew Bennett. The registered managers post is vacant, but The Commission has received an application to register the recently appointed manager. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Ann Peace and Mrs Annie Taggart Regulatory Inspectors carried out this unannounced fieldwork inspection on 8h December 2006. It is called a key inspection and will determine the frequency of visits/inspections hereafter. Prior to the inspection, records held on file and information received from the home since the last inspection were reviewed and comments from residents and relatives taken into account. During this inspection the Inspectors toured the building, visited the majority of rooms, and joined the residents in the lounge and dining areas. The Inspectors talked to one of the Providers Mr Bennett, the manager Mrs Davie, members of staff, residents and visitors. The Inspectors examined records about care being provided to residents; as well as records of any accidents, or concerns or complaints, to make sure that the residents at Fraryhurst are being taken care of. Due to the frailty of a number of the residents it was not possible to gain their opinion, however from their demeanour and interactions with the staff team, the inspectors concluded that they were relaxed and content in their environment. The Inspectors were able to speak to some residents and relatives who were visiting the home and take into account comments. Some comments were: “Everyone is very kind and the food is good. If unhappy I would talk to one of the nurses or matron”. Another resident said, “We are lucky to be so well looked after by nice staff”. A recorded comment on a survey said that the relatives “were very happy with the way their mother is looked after”. Other residents and visitors commented, “ Staff are always happy and welcoming”. “Very happy, I never want to leave here”. “New owners have improved everything and the new manager is good”. From the inspection three requirements were made, however the Inspectors were made aware that action was already being planned to deal with the issues identified. The conclusion of the inspectors was that residents are well looked after by a caring and committed and well-trained staff team. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 6 also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service users guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. Unfortunately because of the frailty of the residents in the home only one resident spoken to could tell the inspectors that they had received information to help them make a decision about the home, records confirmed that all residents had a contract with terms and conditions. Two relatives who act on behalf of residents were spoken to and confirmed that information was given to them and they were clear about the contracts and costs. The complaint procedure is attached to the service user guide and they knew who to complain to. What the service does well: What has improved since the last inspection? The new manager Mrs Davie is working hard to ensure the home meets the National Minimum Standards. The home is continuing to be refurbished to a very good standard by the new owners. New furniture has been purchased and the home nicely decorated which adds to the pleasant atmosphere. Staff training and training records have improved so that it is clearer to monitor which staff have completed the training required. Staff now have formal supervision. An internal quality assurance system has been commenced and some remedial action taken as a result of the findings. Bedroom doors have been fitted with automatic closures that mean residents can have their doors open but that the doors would close in the event of a fire. Fraryhurst DS0000065077.V315149.R01.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. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Prospective residents and their families can be sure that they will receive information about the home, their needs will be assessed and contracts of terms and conditions of residency agreed. Intermediate care is not provided at Fraryhurst. EVIDENCE: The Statement of Purpose and Service User Guide have recently been reviewed and updated to reflect the environmental and management changes in the home. Two family members confirmed that they had received information when making enquiries about the home and one resident said that her daughter had acted on her behalf and had read the information before making a choice. For all residents in the home there were very comprehensive pre-admission assessments in place. For one person who had moved from a long distance, this had not been possible but clear documentation of their needs had been provided from their present accommodation. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 10 Both residents and family members said they were able to visit the home before making a choice about living there and one person said they could have stayed for a meal if they wished. Three residents who were asked about contracts of terms and conditions of residency were not sure if they had one or not but relatives confirmed that contracts had been issued by the home and evidence was seen on resident’s personal files. Welcome information about the home was in all rooms. The comprehensive organisational chart for the home is in the service user guide and points readers to who is responsible for what in the home and the company. Intermediate care is not provided at Fraryhurst. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Resident’s needs are reflected in the assessments and care plans and staff are trained to look after elderly people. The medication procedure is safe and staff are trained to administer medication. Residents are encouraged with assistance to make choices about their lives and the staff protect their privacy and dignity. EVIDENCE: For each person living in the home there is a comprehensive plan of care in place, which has been devised with information from the assessments. The care plans contain detailed information to guide the staff team to the need and wishes of each person and also contain risk assessments, nutritional needs and nursing guidelines. Daily records are maintained to ensure all staff are up to date with the changing needs of the residents. