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Inspection on 06/01/06 for Inglewood Nursing Homes Ltd

Also see our care home review for Inglewood Nursing Homes Ltd for more information

This inspection was carried out on 6th January 2006.

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

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

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

The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The residents are enabled to exercise choice and control of their every day life. The relatives and representatives are welcomed to the home and are kept informed of any changes and are complimentary about the service provided at Inglewood. There is a variety of good nutritious food offered and fresh fruit is readily available. The home is clean, safe and well maintained, which is appreciated by the residents and their relatives. A stable staff team who provide a consistent level of care. The staff were approachable, friendly and professional and were observed to interact well with the residents. There are clear policies and procedures in place for dealing with complaints.The recruitment procedures in place are thorough and robust, thus protecting the residents. There is a strong management team in place that ensure the home is run effectively and competently.

What has improved since the last inspection?

The medication practices within the home continue to be monitored and to improve. The care plans show evidence of review, however ways were discussed of evidencing resident and relative involvement of these reviews and changes to care practice. The residents receive a copy of the menu showing what meals they have chosen. The bed barriers were seen to be clean and are included in the cleaning programme.

What the care home could do better:

From viewing the main care plans and the files kept in the resident`s rooms, there were some areas of inconsistency between the two. The care files in the resident`s rooms were not of the same standard as the main care plan and some were inaccurate and difficult to follow. All the documents regarding residents need to be clear, directive and dated.

