Inspection on 22/05/07 for Trinity Fold

This inspection was carried out on 22nd May 2007.

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

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

Other inspections for this house

Trinity Fold 20/10/05

Trinity Fold 05/05/05

Trinity Fold 13/01/05

Trinity Fold 23/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Trinity Fold Blackwall Halifax West Yorkshire HX1 2BZ Lead Inspector Cheryl Stovin Key Unannounced Inspection 22nd May 2007 06:30 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 Trinity Fold DS0000000997.V339947.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. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity Fold Address Blackwall Halifax West Yorkshire HX1 2BZ 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) 01422 350887 01422 361947 angela.harding@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Mrs Angela Elizabeth Harding Care Home 48 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Old age, not falling within any of places other category (44), Physical disability (1) Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1. The registered person may provide the following category of service only: Care home only - Code 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 - Code OP Mental disorder, excluding learning disability or dementia - Code MD Physical disability - Code PD 2. The maximum number of service users who can be accommodated is: 48 20th October 2005 2. Date of last inspection Brief Description of the Service: Trinity Fold is owned and managed by Anchor Trust and is registered to provide accommodation and care for up to 48 older people. The establishment is situated very close to the town centre of Halifax with easy access to public transport facilities. The property is purpose built and provides accommodation consisting of 48 individual bed-sitting rooms, each equipped with a kitchenette area and all having the provision of en-suite facilities. Communal areas are spacious and comfortable with sufficient space for social and recreational activities to take place. Externally, there are well maintained and accessible garden areas and sufficient parking space for staff and visitors. The current weekly charges at the home are between £339 and £503 per week. Additional charges are made for personal toiletries, personal newspapers, hairdressing and chiropody. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered during a key inspection of Trinity Fold. This included an unannounced visit I made to the home on 22 May 2007. A total of 7.5 hours was spent on the visit. During this visit, a full tour of the building was undertaken, records were examined and discussions took place with management, staff and the people living at the home. In addition to this visit, comment cards were sent out to give people an opportunity to share their views of the service with CSCI. A total of 21 comment cards were returned from people living at the home. The response was generally positive with people expressing satisfaction with the services and facilities provided in the home. Thirteen relatives/visitors also returned comment cards, again the response was generally expressing satisfaction with the home. The last inspection of Trinity Fold was on 20 March 2007. A complaint had been received about people living at the home getting up early, against their wishes, and an early morning visit was carried out. A report was written following this visit and is available on request. Following the visit, the home has altered the early morning working practices and implemented monitoring systems to make sure that people living at the home are able to choose what time they wish to get up in the morning. A pre-inspection questionnaire was sent to the home which was returned promptly and gave useful information. I would like to thank everybody for their warm welcome and the assistance given during the visit to the home. What the service does well: Trinity Fold has a warm and welcoming atmosphere. People living there described it as a “home from home”. Visiting relatives confirmed that this was always the case and that they were always made to feel welcome when they visit the home. The standard of the accommodation is very good, it is well maintained and clean and hygienic throughout. The people living at the home all have individual bed-sitting rooms, equipped with a kitchenette and en-suite facilities. People are encouraged to personalise their rooms and they all reflect the individuals’ interests and tastes. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 6 The communal areas of the home are spacious and comfortable and provide sufficient space for social activities to take place. There are attractive, safe and accessible outdoor areas for people to sit in and enjoy in the warmer weather. There are a range of activities for people to take part in if they choose to do so and the home is very much part of the local community. Regular religious services are held at the home which people said they appreciate. The local branch of the Mothers’ Union, which some people living at the home are members, holds their monthly meetings at Trinity Fold. An active group, the ‘Friends of Trinity Fold’, regularly holds coffee mornings in the home which raises funds for social activities. The staff team are motivated and well trained and committed to providing a high standard of care and attention to the people living at the home. People said the staff are “excellent”, “very kind”, and one person said “they can’t do enough for you”. Relatives’ survey cards included the following comments in response to the question ‘What do you feel the care home does well?’: “Almost everything”. “Very good overall care and attention”. “The home treats people as individuals, they are always happy and polite”. “Very supportive”. “They are a very caring friendly group of people who treat each resident as a person in their own right”. “Interior and exterior surroundings pleasant and well maintained. Fair amount of entertainment and plenty of organised activity”. “Generally a good home with a good level of care and attention”. “Activities are provided, quizzes, crafts and exercises particularly enjoyed”. “The home is nicely decorated and has a good standard of cleanliness, and good staff”. What has improved since the last inspection? The home continues to provide a good standard of care and attention to the people living there. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 7 The response to the complaint received, and the subsequent investigation on 20 March 2007, was handled appropriately and professionally. People living at the home are now able to get up at a time of their choosing. 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. Trinity Fold DS0000000997.V339947.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 Trinity Fold DS0000000997.V339947.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): 1,2,3,5,6 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are assessed before moving into the home and they are provided with written information about the services and facilities provided. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. The document is freely available and details the services and facilities provided by the home. All people are assessed before moving into the home to ensure that their needs can be met. People are encouraged to visit the home before making a decision to move in, to meet the staff and other people living in the home. One relative made the following comment in their survey card. “We visited Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 10 about ten different homes, getting their information packs and seeing for ourselves how things were run. We were encouraged to bring Mum for lunch on more than one occasion to see how she felt about the home prior to making a final decision. We were able to discuss everything in the information pack and any other questions we had”. All people have a contract which clearly states the rights and responsibilities of everyone and what is and is not included in the weekly charge. Intermediate care is not provided in the home. Trinity Fold DS0000000997.V339947.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 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s personal and health care needs are met. People are protected by the medication practices in the home. EVIDENCE: All people living at the home have an individual plan of care. The care plans contain basic information about people’s assessed needs but not much detail as to how the care is actually to be delivered. There is a section in the care plans for information about people’s social history but no information was recorded about people’s backgrounds or their previous interests. There is no suggestion that people’s needs are not being met but how the care is to be provided needs to recorded in more detail. People said that they receive the care and support they need and are treated with dignity and their privacy respected. All of the relatives’/visitors’ survey cards indicated that the home Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 12 always gives the support and care to their relative that they expect. Additional comments made included: “It has been such a help to see Mum looking so much less strained and enjoying the company at Trinity Fold. When we had been out for lunch, it was so good when in reply to her question “where are we going now?”, I said “Trinity Fold” and her response was “Oh good”. “Very good overall care”. “During the time my mother has been a resident at Trinity Fold, her care needs have been met in a highly appropriate way. Also, I have been kept well informed and included in discussions when changes to the care plan were needed”. “Health care has been well managed by Trinity Fold, they have made appropriate appointments as needs have arisen and I have always been kept fully informed”. People living at the home said in their surveys that they always receive the medical support they need. One made an additional comment: “I am happy with everything here”. Risk assessments are in place to help make sure that the people using the service are kept safe. The home uses a monitored dose system (MDS) for the administration of medication. The medication is securely stored in a medication trolley. All staff responsible for administering medication have received training which makes sure that the medication is given safely. Medication Administration Records were completed accurately and stocks of medication reconciled with records held. One person handles their own medication, a self medication agreement is in place which makes sure that there is appropriate monitoring in place. Trinity Fold DS0000000997.V339947.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 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People choose how to spend their time and join in activities provided in the home. The quality of the meals provided is good and mealtimes are relaxed social occasions. EVIDENCE: The home has a warm, welcoming and relaxed atmosphere. People living in the home confirmed that they choose where and how to spend their time. A visit was made to the home on 20 March 2007 in response to a complaint received about people living at the home being assisted to get up very early in the morning. The home provided a detailed response to the complaint and implemented new working practices and monitoring systems to address the matter. This makes sure that people living at the home get up at a time that suits them. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 14 During this visit, people were seen choosing when to get up and only six people were up by 7.30am, all were awake and had been given refreshment. Mealtimes were seen to be relaxed and social occasions. There was a wide choice available at breakfast, cooked to individual order and in accordance with people’s preferences. The main meal of the day is served at lunchtime and, on the day of the visit, the lunch was lamb hotpot or fish cakes served with broccoli, peas and creamed potatoes, followed by cheesecake. The people I spoke to during the visit said that they enjoyed their meals. The majority of people said in their survey that they always or usually like the meals at the home. Five people made the following comments: “The meals at the home have recently become poor and deteriorating. They are often cold. There is little choice. Seems to be very little fresh vegetables. There are long waits between courses which is worrying when you are elderly and uncomfortable”. “The food is not too good, I expect the cook does her best to please so many people”. “I feel that the quality of cooking has deteriorated recently”. “The food could be better”. “Sandwiches every tea time I do not like”. There is a range of activities available for people living at the home to join in with if they choose to do so. An activities co-ordinator is employed for 21 hours a week and has devised an activities programme. Recent activities have included knit and natter, manicures, videos, board games, greeting card making (the cards are on sale in the home), individual shopping trips, a barge trip, social evenings, reminiscence, bingo, baking, quizzes, indoor bowls and discussing local affairs. One person living at the home made the following comment in their survey: “I have enjoyed many varied activities. There have also been trips out which are always well organised”. The local branch of the Mothers’ Union continues to meet at the home. Several people living at the home are members. Regular religious services are held at the home which makes sure that people’s spiritual needs are met. One person living at the home runs a shop once a week selling toiletries, sweets, crisps, soft drinks and other essential items. This is useful for people who find it difficult to get out to the local shops. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 15 A newsletter is produced regularly which keeps everybody up to date with what is going on and what is planned at Trinity Fold. Visitors were seen to be warmly welcomed into the home and said this was always the case. The majority of relatives’ surveys indicated that they are always or usually kept up to date with important issues affecting their relative or friend. One relative made the following comment: “Policy decisions about changes to services provided by the home are not always notified to relatives, eg, recent withdrawal of escort service for residents attending medical appointments. I only found out about this when I was told I would have to do this myself for an imminent appointment”. One relative made the following comment in their survey: “Generally a welcoming atmosphere – staff soon get to know who is visiting who. The place feels ‘more alive’ than other places. Good involvement with the outside community, Mothers’ Union, local churches, regular bring and buy sales and hairdresser”. Trinity Fold DS0000000997.V339947.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): 16,18 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are protected by the policies, procedures and practices in the home. EVIDENCE: The home has a complaints procedure which is given to people who live at the home and their relatives. The document clearly states the procedure to follow and the contact details of all the people to approach if they are unhappy about anything in the home. A complaints log is held which details any complaints received and the outcomes. All of the people living at the home who completed a survey said that they knew who to talk to if they were not happy about anything in the home, with additional comments made including: “I would complain to the manager or supervisor, but this has not been necessary”. “The manager or relatives”. “How could anyone not be happy here?” Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 17 Relatives’ surveys also indicated that they knew how to make a complaint about the care provided by the home. Additional comments made included: “This would be to the home manager initially and if it needed taking further by calling the Anchor Careline”. “I have not had any complaints but the staff have been very quick to respond to my mother’s changing needs when we have spoken about them”. “Anchor homes have a comprehensive complaints procedure. I myself usually go straight to the home manager, who is very approachable”. “The manager and staff will always listen, explain and do what they can to amend anything that is unsatisfactory”. The home has an adult protection policy and all staff have received Protection of Vulnerable Adults (POVA) training. Staff spoken to were aware of the procedure to follow if they suspect or witness that abuse is taking place. Trinity Fold DS0000000997.V339947.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): 19,20,23,24,25,26 People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a well maintained and hygienic environment. EVIDENCE: The home is purpose built and is situated very close to the town centre of Halifax. The accommodation consists of 48 individual bed-sitting rooms all equipped with a kitchenette and en-suite facilities. All of the bedrooms have their own letter box and door bell which adds to the feeling of privacy and independence. The majority of the bedrooms are furnished and equipped with the person’s own possessions which aids orientation. As the bedrooms become vacant, however, Anchor are providing the furnishings to ensure compliance with health and safety regulations. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 19 People living at the home said that they were very satisfied with their own bedrooms and the communal facilities provided. One visiting relative said “they pay attention to detail, fresh flowers were in mum’s room when she moved in. They seem very organised and on the ball”. The communal areas are spacious and comfortable. The main lounge and dining area have recently been redecorated and refurbished and provide a pleasant and comfortable environment. There are safe and accessible garden areas for people to sit out in the warmer weather. The home was seen to be clean and hygienic throughout, visiting relatives confirmed that this is always the case. All people living at the home said in the surveys that the home is always fresh and clean. One person made the following additional comment: “The standards of hygiene and cleanliness are good”. The laundry was well equipped with machines meeting the required hygiene standards. An infection control procedure is in place to protect the health and safety of the people living at the home. Trinity Fold DS0000000997.V339947.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): 27,28,29,30 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are met by a well trained and competent staff team, and are protected by the rigorous recruitment practices. EVIDENCE: There are sufficient staff employed to meet the needs of the people living at the home. There is a commitment to staff training in the home. A programme of National Vocational Qualifications (NVQ) is in place, with 39 of the staff team holding the award. The home is working towards the target of 50 of the care staff to be qualified to NVQ level 2. In addition to the NVQ training, a variety of other training courses have been provided. People said that the staff were kind and attend to their needs promptly. Staff were able to demonstrate awareness of people’s needs. They were seen to be providing support in a sensitive manner, and promoting the privacy and dignity of the people living in the home. They said that they work together as a team and that staff morale was high. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 21 All of the people living at the home said in the surveys that the staff listen to them and are usually available when they need them. They also made the following additional comments: “The staff are always helpful and supportive”. “The staff always listen to me and they are all kind and considerate to all the residents”. “The care staff are remarkable”. “Most of the staff are very kind and caring”. “There are sometimes delays in answering call for assistance, but, overall the staff are very good”. Relatives said in the surveys that the care staff have the right skills and experience to look after people properly, and made the following additional comments: “Some staff are very young, but generally are caring and have a smile!”. “Friendly staff with a caring attitude”. “The staff show respect to the residents”. “The staff are all competent and look after my Grandma very well”. “The staff all seem caring and capable”. “The home seems to have a good training and skills programme”. “They generally give a good level of personal attention”. “I have always observed them to be caring with all the residents”. “They never get cross!”. A selection of staff records were seen. All of the staff files contained evidence that all the required checks had been carried out before being employed by the home. All files contained evidence of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures being received. Two written references are also requested. All staff have job descriptions, contracts and statements of terms and conditions. Trinity Fold DS0000000997.V339947.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): 31,32,33,35,38 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a well run and managed service. People’s health and welfare are protected by the home’s health and safety practices. EVIDENCE: The Registered Manager of the home is experienced and competent to run the home. There is a strong management team in the home with the Registered Manager and the deputy manager working together as a team. Together they Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 23 are committed to ensuring an open and positive atmosphere is prevalent in the home. There are clear policies and procedures for handling finances which means that people’s personal finances are held safely. There are detailed health and safety policies and procedures in place. All staff receive mandatory training in health and safety and safe working practices. Risk assessments are in place which ensure the health and safety of the people living at the home is protected. Trinity Fold DS0000000997.V339947.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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 x x 4 4 4 4 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 3 x 3 x x 3 Trinity Fold DS0000000997.V339947.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. 1 Refer to Standard OP7 Good Practice Recommendations To make sure that all people living at the home receive the care they need in accordance with their preferences, the care plans need to be in more detail. The plans need to show how the care is actually to be delivered. Trinity Fold DS0000000997.V339947.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Trinity Fold DS0000000997.V339947.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. 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