Inspection on 14/11/07 for Frensham House

This inspection was carried out on 14th November 2007.

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

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

Other inspections for this house

Frensham House 09/08/06

Frensham House 15/11/05

Frensham House 26/10/04

Frensham House 25/05/04

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

CARE HOMES FOR OLDER PEOPLE Frensham House 125 New Road Brixham Devon TQ5 8BY Lead Inspector Stella Lindsay Key Inspection (unannounced) 14th November 2007 9:30 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 Frensham House DS0000018354.V350797.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. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frensham House Address 125 New Road Brixham Devon TQ5 8BY 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) 01803 857476 01803 858976 frensham@stone-haven.co.uk WWW.stone-haven.co.uk Stonehaven (Healthcare) Ltd Nicholas Paul Ross Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14), of places Physical disability over 65 years of age (14) Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: Frensham House provides care for up to fourteen persons over the age of 65. The service is designed for residents who have some form of dementia or other mental health problem. It is a detached house on the main road leading to the harbour and town centre of Brixham. Residents are accommodated on two floors, and with access via a stair-lift. There are eight single and three double bedrooms. Four of the single bedrooms are on the ground floor. None of the bedrooms have an en suite toilet. There are five toilets, and two baths, one of which is fitted with a hoist. The home has a dining room, a comfortable lounge beside the kitchen, and a small sun lounge at the front of the building. A sheltered sunny garden is at the front of the home, with chairs and tables provided for residents. To the rear of the building there are three off road parking spaces, and there is ramped access to the front door from here. Fees range from £325 - £545 per week. The most recent inspection report will be made available on request, and is included in the information pack given to people who are seeking information about the home. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a Wednesday in November 2007. It involved a tour of the premises, observation of life in the home, discussion with the Registered Manager, Nick Ross, and with two visiting relatives and four staff on duty. Care records, staff files, health and safety records, and the medication system were examined. The Manager had provided full information about the running of the home prior to this inspection, and surveys had been returned to the Commission for Social Care Inspection by staff, relatives, and professional visitors to the home. What the service does well: What has improved since the last inspection? There has been a major project to build a ramp round the side of the house, to enable people with mobility problems to get out of the house. This is a great improvement for the home. Also, a new stair-lift has been installed, which fully reaches the first floor. Together, these improvements mean that residents are able to have free access, with assistance. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 6 The garden has been developed to provide further interest and activities for residents. Bird tables and feeders have been provided, and a vegetable plot has been developed. Sit-in scales have been provided, so that residents’ weight can be monitored accurately. A powerful carpet cleaner has been provided, to maintain a sweet smelling house throughout. Information provided about the home to prospective residents and their families has been improved, to give an accurate picture of the service. 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. Frensham House DS0000018354.V350797.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 Frensham House DS0000018354.V350797.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 Quality in this outcome area is excellent. Significant time is spent making admission to the home personal and well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new version of the home’s Statement of Purpose was published in August 2007, to ensure that it is up to date and accurate. It includes an impressive account of the staff’s recent training. It is offered to enquirers in an attractive folder along with a recent newsletter and photographs of the staff, the garden, the interior of the house, and activities going on in the home. These are most encouraging, showing residents doing various things including choosing new clothes for themselves, and baking a pudding. Information about an advocacy service is also included. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 9 A Social Care worker returning a survey to the CSCI said that they provide comprehensive care plans on behalf of clients who they introduce, and that these are followed by the Manager and staff in the home. The files of two recently admitted residents were examined. The Manager had visited each in order to assess whether their needs could be suitably met at Frensham House. One visit was alongside a Care Manager, and in both cases health professionals had provided assessments of care needs. A copy was seen of the letter that the Manager had sent to confirm that the home would be suitable for the resident and their care needs. Frensham House DS0000018354.V350797.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): Quality in this outcome area is excellent. Staff ensure that personal care given is responsive to the persons’ needs and is flexible in order to properly meet their changing needs, in consultation with health professionals and the involvement of the family. