Inspection on 10/01/06 for Herons Lodge

This inspection was carried out on 10th January 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

Herons Lodge 11/08/09

Herons Lodge 27/05/09

Herons Lodge 07/07/08

Herons Lodge 07/06/06

Herons Lodge 10/06/05

Herons Lodge 18/10/04

Herons Lodge 26/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Herons Lodge 138 Northampton Road Market Harborough Leicestershire LE16 9HF Lead Inspector Pat Harte Unannounced Inspection 10th January 2006 09:45 Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 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 Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 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 Adults 18-65. 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. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Herons Lodge Address 138 Northampton Road Market Harborough Leicestershire LE16 9HF 01858 465441 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) www.mentauruk.com Mentaur Limited Vacant Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10) of places Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling with category MD may be admitted to the home unless that person also falls within category LD, i.e. dual disability. 15/11/05 Date of last inspection Brief Description of the Service: Herons Lodge is a care home providing personal care and accommodation for ten young adults with learning disabilities. The Company Mentaur Limited owns the Home; the home is one of a number of care homes owned by this Company in the Midlands area. The Manager’s position is currently vacant and in the interim period the Home is being managed, by agreement by the Commission, by Mrs. L. Chamberlain. The home is located close to the town centre of Market Harborough where Residents can easily access to shops, pubs, the post office and other local amenities. The home is easily accessible by private or public transport. The premises consist of a large old house with a modern extension to the rear, there are two floors and access to the first floor is by use of the stairs. There is level entry access to the home. The range of facilities includes two lounge areas and a dining room for communal use. There are ten single bedrooms, nine without en-suite facilities. The home has a garden to the rear of the building accessible to all Residents; the garden area is securely fenced. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for Service Users and their views of the service provided. Inspection planning took one and a half hours and consisted of a review of the last Inspection report, previous requirements and recommendations and the Home’s service history including notifications and events. In September 2005 the Commission carried out a Complaint Investigation, over a five-day period, at the Home. The complaint concerned the care of Residents and the fulfilling of 1 – 1 contracts; the security of premises; health and safety, low staffing levels, staff support and low staff morale, insufficient training for Agency staff, a lack of staff recruitment and Medication management. All but one area of the complaint was founded. A number of additional issues were identified during the investigation concerning Care planning, Activities, Staff supervision and training, the management of complaints and Residents’ moneys, the cleanliness and maintenance of the Home and respect for Residents and their belongings. The Commission reviewed the findings with the Provider’s Representative on 6th October 2005 and expressed serious concern on the running of the Home. Two further Inspections were carried out on 24th October and 15th November to monitor progress and compliance to requirements made. As part of this Inspection all outstanding requirements have been reviewed. The primary method of inspection used was ‘case tracking’ which involved selecting three Residents and tracking the care they receive through review of their records, observations on care practice and discussions with care staff. In addition four staff and three Residents were spoken with to obtain their views. A partial tour of the premises took place, a selection of records was inspected and observations made on care practices. Discussions were held with the Acting Manager and the Company’s Responsible Individual. The Inspection took place during the morning and afternoon over a period of six hours and was carried out on an unannounced basis. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? The process for assessing prospective Residents has been revised and is thorough in approach. Residents care plans have been reviewed and significant improvements made on the level of information and instruction for staff on how the care needs are to be met. Improvements have been made to the overall Residents’ activity programme to include visits to the theatre and to leisure centres. Residents’ health care has improved with increased monitoring and prompt referrals made to Medical Professionals. All staff have received training or updates in the Protection of Vulnerable Adults procedures. Notifications are now being made to the relevant Authorities on allegations of abuse including incidents of Resident-to-Resident abuse. Attention has been paid to the general maintenance of the premises and equipment. Improvements have been made in domestic and hygiene maintenance, standards are now good. The successful recruitment campaign has resulted in reducing to a minimum the use of Agency staff. This has improved staff morale and ensured consistency and continuity of care for the Residents. The stability of the staff group has improved and it is significant that the number of incidences of aggressive behaviour by Residents has dramatically reduced. The atmosphere of the Home is much calmer and Residents are more settled and happier. Relationships between Residents and staff were observed to be good. Recruitment practices have been reviewed and now reflect expected good practice. Attention has been paid to increased training for staff to develop their skills and equip them to meet the needs of their Residents. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 7 Regular staff supervision has been put in place. Staff stated that they felt supported by the Acting Manager and the Company. 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. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Prospective Residents are provided with information on the Home’s services and facilities to enable them to make informed choices on a placement. EVIDENCE: No new Residents have been admitted to the Home since the Inspection of July 2005. The Home has an information pack on it’s services and facilities which is given to prospective Residents and their Relatives in order that they are able to make an informed choice on a possible placement. The assessment process ensures that senior staff visit all prospective Residents and carry through an assessment to determine needs. The assessment format has been reviewed and now adopts a holistic approach. The Acting Manager is aware that care needs to be taken when carrying out future assessments to ensure Residents’ needs fall within the Registration Categories, that account is taken of existing Residents dependency levels, abilities and behaviours and that all the needs of prospective Resident can be met in full. The process of admission ensures that account is taken of individual needs. Opportunities are provided for the prospective Resident and their Relatives to Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 10 visit the Home, meet with Residents and staff, view the accommodation and discuss their needs. Visits, overnight and weekend stays can be undertaken and the pace of admission adjusted to Residents needs. Residents are provided with contracts. The Home has recently reviewed contracts to reflect any 1 – 1 time agreed with the Placing Authorities. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Improvements have been made in the care planning and risk assessment processes however care plans are not fully reflective of Residents needs. EVIDENCE: All care plans have been reviewed and improvements been made to the level of information, instruction and guidance for staff. Resident’s plans of care are now reviewed regularly and staff have signed to confirm that they have read them Sample checks of three residents care plans identified that there was a good level of detail regarding the assistance Residents needed from staff in relation to their personal care routines. One plan viewed had good detailed information about a Resident’s behaviours. This included references to triggers and indicators of aggressive behaviour. The information had been collated with separate instructions produced on ‘tried and tested’ methods for the management of the behaviours. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 12 The organisation of Residents files was discussed with the Acting Manager and advice was given to ensure that care plan information and instructions is organised in such a way as not to get ‘lost’ with other information. One Resident’s care plan and discussions with staff confirmed that risk management strategies are discussed and agreed with Placing Authorities. The systems for updating risk assessments and revising instructions on care plans, where changes are identified, were not within acceptable timeframes. For example four days prior to the Inspection a Resident had started to exhibit sexual behaviour that had the potential for putting staff at risk. The risk assessment and instructions for staff on how the behaviour was to be managed had not been revised. In discussions with one member of staff it was confirmed that the there had also been a failure in communication and he had not been made aware of the behaviour or risk potential. It was agreed with the Acting Manager that the development of care plan and risk assessing is ongoing. Records relating to Residents’ finances were found to be in good order. There is an auditing system by the Home’s staff and by the Company Representative to ensure all balances are correct. The records relating to three Residents’ finances were inspected and showed that where staff, on a Resident’s behalf, make purchases or pay for services receipts are fully maintained. Discussions with the Acting Manager and staff showed that Residents have access to their finances and are supported and guided in their management. Residents’ savings are appropriately held in individual Residents accounts under an overall Residents’ bank account. Interest is accumulated to each Resident’s account and individual statements are supplied to verify deposits and withdrawals. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15 & 17 Some improvements have been made in the provision of activities and staff are working towards increasing opportunities however a more individual and planned approach needs to be implemented. EVIDENCE: All but three Residents attend day care centres. For some of the Residents these facilities have been provided in the home for the last few months due to renovation work being carried out at the day centre. This work is now complete and Residents are due to start back to their Day Care next week. Three Residents have specific one to one time with staff, which has been agreed, as part of their care package, by the Placing Authorities. Staff allocation to this time is clearly recorded on the rota however observations showed that the designated 1 - 1 staff member was working as part of the general care team. Discussion with the Acting Manager identified that adjustments to the timing of these sessions was needed to better suit the Resident’s needs. This area was under discussion with the Social Worker concerned, advice was given to ensure that the action agreed was clearly Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 14 documented and that a detailed plan for the use of the one to one time implemented. Concerns have been raised on all inspection visits since July 2005 about the approach to the provision of activities. This has been limited to taking Residents for a drive as an activity or as a means of calming a potentially volatile or aggressive situation. Some improvements have been made to providing other activities and staff are working towards increasing opportunities, for example all Residents had been to a pantomime the week before the inspection and the outings to sporting facilities have been reinstated. There is a weekly planner for the Home’s general activities and on individual files there is a log of the activities actually undertaken by Residents. However, no individual Residents activity plans are available to reflect their hobbies and interests or to promote skill development. The Acting Manager is aware of the need to implement a more planned approach to the provision of individual fulfilling activities. This is an ongoing area for development. Records and discussions with staff confirmed that Residents are supported in maintaining family relationships. The Home has an open visiting policy and Residents are enabled to visit or undertake stays with families, where possible. The Acting Manager is aware that further attention needs to be paid to Residents rights to maintain links with friends and develop intimate personal Relationships. Steps are being taken in one instance to ensure a Resident can visit her friend and enjoy trips out with her. There is a need to ensure that where Resident’s develop relationships their vulnerability and understanding is assessed, education and specialist guidance should be sought to enable them to make appropriate decisions. This is an ongoing area for development. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 Resident’s healthcare needs are monitored and appropriate referrals to relevant Healthcare Services are made. EVIDENCE: Records did not indicate that one Resident’s healthcare needs had been followed up. However staff showed that they had taken the appropriate action and referred to the relevant medical services. Observations confirmed that staff are now far more aware and responsive to Residents healthcare needs, this has been an area of previous concern. Staff were observed to monitor Residents and respond quickly if they showed signs of being “under the weather”. Care has been taken to note female Residents’ menstruation cycles giving indicators where behaviours may be affected by PMT or where pain may be experienced. Appropriate PRN pain relief was giving where necessary. The lack of Management, organisation, monitoring and supervision of Residents together with the high usage of untrained and unfamiliar Agency staff and shortages of permanent staff had resulted in a high number of incidents in September and October 2005. The Company has taken steps to recruit staff and there is now better continuity and consistency of care. The Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 16 atmosphere was generally much calmer and Residents behaviours have improved with a significant reduction in incidents and instances of aggressive behaviour. It was also pleasing to note that the administration of one Residents PRN medication, prescribed for adverse behaviours, had been significantly reduced. The management of the Home’s medication system was in good order. The required records were well maintained. Storage was secure and appropriate. The Acting Manager now carries through regular audits on stocks of medication and on the completion of the records ensuring that the good standard is maintained. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The Home has effective Complaints and Adult Protection procedures that ensure Residents views are listened to and acted upon and that they are protected from abuse. EVIDENCE: Residents and their relatives have been given information on how to complain. Since the Inspection in July 2005 one complaint has been investigated by the Commission and is outlined in the summary introduction of this report. The record of complaints maintained by the Home shows that one further complaint has been received from a Relative on inappropriate clothing packed for a home visit. The Acting Manager has investigated the complaint within appropriate timescales. The complaint was founded and action has been taken to prevent a similar occurrence. The Acting Manager is in the process of finalising the outcome report to response to the complainant. The Company and Acting Manager have addressed staff training on the Protection of Vulnerable Adults. Appropriate referrals are now being made to the relevant Authorities and the Commission on allegations made or instances of Resident-to-Resident abuse. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 & 30 Residents are provided with a comfortable and safe environment. Standards of domestic and hygiene maintenance are good. EVIDENCE: During the Complaint Investigation of September 2005 serious concerns were raised with the Company on general maintenance issues. Action has been taken to address and resolve all issues. The Company now has a routine checking system to identify areas in need of attention. The premises were found to be in good order. Previous issues relating to the cleanliness of the premises and hygiene maintenance have been addressed and standards were viewed as good. Attention has been paid to fencing the garden area to ensure freedom of access by all Residents. Residents are enabled to personalise their rooms as they wish and have their belongings around them. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 The recruitment of more permanent care staff has provided stability and consistency of care for the Residents. Staff turnover has been reduced and staff morale much improved. EVIDENCE: A successful recruitment programme has been carried out reducing the need to employ Agency staff. This has resulted in the improved morale of permanent staff. There is a greater stability within the staff group who are now able to provide consistency and continuity of care for their Residents. It was notable that the staff group now work as a team. It was also clear that relationships between Company and the Home’s staff had much improved raising staff morale in general and extending the teamwork approach to improve the overall service. Observations confirmed good relationships and positive interactions between staff and Residents. A sample check of staff rotas and observations during the Inspection indicated that there were sufficient staff to meet the needs of Residents. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 20 The records of four new staff were inspected and showed that employment practice had been improved. Two references and the appropriate POVA 1st and Criminal Records Bureau checks had been undertaken. The Home’s induction training has been revised and now includes the Sector Skills Councils’ recommended training programme. Staff spoken with commented that training in general had improved. Training and updates completed this year includes the Principals of Care, Understanding Learning Disabilities, Infection Control, Dealing with Epilepsy, Dealing with Violence and Aggression (NAPPI), Challenging Behaviour, 1st Aid, Movement and Handling, Fire Safety, Food Hygiene, Sexuality and Effective Communication. Training in Mental Health needs is currently being arranged in relation to the specific conditions of existing Residents. 7 staff have obtained a National Vocational qualification, a further 2 staff are currently undertaking the training and arrangements for a further 4 staff to commence the training are being finalised. The Company is currently developing the training plan for 2006. Staff records evidenced that formal supervision is provided. Staff stated that they were able to access informal supervision and there was a system of on call back up should the need arise. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 & 42 Interim management arrangements for the running of the Home have been revised and have effected a positive change and improvement in the service. EVIDENCE: The recruitment process for a new Manager is on going. In the interim the Commission has agreed that the Company’s Service Development Manager holds the Acting Manager position with responsibilities for the day-to-day running of the Home. Staff spoke of feeling supported by the Acting Manager who was readily accessible to both staff and Residents. The Company’s Responsible Individual and the Acting Manager have worked hard to improve the service and address issues and requirements raised in previous reports. Whilst it is acknowledged that there are areas for ongoing development the Home has a good basis to move forward. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 22 Due attention is paid to the Health and Safety of Residents and staff. Training for staff in health and safety areas is provided. Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 2 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X X 3 X X X 3 X Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Herons Lodge DS0000035094.V272153.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!