Inspection on 16/05/08 for The Laleham

This inspection was carried out on 16th May 2008.

CSCI found this care home to be providing an Good service.

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 Laleham 31/05/07

The Laleham 29/05/06

The Laleham 03/10/05

The Laleham 23/05/05

The Laleham 17/01/05

The Laleham 09/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Laleham 117/121 Central Parade Herne Bay Kent CT6 5JN Lead Inspector Lisbeth Scoones Key Unannounced Inspection 16th May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Laleham DS0000023571.V363351.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 Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Laleham Address 117/121 Central Parade Herne Bay Kent CT6 5JN 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) 01227 363340 Kent County (Residential Homes) Ltd Lynn Marie Laxton Care Home 75 Category(ies) of Old age, not falling within any other category registration, with number (75) of places The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 75. 2. Date of last inspection 31st May 2007 Brief Description of the Service: The Laleham is registered to provide accommodation and personal care for up to 75 older people. The home also looks after one younger adult who has a learning disability. The premises comprise five older properties, which have been converted into one building. The accommodation is arranged on three floors. There is a passenger lift giving step-free access to each of the levels. There are 43 single occupancy bedrooms and 15 bedrooms, which have, in the past, been shared by two people. At the time of the inspection visit, all of the bedrooms were being used as singles. The Registered Provider says that this will remain the case, unless two people specifically request to share. There is a call bell system which is designed to assist residents to request assistance from most locations in the accommodation. The home is located close to the centre of Herne Bay. Residents have access to the front, with views across the promenade and the sea. Whilst there is a garden at the rear of the home, currently residents do not access it. The Registered Provider is Kent County (Residential Homes) Ltd, a private company for which there are two Directors. The registered manager is in dayto-day charge of the service and reports directly to the two Directors. The Registered Provider supplies information to prospective residents through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure, which outlines the principal features of the facilities and services available in the service. A copy of the most recent inspection report is on display for all who wish to read it. Current weekly charges range between £315.00 and £400.00. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection was carried out over one day. It comprised discussions with the manager and one of the Directors, members of staff and 8 residents. A tour of the premises was made and records pertaining to care planning, risk assessments, medication records, menus, staff files, policies and procedures and staff training were examined. Included in this inspection was a ‘thematic probe’ relating to Safeguarding Vulnerable Adults. It involved the additional information gathering on a particular theme. The purpose of this is to assess how well the service is able to protect residents in their care. As part of the process for a Key inspection, services are requested to complete and return an Annual Quality Assurance Assessment (AQAA). This is a legal requirement, and provides information about how the service is performing; the AQAA was completed prior to the site visit. Other information about the service was obtained by sending out 8 surveys to people who are using the service and staff working at the home. Comments received are incorporated in the report. At all times the staff were helpful and co-operative. Key Lines of Regulatory Assessment (KLORA) have informed the judgements made based on records viewed, observations made and written and verbal responses received. KLORA are guidelines that enable The Commission for Social Care Inspection (CSCI) to make an informed decision about each outcome area. It is concluded that the Registered Provider provides a good service enabling the residents to receive the support and assistance they need in a homely environment. What the service does well: Residents spoken with said that the home is relaxed, homely and comfortable. They said that they liked the staff who know them well, talk to them and look after them. Staff are kind and thoughtful. “Support is excellent,” said a resident. “Staff listen and always do their best to help”. The home promotes Equality and Diversity as evidenced through staff training and practices observed. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 6 Good arrangements are in place to assist residents to manage potential risks to their health and safety. It was observed and confirmed by the residents that they enjoy wholesome, varied and nice meals. A resident said, ”The food and presentation is excellent. “Especially the desserts” said another resident. Residents’ personal and social care needs are reflected in comprehensive care plans Residents are protected by staff who are well trained including in the Safeguarding of Vulnerable Adults. Staff like working at the home and there is good staff retention. 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 The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is good. Prospective residents are provided with up to date and comprehensive information about the services provided. Prospective residents have their needs and wishes assessed before moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home keeps its Service User Guide updated (last reviewed in January 2008) to provide residents with up to date information. A resident said” I do not go by brochures. It is the feel of the place I go by. This home was very favourable and has proved me right” The manager said that she completes an assessment of each prospective resident’s needs for assistance, before a decision is made whether the home The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 10 would be suitable. She said that she is aware of the need to ensure that information is collected about someone’s established lifestyle and preferences. This evidences that the home promotes Equality and Diversity. This is an important aspect of person-centred care as it enables care staff to promote the continuation of the person’s chosen way of living, if this is their preference. See also standard 7 in relation to care planning. Care staff said that they are briefed fully about the needs of new residents. Some residents are admitted to the home for shorter periods of time. This might be done in order to allow some free time for relatives who provide care at home for the person. Or, it might be to enable someone to leave hospital before they are quite ready to return to their own home. Suitable arrangements are in place to help people return home as and when this is appropriate. A resident said, “I visited for a lovely week”, another, “I already had two short stays here before I moved in permanently.” The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. Every resident has a care plan that sets out their assessed health and personal care needs. Good medication procedures are in place. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said that the care staff offer them all the assistance they need in a reliable and consistent manner. Every resident has a written individualised care plan drawn up with the signed agreement of the resident or their representative. These are important documents as they form one of the means by which a resident can be informed about and can agree to the assistance he or she will receive. Care plans are an essential source of information for staff providing consistent guidance and assistance in delivering The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 12 care and support. Care plans are regularly reviewed, supported and informed by risk assessments. If a resident were at risk of loosing weight, weight charts and daily food records would be maintained. This would provide an audit trail evidencing the care provided in this respect. It was discussed with the manager that care folders would benefit from audit thus ensuring that all documents are completed, cross-referenced, signed and dated. Residents are encouraged to be as independent as possible with their personal care. As evidenced in the care records seen, care staff ensure that residents receive prompt medical attention when the need arises. Nursing care is provided by a team of district nurses who visit the home regularly. They keep their own records. Suitable arrangements are in place to ensure that residents receive the medication they have been prescribed in a timely and safe manner. Good medication records are maintained. Following risk assessment, residents are encouraged to manage their own medication. It was observed that staff interact with the residents in a friendly, kind, patient manner respecting their dignity and individual preferences. The Laleham DS0000023571.V363351.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): 12, 13, 14, 15 Quality in this outcome area is good. Residents are provided with a variety of social activities. They are able to choose their life style and to keep in touch with family and friends. Residents are provided with varied and wholesome meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In-house activities are provided by the staff as no activities coordinator is employed. A calendar of social events was seen on display. Residents spoken with said they have plenty to do. They can join in with activities or not as they wish. Music was playing in the background. The residents said this was much enjoyed. Residents said that the pace of daily life in the home is relaxed and unhurried. They are free to decide what to do each day. As appropriate, they can retire to the privacy of their bedroom. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 14 Residents are encouraged to keep in touch with members of their families if this is their wish. Family members and friends are welcome to visit the home at any reasonable time. Residents are free to spend time in private with their relatives and friends, should they choose to do so. It was observed and confirmed by residents spoken with that the meals are good and varied. They consider meal times to be a relaxed and pleasant experience. The chef said that fresh fruit and vegetables are provided as well as home made cakes. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 15 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): 16, 18 Quality in this outcome area is good. Residents know that their complaints will be listened to. Residents’ wellbeing is promoted and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a written complaints procedure explaining to residents and their representatives how to raise a concern. Residents spoken with said that they feel comfortable to speak to staff if there is anything troubling them. Since the last inspection one complaint was logged in the home’s complaint file. This had been investigated and addressed in a timely manner. All care staff spoken with have a sound understanding of what is recognised to be good care practice. They have a good knowledge of what constitutes abuse and the steps to take if this was ever witnessed or suspected. All staff receive regular training in Safeguarding Vulnerable Adults. Residents said that they feel safe living at The Laleham. The manager confirmed that a policy and procedure is in place detailing the steps to take to make a referral to the appropriate authority. This includes a Regulation 37. The Laleham DS0000023571.V363351.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): 19, 20, 21. 22, 23, 26 Quality in this outcome area is adequate. Residents live in a generally comfortable and safe environment, which promotes their independence. Infection control measures are in need of review. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said that they are comfortable living in The Laleham. They consider the accommodation to be homely and welcoming. “A lovely place to live” said a resident. “This really is a homely home. It has a nice cheery atmosphere”. “Very important” said another. A number of dining areas and lounges are provided boasting magnificent views of the sea and promenade. Residents have limited access to the front of the The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 17 home as it is also used as a car park. Residents confirmed that they sit out and are assisted in walking along the promenade for an ice cream and visit to the promenade garden. Potentially a part of the garden at the rear could be used. This has however not been available to residents for some time and would have to be upgraded and made accessible before it could be used. The home’s development plan for 2008 includes “consider more paving in rear areas.” As reported at the previous inspection, some parts of the exterior of the rear of the property look rather run down. There are areas where paintwork on the window frames is peeling away or where it has become discoloured with age. The Registered Provider has applied for planning permission for the window replacements and quotes for the work to be undertaken have been obtained. Rubbish has been taken away from the back garden though it still contains large miscellaneous objects. The previous report identified that some of the bathrooms and toilets were rather bare. It reported that more could be done to make them into welcoming and personal spaces. In one of the bathrooms, damaged linoleum flooring has now been replaced. At this inspection it was noted that infection control measures in bathrooms and some toilets are inadequate. Some toilets are without hand wash facilities. Whilst alcohol hand gel has been provided, this should only be used in addition to hand washing. Instructions to staff on display in bathrooms referred to the cleaning of commode pots. It is recommended that the procedure be reviewed and adequate cleaning materials made available for this purpose. The possibility of designated sluice facilities was discussed. Recently acquired foot operated bins were faulty. The manager was aware and has requested replacements. A bathroom door had a faulty lock. A toilet window had no restrictor and was wide open. Apart from the issue identified above the home was clean and fresh with no unpleasant odours. The property is fitted with a modern automated fire detection and fire containment system. This is designed to give a high level of protection to the residents. Since the previous inspection, a Fire Safety Risk assessment has been submitted to the Kent Fire and Rescue Service. The kitchen is well equipped, orderly and clean. The chef has a good understanding of how to maintain suitable levels of food hygiene. The Environmental Health department regularly inspects the home and no recommendations were outstanding. Suitable arrangements are in place to assist those residents who have difficulty getting about. There are hoists in the bathrooms as well as a mobile hoist. Care staff said that they have all the equipment needed to enable them to safely assist the residents. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 18 Residents spoken with said that the accommodation is comfortable and warm. Radiators are protected with guards to reduce the risk of scalding if they have a fall near a radiator. Hot water taps used by residents have been fitted with special valves. These reduce the temperature of hot water to a level that is not likely to scald someone. The home has a well equipped and spacious laundry facility staffed 7 days a week. No complaints were made regarding the laundry arrangements. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29, 30 Quality in this outcome area is good. Residents are cared for by sufficient numbers of well-trained and supervised staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, 6 care staff and the manager were on duty for the morning shift. In the afternoon there were 5 care staff and the manager. In view of the number and dependency of the residents, these staffing levels are deemed sufficient to meet all residents’ needs. In addition to the care staff, the home employs catering, domestic and maintenance staff. One of the Directors undertakes many administrative duties. The home operates a key worker system. This means that every staff member has additional responsibilities for a number of residents. Staff spoken with demonstrated a good awareness of their role and had a detailed knowledge of the needs and preferences of each resident. More than half the care staff have acquired a National Vocational Qualification (NVQ) level 2 or 3 in health and social care. Others are in the process of doing so. This qualification provides care staff with a range of opportunities to The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 20 confirm elements of good care practice and to extend their range of skills. A staff member said how much she enjoyed the training. A sample of staff files was examined to ensure that the home’s employment practices are sound and residents protected. The employment process includes the taking up of two references, a POVA and CRB check. Staff files have a checklist, which in some cases was not completed. It was recommended that staff files be audited to ensure that all information is readily available. Staff spoken with said they enjoy working at the home. “We work as a team”. Staff retention is good and many staff have worked at the home for a considerable time. All new care staff receive Skills for Care compliant induction training. This is designed to ensure that they have the basic knowledge and skills they need in order to be able to work effectively without direct supervision. After their introduction to the service, care staff undertake a number of further training courses. These are designed to enhance their capacity to deliver care. The Registered Provider said that she has reviewed the adequacy of the knowledge and skills possessed by each of the existing care staff. A training matrix has been devised and individual staff profiles maintained. A member of staff said how much she had enjoyed a course on dementia care and was looking forward to training on how to care for a resident with a diagnosis of Diabetes. All staff spoken with confirmed the statutory training attended. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is good. The home is well managed in an open, positive and inclusive manner. The home is run in the best interests of the residents. The home promotes the health, safety and welfare of all who live and work in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection, the acting manager has become registered with the CSCI. She has many years of experience and a good knowledge of what is going on in the service and of any issues to be addressed. She receives good The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 22 support from the Registered Provider, her deputy and other senior staff. She is in soon to start her Registered Managers Award (RMA) training. The manager said they work as a team. Care staff said they feel supported by the manager who is knowledgeable about residential care provision. They feel that they can ask advice as and when they need it. It was evident in staff files seen that staff receive regular formal supervision. The home is run without any unnecessary rules or routines. This means that residents may continue to experience a normal home life of their choosing. In addition to everyday informal consultation, the Registered Provider has a more formal system whereby residents and their relatives are invited to comment about the service. A recent satisfaction survey has been carried out and the results collated. A quality Assurance mission statement and Quality Report have been prepared. This summarises the outcome of the consultations already completed and is to be shared with the residents. There is a development plan for 2008 outlining projects already and still to be undertaken this year. It is recommended that a review of polices and procedures and regular audits of e.g. care plans and staff files be added to the quality programme. As one of the Directors spends a lot of time in the home, formal Regulation 26 visits are currently not carried out. If this were to change, the Directors need to ensure that such visits take place and a report devised. Residents look after their own weekly personal spending allowance. Where assistance is needed, good arrangements are in place including records of monies coming in and spent. The Registered Provider said that all items of equipment in use in the home remain in good working order. There are various contractors’ certificates in place confirming this. Regular checks are completed to ensure that the home’s automated fire detection and alarm system remains in good order. The manager ensures that all accidents are appropriately recorded, acted upon and risk assessments reviewed. The Registered Provider monitors the premises and the accommodation so that potential hazards to health and safety can be identified and resolved. It was said that there are no significant hazards waiting to be addressed. As already mentioned under standard 26, infection control measures are in need of review. As evidenced on the training matrix and confirmed by staff spoken with, all staff receive regular statutory training. The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 2 2 x x x 3 2 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 3 2 x 3 3 x 3 The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 24 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. 1 2 3 Refer to Standard OP19 OP20 OP21 OP26 OP33 Good Practice Recommendations That residents have access to the garden That infection control procedures be reviewed That the Quality Assurance systems include the audits of care plans and staff files in respect of recruitment documentation The Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Laleham DS0000023571.V363351.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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