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Inspection on 13/02/08 for Houndswood House

Also see our care home review for Houndswood House for more information

This inspection was carried out on 13th February 2008.

CSCI found this care home to be providing an Adequate service.

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

People living in the home and visitors spoken to were quite positive about the standard of care in the home; "I am very happy" and "the staff are helpful and kind" were two comments made. The impact of the activity organisers on the care experience observed at one point in the inspection was noticeable and welcome, catching the interest of the people concerned and engaging them in a very positive way. The addition of a sensory garden area has enhanced what was already a very pleasant facility for those people living in the home who are able to access the home`s extensive and well-maintained grounds.

What has improved since the last inspection?

As noted above Houndswood is again in a period of transition with the appointment of a new manager, and although this has been managed well it is perhaps inevitable that some adjustment is inevitable before the pace of change within the home can be accelerated. The morale of staff was again found to be good and improvements in the way that people living in the home`s dignity is recognised and promoted has in general been maintained since the last inspection. Staff training remains a high priority for the new manager and enhanced dementia care training at NVQ level 2 has already been identified. People living in the home benefit from high quality staff training and the staff team are also encouraged and supported to obtain and enhance their skills through it. There were no concerns with the home`s recruitment practice found on this occasion, which represents an improvement over the last inspection.

What the care home could do better:

Although some excellent work by the activity team was seen, there is a need to widen the scope and frequency of activities throughout the day, in order to prevent long periods when not much activity appears to take place for people living in the home. There were some failures in medication administration good practice which could potentially have had seriously compromised the wellbeing and safety of people living in the home. It is also important that a higher standard of vigilance is maintained at all times when hazardous substances are being used in close proximity to people living in the home, as any momentary lapse can potentially have major health and safety consequences especially for those who may be living with dementia.

