Inspection on 15/02/06 for Spring Mount

This inspection was carried out on 15th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Spring Mount 05/01/07

Spring Mount 15/09/05

Spring Mount 16/11/04

Spring Mount 29/06/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Spring Mount Parsons Road Heaton Bradford West Yorkshire BD9 4DW Lead Inspector Barbara Grell Unannounced Inspection 9:00 15 March 2006 th X10029.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 Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Spring Mount Address Parsons Road Heaton Bradford West Yorkshire BD9 4DW 01274 541239 01274 772000 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) Mrs Janet Bell Mrs Jacqueline Taylor Smith Mrs Janet Bell Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24) of places Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Spring Mount was established and first registered in 1987. Janet Bell and Jacqueline Taylor Smith are the registered providers and also manage the home. It is an impressive detached house situated in it’s own half acre of well maintained garden. The grounds are secure in order to ensure the safety of the service users whilst enabling free movement. Spring Mount aim at providing a homely, family type environment for individuals of all ages suffering from memory disorder and dementia. Accommodation is provided on three floors. Those with mobility needs have rooms on the ground floor, as there is no lift installed. The local area features shops, bus routes, pubs and the Lister Park. The overall philosophy at Spring Mount is to care for people with dementia without the effects created by the administration of sedating medication. Staff in the home use a holistic, psychotherapeutic approach toward problems associated with dementia, enabling the person to come to terms with, and learn to live with their dementia in a positive way, regaining dignity and selfrespect. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The inspector arrived at the home at 9:00 and the inspection lasted 6 hours. During this inspection the home was assessed against a number of core standards and this included previous recommendations and requirements. Reports and information on this and other registered care homes and services can be found on the CSCI Website on www.csci.org.uk. The following methods were used in collecting the information and evidence leading to judgements made in this report. The service users were as fully involved in the inspection as possible and 17 service users out of the twenty four were able to make comment about their care. The interactions between staff and service users were observed during breakfast and lunch and in communal lounges and the grounds in between meals. The service users activities and routines were observed and how staff help, assist and enable service users monitored. As part of this inspection three case records were tracked. Two staff personnel files and training and supervision records were inspected. The food provision, menu planning, food stores and kitchen facilities were inspected. The inspector focused on hygiene as well as nutrition and hydration. This inspection further focused on if and how the home ensures a good quality of life and positive routines and experiences for service users. The inspector was able to have discussion about the standard of care and services with two NHS nurses who provide for any nursing treatments needed. Two visitors were seen and both had the opportunity to comment these informed the inspection. The inspector was also able to have discussions with the senior care assistant; three care assistants, two cooks and one of the providers. What the service does well: Service users are treat as individuals and their personalities and choices are accepted by staff and underpin the way care and services are provided. Service users were seen to be confident and relaxed. When able individuals were able to move around the home and gardens, spend time by themselves or with others. There was a good deal of conversation and banter. Staff ensured that when anyone looked lost, bored or anxious they were offered activities and reassurance. Personal care was provided in private and staff were discreet to ensure dignity and self-respect was maintained. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 6 Service users enjoyed a choice of well-prepared and wholesome meals and had a relaxed and sociable dining experience. Staff are well trained and the staff team is in the main stable with several long-standing team members. Policies and information is accessible to all employees and ongoing supervision and staff appraisals are ensured. This leads to expectations being known and a good continuity of care for service users. 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. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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 The service users needs are assessed and recorded. Care plans reflect the service users needs including health care needs. Regular review ensures that the changing needs of service users are recognised and acted upon. EVIDENCE: The previous inspection found that there was a need to develop the care planning review, evaluation and update of care plans/assessments. The registered persons ensured that the team was made aware of these shortfalls. The senior carer on duty was able to comment that review of all case records had been undertaken and some had been changed in line with observed Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 10 changing needs. There is a good degree of commitment amongst the staff team to provide a high standard of care and a good quality of life. Care plans seen reflected a person centred approach that clearly takes account of the individuals needs, preferences, skill level and choice. The service users health care needs continue to be well recorded, monitored and addressed. NHS nurses continue to provide for any nursing needs individuals may have from time to time. The two nurses on the premises that day had good relationships with staff and afforded much patience when attending to individuals. Improvements and deteriorations are discussed and any actions needed by staff included in the care plan. All service users have a choice of local GP. Baseline and medical reviews are undertaken periodically. There are policies in place pertaining to service users consent to treatments and care. Staff are aware of the content and endeavour to give as much choice as possible. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 The service users are able to exercise choice and control over their routines and actions in the home. Staff assist and enable rather than “do” and this benefits service users to maintain their skill level, confidence and dignity. The meals and meal times are well done and residents feel this is a strong point. EVIDENCE: Whilst the service users skill level and understanding varies from person to person staff ensure that this level is known and individuals encouraged and enabled to make decisions within their skill level. This ensures that care giving does not compromise the individual’s abilities and allows individuals to continue to practice their skills. Service users choose how to spend their time. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 12 Staff members are available to help. There is much conversation and staff showed a great deal of patience and understanding when communicating with individuals. Staff involve groups and individuals in conversation and activities. Consent is sought for care giving. Individuals in the home are rarely prescribed with any sedating medication. The outcome is that service users continue to be active and involved and any challenging behaviour or anxiety is addressed by providing stimulations and activities that overcome these. Several good examples were observed. Triggers that result in anxiety, discomfort, or challenging behaviours when known are noted and avoided. Service users are allowed and encouraged to individualise their own room and bring in items of furniture or decoration. Staff know service users as individuals and are accepting and know their preferences and individual routine. The menus are planned taking account of the service users needs as well as their likes and dislikes. Several individuals have dietary needs including sugar free diets, vegetarian, soft and reducing diets. The care plans and nutritional assessments provide details about individual’s needs and preferences. The choices available are displayed to allow individuals visual prompts when choosing food. There are always several choices available at each meal. The dining room allows for meal times to be a social occasions. Plenty of time is allowed. At breakfast most of the service users were in the dining room and they enjoyed a variety of continental and cooked choices. Residents were having conversations with each other and staff. Staff discreetly assisted some individuals. An enjoyable mealtime was observed. At lunch a two-course meal is provided. Individuals can help themselves to fruit juices. Residents were seen to help each other at times and again there was conversation and enjoyment apparent. Individuals were allowed a choice of food portion and choice of the menu. Seconds were offered both of main course and pudding. Service users were relaxed and able to enjoy their meal. Service users said that they enjoy the food and that there is plenty of choice. Staff were seen to provide drinks and snacks in between meals. The inspector had discussions with the two cooks. They had both received appropriate training in respect of hygiene and infection control. They were able to discuss menu planning and their cleaning schedules. The kitchen was clean and tidy and well organised. Fresh ingredients are used including fresh fruit and vegetables. The home aims at providing a healthy, wholesome and nutritious menu. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 & 18 There is an effective and transparent system for complaint and protection. EVIDENCE: The complaint procedure is part of the service user guide and known to visitors and staff working at the home. Complaints are taken seriously, investigated and records kept of findings and action taken. Staff were able to comment that they had received training in respect of adult protection. They were able to discuss how to detect and report any allegations or observations. The registered person is aware of local adult protection procedures and the use and aim of the POVA (Protection of Vulnerable Adults) register. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 & 26 The gardens and communal rooms are for the most part well maintained and enjoyed by service users. However, areas not level and posing a trip risk must be made good. The home is clean and good hygiene standards are maintained. EVIDENCE: The gardens, communal rooms, kitchen and laundry were inspected. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 15 One garden wall bordering to a neighbour had collapsed and additional fencing fitted to make this area safe. Mrs. Bell was able to say that this wall was the responsibility of the neighbouring property and she had made every effort and asked the person responsible to undertake repairs to this boundary wall. The wall collapsed in November 2005. It was noted that that there are two surfaces that are in need of repair and levelling to reduce the risk of trips and falls. This is the entrance that has two slight ledges that are difficult to see and hence easily tripped on by people entering or exiting the home. Levelling these would reduce this trip hazard. The area leading from the rear entrance toward the garages has a number of potholes and ledges that needs to be filled and levelled. This area especially is in continued use by service users and prompt acting should be taken. The gardens benefit the service users and all have free and independent use. Many said that they enjoy going out for a walk. Several smokers in the home go outside to smoke, as this is not allowed in the house. Staff provide supervision during this time. Two of the residents said that they like to help around the garden. The handy man and staff involve individuals in tasks and this benefits individuals and increases confidence and a sense of worth. Others enjoy the flowers and benefit from the fresh air and physical exercise whilst outside. The lounges are comfortable and equipped with various entertainment facilities including TV, stereo and fish tank. Visitors and service users feel that the entrance, staircase, corridors, lounges and conservatory had been well updated and maintained over recent times. This has been achieved by updating and refurbishing the décor and carpeting. The dining room would benefit from a similar update. The laundry at the home was clean and tidy. Adequate equipment is provided to maintain good standards of hygiene and cleanliness. The kitchen is well equipped with industrial stainless steel fittings, six-hob cooker and double ovens, fridges and freezers, dishwasher and large size grill. The kitchen was clean and tidy and cleaning schedules followed. Staff were able to discuss how they sanitise and clean areas. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29 The recruitment and selection practices ensure that employees are appropriately vetted. The staff are supported and encouraged to undertake NVQ training and standards are met. EVIDENCE: Two personnel files were inspected. These showed evidence that individuals are subject to appropriate checks including CRB (Criminal Records Bureau), POVA and Home Office clearance when needed. Two references were available in each case and any qualifications and copies of training certificates are also held. Personnel files gave details of any disciplinary or grievance. All prospective employees are subject to interview and a trial period. The interview is used to determine the candidate’s history, attitude, skill and knowledge. More than 50 of staff are qualified to NVQ level 2 or above. Senior care staff are encouraged to and supported to undertake NVQ level 3 training. All staff on duty felt well supported by senior staff and the registered persons. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 17 Individual employees felt valued and felt that they were encouraged to achieve professional development and growth. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 38 The quality of services and care provided is regularly monitored and service users and visitors opinions ascertained. Risk assessment and management ensures that service users are safe. EVIDENCE: Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 19 Mrs Bell and Mrs Smith the registered providers also manage the home. They are present at the home to provide supervision, training and oversee care giving on an ongoing basis. All areas are subject to regular review and monitoring. Surveys are undertaken regularly and the outcome informs change when needed. Visitors are able to have informal discussions with staff or the managers. The registered persons are able evaluate, review and make appropriate changes. High standards are aimed at and regular supervision of staff and clear policies ensure that expectations are made clear. The well being and outcomes for service users is the central consideration. Risk assessment is undertaken in respect of the environment and services provided and this includes risk assessments pertinent to individual needs such as manual handling needs. Contractors attend to maintain and service equipment such as gas, electric and fire safety systems and equipment. Emergency lighting and fire alarm systems are regularly checked and records kept to evidence good working order. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X 37 X 38 3 Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13 Requirement The wooden ledges to the entrance should be made even. Potholes and uneven areas near the rear entrance and leading to the garages must be levelled to minimise the risk of trips and falls. Timescale for action 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Spring Mount DS0000001147.V283036.R01.S.doc Version 5.1 Page 23 - 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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