Inspection on 02/08/06 for Gracelands

This inspection was carried out on 2nd August 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

Gracelands 13/08/07

Gracelands 13/12/05

Gracelands 10/08/05

Gracelands 21/02/05

Gracelands 07/10/04

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

CARE HOMES FOR OLDER PEOPLE Gracelands 42-48 Richmond Avenue Bognor Regis West Sussex PO21 2YE Lead Inspector Mrs Kerry Leppard Unannounced Inspection 2nd August 2006 10:30 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 Gracelands DS0000059816.V300023.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. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gracelands Address 42-48 Richmond Avenue Bognor Regis West Sussex PO21 2YE 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) 01243 867707 01243 868331 Macleod Pinsent Care Limited Margaret Anne Kerbey Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (15) of places Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 31 service users in the category Dementia Elderly DE(E)of whom one named person may be in the category mental Disorder (MD) excluding learning or dementia There are currently up to 15 male and / or female service users in the category of old age, not falling within any other category. No further service users in this category may be admitted. Only persons over 65 years can be admitted. Total number of service users accommodated may not exceed 31. Date of last inspection 13th December 2005 Brief Description of the Service: Gracelands is a care home registered to provide care and accommodate to thirty-one service users over the age of sixty-five with dementia (DE(E)). The homes registration also permits the home to provide care and accommodation to one service user under 65 with a mental disorder and up to 15 service users currently residing in the home who are in the category of old age, not falling within any other category. No further service users in this category may be admitted. Gracelands is situated in Bognor Regis within close proximity of local shops and the seafront. Accommodation is provided on two floors, which are accessible by passenger lift, and consists of twenty-five single rooms and three double rooms. Communal space consists of four lounge areas and a dining room on the ground floor and a garden to the rear of the property. Macleod Pinsent Care Limited privately owns Gracelands. Mr Russell Pinsent is the Responsible Individual on behalf of the organisation. The Registered Manager responsible for the day-to-day running of the home is Mrs. Margaret Anne Kerbey. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced field work visit was conducted on Wednesday 2nd August 2006 between 10:30am and 6:30pm. Prior to the visit information was requested and received from the home in the form of a questionnaire. Comment cards were supplied to the home for distribution to both residents and relatives/visitors and prior to the visit five resident and six relative/visitor comment cards were received. During the visit the inspector spoke with five residents and two relatives and spent time observing interactions between residents and staff. The inspector was unable to obtain feedback from all residents due to their level of disability. The inspector spoke with four staff throughout the process of the inspection. The registered manager was available to assist the inspector also. A variety of records were reviewed including, assessments, care plans, medication administration records, staff recruitment and training records. Feedback and comments from comment cards and discussions have been included in this report. What the service does well: Residents who completed a comment card said that staff listen and act on what they say. Their comments about staff include ‘I am very comfortable here and find the helpers most kind and attentive, my room is very comfortable and kept spotlessly clean’ and ‘I’ve enjoyed much kindness and help from staff here’ Relatives/visitors also commented positively on the quality of the staff at Gracelands, they said ‘the staff are always ready to care for not only the residents but visitors as well’ ‘The staff are very helpful and several are par excellence, they are very kind’ ‘my [relative] is very well looked after in the home….the staff work very hard to keep residents and visitors happy at all times’ In addition, 100 of relatives/visitors commented that they are satisfied overall with the care provided at Gracelands. Comments received from relative/visitors about the service include Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 6 ‘I was very pleased with the home and the staff and the care my [relative] receives’ ‘My [relative] seems very happy and is looked after very well’ and ‘I have no complaint about the care my [relative] is receiving I know he is well cared for’ A resident also commented ‘I have been quite happy living here’. What has improved since the last inspection? What they could do better: It is a requirement for action that the home develop a quality assurance system including obtaining the views of residents to ensure the home is run in their best interests. It is recommended that a system be developed to ensure that residents and/or their representatives are consulted about the development of their individual plan of care. The procedure for administering and recording the administration of medicines should be reviewed to ensure that staff responsible for administration know Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 7 what they are giving is what has been prescribed and that the person administering completes the record of administration. Works to improve the environment should continue to ensure all areas of the home are welcoming, safe, well maintained and free from unpleasant odours. Work is needed to ensure that 50 of care staff hold an NVQ (National Vocational Qualification) at Level 2 or equivalent. The registered manager should continue to study toward achieving her management qualification. 