Inspection on 19/12/06 for The Coombe House

This inspection was carried out on 19th December 2006.

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

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

Other inspections for this house

The Coombe House 10/01/06

The Coombe House 24/06/05

The Coombe House 09/11/04

The Coombe House 29/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Coombe House The Coombe Streatley On Thames Berkshire RG8 9QL Lead Inspector Julie Willis Unannounced Inspection 19th December 2006 09:55 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 The Coombe House DS0000011218.V316887.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. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Coombe House Address The Coombe Streatley On Thames Berkshire RG8 9QL 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) 01491 872174 suzwindy@hotmail.com Mrs M J Windebank RGN Mrs Suzanne C Major Mrs Susan Rosemary Hutchinson Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: The Coombe House provides accommodation and care for up to twenty-four service users over the age of sixty-five, who have care needs associated with old age. The home is not registered to provide care to individuals who have dementia or require nursing care, over and above the care that can be provided by the community nursing team. The home is located in a rural village and is within walking distance of a range of amenities. Accommodation is situated on the ground and first floors of the home and five bedrooms are situated in an annexe, which is separate to the main building. There are twenty single and two double occupancy rooms. The home and gardens are maintained to a high standard, with appropriate aids and adaptations to meet the care needs of service users. There is a registered manager in post. The current fees charged at this home vary between £515 and £580 per week. The Coombe House DS0000011218.V316887.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 an unannounced ‘Key Inspection’. The inspector arrived at the service at 09:55 am and was in the service for five and a three-quarter hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector toured the building, looked at service users and staff records and observed care practice. The inspector met 10 of the residents and 2 relatives and spent time talking to them at length. Time was also taken to observe what was going on in the home and how staff cared for the residents. As part of the inspection process a number of questionnaires were sent out by the Commission to health and social care professionals and to residents to ask for their views about the service. Responses were highly complimentary about the quality of care provided by the home. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. There were no legal requirements made following this inspection. The CSCI are not aware of any complaints about the home in the past year. What the service does well: The home is comfortable, clean and homely. Residents are encouraged to personalise their own rooms and these are decorated and furnished to a good standard. The staff team are highly skilled and have received the training they need to provide good quality care. Most have achieved professional qualifications in care to improve their skills and knowledge. It is evident that the staff team work well together to provide a happy and cheerful home for residents. The home is well run and the management react quickly to the views, concerns and comments of users and their relatives. They respond well to any requests or suggestions made. Service users are encouraged to have a say in how the The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 6 home is run and to remain as independent as possible. The routines of the home are designed around the needs of residents. Residents enjoy a full and stimulating lifestyle. The activity programme is varied and interesting and includes trips out to local shops, boating on the river and barbeques in the garden. Residents take an active part in the community and visits by friends and relatives are welcomed and encouraged. The food is varied and nutritious and offer residents choice. Meal times are considered an occasion each day and are relaxed and unhurried and taken in comfortable attractive surroundings. Records are well kept and provide staff with information they need to provide high quality care to residents. 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. The Coombe House DS0000011218.V316887.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 The Coombe House DS0000011218.V316887.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. Service users are fully assessed prior to admission to ensure their needs can be met effectively by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the pre-admission assessment documentation for 3 users evidenced that all necessary information about the users health and personal care needs are sought prior to admission, along with information about the users dietary needs, communication needs, mobility needs, history of falls, continence, medication regime and mental state. Information was gathered from a variety of sources, including the user, their family and other health and social care professionals where appropriate. The information gathered was used to produce an initial care plan and to ensure that any aids or equipment needed by the user were available on admission. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 9 Service users confirmed that they had been invited to look around the home prior to their admission to meet staff and other residents and to see the room that they would be moving into. One user said that they had immediately “liked the home because it appeared small and friendly” and staff were “welcoming and kind”. The Coombe House DS0000011218.V316887.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 excellent. Clear information is in place to enable staff to effectively meet the health & personal care needs of users effectively. Service users are encouraged to participate in the care planning and review process from the outset. Service users are provided with quality care in a manner, which maintains their right to dignity, privacy, independence and choice. 