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 12 Where bed-rails are in use, an agreement and risk assessment is in place, which has been agreed and signed by the G.P. and other professionals involved with the person’s care. The staff members on duty were seen to treat people in a respectful and caring manner, to offer choice and ensure privacy and dignity. The records were very good, well maintained and had been updated. Pressure relieving mattresses were in place where a risk had been identified Mrs Davie was advised to remind staff to check the inflation on the airflow mattresses to ensure they are set at the correct inflation for the weight of the residents. One resident said, “ I have no complaints, the staff are good and they are very kind. I can have a cooked breakfast and I am given a choice of what I want to do. If I had a complaint I would go to the senior nurse. Another resident said, “We are lucky to be so well looked after by nice staff”. One recorded comment on a survey said that the relatives were very happy with the way their mother is looked after and that staff always happy and welcoming”. Residents said call bells were always answered promptly Part of the lunchtime medication round being undertaken was observed and was seen to be safe with proper procedures being taken. Residents who are capable of self-medicating have assessments. The inspectors had a discussion with Mrs Davie about who should authorise what is recorded on the resident’s notes regarding dying. Mrs Davie is advised to take further advice from a professional or legal body. Fraryhurst DS0000065077.V315149.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service There are activities available to offer interest and stimulation, residents have access to family, friends and the local community and a variety of fresh, home cooked meals are supplied. EVIDENCE: There are a variety of activities available to ensure that stimulation and the interests of residents are provided for. One person attends a day-care facility on a daily basis three times a week and activities recorded include gentle exercise, music sessions, art, quiz’s reflexology and outings into the community. The home was attractively decorated for Christmas and a list of entertainment such as a pantomime, carol singers a party for families and friends and a lunch at the local community centre were on offer. Most people said they enjoyed the activities offered but some people said they preferred not to join in and confirmed that their choice was respected. The people living in the home said that the staff team were kind and caring and also said that they were treated kindly and with respect. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 14 Three visitors, who were present during the visit, made very positive comments about the improvement to the home and said that they were made welcome at any time. Menus show that a variety of fresh, home cooked meals are available and residents confirmed that they were offered a choice. Lunch, which was the main meal of the day was battered cod with home made chips and peas or ham, egg and chips followed by marmalade cake and custard. Some residents said that they had also enjoyed a cooked breakfast. One inspector sampled the meal and confirmed it was well balanced and tasty. Nutritional needs and likes and dislikes are recorded and the cook confirmed that special diets and nutritional supplements are available if required. Fraryhurst DS0000065077.V315149.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families can be confident that their complaints will be recorded and acted upon and the home’s working practices and staff training are designed to protect residents from risk of abuse. EVIDENCE: The home has a complaints procedure in place, a copy of which is detailed in the Service User Guide. There is also a copy posted on the notice board so as to be available to visitors to the home. Residents said that they were not familiar with the formal complaints procedure but felt confident, that if they did have any concerns, these would be taken seriously and dealt with by the manager. Family members and a visitor confirmed they were aware of the procedure and also felt confident that any issues would be suitably addressed. Three formal complaints have been recorded in the last year and the manager of the home has dealt with these in an appropriate and timely manner. All of the staff team have attended training in the protection of vulnerable adults from abuse and those spoke to during the visit showed an awareness of their responsibility should they suspect an abuse of any kind had taken place. One person said, “ I would report it straight away to the manager and if I suspected someone senior was at fault I would go right to the top to the owners”. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 16 Fraryhurst DS0000065077.V315149.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Residents live in a comfortable, homely, clean and comfortable environment and there are sufficient facilities and equipment to meet their needs, refurbishment work is still being undertaken at the home. EVIDENCE: When the Inspectors arrived at 8am. The home was warm, clean well lit and homely. It had been tastefully decorated for Christmas. The home has been vastly improved with new decoration and lighting, some areas had been opened out to give a more spacious look. Inspectors toured all areas and bedrooms were clean, comfortable and personalised with resident’s belongings. People were happy with their bedrooms and had their own belongings around them. Some had own furniture and own phone fitted. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 18 Communal areas were clean, homely nicely decorated and new tasteful appropriate furniture has been purchased. One carpet did have what looked to have oil stains in one area the cleaner said she had tried everything to remove but to no avail. The provider did tell the inspectors why the carpet had not been replaced but was advised to try to sort this out There is a small corridor which residents do not have access to which is used for storage. The courtyard area in the middle of the home was decorated with pots and containers with flowers and bushes and there is a nice garden to the rear of the home. Records relating to the testing of water temperatures and testing of emergency lighting were not as clear as they should have been and Mrs Davie said she would ensure that these were improved. The laundry and the kitchen are in need of refurbishment, however inspectors were told that this work was due to be started the week following the inspection. The majority of rooms had lockable drawers or a lockable box. Mrs Davie was reminded that the standard states “that doors to residents private accommodation are fitted with locks suited to residents capabilities and accessible to staff in emergencies”. Mrs Davie was advised to ask residents if they would like one and if so they should have one fitted. Not all records were kept at the home; the Schedules in The Care Home Regulations inform providers which records should be maintained at the home. However the records required were brought to the inspectors during the inspection. Mrs Davie said that in future those identified would now be kept in home. Fraryhurst DS0000065077.V315149.