Inspection on 16/07/07 for Trembaths

This inspection was carried out on 16th July 2007.

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

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

Other inspections for this house

Trembaths 01/06/06

Trembaths 22/02/06

Trembaths 11/11/04

Trembaths 11/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Trembaths Talbot Way Letchworth Hertfordshire SG6 1UA Lead Inspector Mrs Jan Sheppard Key Unannounced Inspection 16th July 2007 10:00 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 Trembaths DS0000019596.V344561.R02.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. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trembaths Address Talbot Way Letchworth Hertfordshire SG6 1UA 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) 01462 481 694 01462 485 606 home.let@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mr Alan Dickinson Care Home 41 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (15), Old age, not falling within any other of places category (41) Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This home may accommodate 15 older people who require personal care. This home may accommodate 15 older people with dementia who require personal care. This home may accommodate 31 older people who require nursing care. 1st June 2006 Date of last inspection Brief Description of the Service: Trembaths is a two-storey, purpose-built care home providing nursing, personal care and accommodation for 41 persons over 65 yrs of age. It is owned by Methodist Homes and is situated in a quiet residential area of Letchworth within easy reach of the town and shopping facilities. All bedrooms are single with en suite wash hand basin and toilet. The ground floor comprises a self-contained unit for 15 persons with dementia. The ground floor has its own lounge, dining room, kitchenette, 4 assisted bathrooms and three separate assisted toilets. Also on the ground floor are a main lounge, a hairdressing salon, an administration office, a smaller office, the main kitchen, the laundry room and a staff dining and changing room. The second floor is divided into 2 units for a total of 26 persons requiring nursing care. Each unit has its own lounge, dining room and kitchenette and shares 5 assisted bathrooms and 4 assisted toilets. The managers office is located on the first floor. To the front, the home affords ample parking spaces. It has a very pleasant rear garden, which is securely enclosed, with a patio, a circular concrete path, a summerhouse and raised beds. Information about the home recent Inspection Reports, the statement of Purpose and Complaints Procedure are available in the entrance foyer along with facilities seeking the views and comments of visitors and friends. The fees which are determined according to the level of care needs range from £594 to £741 per week. Additional charges are made for newspapers toiletries chiropody and hairdressing. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 5 Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over an eight hour period on one day during which one inspector talked with the homes Managers, spoke with some residents, relatives and staff on duty , examined and spot checked a selection of records and made a tour of the building. The details in this report reflect the findings on that day and also take account of information sent periodically to the Commission by the Homes Manager and also with information received from residents and relatives prior to this inspection . This inspection focused on all the key standards as defined in the National Minimum Standards and was a very positive inspection. It found that the atmosphere within the home was peaceful and homely. Staff were observed to be interacting closely with the residents and to be fully meeting their care needs in a calm and kindly manner. The written response of one resident stated that …” The care at Trembaths is second to none the staff are superb very attentive and extremely caring “ The requirements made at the last inspection have been met or are in process of being met. Two requirements are made following this inspection. What the service does well: Very good care and support is offered to the residents following their care needs as identified in their individual care plans. Staff are fully committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. The home is very well appointed, attractively decorated with a light airy and spacious ambience that contributes to its homeliness. The physical layout of the home, it is divided into small independent units, also contributes to its small and homely feel. Excellent training opportunities are offered for all the staff who have achieved a high level of professional qualifications. Staff retention is also very good thereby assisting with the continuity of care for the residents. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Trembaths DS0000019596.V344561.R02.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 Trembaths DS0000019596.V344561.R02.