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a person centred care plan which records in detail the actions staff need to take to provide for their care. Information provided in surveys returned to the CSCI confirmed that families are involved where possible, and that an individual approach is maintained at all times - ‘Very holistic individual support’. When difficulties arise, and changes in the care plan may be needed, the Manager arranges a meeting. The care plans are up dated as often as is needed, and checked formally at least once a month. Social interests were included, and advice to staff on the best approach to take. A summary was made in the form of a pen picture. Life history books were introduced in 2006, and have been maintained and added to, as a way for staff to get to know their residents better. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 11 Staff go along with residents’ preference for washing and dressing, while at all times helping them to maintain their own dignity. There is not a choice in bathing facilities. Some residents are not able to use the bath, sometimes because of the anxiety caused by fear or lack of understanding of the hoist. Staff ensure that people maintain their personal hygiene with strip washes. Provision of an accessible shower would give choice in bathing facilities. A relative said that they had been very happy with the Manager’s attention during a recent illness when he had visited their relative in the local hospital and made arrangements to enable a return to Frensham House. Another said, ‘The Manager & staff always have time for Mum. I always find them caring and considerate to her needs. They are never left alone.’ Good records were seen to be kept. These showed that District Nurses were involved regularly. They had recently provided appropriate equipment for residents who had become bed bound. There were records of recent visits by the Occupational therapist, Community Psychiatric Nurse and physiotherapist, and the care plan had been up dated. Where bed guards had been recommended and provided by the District Nurse, a Restraint form had been completed by the Manager to explain why this was considered best practice, and the Next Of Kin had signed to show agreement. All residents’ nutritional needs are assessed. Sit-in scales are provided so that all can be weighed accurately. The home has a policy and procedure for the administration, storage and recording of medication, and staff were seen to be working in accordance with it. A competent staff member was seen to giving the medication individually at the end of lunch, and signing the Medication Administration Record at the same time. No gaps were seen in the record. Where PRN drugs are given (as required) the reason is recorded, as well as who has made that decision. This is good practice in accountability as well as a record for helping to monitor how well the medication helps with the problem eg disturbed behaviour for which it has been prescribed. Frensham House DS0000018354.V350797.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): 12,13,14,15 Quality in this outcome area is excellent. The team have continued to provide imaginative and varied opportunities for a full and stimulating lifestyle. Further progress could be made in the quality of meal times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The daily routine is arranged around the residents. They may have a lie-in, or breakfast in bed. Individual attention in the form of manicures is part of normal life, and staff were seen to be engaging with residents in a positive way throughout the day. Regular questionnaires are sent out to hear from families about ideas for activities. The Manager also listens to professionals and keeps up to date with professional journals for good practice in provision of enabling and therapeutic activities for the residents. A Diamond Wedding was celebrated in the home, with family and residents enjoying the day together. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 13 Brixham Activity Services are regular visitors. The ‘Animal Man’ is very popular, engaging residents in petting and grooming the animals. Because of this love of animals, the staff organised their first outing to Paignton Zoo, which was recorded in many photos, circulated in the latest Frensham House News Letter, showing some very cheerful people. Staff noticed that residents were pleased to watch children playing and babies in prams as well as the zoo animals, and will bear this in mind when planning the next trip. A weekly activities programme is produced, showing the expectation that activities will take place every day. Seasonal activities are arranged, the most recent being Pumpkin Carving. Staff respond to the energies of residents, and will introduce singing, dancing and game, reminiscence and discussion as past of normal life in the lounge. One to one attention can be given for particular activities such as baking. Staff said that they come in on their day off to take residents to the shop. A short walk should be possible in their normal working day. The development of the garden has given great interest this season. A visiting relative said their mother enjoyed the colour, and another said their relative does not feel confined here. A vegetable patch has been producing vegetables for the table. Bird tables, bird feeders, and window bird feeders have been provided to attract birds for the residents interest. Following the building of the ramped access, the garden has been redesigned, and provides more space, interest and variety for the residents. Care staff take turns to cook, and though there is no question of their general ability, a trained cook may have more focus on interesting menus and presentation. They were pleased that the provision of fresh food, especially meat, had improved. Fresh milk is available, while powdered milk is also used. Fresh vegetables are available, although not served on the day of this inspection. The sausage casserole was very tasty, but accompanied by bland frozen runner beans. The rhubarb and apple pie served for pudding was not home-baked and some residents found the pastry hard. Staff knew residents’ preferences, and the Manager said residents can have special requests, for example, a resident likes liver which she now has every so often. Only three residents came to the dining room for lunch, while three stayed in their own room, and one was out with a relative. The others stayed in the lounge. While their preference must be respected, the team might consider how to make the dining room more attractive, as it may be beneficial to residents to have a change of scene and good posture for eating. Frensham House DS0000018354.V350797.