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service There are sufficient staff employed to ensure that resident’s needs are met. The home’s recruitment policy is robust and does protect residents. Staff training is provided and staff are competent to do their jobs, all staff have instruction in adult protection procedures. EVIDENCE: Duty rotas showed that an adequate number and skill mix of staff is employed over a 24-hour period for 20 residents. Comments verbally and in surveys suggested that residents are getting the support they needed. All residents spoken with very complimentary about staff, residents who could not offer an opinion were noted to be at ease with staff. Staff were observed going about their work and they seemed happy and were caring and patient towards residents. Those spoken to say they enjoyed working at the home. Seven staff were spoken to and all said they were well supported and that they were able to look after residents how they would wish. They confirmed training and all knew the adult protection procedure. Staff said they are encouraged to undertake other training for instance NVQ and manager said over 57 of staff have now completed NVQ 2. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 20 The home ensures the staff have specific training to meet needs of the residents accommodated and these training records were seen. Staff recruitment records were seen and the majority were in order. Mrs Davie was reminded that Criminal Record Bureau Checks (CRB) are not transferable. As Mrs Davie has only been manager of the home since September she was advised to audit the staff records to ensure that they comply with the Schedules in the Care Home Regulations. Fraryhurst DS0000065077.V315149.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Fraryhurst nursing home provides an open environment for residents to live in. Mrs D Davie is the Manager and under her leadership the home runs well and the staff are supported to carry out their work. It is apparent that the home is run in the best interests of residents. Record of monthly visits carried out by the Responsible Individual were available to evidence that the providers are monitoring the home. EVIDENCE: Mrs Davie was not on duty on the day of the inspection but came in to meet inspectors, she and the staff were very helpful throughout the day. The inspectors concluded that residents and staff benefit from ethos, leadership and management of the home. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 22 Mrs Davie has applied to the Commission to become the registered manager for the home; she has completed her Registered Managers Award and has a Level 4 National Vocational Qualification in Care. Residents spoken to knew the management structure at the home and one relative said that Mrs Davie has an open door policy so is readily available, staff and relatives also confirmed this. Residents told inspectors that Mrs Davie has a high profile in the home, which they like. Staff confirmed that they are supervised regularly and these sessions are recorded. A quality assurance survey was recently undertaken with the relatives and residents, notes were taken and remedial action taken as a result in a few cases where necessary, in others, residents and relatives said they were satisfied. Mrs Davie is also undertaking an internal Quality Assurance on the practices within the home a template for this was seen. The company also plan to bring an external auditor in to monitor the home in the near future. Two family members confirmed that they had received information when making enquiries about the home and one resident said that her daughter had acted on her behalf and had read the information before making a choice. Appropriate policies and procedures are available and Insurance cover is available in the home and was displayed on the wall in the hall. Service users are encouraged to manage their own affairs with the help of relatives or advocates if necessary. From reviewing records, speaking to resident’s relatives and staff the inspector concluded that in the majority of cases service users rights and best interests were safeguarded by the home’s record keeping. However the maintenance records should be organised to ensure dates of testing safety systems are clear and the manager was reminded that criminal record bureau records are not transferable between different organisations and staff files should be audited to ensure they comply with Schedule 2 of the Care Home Regulations 2001. The environment in the kitchen and the laundry were not up to standard but the Inspectors were told by Mrs Davie that work in the kitchen and the laundry was due to be started the week following the inspection. A phone call confirming this was later received. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 23 Staff training records are available to indicate that staff have received training in appropriate health and safety procedures and that further regular training is been planned throughout the year. Induction training records were seen for new staff. Evidence was available that Regulation 26 visits are being carried out and reports written on the conduct of the care home which show the Providers are monitoring the home. The manager does not act as an appointee for any of the people living in the home and families or legal representatives manage resident’s financial affairs. For some people small amounts of cash are held in the home’s safe for day-today expenditure and where this happens receipts are kept and transactions documented. A sample of resident’s monies were checked and found to be correct. Regular management and staff meetings are held. The comprehensive organisational chart for the home is in the service user guide and points readers to who is responsible for what in the home and the company. Fraryhurst DS0000065077.V315149.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 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 2 3 3 3 3 2 2 2 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 3 2 X 3 3 2 2 Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The floors and walls in the laundry and kitchen areas to be refurbished to ensure they can be cleaned effectively. CSCI to be informed when the planned work will be completed. Maintenance records should be maintained so that records of testing are clear. CSCI to be informed of action taken by Timescale for action 31/01/07 2. OP37 13 4 (c ) 31/01/07 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 OP29 OP24 Good Practice Recommendations Recruitment files to be audited to ensure they comply with legislation. Mrs Davie was advised to ask residents if they would like a DS0000065077.V315149.R01.S.doc Version 5.2 Page 26 Fraryhurst lock on their door and if so, they should have a suitable one fitted. Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 Fraryhurst DS0000065077.V315149.R01.S.doc Version 5.2 Page 28 - 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. 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