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. Gracelands DS0000059816.V300023.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 Gracelands DS0000059816.V300023.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents needs are assessed before they come to live in the home. Intermediate care services are not provided at Gracelands. EVIDENCE: Evidence gathered from case tracking two residents who have come to live at the home recently indicates that the registered manager conducts a basic assessment of the prospective resident in order to determine if the home can meet their needs. In addition to that the registered manager had obtained information from other professionals such as social workers prior to the admitting residents to the home. Gracelands DS0000059816.V300023.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 at least once during a 12 month period. 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 the service. Residents needs are set out in an individual plan of care. These should be developed in consultation with residents and/or their representative. Residents health needs are met. Arrangements for the administration of medicines and the recording of administration should be reviewed for the protection of residents and staff. Residents privacy and dignity is respected. EVIDENCE: Care plans are in place for each resident and three care records were sampled as part of case tracking the care provided to residents at Gracelands. Care records include information about the resident’s physical and mental health care needs and risks to their health, safety and well being including pressure sores and manual handling and are reviewed monthly. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 11 From observation and discussion it is evident that staff at Gracelands have access to care plans and senior staff take responsibility for recording daily events. The registered manager is working on transferring all care records to a new format, it is recommended that resident’s and/or their representative be involved in this process and a system be developed to ensure that consultation about residents needs and care is ongoing. The registered manager agreed to give consideration to how actions to minimise identified risks are written, to ensure they adequately inform staff of what they are to do to protect residents. For example, ensuring the environment is safe may include moving, removing and/or replacing furniture and other hazards in the resident’s bedroom and other areas of the home and these details were not recorded. Discussions with staff indicate that the home has access to medical professionals to enable them to meet resident’s health care needs. Residents who answered the question ‘do you receive the medical support you need?’ said this is always or usually the case. Arrangements for the storage of medication were observed during the fieldwork visit and were found to be satisfactory. Following lunch a care assistant administered medication to residents that had been ‘popped’ out of a blister pack by a senior care assistant, the senior care assistant then recorded this on Medication Administration Records (MARs). It is a recommendation that procedures for the administration of medication at Gracelands be reviewed to ensure that staff administering medication know that what they are giving is what has been prescribed and that the person administering is then signing the MAR chart, this is to protect residents and staff from the risk of wrongful administration. Both senior care assistants who spoke with the inspector confirmed they have undertaken training in the handling of medicines. A sample of MARs were looked at and were fully complete, they are used to record medication received into the home and one handwritten MAR had been signed by the resident’s GP. To further improve medicine handling in the home, care plans should be drawn up to guide staff as to the triggers for administering medicine that is prescribed on an ‘as needed’ basis, this helps protect staff from the risk of wrongful administration. The inspector observed that locks are provided on doors to resident’s rooms and screens are provided in shared rooms to maintain resident’s privacy and dignity. Relative/visitors who completed a comment card also said they are able to conduct their visits in private. Gracelands DS0000059816.V300023.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 at least once during a 12 month period. 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 the service. A programme of activities is provided, this should be developed to ensure the lifestyle experienced in the home matches residents preferences and expectations. Residents are supported to maintain contact with their friends and relatives. Residents are supported to make choices and decisions A varied diet is provided in a congenial setting. EVIDENCE: The inspector noted that a programme of activities, including musical entertainment provided by external facilitators, is operating at Gracelands. Although an activity session was not seen it was noted that the job of facilitating a game of bingo was allocated to a member of staff during the Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 13 afternoon hand over meeting. The inspector did observe staff and residents singing and dancing together during the morning and a staff member accompanying a resident for a walk outside the home during the afternoon, another resident had told the inspector that