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): 16,18 Quality in this outcome area is excellent. Residents are protected by the open and questioning nature of the management. Understanding and responding to their wishes is the focus of this service. Staff are alert to any developments of disturbance in behaviour. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure has been produced using friendly and encouraging language, to encourage people to come forward with views and feedback about anything that happens in the home. No complaints had been received by the home or by the CSCI. A Social Worker responding in a survey said, ‘I have witnessed staff at Frensham responding appropriately to any concerns on the rare occasions when family members have raised issues’, and a typical quote from a family member was, ‘any queries I have I just speak to Nick or the one of the girls’. The home’s policy on the Protection of Vulnerable Adults was clear, and all staff had received training in POVA awareness. Some had also attended training in dealing with challenging behaviour, and the Manager and one of the Senior Carers had training in 2007 in Non-abusive Physical and Psychological Intervention. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 15 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): 19,20,21,26 Quality in this outcome area is good. Frensham House is a safe and attractive home for people with dementia. Accessibility around the house has greatly improved. Improvement is still needed to the bathing facilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two major improvements had taken place since the last inspection. Previously, some residents had been unable to go out, because of the steps to the pavement at both back and front of the house. A thirty-foot ramp has been built from the car parking area at the back of the house round to the front door, giving safe and easy access for all. The ramp had good solid rails and a non-slip surface. The garden had been attractively redesigned around this feature. Shrubs had been cleared back, giving additional space. Planters and tubs had already been planted up with winter-flowering displays, making the house look colourful and well cared for. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 16 The other improvement was the installation of a new stair lift. It goes the entire length of the stairs to the first floor, and turns at the top to allow safe and easy transfers from wheelchairs. Measures recommended by a Falls Nurse had all been implemented, including the provision of five new dining chairs. At present this may be enough, as few residents were actually using the dining room, but the old ones should be replaced, as they are not safe, and a resident had recently tipped backwards in one. The dining room also serves as an alternative lounge, having easy chairs in one corner. Space is at a premium. The room would benefit from the removal of an unused fireplace. Redecoration throughout the house has referred to professional advice on colour schemes suitable for people with dementia, with warm or calming colour schemes, toilet doors all the same colour, clear edges to rooms, and plain carpets. Residents have been consulted on colour schemes in their own rooms. The doors had large pictures, showing what room it is, and residents had pictures on their own doors, sometimes of themselves in their youth. There are two bathrooms, but only one is used, as it has a hoist. The unused bathroom is too small for assisted bathing. It might be knocked through with the adjoining toilet and lobby, giving sufficient space for an accessible shower. This would be a great benefit to Frensham House, providing choice in bathing facilities, and giving the possibility for all residents to bathe. Some residents at Frensham House refuse baths, and some find the hoist alarming. A new and powerful carpet cleaner had been purchased. No bad odours were encountered anywhere in the house, which is commendable as many residents have problems with continence. Stylish and washable furniture had been purchased for bedrooms. Paper towels and liquid soap had been provided in communal toilets. Staff have received training in Control of Infection. An air filter machine has been provided to screen out airborne infections. The Manager attended a course on the Control of Infection, following which colour coded cleaning equipment has been introduced, to prevent contamination between different parts of the building. No bedrooms have en suite toilets. Several residents need commodes for use by night, and this need is not likely to diminish. At present, staff wash the commode pots in the sink in the wash room of the laundry, but this is not ideal as it is supposed to be for hand washing. A dedicated place should be provided for washing commode pots. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 17 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 excellent. This stable team of carers is trained and motivated to provide consistent quality care to the residents at Frensham House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A stable group of staff have worked together at Frensham House for some time, which is good for communication with the residents, and understanding their needs. There is a written rota which is planned four weeks in advance. The Manager has authority to increase staff if residents’ needs increase, eg due to illness. Generally there are two care staff on duty each morning, as well as one on cooking duty, and one on cleaning duties. The Manager is additional five days per week. A third carer is on duty between 5 – 7pm to make sure there is enough help at tea-time. This is sufficient to meet residents’ care needs, provided one to one attention at times, and ensure that groups of residents have attention at all times. All staff have either NVQ2 in care, or its equivalent, or are working towards it. Senior Carers have NVQ3 or are working towards it. The Company recognises these achievements in the pay packet. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 18 The file of the only recently appointed staff member was examined. It contained evidence that all checks had been carried out to assure residents’ safety. The Manager said that no member of staff starts work until their clearance with the POVA list is checked, and they may then work under supervision until their Criminal Records Bureau check is received and is acceptable. The provision of staff training is commendable. All staff in surveys said that they received training which helped them understand and meet the needs of the residents, that are relevant and keep them up to date with new ways of working. The Manager keeps up to date charts showing staff achievements and training or up-dates that are needed. Training in 2007 had included sessions on Principles of care, Dying and bereavement, Nutrition and dysphasia, Parkinson’s Disease, Challenging behaviour, and Advanced Medicines Management, as well as the Dementia Aset course and Ex-Memoria, which is a dvd training resource from Bradford University. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 19 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 excellent. The Registered Manager has consistently driven improvements in all aspects of service delivery, with positive support from the company. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager, Mr Nick Ross, has achieved the Registered Managers Award, the A1 Assessors Award, and has qualified as a Moving and Handling trainer. He has been in this post for five years, and is constantly up-dating his own training and keeping up to date with good practice in dementia care. He has recently had training on advocacy which enables him to provide information on this during pre-admission assessments. Every opinion given about the Manager was positive. One visiting professional said that he is ‘empathetic and forward thinking – he works ‘outside the box’ Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 20 which is brilliant’. A staff member said ‘I have never come across a workplace that is so supportive and that strives to improve services all the time.’ Mr Ross promotes positive views of his service by submitting illustrated accounts of activities and events in the home to local papers as well as national journals. The Manager and Senior staff were pleased with the support they have received from Stonehaven (Healthcare) Ltd, with resources provided to enable them to sustain the progress in the service. They have joined an advisory body to keep up to date with employment law. A handbook for staff is being compiled. A representative for the company visits monthly to monitor the service and supply a report to the company and to CSCI. Feedback is gathered informally and by the use of questionnaires, plus questionnaires about meals. Suggestions from relatives have been included in the bi-monthly newsletters. A plan for work to maintain or improve the environment was supplied. Small amounts of cash are kept on behalf of residents, to pay for personal requirements. Proper records are kept, with two signatures and a running balance, and receipts kept. A sample were checked and found to be accurate. The Manager provides two monthly supervision sessions for staff, with records kept that show that any issues arising in the home, new initiatives, and training needs are discussed. Staff returning surveys all said that they feel well supported to perform well at work. There are regular care team and resident meetings at least every three months. The Manager ensures as far as possible the health, safety and welfare of residents and staff. Accidents are reported and recorded, and the records are checked and analysed. The Manager has observed a reduction in accidents since the plain carpets have been fitted. Incident reports show that professional advice had been sought appropriately following disturbed behaviour. The fire precaution system had been serviced professionally in February 2007. Fire risk assessments are reviewed three monthly. The Fixed Wiring certificate was renewed in September 2007. There is a First aider on duty at all times. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 21 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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 3 2 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 22 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 OP21 Regulation 23 Requirement In order to meet the needs of residents, an accessible shower must be provided. Timescale for action 30/06/08 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 OP15 OP26 Good Practice Recommendations Variety in fresh vegetables and home baking should be promoted, and arrangements in the dining room reviewed. A suitable facility for washing commode pots should be provided. Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Frensham House DS0000018354.V350797.R01.S.doc Version 5.2 Page 24 - 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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