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Inspection on 20/08/07 for White Lodge & St Helens House

Also see our care home review for White Lodge & St Helens House for more information

This inspection was carried out on 20th August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents have their needs fully assessed before being offered a place at the home. Care plans are developed to ensure that health and social care needs of residents are met. Medication is administered safely within the home. Residents of leisure, social and spiritual needs are catered for. Residents are provided with a balanced and varied diet. Employ sufficient levels of qualified staff to meet the needs of the residents who are recruited in line with the practice. The home is well maintained, kept clean and in good decorative order.

What has improved since the last inspection?

Recruitment practices have been improved and now comply with Regulations. The home is planning to take action to make radiators safer by installing low surface temperature type radiators. Areas of the home had been redecorated since the time of the last key inspection.

CARE HOMES FOR OLDER PEOPLE White Lodge & St Helens House 15-17 Boscombe Spa Road Bournemouth Dorset BH5 1AR Lead Inspector Martin Bayne Unannounced Inspection 20th August 2007 10:00 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 White Lodge & St Helens House DS0000003986.V348926.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. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service White Lodge & St Helens House Address 15-17 Boscombe Spa Road Bournemouth Dorset BH5 1AR 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) 01202 395822 01202 569587 wl-office@btconnect.com Mr John Higginson Mrs Christine Higginson, Mrs Karen Frances Watt, Mr Peter John Higginson, Mrs Caroline Jane White Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person (as known to the CSCI) under the age of 65 may be accommodated to receive care. 3rd October 2006 Date of last inspection Brief Description of the Service: White Lodge and St Helens House are adjoining properties with an extension that links them on each level. The home is registered to accommodate fiftyfour residents in the old age category. All residents enjoy single rooms, which offer a wide variety of sizes and outlook. The buildings were constructed on sloping land and are on four levels, lower ground, ground, first and second floors. The home has a passenger lift. There are pleasant well-maintained gardens at the rear of the property, but access for frail residents is limited as there is a steep path and steps to gain access. The home is located within a ten-minute walk of the Boscombe shopping area and the local beach; the latter requires the negotiation of a small hill. The home has a regular programme of social activities and seasonal outings. The fees for the home range from £363 - £450 per week. Further information about fees in residential homes can be found at: http:/www.csci.org.uk/pdf/oft_care_home_response.pdf Service users at the home are able to obtain a copy of this report from one of the registered providers. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 9am and 4pm, with the aim of evaluating the home against the key National Minimum Standards for older people, and to follow up on the one of requirement and two recommendations made at the last key inspection in October 2006. Time was spent with two of the Register Providers discussing how the home was managed as well as viewing various records that the home is required to maintain. A tour of the premises was made, during which time residents were spoken with about their experience of living in the home. The inspector spoke with a large group of residents in the conservatory and also with individual residents within their bedrooms. A sample of four residents was chosen to track the required records that the home is required to maintain as evidence of the care provided within the home. Prior to the inspection the Registered Providers had returned a quality assurance information question, which provided information about the home to assist with the inspection. In addition, comment cards for residents, relatives and health and social care staff were left at the home for completion. All of the above were used to form the judgements contained within this report. What the service does well: Residents have their needs fully assessed before being offered a place at the home. Care plans are developed to ensure that health and social care needs of residents are met. Medication is administered safely within the home. Residents of leisure, social and spiritual needs are catered for. Residents are provided with a balanced and varied diet. Employ sufficient levels of qualified staff to meet the needs of the residents who are recruited in line with the practice. The home is well maintained, kept clean and in good decorative order. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The contract as detailed within the Terms and Conditions of Residence should be reviewed and updated. Care plans should be reviewed and monitored monthly and the home should evidence how residents or relatives are involved in developing the plans. Staff should be offered training concerning the new Mental Capacity Act 2005. The home should check that the induction training offered to new staff complies with the standards set by Skills For Care. It is recommended that the home make plans for the refurbishment or replacement of the laundry area. Please contact the provider for advice of actions taken in response to this White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 7 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. White Lodge & St Helens House DS0000003986.V348926.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 White Lodge & St Helens House DS0000003986.V348926.