staff accompany her for a walk outside on occasion. Responses from residents, who completed a comment card, to the question ‘are there activities arranged by the home that you can take part in?’ varied from ‘never’ to ‘always’ and some discussion was had with the manager about developing the activities programme, including social contacts outside the home to reflect the preferences and expectations of residents. The inspector met and spoke with visitors throughout the day, those who spoke with the inspector expressed satisfaction with the care being provided and comments on relative/visitor comment cards indicate they are welcomed into the home, they said ‘…the staff are very friendly and always make me welcome’ and ‘we have been treated very well as visitors to my [relative]’. From observation and discussions the inspector concluded that residents at Gracelands are supported to make choices and decisions in relation to how and where they spend their time, the food they eat and the routine of their daily life. Residents told the inspector that they have the choice of eating a cooked breakfast each morning, which some enjoy, others prefer a lighter breakfast. Lunch is the main meal of the day at Gracelands, most residents ate in the dining room and staff were available to provide support to those who needed it. The meal provided was gammon, pineapple sauce, new potatoes and vegetables followed by meringue nests with summer fruits and cream. Some residents who are vegetarian chose an alternative, these included omelette and cauliflower cheese and a hot dessert was also available. The meal was nicely presented and appetising and residents spoke positively about it. Additional helpings of the meal were offered to residents. The majority of residents who completed a comment card said they ‘always’ or ‘usually’ like the meals, their comments included ‘quite happy with the meals available’ and ‘don’t like…most vegetables, so I have meals without these on them. I am always offered a variety of other foods and eat in their place’ Gracelands DS0000059816.V300023.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 inspected at least once during a 12 month period. 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 the service. The complaints procedure is publicised and complaints are listened to and acted upon. Staff are trained to protect residents from abuse. EVIDENCE: The home has a complaints procedure that relative/visitors feedback indicates is available to them. Similarly, residents who completed a comment card said they know who to speak to if they are not happy and how to make a complaint. The registered persons have demonstrated a commitment to dealing with expressions of dissatisfaction that have been brought to their attention. Staff have received training in abuse awareness and discussions with staff confirmed that this included the types of abuse and the signs they should be aware of. Staff were also clear of their responsibility to report any suspicion or evidence of abuse to a superior. Following her registration the registered manager has attended training provided by the local social services department and has demonstrated an Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 15 understanding of her responsibility to report any evidence of abuse to the social services department. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is subject to redecoration and refurbishment to ensure it is safe and well maintained. Residents have access to safe and comfortable indoor and outdoor communal facilities. Improvements have been made and should continue to ensure lavatory and washing facilities are welcoming. Improvements have been made to ensure the home is clean, tidy and hygienic. EVIDENCE: It was evident at this fieldwork visit that the home has been subject to some refurbishment, most notably windows have been replaced, as has carpeting in Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 17 communal areas both of which have made a positive improvement to the environment. Communal spaces have been changed to provide a variety of sitting areas and a main dining area. These areas are homely and comfortable for residents and their visitors to enjoy. The inspector is pleased to note that fire doors were not propped open and action has been taken to ensure devices that respond to the fire alarm are in use where it is the resident’s wish to have their door open. This ensures the health, safety and welfare of residents and staff. The inspector is pleased to note that tiling in the ground floor shower room has been completed and a suitable seat has been provided for residents to use the facility. Two other bathrooms provide assisted facilities, these and toilets around the home remain in need of works to ensure they are welcoming. The registered persons have demonstrated a commitment to improving the environment and this should continue to ensure all areas of the home are safe, well maintained and free from unpleasant odours. On the day of inspection housekeeping staff were on duty during the morning and from staff rotas, the inspector concludes this is the case five days per week. The home appeared clean and tidy which is an improvement since the last inspection. This observation is supported by resident feedback; on comment cards residents said that the home is ‘always’ fresh and clean. The provision of hand washing facilities in all toilets around the home is an improvement that contributes to a good standard of hygiene. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. 