CARE HOMES FOR OLDER PEOPLE Inglewood 7-9 Nevill Avenue Hampden Park Eastbourne East Sussex BN22 9PR Lead Inspector Debbie Calveley Unannounced Inspection 6 January 2006 3:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 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. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Inglewood Address 7-9 Nevill Avenue Hampden Park Eastbourne East Sussex BN22 9PR 01323-501086 01323-500102 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) Inglewood Nursing Homes Limited Mrs Catherine Mary Duggleby Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (60) of places Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is sixty (60). Service users must be aged sixty-five (65) years and over on admission. Service users may have a physical disability and be aged forty-five (45) and over on admission. 20th July 2005 Date of last inspection Brief Description of the Service: Inglewood is a registered care home providing nursing care for sixty residents, who meet the registration category of elderly and physically disabled. The accommodation offered consists of fifty single rooms of which twentyseven have an ensuite facility, five double rooms one of which has an ensuite facility. There are ample communal bathrooms with specialist equipment to ensure the safety of residents whilst bathing. The home has the necessary specialist equipment required to meet the varied needs of residents, including hoists, air mattresses and cushions. There is level access to all parts of the home by passenger lifts. The home is well maintained internally and externally, with well-tended gardens that are accessible for wheelchair users. The home is situated in a residential area of Hampden Park, near to an attractive park and the local shops. There are public transport amenities close to the home. Inglewood is set back from the road and has parking facilities to the front for approximately ten cars. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 6 January 2006 at 3.30 pm and took place over 4.5 hours. A second visit took place on the 9 January 2006 specifically to view the recruitment files and to give feedback to the management team. There were fifty-eight residents in the home at this time. The staff on duty for providing care were two registered nurses and nine carers. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for ten residents and informal interviews with twelve residents, six relatives and four members of staff. It was a positive inspection where it was found that the standard of care has been maintained to a high standard. The feedback from residents, their relatives and the staff on duty was open and honest and the inspector would like to thank them for their time and their insight in to life at Inglewood. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The residents are enabled to exercise choice and control of their every day life. The relatives and representatives are welcomed to the home and are kept informed of any changes and are complimentary about the service provided at Inglewood. There is a variety of good nutritious food offered and fresh fruit is readily available. The home is clean, safe and well maintained, which is appreciated by the residents and their relatives. A stable staff team who provide a consistent level of care. The staff were approachable, friendly and professional and were observed to interact well with the residents. There are clear policies and procedures in place for dealing with complaints. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 6 The recruitment procedures in place are thorough and robust, thus protecting the residents. There is a strong management team in place that ensure the home is run effectively and competently. 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. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3, 4 and 5. The Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. A contract/statement of terms and conditions is given to all residents on admission, which confirms the facilities offered and care agreed. A pre-admission assessment is undertaken on all prospective residents before admission to ensure the home can offer them the care they require. EVIDENCE: The Statement of Purpose and Service Users Guide were viewed, these documents were found to be up to date and contained information that prospective residents need to make an informed choice of where to live. Inglewood has a website which is informative and is kept up to date. There is a video link in the reception area that gives up to date information on a daily basis of the staff on duty, including the chef and ancillary staff with a photo of the staff and their details. Visitors said they found this very helpful especially when they first visit. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 9 There is a written contract/statement of terms and conditions that all residents receive on admission to the home. This contract is confirmation of the room booked, the type of admission, either respite or permanent and the fees to be paid. Some minor changes to the contract are under review at present. An assessment tool, which covers all the needs as defined in standard 3.3 is in use, which is used for all prospective residents. Ten pre-admission assessments were viewed, and were found fully completed and informative. The assessment takes place at the prospective residents’ place of residence, and involve the relatives whenever possible and input from other relevant professionals is sought when required. Four residents spoken with said they remembered someone from the home coming to see them before they left hospital and confirmed that it had made the transfer to the home smoother as they felt they would as least recognise one person. Two residents could not remember being involved, but said they had been quite poorly at the time. The pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. These can then be discussed with the resident and their representative to ensure that the home can meet their needs and if necessary ensure that the correct equipment is in place before admission. The Statement of Purpose also gives information regarding the services they provide. Prospective residents can visit the home to meet residents, to look at rooms that are available and the facilities provided before they make any decision regarding accepting a place. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. All residents benefit from an individual care plan, which demonstrates the care required to meet their health, social and recreational needs. The medication systems in place are well-managed, promoting good health and the safety of the residents. The residents are treated with respect and courtesy in all aspects of their care. EVIDENCE: Ten care plans were viewed at this inspection, and were found to be clear and informative. All resident’s were found to have a comprehensive plan of care, which is generated from the initial pre-admission assessment. The care plans clearly identify the specific health, personal and social care needs of the residents. The care plans and risk assessments were clear and were seen to have been updated on a regular basis. The plan of care kept in residents rooms were not consistent with the main care plan for all residents, and this needs to be addressed to ensure that all staff are kept updated on any changes to a Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 11 residents needs, in particular the dietary and moving and handling documents. The regulation 26 visit has also identified this shortfall and plans are already in place to review and update these documents. There is evidence of resident/representative consultation in individual plans. Three residents and relatives said they had been involved in the discussions regarding their care plan. From viewing the information available in the care plans and then meeting those residents, it was found that the health needs of the residents were met. Specialist equipment was found in place where required, e.g air mattresses, cushions and various hoists with different slings. Input from speciality professionals is sought when needed. One relative said that the home “had all the necessary equipment to look after her family member well”, another relative said “we are very pleased with the care”. One resident said “I have been here for three weeks and the care is excellent”, another said “they look after me very well, thank you”. The full standard regarding medication was not inspected at this time, however the Medication Administration Charts were examined to monitor the effectiveness of the audit that is performed monthly. The charts were found correctly completed in the main, with only three omissions found which were discussed at feedback. The audit is proving beneficial and is raising the awareness of staff by questioning gaps and poor practice issues. The staff were seen caring and offering support to residents with dignity and respect and the atmosphere was calm and inclusive. One relative said that “ the staff were always polite and cheerful to both residents and visitors and that they always felt welcome”. A resident remarked that, “ the staff were helpful and encouraged her to be as independent as possible”. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The residents are enabled to exercise the choice and control of their every day life. The majority of residents benefit from a lifestyle that matches their expectations and preferences and the activity programme in place meets their social, religious and recreational needs. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents. EVIDENCE: All of the residents spoken with were aware of the activities offered and were complimentary regarding the range and those that attended thoroughly enjoyed them. Many of them mentioned the Christmas festivities and how much they had enjoyed them. Relatives also spoke of the activities arranged and how much the residents looked forward to certain events. The activity programme for January was seen and evidenced a variety of differing events such as bingo, quizzes, exercise classes. One male resident expressed an interest in doing some more creative activities and this was discussed on feedback and will be followed up by the activity co-ordinator. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 13 It was confirmed by talking to residents that the routines of daily living have a degree of flexibility; residents can request meals at a different time if they are going out and in their preference for getting up and for going to bed. They can choose when they have a bath, and how many baths they want. There is open visiting and two relatives said they were welcomed to the home, whenever they visited, tea and coffee was always offered and they could join their relative for lunch or supper if they should wish to do so for a small charge. One son said the “staff are all very good, always made him welcome and kept him informed of his mothers’ condition”. Another relative said “the staff were very hospitable and her mothers’ care was good”. The menus are distributed to the residents a week in advance and are also on display in the dining rooms. They demonstrated choice and variety and indicated a well balanced diet. All residents are given a copy of their choices so they can refer to it whenever they want to. The menus rotate on a four weekly basis and change according to the seasons. Fresh fruit is readily available. Residents feedback regarding the quality and quantity of food was very positive, some comments received were “ food is excellent”, “ tasty and plenty of it”, “food very good”, “the chef is wonderful, he does themed evenings and we all enjoy them”. Due to the time of the inspection, many residents were seen having their supper in their room or in the lounge, the dining area was not in use. From talking to staff and residents, this was their choice of venue. The food service was seen to be efficient in the main, however there were two separate queries regarding residents needing assistance that were identified to the senior nurse on duty and dealt by with immediately. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. The complaint procedure in place enables residents and their families to share their concerns formally and confidentially. EVIDENCE: There are appropriate policies and procedures in place and it was confirmed that these are followed when investigating any concerns raised at the home. The staff interviewed, were knowledgeable of the complaint procedure and of how to start the process if the manager is not available. The complaint book was viewed during the inspection and was up to date and evidenced that the policies and procedures are adhered to. Three of the residents referred to the Inglewood Brochure when asked if they knew how to make a complaint, whilst one resident said “she didn’t know of a proper procedure, but would go the senior nurse and that it would be dealt with”. Two relatives said that if they did have a complaint they would go straight to the manager, they have found her approachable and always takes their concerns seriously. Four complaints have been received in- house since the last inspection, and have been fully investigated and documented. There have been no complaints received by the CSCI. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The home provides a comfortable, clean and safe environment for those living there and for those visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the residents’ personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: The home is well furnished with good quality co-ordinated furniture. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All personal items are listed in the individual care plans. Four residents and two relatives said they were encouraged to bring in items of furniture and pictures. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 16 There is an ongoing maintenance programme and the home was found well decorated and maintained at this time. The home provides adequate attractive communal space. The communal rooms were comfortable and provide adequate communal space. Residents were seen entertaining families and friends during the evening. There is a dining area, two lounge areas of a good size, one leading in to a conservatory. One lounge area has a television, whilst the other lounge area with the conservatory is the quiet lounge with music available. Two residents were seen being offered a choice of which lounge they wished to be in and moved accordingly. Specialised equipment to encourage independence is provided e.g handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. A call bell system is in place and provided in all areas of the home which are used by the residents. Water temperatures were randomly tested and were of the recommended level. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. An evening domestic is now employed to ensure the cleanliness of the home is maintained. Good practice by staff was observed during the inspection whilst serving food and attending to residents. Sluice areas and equipment were found clean and hygienic. Residents and their relatives said that the home was always clean and the domestic staff work very hard. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. The staffing levels in place were adequate to meet the assessed needs of the residents. Robust recruitment procedures address the protection of the residents. EVIDENCE: The staffing levels on the evening of the unannounced inspection were found to be adequate for the needs of the residents. The nursing staff regularly assess the staffing levels and adjusts them according to the documented needs of the residents. The staff spoken to said they felt the staffing levels were sufficient to ensure a good standard of care. They also said that if more staff were needed for a poorly resident it would be provided. One resident said that she never had” to wait long if she rang for assistance” and during the inspection there was a prompt response to all call bells. Two relatives said they had no concerns regarding the level of staff, they also mentioned that the staff seemed to stay and so they got to know them. A further two relatives said that they felt that there was enough staff on, and that the staff team was consistent. The staffing rota was viewed and the number of staff on duty were consistent with the rota. Five staff files were examined and it was proven that rigorous recruitment procedures are in place and these demonstrate that correct employment practice and legislation is adhered to. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 18 Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Residents benefit from a Manager who is competent and runs the home efficiently and effectively. The ethos of the home is open and transparent enabling residents to participate in the running of the home, should they wish to. All aspects of resident’s health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager has been the owner and manager of Inglewood for eighteen years. She is a registered nurse with a diploma in Advanced Management of Care. There is a clear structure of management in the home, and this is clearly demonstrated in the Statement of Purpose and Service Users Guide. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 20 The atmosphere of the home on this unannounced inspection was positive, calm and inclusive. The staff were observed doing their work competently and showing respect to their colleagues and the residents. The residents and relatives spoken with were appreciative of the manager and her staff. Regular staff meetings and supervision sessions encourage the staff to communicate their views and if appropriate acted on. Relative and resident meetings are held regularly and are well attended and beneficial. Handover sessions at every shift are greatly valued by the staff and enable staff to be brought up to date on any changes or problems. Regulation 26 visits are performed monthly and a copy sent to the CSCI area office, these documents form an important part of the running of the home. A quality assurance system is in place and has proved beneficial in the running of the home. The management team continues to provide a training programme that is suitable for the staff and for the needs of the residents. The staff stated that they receive a variety of training, which has helped them to provide a good standard of care. The home has a comprehensive set of policies and procedures, which govern the running of the home. Staff are supported by the management team on a daily basis and more formally through supervision. They receive regular supervision and annual appraisals, which are in a written format and copies are kept in the staff files. The manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. The staff are issued with certificates for Manual Handling, for Fire Safety and Food and Hygiene. All relevant legislation and procedures are in place and in accordance with the Standard. The records required by regulation for the protection of the residents are in place and accurate. Individual records and home records are kept secure and up to date and are maintained in accordance with the Data Protection Act 1998. The management team of Inglewood is very organised and has a thorough understanding of the National Minimum Standards and the accompanying regulations. Good practice was observed throughout the inspection in respect of health and safety. The first aid boxes are checked regularly, all fire exits were found clearly marked and free from obstruction. The equipment used for residents are regularly serviced and kept in good condition. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 x 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement That the method of recording and care planning is reviewed to ensure that all the paperwork is consistent and correct. Timescale for action 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations That evidence of resident/representative involvement in the review of care management is incorporated in the care planning of the resident. That the audit for medication administration is continued. Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Inglewood DS0000014005.V262170.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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