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 spoke at length to 10 of the service users and 2 relatives that were visiting at the time of inspection. Users were highly complimentary about the quality of care provided by the home. They said that they were encouraged to remain as independent as possible and were provided with the support and assistance they needed to remain “socially active and interested in The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 11 life”. One user showed the inspector their kitchenette and said that they regularly made tea, coffee and light snacks for themselves and their visitors. Another said that they “enjoyed their daily walk into Goring”. It was clear that users are positively encouraged to remain an integral part of the local community and to say how they wish to be treated and cared for. The files of five service users were examined in detail and case tracked from pre-admission assessment to date. The written records were detailed, comprehensive and well documented. They provided staff with sufficient information to enable them to offer the appropriate level of care to users of the service and to over-see self care. The home has an effective review system in place. All care plans are reviewed monthly and any changes were well documented. Staff were highly knowledgeable about each resident and there was evidence of the time given to each user to ensure that the care plan continues to reflect their individual need. Risk assessments had been undertaken on manual handling, risk of falls and bathing. Where risk was identified there were effective risk reduction measures in place. The care plans gave clear instruction on how staff should reduce the risks identified. Observation of care practice concluded that users were encouraged to remain as independent as possible by providing appropriate levels of support to maintain the users privacy, dignity and independence. Staff were observed to provide personal care in a discreet and sensitive manner and were heard to be polite and courteous to users at all times. Staff routinely knocked and waited until they were invited in, before entering users bedrooms. Service users confirmed that they were provided with access to health and social care professionals when required. Several users received physiotherapy treatments and treatment by the Community nurses at the time of inspection. Most users are transported by the home to visit the local surgery. The visits were well documented in service user plans. Service users confirmed that screening and preventative treatments are offered routinely. Several users confirmed that they had been given a flu vaccination by their GP in recent weeks. There was evidence on file that users have regular chiropody treatments, hearing tests and eye tests. Feedback from surveys provided by the CSCI to health professionals involved with the home confirmed that the home is well respected and provides a good standard of care. Quotes taken from the surveys said’ The home is always happy to assist the district Nurse team’, ‘an excellent home’, ‘and a model’. Examination of the daily records, although minimal in content, evidenced that care was being delivered in accordance with the individual’s wishes. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 12 From examination of the medication administration system and discussion with management it is clear that the home follows best practice guidance in relation to the storage, administration and disposal of drugs. Staff have been trained in the administration of medication and are regularly in receipt of refresher training and supervised practice. A monitored dosage system is in operation at the home and medication is delivered to the home on a monthly basis. Storage systems are effective and disposal systems are safe. Five of the current users are supported to selfmedicate and have been supplied with a lockable cupboard for their drugs. All users who administer their own medication have their doctor’s consent and support. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 13 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 excellent. Service users are provided with the opportunity to participate in a range of leisure activities, trips out and entertainments. Service users are encouraged to maintain contact with the local community, their friends and relatives. The meals in the home are good and offer users both choice and variety. Special dietary needs can be catered for effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From discussion with the management, staff and service users it was clear that service users are offered the opportunity to participate in a range of activities suited to their needs. The home engages an activity organiser once a week that encourages users to engage in passive exercise, quizzes, scrabble and craftwork. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 14 Singers and musicians are regular visitors to the home and there are parties and other entertainments arranged for the Christmas period and for other festivals throughout the year. During the run up to Christmas this year the home has had entertainments provided by carol singers from the Free Church, an advent service, ‘songs of praise’, a residents party, bell ringers and local school children giving a concert. Each month a number of residents attend the ‘Pic-a-flic’ at the local church. Church members transport them. The film shown the week of inspection was ‘Calendar Girls’ and was particularly popular with residents. Tea and cakes followed the film show. A barbeque was held during the summer to which users families were invited which was enjoyed by all. A boat trip arranged on the Thames in summer was well attended. The home is situated two minutes from the local shops and pub and several users regularly walk to the shops in Goring. The home regularly provides transport into Wallingford and Goring for users to do their own shopping. Service users in the main remain responsible for their own money and administer their own bank accounts. The cash accounts held for two users were accurately kept and money spent on their behalf was appropriately receipted. Service users confirm that their visitors are made most welcome at any time and are offered appropriate hospitality during their visits. Several visitors had coffee with the residents and others stayed to lunch. A number of social events are held throughout the year, which promote community involvement and which provide residents families with the opportunity to engage with the staff and users on an informal and regular basis. Service users confirm that they are encouraged to express their views in regular residents meetings. These are well attended by users. Minutes of the meetings indicate that users are encouraged to express their personal feelings in relation to a wide variety of topics including menus, activities in the home and daily routines. It is clear that the home operates around the needs of its users; daily routines are flexible and responsive to individual need. The food is excellent quality. The users were eating lunch on the day of inspection of lasagne; roast diced potatoes, carrots and mixed vegetables followed by trifle. There are a number of alternatives to the main course each day. Special diets can be catered for including diabetic or vegetarian meals. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 15 Discussion with service users evidenced that the food was well cooked tasty and plentiful. A number of service users made comments such as “the food is terrific”, “there is always a choice” and “an excellent menu”. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system. Service users feel their views are listened to and acted upon. Service users are protected from abuse and exploitation by well-trained and competent staff that can demonstrate knowledge of the homes abuse of vulnerable adults and whistle-blowing policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaint policy in the home meets the requirement of Regulation and Standard. Examination of the complaint records indicated that there have been 11 minor complaints made to the home since 1st January 2006. The details of the complaints were well documented and evidenced outcomes provided to complainants. The CSCI has not been made aware of any complaints made about the home since the last inspection. Service users said that that they felt confident that any concerns or complaints would be taken seriously by the home and efforts would be made to remedy any problems in a timely fashion. 