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 the service. Staffing levels in the home have improved to ensure residents needs are met. Training is provided including induction but work is needed to ensure that staff are qualified. Recruitment procedures have been improved and are now robust for the protection of residents. EVIDENCE: During the morning of the fieldwork visit five care staff, including a senior care assistant were on duty in addition to the registered manager. A cook, kitchen assistant and housekeeping staff were also on duty. Rotas provide evidence that the number of care staff on duty in the afternoon is four and most shifts include a senior care assistant or team leader, two waking night staff cover 8pm-8am, a laundry assistant works five mornings a week and kitchen staffing arrangements have been increased to avoid care staff preparing food. This is an improvement since the last inspection and the inspector’s finding is supported by resident and relative/visitor feedback on comment cards, residents responded ‘always’ and ‘usually’ to the question ‘are staff available when you need them? and all relatives/visitors said that in their opinion there are always sufficient numbers of staff on duty. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 19 From information provided prior to the inspection it is noted that only 18 of the care staff employed at Gracelands are qualified to NVQ (National Vocational Qualification) Level 2. This does not meet the National Minimum Standard of 50 and the registered persons have provided information to indicate that a plan to achieve the minimum standard is in place. Information provided and discussion with staff indicates that a programme of training is in place that includes induction, health and safety topics, abuse awareness and training specific to the needs of residents with dementia. The inspector is pleased to note that employment records, relating to two recently employed members of staff indicate that the procedure for recruiting staff has improved. Records include written references and a CRB (Criminal Records Bureau) disclosure that has been secured prior to the member of staff commencing employment. One other record sampled did not demonstrate equally good practise insofar as the member of staff commenced employment prior to receipt of all information required by Schedule 2. The registered persons assured the inspector that they are aware of Department of Health guidance, which recommends that a member of staff can only commence employment prior to receipt of a full CRB disclosure if all other recruitment checks have been completed, a PoVA (Protection of Vulnerable Adults) First check has been obtained, they begin a programme of induction and are supervised. The registered persons were advised to apply this guidance where necessary following the audit of their recruitment files. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The registered manager is experienced and competent, she is a registered nurse but does not yet have a management qualification. A development plan has been produced for the home but a system of quality assurance has not been established which ensures that resident’s views are sought and that the service is run in their best interests. Residents financial interests are safeguarded. Equipment servicing and maintenance and staff training promotes and protects the health safety and well being of residents and staff at Gracelands. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager is a registered mental health nurse with significant experience in residential settings. She is currently studying to achieve the Registered Manager’s Award to meet the National Minimum Standard. Staff and relatives made positive comments about the changes the registered manager has effected since she began at Gracelands. Other comments received about the management of the home included ‘I am very pleased with how the home is being run’ and ‘..the manager is a very caring and hospitable lady’. The registered manager has produced a development plan for the home in which she has prioritised work that is needed to raise standards in all aspects of the home. Improvements that have been noted in this report and the registered persons own monthly visit reports demonstrate a commitment to improve the quality of the service provided at Gracelands. However as yet a system of quality assurance has not been established which ensures that resident’s views are sought and that the service is run in their best interests. This was recommended on the last report and is now a requirement for action. The home does store money on resident’s behalf and records are made of incomings, outgoings and the balance, with receipts retained for money spent. Records are clearly maintained and audited regularly. Information received prior to the visit indicates that arrangements have been made to ensure equipment is serviced regularly. The registered persons advised the inspector that arrangements have been made to replace a boiler that is no longer suitable for use. Staff confirmed that they receive fire safety training, those spoken with knew the procedure to follow in case of fire. Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 24 (1, 2, &3) Requirement The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home…The registered person shall supply to the Commission a report in respect of any reviews conducted by him for the purposes of paragraph 1 and make a copy of the report available to service users. The system referred to in paragraph 1 shall provide for consultation with service users and their representatives. Timescale for action 02/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridge worth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Gracelands DS0000059816.V300023.R01.S.doc Version 5.2 Page 25 - 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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