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): 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from their needs being assessed before they are offered a place at the home. EVIDENCE: The inspector was informed that following an enquiry about a vacancy at the home, a letter and a brochure is sent out to the person concerned. Prospective residents or relatives are welcome and invited to visit the home. Should a person wish to move into the home one of four senior staff will go and visit the person and carry out an assessment of their needs. It was found that for the four residents tracked through the inspection, a pre-admission assessment of need had been completed and recorded on a form developed White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 10 from this purpose. The form used by the home covered all of the topics detailed within the National Minimum Standards for older people. Should it be assessed that the home can meet the needs of the prospective resident, a letter is sent out to inform that a place is offered at the home on a trial basis. The letters were seen on file for the four residents tracked through the inspection. In cases where residents are referred through social services, the home obtains a copy of the care management assessment and this is also used to establish whether the home can meet the needs of that particular person. When a person is admitted into the home they sign a contract in the form of Terms and Conditions of Residence. It was agreed that the contract would be reviewed as some of the information contained within this document was out of date, such as the statement that residents are allowed to smoke within their rooms. The home does not provide an intermediate care service. White Lodge & St Helens House DS0000003986.V348926.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit by their health and social care needs being met through care planning, safe administration of medication and by being treated with respect and dignity. EVIDENCE: The inspector was told that care plans are developed with the resident or in some cases their relatives or representative and then written up on the home’s computer. For the residents tracked through the inspection care plans were seen and these provided sufficient information for a new member of staff to provide care to that person. On the front of the care plans was a copy of a recent photograph of the person to assist the staff in identifying the resident. It was found that the computer flags up the need for a review of the care plan White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 12 after three months; however the standards required that care plans be monitored monthly. It was also found that there was nothing to indicate that residents or relatives had been involved in developing the care plan, such as their signature. It was recommended that the system be put in place to ensure that care plans are reviewed at least monthly and that there is some evidence of relatives or residents being involved in developing care plans. From the care plans and information within the persons file, there was evidence that residents’ health needs were being met with each resident registered with a GP, district nurses being involved appropriately and other health needs such as chiropody, dentistry and eye care tended to. It was also found that risk assessments had been carried out to minimise the risk of harm for residents. These included moving and handling assessments, skin care assessments and other monitoring charts that were put in place when required. One resident was observed being assisted by the staff and appropriate techniques were being used. The residents spoken with during the inspection said that their health and social care needs were met. One person who had lived in the home for many years said, ‘I have never regretted moving here’. Another person informed, ‘the staff are always very attentive and cant do enough for us’. One of the senior staff talked through medication administration procedures and showed the inspector where medications are stored. The home has a trolley that is locked and fixed to the wall when not in use. The home uses a unit dosage system and medications are supplied to the home by the local pharmacist. Within the medication room there was also a locked cupboard where surplus medication is kept. There is accountability for medication held with the senior on duty holding the keys and being responsible for medication administration on their shift. Only senior staff who have received training in safe administration of medication can administer medication to residents. At the time of inspection there was one resident who had been prescribed a controlled drug. These were being kept within an inner lockable facility and were being administered correctly with two staff signing the record and maintaining a balance of the medication held. It was agreed that the home would obtain a controlled drugs register for recording the administration of controlled drugs. Some residents had been prescribed medications that required refrigeration. The home has a separate small fridge and the maximum and minimum temperatures were being recorded daily to ensure medications were stored at the correct temperature. The medication administration records were seen and it was found that these were being completed correctly with no gaps within the records. It was agreed that a photo of each resident would be put at the front of their medication administration records so that a new member of staff could easily identify and make sure that they were giving medication to the correct person. White Lodge & St Helens House DS0000003986.V348926.