Inspection on 18/05/07 for Larchfield

This inspection was carried out on 18th May 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

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

CARE HOMES FOR OLDER PEOPLE Larchfield Larchfield Road Maidenhead Berkshire SL6 2SJ Lead Inspector Julie Willis Unannounced Inspection 18th May 2007 09:50 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 Larchfield DS0000068889.V331407.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. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larchfield Address Larchfield Road Maidenhead Berkshire SL6 2SJ 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) 01628 639428 01628 635936 larchfieldcare@aol.com European Care (West) Limited Sithembiso Hlalakuhle Care Home 75 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (70) of places Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: The European Care Group owns Larchfield. The group runs services for younger people and older people in many areas of the UK and Europe. Larchfield opened in December 2006 and is situated in a quiet residential area within half a mile of Maidenhead town centre. It is a nursing home that caters for the needs of people aged 65 years or over, who, because of physical or mental incapacity, require help with daily living. Larchfield can meet the needs of 74 residents. The home is purpose built over three floors and has the necessary adaptations, aids and equipment to meet the needs of its user group. Each person is provided with a single room with en-suite facilities and has the use of all communal facilities. Cost of services range from £635 to £735 per week. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was the first inspection since the home registered with the CSCI and opened for business in December 2006 and was an unannounced ‘Key Inspection’. The inspection took place on Friday 18th May 2007 between 09.50am and 4.20pm and covered all the standards for older people. At the time of inspection only three of the five units had been opened. 45 residents occupied the home. Prior to the visit a questionnaire was sent to the manager along with survey and comment cards for residents, relatives and visiting professionals such as doctors and nurses. Any replies were used to help form judgements about the service. Consideration has also been given to other information that has been provided to the Commission since the home opened for business. The inspector toured the building, examined records and met most of the residents and four relatives who were visiting at the time of the inspection. The inspector also spent time talking to staff and observing how care was being delivered to the residents. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals with various religious, racial or cultural backgrounds. The inspector gave feedback about her findings to the home’s manager at the end of inspection. There were no legal requirements made as a result of this inspection. The Commission has received no information concerning complaints since the home registered. What the service does well: Larchfield is well run for the benefit of its residents by a committed, caring and enthusiastic manager. The staff work well together as a team, so that there is a warm and relaxed atmosphere throughout the home. This is a specialist service, which meets the needs of residents with mental frailty. The home has been purpose built for its residents and has been equipped to a good standard. Residents benefit from living in a clean, comfortable home which is staffed with sufficient nurses, carers and ancillary staff to meet their needs effectively. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 6 The home works well with other agencies, seeking support and advice when needed so that it may meet the needs of residents more effectively. Staff records are well kept and all checks have been carried out to ensure that residents are kept safe from harm. Residents say that staff are caring and kind and offer them care in a manner which maintains their right to dignity, privacy, choice and independence. The staff team is well trained and professional and feel that they are well supported by the management. The home has a team of activity organisers who provide a range of interesting activities for residents to participate in. Residents say that they like to join in and particularly like musical events. The home and grounds are very well maintained and provide plenty of space for residents to enjoy in safety. 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. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 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 Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. All potential residents are fully assessed prior to their admission to the home to ensure that the service will be able to effectively meet their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examination of the documentation of five residents it is evident that a full needs assessment is carried out on each person before they are admitted to the home. The service considers carefully all information it has gathered during the pre-admission process before offering a placement. This ensures that staff have the skills, ability and qualifications to effectively meet the person’s need. The home uses a comprehensive and holistic tool to gain a picture of the needs of the individual. Where the local authority has referred a person to the home, a copy of the care management needs assessment is sought. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 9 Information about the needs of the potential resident is gathered from a variety of sources including the person themselves, a friend, relatives, advocates and other social and healthcare professionals. The information gathered forms the basis of the care plan. The home operates a strong diversity policy and has a commitment to ensuring that no-one is excluded on the grounds of their ethnicity, religion or culture. Therefore, as part of their pre-admission assessment the home discusses with each resident and/or their relatives how the person’s individual and cultural needs can be met effectively by the home, and this is then incorporated into the care plan. Various churches and religious groups have links with the home and provide pastoral support and guidance. A local church provides a communion service at the home at regular intervals. All prospective residents and their families are offered a visit to the home prior to agreeing admission, where they can meet staff and other residents. Staff are mindful of the need to make people feel at home and to welcome them. They recognise that this is often a difficult time for families and so they offer the necessary reassurance and support. The inspector spoke with several relatives who were visiting at the time of inspection. They confirmed that the admission process had been well managed. Relatives said, “It was a hard decision to make”, “I went to see other homes but this one impressed me the most”, “The staff were cheerful and kind and the manager seemed honest and up-front”. They said, “I was able to ask questions, I felt that they really knew what I was talking about and had experienced it all before. They seemed really knowledgeable and so I knew Mum would be safe here”. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area is good. Sufficient information is in place to enable staff to effectively meet the health and personal care needs of users. The system for the administration of medication is good with clear and comprehensive arrangements in place to ensure the safety of users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector case-tracked five of the residents from their initial referral to the home by social services or privately, to date. There was evidence that the written records were detailed, comprehensive and well documented. Clinical tools were being used routinely to assess and monitor tissue viability, nutrition, dependency levels and mental state. Where a risk had been identified, there were effective risk reduction measures in place and care plans gave clear guidelines to staff on how to reduce the risks identified. Risk assessments had been routinely undertaken on a range of risks including manual handling, risk of falls, use of cot sides and bathing. In addition there Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 11 were a range of risk assessments relating to the resident’s mental health. These included likelihood of absconding and risks associated with verbal and physical aggression. From examination of documentation it is evident that the home reviews care plans monthly and any changes in users’ needs were well documented and were responded to appropriately. The plan is a working tool and staff are involved in writing the daily report called ‘the daily statement of well-being’, the keyworker input chart and keeping the care plan up-to-date. The home uses a specialist tool called the ‘Modified Cohen-Mansfield Agitation Inventory’ which identifies ‘triggers’ to certain behaviours and which helps staff to identify when additional medication or specialist support is needed. All new residents have a ‘three day’ assessment post admission to ensure that they settle into the home and are being supported appropriately. The staff team were observed to be polite and courteous to residents at all times. They were mindful of the need to encourage residents to remain as independent as possible by providing the appropriate level of support. Staff took a uniform approach to the behaviours of individual residents offering gentle persuasion and a range of diversionary tactics to reduce the likelihood of confrontation or challenges to the service. Management confirmed that residents were provided with access to appropriate health and social care professionals when needed. The local GP visits regularly each Wednesday and, in addition, will visit when called. Screening and preventative treatments are offered routinely. There was evidence on file that users have regular chiropody treatments, hearing tests and sight tests. A local psychogeriatrician is a frequent visitor to the home and provides specialist advice and support to staff about dementia issues. There are four beds provided for palliative care, which are supported by McMillan nurses who provide advice on ‘End of Life’ care and pain relief issues. From examination of the medication administration system and discussion with staff it is clear that the home follows best practice guidance in relation to the storage, administration and disposal of drugs. The home operates a monitored dosage system and medication is delivered to the home on a monthly basis. Storage systems are effective and disposal systems using the ‘doom box’ system are safe. The relatives of residents made various comments to the inspector about the quality of services including, “I think the care is good”, “Dad is much more settled since he came here, staff know how to deal with him”, “Generally the care is very good, I trust the staff”. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area is good. There is a variety of activities within the home tailored to the specific needs of the residents. Mealtimes are a social occasion and the staff work together to ensure that residents enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home currently employs two activity organisers and is soon to recruit a third. From discussion with one of the organisers and observation of activities it is evident that residents enjoy a varied, interesting and stimulating lifestyle. There is a full programme of activities that have been specifically designed with the preferences and capabilities of the residents in mind. At the time of inspection residents were joining in with ‘parachute play’ skittles and ball games. Most activities are provided in small groups or on a one-to-one basis. Residents are actively encouraged to keep in contact with friends and relatives and they are free to visit anytime. Residents can choose to entertain their visitors in their bedrooms or in the communal areas. The large entrance hall to the home is particularly popular as a venue for such visits. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 13 The provision of meals is considered a social occasion in this home and residents are encouraged to eat in the communal dining rooms. These are spacious and airy and are well used by the residents. Each dining room has a juice machine where residents can help themselves to drinks throughout the day. The menu has been developed by the chef and management to meet the cultural and dietary needs of the residents and is attractively presented, varied and nutritious. On admission to the home the residents and their relatives are consulted about diet and nutritional requirements and these are notified to the kitchen. Food is served that can meet the needs of all residents including those who have swallowing or chewing difficulty. People that need support and assistance to eat are fed discreetly and sensitively before other residents sit down at the tables. This means that mealtimes are relaxed and unhurried and residents don’t feel pressured or self-conscious. Lunch on the day of inspection consisted of fish and chips with peas or alternatively a jacket potato with cheese followed by Swiss roll and custard. In addition the residents always have a choice of salad, sandwiches, omelettes or finger foods. Tea was soup and sandwiches or beef burgers, tomatoes and sauté potatoes followed by semolina. The chef can provide a range of special diets including diabetic options, soft and pureed meals for individual residents. Residents made comments about the lunch menu such as, “I like the food, it’s lovely”, “I don’t usually eat as much as this”, and, “Fish and chips are my favourite food”. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system. Residents feel their views are listened to and acted upon. Residents are protected from abuse and exploitation by staff who can demonstrate knowledge of the home’s abuse of vulnerable adults and whistle-blowing policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints procedure, which is clear and accessible to residents. Service users are provided with information on how to make a complaint to the home, the timescale for response and the stages and process of the organisation’s complaint process. There is a need, however, to make some minor amendments to the policy to reflect the address and phone number of the local CSCI office. Examination of the complaint records indicated that there have been four minor complaints made to the home since 1st January 2007. The details of the complaints were well documented. The complaints had been fully investigated by management and an outcome had been provided to the complainants. Relatives spoken to at the time of inspection confirmed that they felt confident that concerns would be taken seriously by the home and efforts would be made to remedy any problems in a timely fashion. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 15 On the day of inspection a number of staff were undertaking ‘safe guarding adults’ training in an upstairs lounge, provided by the organisation’s trainers. Additionally, there was evidence in staff files and from discussion with staff, that they receive training in the protection of vulnerable adults as part of their formal induction to the home. This learning is later consolidated when undertaking NVQ training in which it forms a core module. Staff interviewed were aware of the home’s whistle-blowing policy and understood the importance of protecting users from abuse and exploitation at all times. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome area is good. Standards of hygiene, décor and furnishings in this home offer residents a comfortable and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection much of the home was unoccupied by residents as the home only opened for business in December 2006. Three of the home’s units called Thames, Test and Avon were accepting residents and the palliative care wing had been previously utilised but was unoccupied at the time of inspection. One resident was being accommodated at night on Cherwell Unit where they were receiving 1:1 care. A tour of the home evidenced that the home was well maintained, clean and odour free. All furnishings are domestic in character and provide a pleasant environment for the users. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 17 Communal areas were spacious, bright and airy but required further personalisation to meet the needs of residents with mental frailty. Hallways and communal bathrooms were clean and well kept but appear somewhat bland and uninviting. The manager confirmed that she was intending to personalise the rooms by adding touchboards, themed areas and by using texture and colour to enhance the environment for residents. The home has pleasant gardens to the rear of the property with patio areas, seating and a small greenhouse for the use of residents. The activity organiser and maintenance man informed the inspector that gardening was particularly popular with a number of male residents at the home and there are plans to build a vegetable plot and provide a sensory garden. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area is good. The staff team were able to demonstrate that they have the necessary skills and experience to effectively meet the needs of residents in their care. Staff recruitment procedures are robust and protect residents from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector examined the recruitment records for five staff. The files evidenced that all necessary checks are undertaken on prospective staff to ensure the safety and protection of residents. The content of the files met the National Minimum Standards and Regulations. The policies and procedures relating to selection and recruitment ensure resident safety and are robust, transparent and meet the requirements of current good practice guidance and legislation. There was evidence that care staff have been properly inducted to Skills for Care Standard and have received core skills training in fire safety, first aid, manual handling, food hygiene, health & safety, COSHH and infection control. A number of staff were receiving training in adult protection at the time of inspection. This forms part of everyone’s induction and is a core module in NVQ training. All staff at the home are well motivated and the majority have either achieved or are working towards a National Vocational Qualification at Level 2 or 3. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 19 All staff receive ongoing support and are formally supervised at least six times a year. They have additional opportunities to air their views and to have a say in the way the home is run in the regular team meetings, head of department meetings, qualified staff meetings and senior care assistant meetings. The minutes of these meetings were examined by the inspector and appeared resident focused. Staff interviewed informally by the inspector seemed knowledgeable, motivated and caring and clearly knew the needs of individual residents well. The relatives of residents were very positive about the qualities and attitude of the staff team. They made comments such as, “warm & welcoming”, “kind” and “always helpful”. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35, 38 Quality in this outcome area is good. Residents benefit from living in a well run home, where there is evidence that health, welfare and safety is of primary importance and where quality assurance systems seek their views. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has the necessary qualifications and experience to manage the home effectively. It is evident that she is popular with residents, relatives and staff who say that she is approachable, conscientious and an effective leader. There is evidence that the ethos of the home is open, inclusive and transparent. Staff confirm that they have the opportunity to express their opinions openly in staff meetings, supervision sessions and staff handovers. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 21 They say that they are provided with plenty of opportunity to express concerns, share information and to feel included and involved in the way the service is delivered and this is evidenced in the minutes of these meetings. The home operates an ‘open door’ policy and actively encourages suggestions, comments and recommendations from residents and relatives. The manager holds a weekly ‘surgery’ out of hours to give residents, relatives and staff an opportunity to meet the manager privately to discuss any issues of concern. Details of these surgeries are displayed in reception. Each month 10 of the current service users’ relatives are sent a satisfaction survey for completion. The surveys are collated at head office and an action plan developed to identify where improvements should be made. From discussion with management it is clear that the home is currently reviewing how it manages residents’ personal monies. Most residents have a relative or advocate who deals with their financial matters on their behalf. However, appropriate assistance with money and valuables is offered by the home when necessary. The home holds small amounts of cash for residents to enable payment to be made for newspapers, toiletries, hairdressing and chiropody. The current method for auditing these accounts is safe and well managed. Examination of a sample of the health and safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for residents. All risks are effectively risk assessed and managed. Residents’ relatives said that, “The manager is very effective” and that they feel that they can express their opinions about the quality of the service “openly”. Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 22 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 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 3 x 3 Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations Consideration should be given to improving the quality of the environment so that it is more personalised and homely for residents with mental frailty. The organisation’s complaints procedure should provide details of the CSCI local office so that residents and relatives may contact the office if they wish to do so. 2 OP16 Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Larchfield DS0000068889.V331407.R01.S.doc Version 5.2 Page 25 - 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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