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Inspection on 17/05/05 for Holyport Lodge Nursing Home

Also see our care home review for Holyport Lodge Nursing Home for more information

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Five residents who were able to express their opinions were asked their views on the quality of life in the home and if there was anything about the home and the service they would improve. All individuals gave positive comments that they were happy with the service, recognising it was not the same as being in your own home but none could think of any improvements or changes they wished to make. The home has a well-established activity schedule for all its residents with two dedicated staff providing a wide range of activities, events, games and outings and will provide appropriate activities for those less able to join in communal events. The home has just appointed a qualified chef with suitable professional experience and skills. The home had a warm inviting atmosphere and was seen to make visitors very welcome.

What has improved since the last inspection?

Recruitment documentation has improved. The appointment of a new Deputy Manager in February has improved the strength of the management team in this large home, and her efforts on improving the documentation and support to nursing staff was recognised by the Inspector.

What the care home could do better:

Basic care plans should be in place within seven days of admission to ensure that resident`s needs are assessed and met appropriately. The Registered nurses have responsibility for care plans and appeared to be leaving them to the Deputy Manager to complete. Registered nurses are accountable for the care they give and are responsible for ensuring that records are maintained and are accurate. The gardens were unusually untidy and in need of attention, this was apparently due to a change in contractors.

CARE HOMES FOR OLDER PEOPLE HOLYPORT LODGE Holyport Maidenhead Berkshire SL6 2JA Lead Inspector Sue Burton Unannounced 17 May 2005 @ 09:45 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 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. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Holyport Lodge Address Holyport Maidenhead Berkshire SL6 2JA 01628 781138 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Ltd Mrs Marilyn Sayle Care Home 45 Category(ies) of Older Person (OP) - 41 registration, with number Physical Disability (PD) - 4 of places HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: People with a physical disability will not be admitted below the age of 55. Date of last inspection 17/02/05 Brief Description of the Service: Holyport Lodge is an elegant, homely Edwardian house, situated on the edge of the Village Green in Holyport, near Maidenhead in Berkshire. It is owned by BUPA and registered to provide care for up to 45 older people, or to those who have a physical disability, or to those who require convalescence.The home has been converted but retains many of its original features and character, including an impressive oak staircase and hand carved oak panelling. There are two lounges, (one of which is used as a quiet room) and a dining room. These areas provide a central meeting place where service users can get together to read, watch television or chat. The gardens are attractively landscaped, and add to the ambiance of the home.The village of Holyport is situated close to the towns of Maidenhead and Windsor. Central London is easily accessible. Much of the above information was taken from the homes Statement of Purpose. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on Tuesday 17th May 2005. A Fire Officer from the Royal Berkshire Fire & Rescue Service had visited the home on the 9th May 2005 and had issued a “Fire Safety Deficiencies” notice that requires the home to make improvements to the fire safety systems in some areas of the building and make a fire risk assessment available by the 9th August 2005. A number of care plans were reviewed during this inspection along with the records of recent admissions to the home. Some residents had been in the home for over a month and did not have even a basic care plan in place, which was of concern. Generally the home was warm, well, decorated and provided a comfortable environment for the residents. Rooms are furnished with the individual’s own furniture and personal possessions, if wished. The home was generally clean and tidy. The results of a BUPA customer satisfaction survey are available for residents and relatives. The results of the 14 responses received in the survey indicated that 83 of those who responded thought the quality of service in the home was excellent or very good. What the service does well: Five residents who were able to express their opinions were asked their views on the quality of life in the home and if there was anything about the home and the service they would improve. All individuals gave positive comments that they were happy with the service, recognising it was not the same as being in your own home but none could think of any improvements or changes they wished to make. The home has a well-established activity schedule for all its residents with two dedicated staff providing a wide range of activities, events, games and outings and will provide appropriate activities for those less able to join in communal events. The home has just appointed a qualified chef with suitable professional experience and skills. The home had a warm inviting atmosphere and was seen to make visitors very welcome. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. New admissions to the home have appropriate pre-assessment information in place. EVIDENCE: The records of those residents admitted to the home over the last two months were examined. All had documentary evidence that pre-assessment information was in place and covered all their individuals needs. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,10,11 Not all of the most recently admitted residents had plans in place that set out their care needs or how staff were to meet them. Residents who had lived in the home for some time had established care plans, which had for example detailed nutritional, manual handling and mobility assessments in place. Staff were observed at the inspection to be treating residents with respect. Care given at the time of a resident’s death was sensitive and appropriate. EVIDENCE: A sample of residents admission records from March 2005 onwards were examined and it was seen that some were without any form of basic care plan. The Deputy Manager confirmed this situation and reassured the Inspector that this was being addressed. These more established care plans, which were reviewed, were seen to contain information on resident’s weights, their mobility needs, moving and handling needs and assessments for risk of pressure sores etc. However there were many inconsistencies in the documentation of the plans as some were signed and dated with regular reviews and others were not. A resident admitted with a high-risk infection 4 weeks prior to the inspection also had no care plan in place. Daily entries for that individual showed that hydration was a problem but no fluid chart was put HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 10 in place, there was no nutritional assessment and no pressure sore risk assessment. Registered nurses are responsible and accountable for ensuring that the care they give is recorded and that documentation is correct and up to date. Staff were seen with a number of residents who needed assistance with eating and they were observed as attentive and responsive to individuals needs. The records of a resident who had passed away recently were examined and the documentary evidence supported that the nursing staff gave appropriate care and that the GP had been in recent attendance and the advice given was carried out by the staff. Funeral requests or arrangements were seen recorded at the time of admission in the majority of records examined. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,14,15 in part The home offers a wide range of activities, outings and events to residents of all abilities. Residents are asked for their likes and dislikes with regard to food. Residents are encouraged to personalise their rooms with their own possessions. Residents who required assistance with feeding were treated with sensitivity and dignity. EVIDENCE: The home has a dedicated activity room and employs two members of staff specifically to provide a wide a range of activities. A record of the homes activity schedule was available and gave details of numerous well planned events such as exercise classes, videos, quizzes, board games, painting classes and a trip out to Savill Gardens. At the time of the inspection 8 residents were taking part in board games and were seen to be enjoying the activity. Some residents had been involved in the repotting of houseplants. The home has a montage of photographs in the hallway, which showed one of the homes themed lunches for Valentines Day. Photographs of the music therapy, drama groups and the visits of the Pat-a-Dog service were displayed. Records evidenced that resident’s choices with regard to food likes and dislikes are noted at admission and passed on to the kitchen. The rooms that were visited evidenced that individual’s personal possessions were suitably arranged. Property lists are kept to record what has been HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 12 brought in by the residents. One room was ready and waiting for its new occupant and had all the individuals’ china and silverware displayed with their own furniture and pictures on display to give the room a highly individualised atmosphere. Five residents were asked for their views on the home and all gave positive comments and none could think of anything they would change for the better. The home had just appointed a highly skilled and qualified Chef who had only started the day before the inspection; brief discussion took place with regard to the dietary needs of the residents and will be followed up in more detail at the next inspection. The dining room has two sittings the first of which commences at approximately 11.45 for those individuals who need assistance with meals. There appeared to be enough staff in the room to ensure the individuals were given enough time and support so they could enjoy their meal in an unhurried way. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 18 in part Standards 16 & 17 were not inspected on this occasion but will be covered at the next inspection. The home has a whistle blowing policy and procedure, which is known and used by staff. A residents records did not demonstrate that appropriate observations had been carried out following a head injury. EVIDENCE: During the inspection the Registered manager advised the Inspector of an allegation that had come to her attention on the day of inspection via the homes whistle bowing procedure. The nature of the concern was discussed in brief. The manager had not had an opportunity to fully investigate the allegation but the procedure that would be implemented and followed was discussed and appeared appropriate to the seriousness of the complaint. The manager advised that she would be formally notifying CSCI of the allegation as is required. The inspector found records of a resident with a head injury where there was no documentary evidence of any observations being carried out to monitor his well being, specifically throughout the night. Lack of appropriate monitoring and observation could have put the resident at serious risk. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 22,24,25,26 The home has a number of fire safety issues that require attention. A previous requirement that the home demonstrate that an assessment by a suitably qualified person to ensure that all appropriate adaptations, equipment and facilities are in place to meet all service users needs, would be discussed further at corporate level. The home was well maintained and comfortable for the residents. Bedrooms are provided with furniture and equipment, this assures privacy and comfort. The rooms are well lit and appropriately heated. The laundry staff follow suitable procedures to prevent the spread of infection. EVIDENCE: A Fire Officer from the Royal Berkshire Fire & Rescue Service had visited the home on the 9th May 2005 and had issued a “Fire Safety Deficiencies” notice that requires the home to make improvements to the fire safety systems in some areas of the building and make a fire risk assessment available by the 9th August 2005. CSCI had been advised by the proprietors in November 2004 that it takes fire safety very seriously and that a complete review had been undertaken earlier in the year, which had identified all works required, and that the home would have a detailed programme of works by mid December HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 15 2004 with the fire risk assessment. The manager advised the Inspector that the estates manager was aware of the notice and was in the process of obtaining quotes. The programme of works and fire risk assessment were not available at this inspection. The manager was asked to respond formally via the estates manager on the organisations response to the improvements required by the fire service separately to the inspection process. A tour of the home took place with a random sample of rooms and bathrooms visited. Bathrooms were clean and appropriately furnished, bedrooms were decorated appropriately and staff were responsive to resident who wished to have their room less conventionally cleaned and lit. The ground floor has a large separate dining room, sitting room and separate drawing room with a piano. The home also has a resident cat. Relatives and visitors who wish to have some privacy often use the room, that can also be used if desired for formal events and parties. The large expansive garden is usually very tidy and well managed but on the day of inspection was in need of attention, the manager advised that this was due to a change in contractors and would hopefully be addressed very soon. A number of broken plastic garden chairs were seen on the patio and the manager agreed to remove them straight away. The home has a small garden pond at the side of the home that is potentially a risk to less able residents and small children visiting and requires review to ensure it is safe. Bedrooms are not currently provided with lockable drawers but some wardrobes were seen to have keys, individuals can be provided with a small metal cash box for their money. The manager advised the Inspector that this would hopefully resolved in the next phase of refurbishment. Most bedroom doors were fitted with locks, if the residents wished to secure their bedroom. The homes laundry was visited and the laundress spoken with, she appeared to be well aware of the procedures required for the prevention of cross infection and good hygiene procedures. The manager is considering how to improve the homes infection control procedures with regard to staff uniforms, in line with current good practice recommendations from the Royal College of Nursing. From records seen in the home infection control appears to be a subject that is under current discussion with care staff and may be followed up further at future inspections. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The numbers of staff on duty appeared appropriate for the needs of the residents. The skill mix of nursing staff was discussed in view of the homes care plans. Recruitment procedures have improved and were seen to be appropriate to ensure the safety of the residents. The home has a well-planned training programme for its staff. EVIDENCE: From observation the numbers of staff in relation to the homes current dependency and occupancy levels appeared appropriate. The Nursing staff skill mix was discussed with the Deputy and the homes Registered manager with regard to the failure of appropriate documentation required for residents care plans. Both were aware of the strengths and weakness of the teams and were trying to resolve those issues. Evidence from the minutes of the last staff meeting showed that documentation had been discussed with care staff as well as, infection control, cleanliness and timekeeping. The home has separate meetings for senior nursing staff issues and covered infection control, leadership issues, low morale and lack of teamwork. Recruitment documentation and checks met the required regulations. The manager advised the Inspector that mandatory training in manual handling and fire were all being updated for staff, this included night staff. The manger advised that there were plans to train all staff in first aid. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34,35 in part, 36, 37, 38 The Registered Manager is qualified and experienced to manage this home. There appears to be a clear sense of leadership within the home. The home has undertaken a formal customer satisfaction survey. Arrangements have been made so that residents have separate bank accounts away from BUPA’s own corporate accounts. Corporate arrangements have been made with NCSC/CSCI in regard to inspection of the homes financial position. The formal supervision of staff care practices takes place. Records such as care plans were not always in place and were not consistently reviewed, signed or dated, which is required. The home has regular maintenance contracts in place for its utilities. Risk assessment for safe working practices are in place. Records indicate that regular checks on the homes fire equipment take place. EVIDENCE: HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 18 The Registered manager has recently completed her NVQ4 registered mangers award; the validation certificate was seen on display. She has also undertaken training in dementia care, and has updated manual handling and fire training. The manager is open to the inspection process and willing to share and explore the management issues facing the home. Difficulties in maintaining a stable reliable staff group are apparent. Records of the staff meetings evidenced the management strategies to try and resolve the concerns. The new Deputy has improved the strength of leadership and support to the staff and she was seen to have been working to try and resolve the lack of care plan documentation. BUPA has made available the results of March 2005 customer satisfaction survey sent out to 23 individuals. Only 14 were returned which is a low representation of the 34 individuals in residency at the time of inspection. The results from this survey reported that 83 of those who responded gave an excellent/very good response to the quality of service in the home. The home keeps an “Accolade” file that was reviewed from the point of the previous inspection in February. The home had six “thank you” cards and letters from families in appreciation of the care and support given by staff. Corporate arrangements have been made with BUPA and CSCI with regard to the banking arrangements for resident’s monies. Documentation received by CSCI states that residents are able to have a separate account, which will supply on demand a separate itemised account detailing transactions undertaken with individual interest calculated and added to each residents account. The document states that residents have immediate access to any money they require. The working of these arrangements in the home were not inspected on this occasion. The supervision records of a small number of staff were seen and evidenced that the care practices of the individual were reviewed. The home has an annual appraisal for all staff where issues such as training and performance are covered in more depth. The poor performance of the home with regard to ensuring the care plans are in place and that all plans are kept up to date, signed for and were regularly reviewed meant that residents care needs were not seen as efficiently and effectively protected. Risk assessments for the garden pond and the window opening on an upstairs landing above a narrow ledge are recommended. Records of the homes service and maintenance contracts were seen. Risk assessments for safe working practices were in place, these included the use of lifting equipment, bedrails/cotsides, safe bathing, oxygen use, events outside the home and the use of portable fans etc. Fire equipment checks were regularly recorded along with water temperatures. The home had a group of staff on fire training during the inspection. Records HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 19 showed that 15 staff had undertaken updated load management training so far. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 1 x x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 3 3 3 3 3 2 2 HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 21 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. 1. Standard 7 Regulation 15 Requirement The Registered Person ensures that care plans are detailed on how residents needs are to be met by staff in respect of their health and welfare. A draft care plan to be in place within seven days of admission Care plans are to be kept under regular review and revised at any time with regard to change in circumstance or health. Plans are to be signed and dated The Registered Person ensures that any monitoring of a residents well being, following injury, is actioned and documented. The Registered Person ensures that home complies with the requirements made by the Royal Berkshire Fire & Rescue Service. The homes Fire Risk Assessment is to be sent to CSCI. The home is to send an action plan as to how the home will comply with the requirements made by Royal Berkshire Fire & Rescue Service. 5. HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 22 Timescale for action 17/6/05 2. 8 14 17/6/05 3. 18 13 (2) 17/6/05 4. 19 23 (4) 9/8/05 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 38 Good Practice Recommendations Risk assessments are to be put in place for the garden pond and for the landing window to restrict access HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA 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 HOLYPORT LODGE H52-H01 10993 Holyport Lodge V227520 170505 Stage 4.doc Version 1.30 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. 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