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. This judgement has been made using available evidence including a visit to this service. Residents benefit from their spiritual, recreational and leisure needs being met and form being provided with a balanced and nutritious diet. EVIDENCE: The home employs an outside activities coordinator who visits the home twice a week to run group activities, such as keep fit, quizzes and other games. One resident informed that they liked reading and that the visiting library visited the home regularly. Two hairdressers visit the home, one every Friday and one on Tuesdays. Residents’ birthdays are celebrated with the chef making a cake and a small gift is also given to the person. The home arranges the occasional outing for residents as the home has the facility of a people carrier. The inspector was informed that residents are also taken out for walks down to the beach or to go to the shops. Where possible, staff escort residents for hospital appointments. The inspector was told that there is an expectation White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 14 that staff should spend individual time with residents when not involved in providing personal care. The residents spoken with said that they were happy with the level of activities provided within the home. Two comment cards returned from relatives informed that they would like to see more outings for residents away from home and the registered providers should consider and plan with residents whether this is what they would want. At the time of inspection two relatives were visiting the home. The residents spoken with informed that there were no restrictions on visitors and that their visitors were made welcome at the home. A church service is held in the home of each month and every Sunday residents who wish to receive Holy Communion have this given by a visiting member of clergy. The inspector was told that some residents also go out from the home to the local church on Sundays. The residents spoken with informed that they could get up and go to bed when they chose and that their right to choose and have control over their lives was respected. The residents spoken with were asked about the standard of food provided in the home and in general their comments were favourable. Residents are able to have their breakfast from 6:30am onwards and can have a tray within their room or have their meal in the dining room. Residents can have a cooked breakfast on request or have a selection of toast, cereals, porridge or fruit. The list was seen for breakfast choices and this informed of where residents wish to have their meal, what they wish to have and at what time. Lunch is served at 12:30pm with most residents having their lunch within the dining room, although residents can have their lunch served in their room if that is their choice. There is one main meal provided although residents can choose on request to have another option. The records were seen of the food provided and there was evidence of a varied and balanced diet with fresh vegetables served. The residents spoken with informed that the chef knew of their likes and dislikes and the quantities that they wished to have. Residents are provided with an evening meal on a tray within their room. A list of choices and things that people would like to eat was seen. White Lodge & St Helens House DS0000003986.V348926.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. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well publicised complaints procedure and from the staff being trained in adult protection. EVIDENCE: The complaints procedure is displayed on the residents’ notice board, within the service user guide, the Statement of Purpose and within the Terms and Conditions of Residents. Residents and relatives are therefore well informed of how to make a complaint should they feel this is necessary. It was agreed that home would review all these documents and ensure that they were consistent, as the complaints procedure in the Terms and Conditions referred to the National Care Standards Commission rather than the Commission for Social Care Inspection. Since the time of the last key inspection there have been no complaints or concerns brought to the attention of the Commission. Training in adult protection is provided as part of the induction of new staff and staff are also able to obtain further training from an external course at a later date. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 16 The dataset provided before the inspection informed that the home had copies of all the relevant procedures and policies relating to the protection of vulnerable adults. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 17 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 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well maintained environment, however the laundry room could do with refurbishment to meet good infection control standards. EVIDENCE: The home consists of two properties joined together by an extension. Within the extension is a shaft left provides access to all of the four floors of the home. There is also a stair lift within each building. Residents are provided with single rooms and share two communal lounges and a conservatory/dining room. At the front of the home there are car parking spaces available and to White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 18 the rear of the home there are well maintained gardens overlooking Boscombe Chine gardens. At the last inspection it was recommended that risk assessments of uncovered radiators in the older part of the home be reviewed and action taken where any risk was identified. The inspector was informed that the home had obtained a grant and that this would be used to have all radiators converted to low surface temperature type. Progress will be monitored at future inspections. Since the last inspection the home has been visited by the Fire Officer and work was in progress to fit intumescent strips to all of the fire doors. Following a visit from the Environmental Health Officer, new lighting has been fitted in the kitchen area as required. On the day of inspection the home was found to be clean and there were no unpleasant odours. The home was in good decorative order throughout. The home has policies and procedures for infection control. Staff are provided with alcohol gel dispensers and protective gloves and clothing. The home has a separate laundry room located away from food preparation areas and equipped with sufficient machines and dryers to meet the laundry needs of the home. It was found however that the laundry room could be improved. The home does not have sluicing area and there is only one double sink in the laundry room that serves as a rinsing area as well as a hand washing facility. The laundry area is also very cramped and two washing machines have been fitted in the staff room. This situation was discussed with the proprietors and it is recommended that plans for refurbishing or possibly re-siting the laundry room should be considered in terms of long-term improvements. White Lodge & St Helens House DS0000003986.V348926.