Inspection on 22/03/07 for Kexborough House

This inspection was carried out on 22nd March 2007.

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

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

Other inspections for this house

Kexborough House 15/03/06

Kexborough House 05/10/05

Kexborough House 01/10/04

Kexborough House 01/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Kexborough House 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN Lead Inspector Ivan Barker Key Unannounced Inspection 22nd March 2007 10:00 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 Kexborough House DS0000018260.V325086.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. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kexborough House Address 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN 01226 385046 F/P 01226 385046 none none MJM (Furnishings) Limited 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) Mr Michael Matthews Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: Kexborough House is a large brick built residence with a single storey purpose built extension that stands in its own well kept grounds, in the village of Kexborough. Accommodation is on two floors served with a passenger lift. The large gardens are landscaped and include a small orchard and rose garden. There are two large patio areas with easy access for residents’ use. Car parking is available at the front and side of the home. Kexborough House is a Christian home, which operates a no smoking policy. The home is registered for 22 elderly people. The home can be easily reached from the M1, motorway junction 38 and following the signs for A637 to Barnsley. Within a short walk from the home is full range of amenities including the post office, health centre, shops, pharmacy, community centre, country pubs, churches and local village club. The Statement of Purpose and Service User Guide was available in the small room adjacent to the entrance. Service user had a copy of the Service User Guide. Mr M. Matthews is the registered person and manager. The fees range from £360. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The persons present at the inspection was: Mr and Mrs Matthews, registered persons and manager. Within this site visit, which occurred over a six hour period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 3 service users (Case tracked means looking at the care and service provided to specific service users living at the home; checking records relating to their health and welfare (care plans and other records); by talking to the service users themselves; viewing their personal accommodation as well as communal living areas) and spoke with other service users, and relatives and also 3 staff and examined assessments, care plans, risk assessments, activity records, menus, staff files and quality audit information. The history of the service was examined prior to the site visit. This included the pre inspection questionnaire, telephone contacts, letters, notifications etc. What the service does well: Service users were satisfied with the care and service they received. The positive comments were; ‘It’s nice here’. ‘Care is ‘good’ and ‘very good’’. ‘The care is 10 out of 10’. ‘Very happy with mum’s care’. ‘This place was full and I had to wait a long time for a place. People only get to know about this place by word of mouth.’ ‘Had to wait 3 months to come to this place, always full’. ‘We play dominoes regularly, there are sometimes 3 or 4 tables going on at the same time’. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 6 ‘Activities do occur and mum does like to go and watch, but chooses not to participate’. ‘We like to go for walks in the gardens or out into the community, visiting family and friends’. ‘We go to the local church and the Darby and Joan club. ‘The food is ‘good’, ‘very good’’. ‘Always a choice’, ‘Always plenty of choice’ ‘Mum has gained weight’. ‘The place is clean, tidy and well decorated’. ‘Clean and nicely decorated’ ‘I have a nice clean room’ ‘It’s like a four star hotel’ ‘Its ‘nice’, ‘very nice’ here’. The staff are ‘wonderful, kind, and friendly’, ‘good’, ‘very good’ and ‘they give good care’. -------------------Comprehensive assessments were obtained prior to the service user’s admission to the home. The good practices with the administration of medications and intermediate level training should provide protection, for the service users. An experienced registered manager / registered person is in post, and available to service users and relatives, this will contribute to the effective organisation and operation of the service. There was a commitment from the staff and the manager to provide a good to excellent standard of care and service provision. The evidence found through the inspection process, which included the positive comments from service users relatives and staff, showed that this had been achieved. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Kexborough House DS0000018260.V325086.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 Kexborough House DS0000018260.V325086.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): Standards 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accurate comprehensive assessments were in place either from the care management team or from the staff of the service, for the self funded service users. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: On examination of the service users’ care management assessments, two service users had care assessments from the care management team. The other service user was a self-funded individual, who had been fully assessed by the staff of the service. All assessments documents were signed and dated prior to the admission date. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 10 Documentation regarding the assessment undertaken by the staff of the service, was examined and found to be comprehensive, and detailed the service users needs which would assist in providing sufficient information for a care plan to be drawn up. The manager advised that no intermediate care was provided within the service, and that no service users were placed at the service on an emergency basis. All placements to the service were through the full assessment process from a waiting list held by the service. Kexborough House DS0000018260.V325086.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): Standards 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accurate care plans and care reviews will contribute to the delivery of care. Service users were satisfied with the care they received. The good practices within the administration of medications should provide protection for the service users. EVIDENCE: On examination of the care plans, from three service users, it was established that all three care plans were up to date, and had been evaluated on a monthly basis, and had evidence that the service user or family had been consulted on the content of the care plans. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 12 On examination of the daily entries within the care plans, it was established that each entry was a list of codes relating to the delivery of care. Example, a three letter code for – ‘dressed self independently’, a different code for – ‘assistance given with dressing’. Within each plan there was a list of the codes and their means. Some of the daily entries contained further information as well as the codes. To obtain a clear picture of the delivery of care required constant reference to the coding information. On discussing this with the manager, he identified that the system had been previous seen by the inspectors of CSCI, and been accept as a means of recording, and also the staff were fully aware of the coding system and it was working well. On discussing the coding system with the members of staff, they were able to read and interpret the coding within the daily entries, without reference to the coding information. The possibility of agency care staff having difficulty with this system was discussed with the manager. He advised that agency staff was never used within the service. He supported this by producing copies of the duty rotas, which indicated only permanent staff. The system, although not conventional, did appear to be working and understood by the staff. Risk assessments were included within the documentation and included moving and handling. Service users and relatives expressed their views, during the inspection. Their opinions were; ‘It’s nice here’. ‘Care is good and very good’. ‘The care is 10 out of 10’. ‘Very happy with mum’s care’. During the discussions regarding care, two service users stated that; ‘This place was full and I had to wait a long time for a place. People only get to know about this place by word of mouth.’ ‘Had to wait 3 months to come to this place, always full’. The storage, ordering, administration and disposal of medication procedures were discussed with the manager. The manager explained that the service holds a medication stock of just 7 days. The pharmacist, who provides the medication from the prescriptions, stores the remaining amount of the 28 days supply, because of the limited storage space within the service. The ordering, Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 13 administration and disposal procedures explained by the manager were satisfactory. On examination of the medication administration records it was found that there were no omissions of signatures. All medication records had been signed when being checked in from the pharmacy. Kexborough House DS0000018260.V325086.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): Standards 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities were organised within the service, and there was considerable involvement in the local community, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the activities and provision of meals. EVIDENCE: The manager advised that the staff were responsible for organising activities. The activities included playing dominoes, scrabble, and quizzes on a regular basis, one to one discussions and various other activities. A church service, with communion, was held within the service, twice a month. A service was taking place, at the time of the visit. There were 18 participants. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 15 Also some service users visited the local churches and members from the churches visited the service. Also service users visited many of the local community facilities, which included the local shops, clubs etc. Discussions regarding the title of the home, being a ‘Christian’ care home occurred. The manager identified that the home was based on Christian values, and this was reflected in the Statement of Purpose. On examination of the document it was established that the statement did refer to Christian values and went onto state that all persons were welcome into the home. The manager provided evidence, relating to activities from the documentation within the care plans, These records showed when a service user had participated in a activity or went out into the community. It was agreed that there was several blank spaces within these records. The manager identified that the records had omissions rather than the service user not undertaking activities. The members of the staff supported this statement, when the subject of activities and the activities records was discussed with them. On discussing the activities with the service users, and relatives their opinions were that; ‘We play dominoes regularly, there are sometimes 3 or 4 tables going on at the same time’. ‘Activities do occur and mum does like to go and watch, but chooses not to participate’. ‘We like to go for walks in the gardens or out into the community, visiting family and friends’. ‘We go to the local church and the Darby and Joan club. It was observed that the service was very busy, with visitors arriving and service user leaving to visit the community. Regarding the meals, the manager advised that only ‘branded goods’ were served and the service users were offered for breakfast, 6 choices of cereal, 2 choices of fruit juice and a cooked breakfast, for lunch a choice of a hot cooked meal or a choice of sandwiches, for dinner a choice of 2 cooked meals. Copies of menus were shown to support this comment. The manager also advised that the cook asked each service user, after breakfast, what their choice was for the lunch and dinner. The cook’s records were shown as evidence. On examination of these records it was established Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 16 that a wide choice of meals were ordered, including light meals such as scrambled eggs which were not on the menu. Whilst touring the building, it was observed that lunch was being served and a variety of meals, including sandwiches, light meals and main meals were being served. Positive comments were received from the service users and relatives regarding the food provision. The general comments were that; ‘The food is good, very good’. ‘Always a choice’. ‘Always plenty of choice’ ‘Mum has gained weight’. It was accepted that the activities within the service may be limited, but clearly the service users enjoyed the sessions of dominoes, scrabble, and quizzes. The service users were more involved within the local community. The standard of choice, availability to access and participate within the community and the choice and quality of food were of a high standard. For these reasons, this section was awarded as excellent. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had a complaints procedure in place, however there was minimal available evidence to judge, if it was operating according to the company policy and if complaints were resolved within the expected timescales. The service was able to evidence that the staff had received Safeguarding Adults training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: The complaints procedure was displayed and available to the service users and relatives. On discussing complaints with the service users, and relative they stated that they were satisfied with their care and service provision, and had no complaints. During the discussions with the manager, he identified that the last recorded complaint within the complaints book was in 2003, and that only verbal concerns had been raised and were immediately acted up and addressed that day. It was discussed that it could be beneficial to record the verbal concerns and to use this information within the quality monitoring of the service. The manager accepted this comment. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 18 Regarding safeguarding adults, the service had policies and procedures which were available to staff. Staff had undertaken safeguarding adults training, and the manager was able to evidence this by showing training records and certificates. This was a previous requirement, which had been acted upon and resolved. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment, monitored at the site visit, had been maintained to a high standard to provide a safe, well-maintained environment for services users, except for the window, which was secured at the time of the visit. EVIDENCE: On touring the building, the home was found to be clean, tidy, well maintained and decorated and furbished to a high standard. However within Room 20, located on the first floor, the window could be opened more than 45 cm, as there was no restrictor. The manager identified that most of the windows had been replaced, but this one was yet to be Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 20 replaced. The manager agreed that a restrictor needed to be fitted. The window was secured and locked to restrict its opening and to make it safe. The manager advised that a restrictor would be fitted within 24 hours. As the window was secure and the manager expressed a commitment to act immediately on the matter, this timescale was accepted. Positive comments were received from the service users and relatives regarding the home. The general comments were that; ‘The place is clean, tidy and well decorated’. ‘Clean and nicely decorated’ ‘I have a nice clean room’ ‘It’s like a four star hotel’ ‘Its nice / very nice here’. The service users’ rooms had been personalised and many contained photographs, personal belongings and items of furniture, which the individual or the family had provided. Some of the rooms were considerably larger than the minimum required size. The manager advised that when a room became empty, then the room was redecorated, often in the colour chosen by the next service user or family and the room re carpeted. The call system operated on a call and pagers system. When assistance was required the system would activate all the pagers and identify the room where assistance was needed. All care staff including the manager carried a pager. On discussing this system with the manager, he identified that the system contributed to a quiet and calm environment within the home, as alarms were not constantly ringing, as in other homes. Whilst the inspection was taking place, the pager in the manager’s possession was observed to bleep on several occasions and was reset by the cancellation of the call, where a member of staff had attended, within a short timescale. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager was not able to provide evidence that staff had received training, which could reflect on the quality of care being delivered to the service users. The staff recruitment process should provide protection for the service users. EVIDENCE: On examination of the staff rotas and examination of staff on duty, the following was established: Am. shift – Pm. shift– Night shift – Plus A manager Ancillary staff included. Domestic and catering staff. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 22 2 carers plus 1 care 9am to 1pm 2 carers plus 1 carer 6pm to 9pm 2 carers Caring for a present occupancy of 22 service users. A full assessment of the dependency levels of the service users was not undertaken and compared with the indicated staffing levels. On examination of the three staff files, all contained the required documentation, including Criminal Records Bureau and POVA (Protection of Vulnerable adults) checks. The manager advised that the workforce was fairly stable within the service, because of the fact that the staff received above the minimum wage, the staff operated as a team, and the home had a good atmosphere in which to work. On analysis of the pre inspection questionnaire this comment was supported by the information regarding staff commencement dates and the turnover of staff. On examination of the staff training records there were records and certificates that indicated the staff had received moving and handling, fire. However it was established that some staff had not attended moving and handling for 14 months. This information was supported from the discussions with the staff, who identified that the last moving and handling training was approximately 14 months ago. The importance of updated training to protect the service users, the staff, and the company was discussed with the manager. The manager gave an assurance that training would be delivered to the staff, as soon as he was able to organise a training course. Safeguarding Adults training and other specific training regarding the client group that they were caring for, had occurred. This included the intermediate level on medication training and intermediate level on food safety training, which is above the expected level of training for this type of care service. Three staff advised that they were of the opinion that the standard of care and service provision was good and that ‘the place was nice and the owners good to work for’. They did not express any concerns. The service users and relatives commended the staff as being ‘wonderful, kind, and friendly’, ‘good’, ‘very good’ and ‘they give good care’. The manager advised that training of the National Vocational Qualification training, (NVQ) continued and all staff either held NVQ Level 2 or Level 3. First Aid training, which was stated as a requirement at the last inspection, had been completed. A member of staff with first aid training was on duty on each shift. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 23 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. EVIDENCE: A registered manager, who was also the registered person, was in post. He had obtained the NVQ Level 4 qualification. Regarding Quality Assurance, the manager produced a file containing standards, which the service was expected to comply with. This was an extensive document produced by the administrator and manager. The benefit Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 24 of a monitoring tool to measure the standards was discussed with the manager. Through these discussions, it was accepted that the manager monitored the service on a daily basis, as he was actively around the service, observing practice and speaking with service users, relatives and staff. Regulation 26 documentations, which are a record of the registered person’s monthly visits, were not necessary for this service as the registered person was also the manager. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; had been received by CSCI (Commission for Social Care Inspection). The pre inspection questionnaire confirmed that the necessary maintenance and servicing had occurred. Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 25 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 26 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 2 Standard OP19 OP30 Regulation 18 13 Requirement The window with room 20 must be restricted in opening to provide a safe environment. All staff should receive moving and handling training within a 12 month period. Timescale for action 22/04/07 22/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Kexborough House DS0000018260.V325086.R01.S.doc Version 5.2 Page 28 - 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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