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): 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Admissions to the home are not agreed until a full needs assessment has been carried out and the home is satisfied that it can meet these needs. Sufficient information is provided for prospective residents and their families to enable them to make an informed choice about admission. EVIDENCE: Careful assessment of their needs is made by one of Trembaths managers for all prospective new residents referred to the home from the Hertfordshire area. Where prospective residents live elsewhere a manager from a MHA home in Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 10 that vicinity would carry out that initial pre admission assessment. These assessment visits are usually made to the prospective residents own home and information is sought from the referring social service department ( if any) and from hospitals and medical Consultants where necessary. Spot checks made of the residents records evidenced that recent assessments had been correctly made with good detail as to the prospective residents care needs, likes and dislikes, interests and a full social history taken. Prospective residents and their families are given good opportunity to visit and test drive the home before any decisions about admission are made. The home always carries a waiting list and at the time of this inspection had one vacancy which was in process of being filled. The home provides comprehensive information for all prospective residents including a Statement of Purpose and Service Users Guide along with the company’s informative booklet “ Welcome to Your New Home … a Guide for New Residents. “ Each new admission is made on a six week trial basis initially. Trembaths DS0000019596.V344561.R02.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 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The home maintains care plans for every resident but these records do not always evidence the good care that is in fact being delivered and the maintenance of these records is inconsistent. Residents are given every encouragement to make decisions about their lives where it is safely possible for them to do this. The homes medication administration and storage systems are sufficiently robust so as to give consistent protection to the service users. EVIDENCE: Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 12 The health and personal care needs of the residents are very well met following an assessment of their individual needs and with due reference to enabling them to retain their dignity and respect in a very individualised manner. The residents all looked well cared for and those spoken with during this inspection talked very positively about the care they receive and the manner in which this is delivered to them . They commented that they are always enabled to feel respected and that their privacy and dignity is upheld at all times. One relative said,” The care given here just can not be faulted, my Mother is very happy and her every need is attended to “. The records evidenced that the home maintains good working relationships with health services that are community based including the district nursing service , chiropody , dental and optical services and the McMillan Nursing Service . The home has regular visits from its GP and prompt access to Consultants is available when specialist assessments are needed. Aids and Adaptations can usually be accessed promptly to meet newly assessed needs but the home has also purchased a number of such pieces of equipment itself. The care plans are regularly reviewed these reviews with the involvement of the residents and sometimes relatives, signatures were seen on some plans. Current risk assessments were seen to be in place and in some cases these included the stated wishes of the service user. Monitoring charts could also be evidenced along with details of specialist medical support and advice where this had been called upon. A range of specialist equipment was seen throughout the home this chosen to meet individually assessed needs. It is unfortunate that the written care plan records are not all maintained with sufficient detail so as to fully evidence all the good care that is given. Although the standard of these care plan records has improved since the last inspection further improvements are needed to ensure their consistency and sufficient good detail and to achieve a good rather than just an adequate rating. The home operates a sound and well proven medication storage and administration system which is subject to regular internal management and external pharmacy checks. Medication was seen to be well organised and neatly stored with good attention being given to the maintenance of the correct temperatures. However a number of omissions were found on the MAR, (medication administration record) sheets where no explanation or letter codes had been used. The Manager must ensure that these records are accurately maintained this to ensure full safety for the residents. Several of the residents spoken with complimented the staff for their kindness and helpfulness to them. One said “ the manager comes to talk with us every day we can easily talk to him”. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 13 Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The diverse social and activity needs of the residents are supported via the range of activities provided. The residents receive a healthy diet of freshly prepared good quality food. EVIDENCE: Since the last inspection there has been an increase in the hours of the Activity Organiser and extra monies (£2000) allocated to the activities budget. which have enabled the activity programme to be increased to include planned and led activities on every weekday and over every other weekend.. The Activities Organiser is an experienced worker who has undertaken specialist training in activity organisation and in activities suitable for dementia suffers. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 15 Each resident has an activity interests assessment and then a plan to meet their particular needs and interests is drawn up in conjunction with them. Records are made of these assessments and participation and plans are reviewed as necessary. Residents confirmed that they do not have to attend anything even if it is on their plan but most said that generally they looked forward to their activities one said “ life is so much more interesting now there is always something going on”. Extra therapies commenced since the last inspection include massage and music therapy.. Activities are offered both to groups of residents and where applicable to individuals in the privacy of their rooms One resident mentioned the weekly quiz run by a visiting volunteer whilst another spoke of the interesting topics covered in the Ladies Meeting group. A calendar of activity events was seen displayed throughout the home and each month all the residents receive a copy. The home also holds regular social events, a summer garden party and a fete, and outings recently enjoyed included visits to a Garden Centre , a Steam Train ride and a visit to a Butterfly Farm.. Involvement in other local community events is encouraged. The manager said that the homes Friends Group give good support and help add to the variety of these activities and commented that the home fortunate in having help and support from many friends and family members even some whose relatives are no longer resident in the home. Religious services led by a variety of local churches are regularly held in the home for those who wish to attend. The ethos of this activity programme is the sharing of information and the promotion of autonomy and choice for the service users. Residents meetings and family meetings take place in the home and minutes are typed and are placed on notice boards throughout the home. The home also produces a News-Letter three or four times a year. Wholesome meals are provided following a four week rolling planned menu which is seasonally adjusted. Feedback from many of the residents was extremely positive regarding the choice and availability of foods. All the residents have the opportunity to make choices concerning their meals and the foods they eat and when they eat these. Hot and cold drinks are freely available throughout the home. Special food treats are always considered and the inspector was told of the popularity of the recently introduced visit of an Ice Cream Van from which residents can make their choices of old fashioned ice creams which for many bring back happy memories. Staff were observed to be helping one poorly resident whose appetite was very diminished to choose an alternative acceptable dish with staff clearly thinking of alternatives which were not on the planned menu. Lunch was observed and appeared to be served in an unhurried manner in a calm atmosphere with staff helping at an appropriate speed residents who needed assistance. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 16 The spacious kitchen is well appointed and was found to be very clean and well organised with good recording systems in place. A new floor had recently been fitted and some new equipment and utensils purchased.. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The home has a good understanding of the policies and procedures concerning Adult Protection and Whistle Blowing and how these give protection to the residents. The home has clear policies and procedures concerning complaints which are readily available to residents relatives stakeholders and visitors to the home. EVIDENCE: A comprehensive complaints policy and procedure is in place and is well publicised to both residents and to those responsible for them. Two complaints received by the home since the last inspection were seen to have been promptly and properly investigated. Residents questioned confirmed that they knew about the complaints procedure but most indicated that they would first speak to their key worker or the manager who they felt sure would sort things out. A number of complimentary letters have been received by the home since the last inspection. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 18 Staff receive training in issues and procedures around the protection of vulnerable adults. A refresher training course was held in the home for all staff in April 2007 this being followed by an examination. There have been no incidents concerning adult protection or whistle blowing in Trembaths since the last inspection. Copies of the Hertfordshire Joint Agency Adult Protection procedures were seen to be freely available for all staff. Staff questioned had a good awareness of these and also of the Methodist Homes Associations free confidential 24 hour telephone lines to which any concerns could be reported. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The service offers an excellent environment that is well appointed and subject to regular maintenance. The physical layout of the home enables the residents to live in a safe, well maintained and comfortable environment which encourages independence. EVIDENCE: The home which was purpose built within the last twenty years provides for its residents single bedrooms all with en-suite facilities. The accommodation is Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 20 spacious and is divided into small units each with their own lounge dining room small kitchen and assisted bathrooms and toilets. The whole home is extremely well maintained attractively decorated and very well appointed. The Manager explained that a recent award of extra grant monies from the health authority is to be spent on upgrading an assisted bath in one bathroom and laying new flooring in two dining rooms. Residents are encouraged to furnish their own rooms and most do so . One told the inspector “ It is so nice to be-able to bring my own bed it made it seem more like my own home .” One newly admitted resident speaking appreciatively of his new surroundings explained that his son had driven a van from the midlands with his furnishings agreed that this had all helped him to quickly feel more settled in his new surroundings. Since the last inspection landscaping works to the rear of the home have created enlarged patio areas and a number of raised beds where vegetable and flowers were seen to be thriving. The advantage of the raised beds were mentioned to the inspector enabling more of the residents to get involved with some degree of gardening activity. It was noted that all areas of the garden were extremely well maintained. The home was found to be very clean with no mal odours and to be kept tidy. Several of the written comments received from the residents prior to this inspection commented on the very good cleanliness that was continually maintained through out the home. One long standing member of the house keeping staff told the inspector how much she enjoyed her work and said that she had time to get to know the residents individually so that she could help them keep their rooms clean and in the order which they appreciated. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience excellent quality outcomes in this area This judgement is based on a variety of evidence including a visit to the service. Staff at Trembaths are trained and skilled and are in sufficient numbers to support the people who use the service and to ensure the smooth running of the home. EVIDENCE: At the time of this inspection the home was found to be fully staffed and that it had sufficient numbers of staff to ensure the smooth running of the service. Staff retention is very good with more than 60 of staff having been in post for over 5 years. Recent temporary vacancies caused by the extended sick leave of three staff have been covered by staff who work for the homes Bank team thereby ensuring continuity of care for the residents. Where exceptionally an agency staff person has to be used they come only from one agency well known to the home and they will have received an induction training period in the home before commencing their duties. All staff employed at night are required to hold professional qualifications. The manager explained that since the last inspection the home had employed more part time staff of varying grades to cover especially busy periods such Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 22 as the breakfast lunch and supper times and that this new arrangement was working well. The home continues to have as well as a number of trained nurses, more than 95 of care staff professionally qualified holding NVQ level 2 qualifications. Both the Manager and deputy Manager are registered nurses and have NVQ level 4 the Registered Managers Award and the deputy has just completed management training at NVQ level 5. Training on an on going basis for all staff is given high priority in this home and the annual planned training programme to evidence this was seen by the inspector. All staff who work on the dementia Care Units undertake specialist Dementia Care training. Staff spoken with all confirmed that they felt well supported by their Managers one said “ we all work as a team here whatever our role” The homes records evidenced that all staff receive regular supervision offered by staff who have been trained to carry out this role. Checks made of the recruitment records for three new staff recently employed evidenced that these had been correctly carried out with all the required checks made and evidence properly recorded. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use this service experience good quality outcomes in this area. This judgement is based on a variety of evidence including a visit to the service. People using this service are safe guarded by a sound management approach led by an experienced and trained manager and management team whose open approach encourages residents independence and choices. The homes quality assurance system is good and enables the management to assess information to enable them to improve the care experience for the residents. The homes good record keeping promotes the health safety and welfare of the residents. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 24 EVIDENCE: The home benefits from having a very stable management and staff team with high levels of qualification and experience. The openness of the homes management style was evidenced throughout this inspection. The staff said that their views were regularly sought at their regular unit and larger home staff meetings and confirmed that their views and ideas are listened to. The openness of the approach of the manager and deputy manager were positively commented on by residents to the inspector who witnessed during her tour of the home at this unannounced inspection the empowered and spontaneous manner in which the residents related to them. The home has clear health and safety policies and evidence of the regular management checks of these were seen. Random checks by the inspector during this inspection ( of water temperatures, fire testing and accident recording) evidenced that checks are routinely carried out and well recorded. Overall the maintenance of the homes records is well done with good detail and consistency, this safe guarding the service users rights and interests. The home uses a variety of methods for testing quality control and residents spoken with confirmed that their views are regularly sought. A recent residents satisfaction survey carried out by the company evidenced a rating of 82 satisfaction and the manager explained that the home is also subject to an annual major SAVA Standards and Values Assessment company audit. Hertfordshire Social Service Contracting Unit also carries out regular audits of the service. Throughout this inspection the managers demonstrated a good awareness of current good practice national trends and recent developments in the service. They appeared to have a good understanding of equality and diversity issues and a grasp of the complexity and varying strands of these issues. Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15 (2) Requirement All care plans, risk assessments and other documents regarding the service user must be reviewed and fully completed. The registered Manager must ensure that all records of medicines administered and stored are accurate. Timescale for action 31/08/07 2. OP9 13 (2) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Trembaths DS0000019596.V344561.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 - 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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