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. This judgement has been made using available evidence including a visit to this service. Residents benefit from their needs being met by adequate staffing levels and the staff being well trained. EVIDENCE: The staffing levels for the home were discussed. The inspector was informed that there is a minimum of six staff on duty in the home between 8am to 8pm, one carer to each floor with two staff who ‘float’ between the floors. In addition there is one senior carer and also a manager on duty. During the night-time period there are two members of staff awake and two staff who do a sleep-in duty. The duty roster was seen that reflected the above staffing. The residents spoken with indicated that there were sufficient staff to meet their needs and this was also corroborated by speaking with two members of staff. In addition the home employs ancillary staff of four cleaners, one for White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 20 each floor of the home between 8am and 2pm seven days a week. The home also employs a waiter to assist with breakfast and lunchtime meals as well as a chef, a kitchen assistant and a general assistant and maintenance staff. The home has not yet achieved a level of 50 of staff trained to the level of NVQ level 2. It was found however that some of the staff from overseas had qualifications that may be equivalent to this level of training. The home should seek to find whether these qualifications are equivalent to NVQ level 2, as it may be that the home has reached the 50 level. At the last inspection a requirement was made, as some newly appointed staff had started work in the home before the return of a check against the register of people deemed unsuitable to work with vulnerable adults. At this inspection a sample of three staff files was used to check against recruitment requirements. These staff had been appointed since the time of the last inspection. It was found that all the necessary recruitment checks as detailed within Schedule 2 of the Regulations had been complied with including; a photo, proof of identity, a completed application form, a health declaration, two written references, a Criminal Record Bureau check and a check against the register of adults deemed unsuitable to work with vulnerable adults. The requirement was therefore met. Concerning training, all new staff undertake induction training. It was agreed that the home would check that this training met the induction standards as set out by the organisation Skills for Care. All staff receive core mandatory training in moving and handling, fire safety, infection control, health and safety and adult protection. There are sufficient numbers of staff trained in first aid for there to be one first aid trained member of staff on duty at all times. Staff who administer medication have received training in safe administration of medication. It was recommended that the home seek training concerning the Mental Capacity Act 2005 for staff at the home. White Lodge & St Helens House DS0000003986.V348926.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 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed with health and safety promoted within the home. EVIDENCE: The home is a family run business with five family members registered as providers, one of whom has completed NVQ level 4. The management arrangements for the home were discussed and the inspector was informed that there were plans to put forward a person with NVQ level 4 to become the Registered Manager of the home. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 22 The home was found to be well managed and run in the interests of the residents. The home carries out an annual quality assurance survey involving residents and relatives. Forms inviting people to give feedback about the home were found at the front reception area. The home safe keeps small amounts of money on behalf of residents. The financial records of two residents tracked through the inspection were seen and the balance of money held tallied with the detailed records. A sample of certificates was seen that demonstrated that health and safety measures were being promoted within the home. A report concerning the water safety and legionnaires disease was seen, contracts of clinical waste, an occupational therapy report on the suitability of the building to meet needs of older people, a gas safety certificate and an electrical inspection report. The fire officer has recently visited the home and the inspector was informed of action to be taken to meet requirements. Portable electrical equipment wiring testing had been carried out within the last three months. White Lodge & St Helens House DS0000003986.V348926.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 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 17 X 18 3 3 X X X X X X 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 X 3 X 3 X X 3 White Lodge & St Helens House DS0000003986.V348926.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 4 Refer to Standard OP2 OP7 OP16 OP26 Good Practice Recommendations It is recommended that the document, ‘Terms and Conditions of Residence’ be reviewed. It is recommended that systems be devised to ensure that care plans are reviewed monthly and provide evidence of residents or their relatives being involved in this process. It is recommended that the complaints procedure be reviewed to ensure that information is up to date. It is recommended that the laundry room is refurbished or re-sited. White Lodge & St Helens House DS0000003986.V348926.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 White Lodge & St Helens House DS0000003986.V348926.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. Re-publishing this information is in breach of the terms of use of that website. 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