CARE HOMES FOR OLDER PEOPLE Houndswood House Harper Lane Radlett Hertfordshire WD7 7HU Lead Inspector Jeffrey Orange Unannounced Inspection 13th February 2008 08:10 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 Houndswood House DS0000019459.V359834.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. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Houndswood House Address Harper Lane Radlett Hertfordshire WD7 7HU 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) 01923 856 819 01923 853 509 houndswood.manager@craegmoor.co.uk www.craegmoor.co.uk Speciality Care (REIT Homes) Ltd Care Home with nursing 65 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (48), of places Physical disability over 65 years of age (4) Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This home may accommodate 4 older people who require personal care. This home may accommodate 4 older people with physical disability who require personal care. The maximum number of service users who can be accommodated is 48. 11th April 2007 Date of last inspection Brief Description of the Service: Houndswood House is a care home providing accommodation, nursing and personal care for older people as set out above. The home is owned by Craegmoor and registered under Speciality Care (REIT Homes) Limited. Houndswood House was opened in 1997 and is situated in a rural area between London Colney and Radlett. It is a period house with modern extensions, set in extensive parkland gardens with pathways a large patio area and a sensory garden area all accessible to people living in the home. The home is divided into two areas, identified by staff as the ‘main house’ and the ‘extension’. The older part of the house has one large ground floor lounge and a small sitting room. The ‘extension’ has communal areas all on the ground floor, which include dining, lounge and conservatory areas. All bedrooms in the new area have en-suite facilities with toilets. A lift serves each end of the home and a wheelchair lift is in place to enable improved access to one part of the older building. The premises are reached via a driveway from Harper Lane. Car parking facilities are provided to the front and rear of the building. Houndswood House is not served by public transport, but is close to Junction 22 of the M25 Motorway. The service user guide includes contact details for the Commission for Social Care Inspection (CSCI) and copies of the latest inspection report are available in the home. Current fees range from £525 - £1000 (As at February 2008). Additional charges apply for newspapers, hairdressing, personal toiletries, chiropody and private dentistry. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Two inspectors carried out this unannounced key inspection over approximately six hours, beginning as people living in the home were being supported to get up and start their day. During this inspection two hours were spent by one inspector looking in depth at the care being given to a small group of people. These observations were followed up in discussions with the manager and examination of relevant records. This inspection provided an opportunity to monitor the progress made by the home in meeting any requirements made following the previous inspection in April 2007 and also to assess how they had addressed issues raised during a successful application for variation to the registration conditions of the home, made to the CSCI registration team in July 2007. It was also possible to review key records, speak to people living and working in the home and to discuss future plans for the service with the new manager. After a period of progress under the previous manager, this service is again in transition, following his promotion within the company and the appointment of a new manager. It is positive to note that people living in the home have continued to benefit from the way many of the improvements noted following the last inspection report in April 2007 have been sustained and that there is also evidence that further action to improve the standard of care experience for people living in the home has been taken or is planned. However some areas of concern were raised with the manager, including medication administration and it was evident that there is room for improvement in the way that people in the home living with dementia experience care and daily living. The manager and her staff should be encouraged overall by this inspection, and provided recent progress made is maintained and any areas of concern are appropriately addressed, the care experience of people living in Houndswood will improve and this will then be reflected in the future rating of the home by the CSCI. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although some excellent work by the activity team was seen, there is a need to widen the scope and frequency of activities throughout the day, in order to prevent long periods when not much activity appears to take place for people living in the home. There were some failures in medication administration good practice which could potentially have had seriously compromised the wellbeing and safety of people living in the home. It is also important that a higher standard of vigilance is maintained at all times when hazardous substances are being used in close proximity to people living in the home, as any momentary lapse can potentially have major health and safety consequences especially for those who may be living with dementia. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Houndswood House DS0000019459.V359834.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 Houndswood House DS0000019459.V359834.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 4 5 (Standard 6 does not apply to Houndswood House) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People considering moving to Houndswood House can be assured that their needs will be assessed before they do so to make sure that they can be appropriately met. People considering Houndswood House as a home for themselves or someone they are responsible for can be confident that they will be able to visit the home to satisfy themselves that it is somewhere they will feel happy, safe and well cared for. Whilst most of the personal care needs of people living with dementia are met adequately, their need for appropriate stimulation and activity is met inconsistently, leading to periods of inactivity and lack of stimulation for them. EVIDENCE: Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 10 Care plans for people who have recently moved into Houndswood House were seen to include pre-admission assessments of their needs and how they were to be met appropriately. The availability of meaningful activities and stimulation for people living in the home was observed to be inconsistent and intermittent. When and where it was seen, it was often of a good standard and achieved a positive response from people living in the home. At other times, for some people, the level of their engagement and stimulation was seen to be poor, which resulted in significant periods of inaction and disengagement. One visitor spoken with during this inspection visit noted that their relative could “do with more stimulation and activities” Relatives and people living in the home confirmed that they had opportunity to visit the home before a final decision was made about living there and that they were supported and encouraged by the home to reassure themselves that Houndswood House was a place that could meet their needs and where they could be happy. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in general quite well completed and reflect a person centred approach to how care is to be provided in each case, they do however vary in quality and the format does not always assist care staff to access information readily. People living in Houndswood House have ready access to Healthcare services either in the home or within the community and this ensures that their healthcare needs are appropriately and promptly met. People living in Houndswood House are provided with care in a way that takes into account their individual preferences and wishes and reflects the respect and dignity that they are entitled to expect. Although Houndswood House has policies and procedures in place, which should ensure that the administration of medication is done safely, they are not always followed and this could put people living in the home at risk. People living in Houndswood House who are capable of dealing with their own medication are encouraged and assisted to do and this helps them to maintain their independence. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 12 There is good information contained in care plans about the end of life expectations and wishes of people living in the home, drawn up with their consent and participation which should ensure that wherever possible their wishes are met and their cultural and personal requirements are satisfied. EVIDENCE: A number of care plans were looked at, including those for people who have recently moved into Houndswood House and also for those people living in the home that were observed or spoken to during this visit. (This is called casetracking and enables the way care is experienced to be followed through by inspectors from observation and experience of those concerned to make sure that relevant records are accurate and well completed) The new ‘person centred format’ that has been introduced has improved the overall standard of care plans, providing care staff with the information they need to identify existing and changing needs and how these are being met in line with the wishes of the person living in Houndswood House. However, care plans are not always fully or consistently completed and in some cases, for example when there are concerns about nutrition and weight loss, the information about how much weight has been gained or loss is not always recorded or may not be readily accessible. This was discussed with the manager, who indicated that feedback from staff would be used in a process of evaluation of the new format that is currently being undertaken. Where people living in the home require their food to be prepared in a way that enables them to safely eat it, there was some evidence from people living in the home that this has not always been done in line with the requirements of their care plan. The manager and chef addressed this during the inspection and on the day of the inspection appropriately prepared meals were seen to be given to the right people. Care plans seen include good evidence of the involvement of community and acute health services as required, for example a community psychiatric nurse was seen in the home during this inspection. This should reassure people that their healthcare needs will be appropriately met in a timely way. Some poor medication administration practice was seen during this inspection, which was not in accordance with the policies and procedures of the home and which could have put people living in the home at risk. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 13 Care plans contain a particularly full level of information about the end of life wishes of people living in Houndswood House, provided with their involvement and consent and supported wherever possible by their signatures. This should mean that at that significant time it is possible for staff to provide care in a sensitive and appropriate way, reflecting the wishes and requirements of the people concerned. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Houndswood House are able to take part in activities organised for them in the home. These are however provided inconsistently and intermittently which means that some people living in Houndswood House experience periods without stimulation or activity to engage them. Access to community activities on a regular basis is possible for those able to do so, which helps them to maintain links and interests outside of the home. Visitors to the home are welcome which enables people living in Houndswood House to maintain contact with family and friends if that is their wish. Although the quality of food provided is good and reasonably varied, the overall eating experience for people living in Houndswood House could be further enhanced to make mealtimes more attractive and enjoyable for them. EVIDENCE: A very positive conversation was held with the home’s activities organisers, in which they outlined their plans for the future development of activities in Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 15 Houndswood House. This includes more frequent and perhaps longer trips for those interested, provided suitable transport can be arranged. This will benefit people living in the home who would otherwise be isolated from the community and places of interest outside of the home. There has been a meeting earlier in February between the activities organisers and people living in the home and relatives, and this has led to changes being put in place or planned to the activities programme, this demonstrates that they are genuinely committed to provide people living in Houndswood House with choice and the opportunity to influence the daily activities of their lives. Approximately five people regularly attend a local church coffee morning, and this is the highlight of the week for some of those spoken to during this inspection. The activities staff have undertaken some basic dementia care/activity training and have obtained a copy of an Alzheimer’s Society resource for activities organisers. Whilst progress is acknowledged, including the preparation of a reminiscence area, memory boxes and more complete life histories, it was agreed that further research and training would help staff to take account of current best practice, which would be beneficial for those people in the home who live with dementia. One relative spoken to thought that more activity could be provided and several people living in the home spoken to chose not to take place in any activities as they felt they were not appropriate for them. Although a very positive activity session was observed taking place at one point, which had a remarkable effect on lifting the atmosphere for those taking part, at other times there was very little activity or stimulation available and a number of people were observed to spend a very high proportion of their time asleep or withdrawn and disengaged. Comments made about the food were in general very positive, although it was observed that the dining experience could not be described as “The highlight of the day”, which is the title of a CSCI report on mealtimes and how they can be enhanced. If some relatively simple adjustments and improvements were to be made, the experience of people living in the home could be greatly improved and mealtimes could become more sociable and pleasant for them. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Houndswood House and those responsible for them can be confident that they are safe and protected by staff being adequately trained in the safeguarding of vulnerable adults and by robust policies and procedures being in place and put into practice. They can also be confident that any complaints or concerns they have will be addressed and dealt with appropriately. EVIDENCE: The home has a comprehensive complaints procedure in place, which is well publicised and readily accessible to anyone seeking to make a complaint or raise a concern. Staff training records and staff spoken to demonstrate that people living in the home are safeguarded because staff are trained to be able to recognise potential or actual abuse and will know what action to take if it is seen or suspected. There have not been any formal complaints raised with the CSCI since the last key inspection in April 2007. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 17 Those visitors or people living in the home that were spoken to all indicated that they would feel able to approach key staff or the manager with any concerns they had about care or other issues. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Houndswood House provides a safe, comfortable and well-maintained environment for those who live and work there. EVIDENCE: The home was clean and tidy on the day of this visit and there were no problems found with unpleasant smells. Several people spoken to mentioned the pleasant grounds and external environment, which now includes a sensory garden area that provides a valuable resource both for people living with dementia and others. One person living in Houndswood House talked with great pleasure about the birds, squirrels and even deer that come to her window and to the patio area outside her door where there is a bird-feeding station. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 19 Some further development of the area of the home principally used by people living with dementia is underway and this had caused some short-term displacement of filing cabinets and desks into a dining area, however in general the lounge areas were comfortable and warm and provided a pleasant area for people to sit. Those bedrooms seen, at the invitation of the people concerned, were comfortable and well furnished and included considerable signs of personalisation, so that the interests and personality of the person concern were reflected. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels whilst adequate most of the time are not always sufficient at key times and this adversely impacts on the care experience of people living in Houndswood. Staff recruitment and training is robust and thorough and should provide people living in Houndswood with confidence that their care is being provided by suitable staff with the skill and expertise required to do so safely and well. EVIDENCE: Training records seen and staff spoken to provide good evidence of a structured and comprehensive system of training for staff to equip them with the skills that they need to provide a good level of care to people living in Houndswood House. A moving and handling training session for staff was taking place in the home during this inspection. “They are very busy” was a comment received from one relative about staff and at certain times during this inspection call bell response times were monitored at 12 minutes and 7 minutes. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 21 Observing staff at lunch time in one dining room, it was evident that by the time all those who require assistance with their food had finished, their meals would have been unacceptably cold. The standard of care observed was in general good with only one instance seen where the standard of moving and handling was less than satisfactory whilst using a hoist. The manager has identified additional level 2 NVQ training specifically in dementia care which she is trying to source for staff to augment existing training undertaken, for example the “Yesterday, today and tomorrow course from the Alzheimer’s Society that has been used. This specialist training should enhance the care experience of those people living in Houndswood House who are living with dementia. Over 50 of care staff have achieved at least NVQ level 2 in care, which provides evidence of their knowledge and the commitment of the company to provide and support NVQ training for their staff, both of which benefit people receiving care. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This continues to be a well managed home so that those who live there and those responsible for them can feel confident that they are supported and protected by the way each area of its operation and activity is delivered, monitored and administered. EVIDENCE: The newly appointed manager, although not yet registered with the CSCI has considerable experience in managing care settings for people living with dementia. She is in the process of applying for registration and has also applied for an advanced two-year diploma in dementia care with the University of Bradford. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 23 The home has adopted a “person centred “ care planning approach and staff are being supported through improved supervision and training to understand and embed this within their practice. This will benefit all people living in the home including those living with dementia. Although there were significant lapses in medication practice on the day of the inspection and also one example of potentially unsafe use of some hazardous substances, it is felt that these were isolated events rather than being indicative of an overall poor standard. In addition they were quickly dealt with and appropriate action taken both at the time and subsequently. The home and company have a robust and thorough system of internal audit and quality assurance and details of this were seen. This should give confidence to the people living in the home that there is a system of monitoring in place, independent to the day- to- day management of the home that will be able to identify and rectify any potential threats to their health, safety and well-being. Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement In order to fully protect people living in the home the home’s policies and procedures for the safe administration of medication must be fully observed and complied with at all times. Timescale for action 13/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations The manager should obtain a copy of the CSCI report “The Highlight of the Day” and carry out an audit of the home’s mealtime experience, involving wherever possible people living in the home, to see if it can be improved or enhanced. Staffing levels should be kept under active review to ensure that they meet the needs of service users at all times, especially at key times when the demands on staff are greatest. 2 OP27 Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Houndswood House DS0000019459.V359834.R01.S.doc Version 5.2 Page 27 - 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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