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 The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 17 induction to the home. There learning is later consolidated when undertaking NVQ training in which it forms a core module. Staff interviewed were aware of the homes whistle-blowing policy and understood the importance of protecting users from abuse and exploitation at all times. Service users confirmed that they felt safe and well cared for by kind, caring knowledgeable staff. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. The standard of the environment within this home is good providing service users with an attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the communal areas and a number of bedrooms were seen during the course of inspection. All areas were clean and hygienic and furnished in a homely manner. Service users and their visitors confirmed that the home is always clean and well maintained and staff work hard to provide a pleasant environment for the users. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 19 All but one bedroom has en-suite facilities of toilet, sink, bath or shower. The room that has no en-suite has personal use of the adjoining bathroom. All bedrooms were highly personalised. Users have been encouraged to bring with them small items of furniture, pictures and ornaments to individualise their room and make it homely. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. There was sufficient staff on duty at the time of inspection to meet the needs of users effectively. The skill mix of the staff team was appropriate for the size, layout and purpose of the home. Recruitment policies and procedures at the home are robust and transparent and ensure the safety of users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector examined the staff files for 3 of the most recent recruits. The content of the files met the National Minimum Standards and Regulations. From discussion with staff and management it was clear that the policies and procedures relating to selection and recruitment ensure service user safety and are robust, transparent and meet the requirements of current good practice guidance and legislation. All new care staff undertakes induction training to ‘Skills for Care’ specification within 6 weeks of appointment. Foundation training follows within the first six months. Core skills training is encompassed in the induction training and includes fire safety, first aid, health & safety, manual handling, infection control, food hygiene and protection of adults. The staff files and training records evidenced that most of the current staff have either gained or are in the process of attaining NVQ qualifications at The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 21 levels 3 & 4. The Responsible Individual is an NVQ assessor and provides the necessary support and guidance to candidates. All staff receive regular support and supervision. Staff confirm that they regularly attend team meetings at which they are encouraged to express their views and opinions. Service users were highly complimentary about the staff team. Comments such as “welcoming & friendly”, “caring and kind” and “they put themselves out to help us” were made to the inspector. It is clear that the staff work well as a team. They are well-qualified and express caring attitudes towards residents. Staff turnover at this home is low and there is no reliance on agency staff to cover gaps in the roster. The care staff works overtime to ensure continuity of care to residents. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38 Quality in this outcome area is good. Service users benefit from living in a well managed home, where there is evidence that their health welfare and safety is of primary importance. The registered persons are qualified, competent and experienced to run the home for the benefit of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Homes Manager is an experienced registered nurse and has attained an NVQ 4 in care and the Registered Managers Award to further enhance her knowledge and skills. The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 23 Staff confirm that the Homes Manager is a caring and effective leader and is always keen to support individual members of staffs personal and professional development. Staff confirm that they have the opportunity to express their opinions openly and have regular staff meetings, which follow a shared agenda. These meetings, supervision sessions and staff handover times provide plenty of opportunity for the staff to feel included and involved in the way the service is delivered. The whole team aspire to providing quality care to users in line with the aims and objectives of the home and are kept well informed and up-to-date. Service users are highly complimentary about the management of the home. They say that the office is always open and accessible and the manager always makes time to speak with them. From discussion with users it was evident that they are regularly consulted on issues that affect them and feel that their views are taken into account. From examination of the minutes of residents meetings there was evidence that when requests are made or concerns expressed in the meetings the issues raised are followed up promptly by management. The home undertakes regular quality audits. Recent service user satisfaction surveys have included topics such as general satisfaction with services provided and menu planning. The outcome of questionnaires is collated to identify trends and to help identify where improvements can be made to services. Examination of two service user cash accounts indicates that a safe procedure is followed for deposit or withdrawal of resident’s monies. Receipts are kept of all cash spent. Most service users manage their own financial affairs or have family members that deal with their finances on their behalf Service users are regularly consulted about their care needs as part of the formal review process. They can ask to see their records at any time and will be given access. All records required by regulation were found to well maintained, secure and up to date. All staff were aware of the needs to treat information confidentially and to maintain records including computer held records securely in accordance with the Data Protection Act 1998 and other statutory requirements. A number of health and safety records relating to fire safety and the maintenance of the hot water system were sampled and found to be accurately documented and up to date. Routine serving and maintenance of equipment is carried out in accordance with the requirements of legislation and good practice guidance. Activities that pose a risk to users are fully assessed and procedures are put in place to reduce the risk of occurrence The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 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 The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 26 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 The Coombe House DS0000011218.V316887.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!