Inspection on 03/05/07 for Wyndthorpe Hall & Court

This inspection was carried out on 3rd 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wyndthorpe Hall & Court 06/06/06

Wyndthorpe Hall & Court 20/12/05

Wyndthorpe Hall & Court 26/07/05

Wyndthorpe Hall & Court 08/04/05

Wyndthorpe Hall & Court 25/11/04

Wyndthorpe Hall & Court 09/06/04

Wyndthorpe Hall & Court 15/12/03

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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 Wyndthorpe Hall & Court Wyndthorpe Hall 1 High Street Dunsville Doncaster South Yorkshire DN7 4DB Lead Inspector Ivan Barker Key Unannounced Inspection 09:00 3rd May 2007 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 DS0000048425.V331760.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. DS0000048425.V331760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyndthorpe Hall & Court Address Wyndthorpe Hall 1 High Street Dunsville Doncaster South Yorkshire DN7 4DB 01302 884650 01302 890032 None 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) Four Seasons Homes (No 6) Limited (A wholly owned subsidiary of Four Seasons Healthcare) Mrs Susan Howden Care Home 44 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (20) of places DS0000048425.V331760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A service user with a mental disorder, named on variation dated 3rd May 2005, may reside at the home. One specific service user under the age of 65, named on variation dated 20th February 2006 may reside at the home. 6th June 2006 Date of last inspection Brief Description of the Service: Wyndthorpe Hall and Court are one registered service providing two types of service in separate parts of the building. The Hall is a converted building for up to 20 older for people who require personal care. The Court is an extension, for up to 24 older people who have dementia and who require personal care. Both parts of the building are on two floors connected by shaft passenger lifts, and staircases, and are connected to each other on the ground floor. There are a number of communal areas in each part of the building, all on the ground floor, and some have access to the gardens. Most of the bedrooms are single and some have an en-suite toilet and washbasin. There are a number of bathing facilities and toilets around the home. It is set in large gardens at the edge of the village of Dunsville near Doncaster. The regional offices of the company are based in Wyndthorpe Hall. Another home, also owned by Four Seasons, is located in the grounds. Information about the home including fees is available from the home in the form of a brochure and the statement of purpose. The charges range from £375 to £510. Extra charges are made for hairdressing, toiletries, and chiropody. DS0000048425.V331760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Mrs S Howden, manager. Within this site visit, which occurred over a five hour period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 3 service users (Case tracked means looking at the care and service provided to specific service users living at the home; checking records relating to their health and welfare, care plans and other records; by talking to the service users themselves; viewing their personal accommodation as well as communal living areas), and spoke with other service users, and also 3 staff and examined assessments, care plans, risk assessments, menus, complaint files, staff files and quality monitoring documents. Unfortunately no relatives were available at the time of the visit. The history of the service was examined prior to the site visit. This included the telephone contacts, letters, notifications, the pre-inspection questionnaire and any other correspondence received. What the service does well: Accurate comprehensive assessments were in place from some of the care management team and from the staff of the service. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. Accurate care plans will contribute to the delivery of care. Service users expressed their limited views, during the inspection. Their opinions were; ‘I’m looked after’. ‘It’s good here’ Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. ‘The film was good’. ‘Not sure what’s going on’. DS0000048425.V331760.R01.S.doc Version 5.2 Page 6 ‘We do things in here’. (Indicating the reception room) Positive comments were received from the service users regarding the food provision. The general comments were that; ‘The food is good.’ ‘They give me what I like’. The service is well managed and well organised. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes. What has improved since the last inspection? What they could do better: The manager should establish as part of the quality management a system of recording what work is required, who is to undertake the work and within what timescale it is completed. Also ensure that the environment does not again deteriorate to such a poor condition. Continue with the NVQ training so that they achieve the expected 50 . DS0000048425.V331760.R01.S.doc Version 5.2 Page 7 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. DS0000048425.V331760.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 DS0000048425.V331760.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): Standards 3 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate comprehensive assessments were in place from some of the care management team and from the staff of the service. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: On examination of three service users’ care plans examining the care management assessments, two had care management assessments, and the other one had no assessment records. On discussing this fact with the manager, she advised that some assessments were delivered over the telephone by the care management team, rather than a written assessment. Therefore there was no document within the care plan. DS0000048425.V331760.R01.S.doc Version 5.2 Page 10 On seeking clarification of the information given over the telephone, it was established that these referrals were not always emergency admissions but also planned referrals. Despite this fact, the manager or senior care had undertaken extensive assessments of each service users prior to their admission. These assessments detailed the service user’s needs that would assist in providing sufficient information for care plans to be drawn up. The manager advised that no intermediate care, only respite care was provided within the service. DS0000048425.V331760.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): Standards 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate care plans will contribute to the delivery of care. Service users were satisfied with the care they received. EVIDENCE: On examination of the care plans, from three service users, it was established that all three care plans were up to date, and had been evaluated on a monthly basis. There were daily entries within the care plans, these entries recorded the care delivered on a daily basis. Comprehensive risk assessments were included within the documentation and included moving and handling, nutrition, skin integrity, and other risk factors. DS0000048425.V331760.R01.S.doc Version 5.2 Page 12 The manager advised that the format and risk assessment documentation were changing and the staff were in the process of changing over the information to the new documentation, therefore some care plans contained the old and new style of documentation. It was discussed that as part of the process it would be useful to reduce the amount of ‘old’ documents within the plans, and put them into storage, so as to produce a more accessible file. Service users expressed their limited views, during the inspection. Their opinions were; ‘I’m looked after’. ‘It’s good here’ The storage, ordering, administration and disposal of medication procedures were discussed with the manager. The procedures explained by the manager were satisfactory, but further discussions occurred regarding the storage of the trolleys and security of medication administration records. During a tour of the home, it was established that both the areas of the home (Hall and Court) had medication trolleys stored with the dining room. These trolleys were secured to the walls with chains. However these trolleys were often unobserved by staff, and medication administration documents which contained information regarding each service user were left on each of the trolleys. It was discussed that the relocation of the trolleys and documentation into a secure area would both contribute to the security of the medications and documentation, and create a more homely environment in the dining rooms. The manager identified a storage room. There was a signature-checking document, which contained the initials as written on the medication administration document and the member of staff’s signature. On examination of the medication administration records it was found that there were no omissions of signatures. All medication records had been signed when being checked in from the pharmacy. DS0000048425.V331760.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the activities and provision of meals. EVIDENCE: The manager advised that an activities co-ordinator was responsible for the activities, entertainment and outings and employed for 30 hours per week. There was a programme of planned social events displayed. The plan consisted of certain ‘fixed items’ for example quiz morning, film show on a Thursday afternoon and hairdressing on Wednesdays. Different activities were programmed for the other days of the week. During the visit, which occurred on a Thursday, some of the service users were in one of the lounges watching a film. This activity was on the weekly programme. DS0000048425.V331760.R01.S.doc Version 5.2 Page 14 Within each care plan, there was an activities record, which had been completed on a daily basis to indicate which activity the person participated in, a group activity or one to one. On discussing the activities with the manager it was advised that activities and entertainment and outings were planned well in advance. The entertainer was a singer who visited the first Tuesday of every month. Also a ‘ motivation lady’ visited on a monthly basis. Her contribution was to encourage service users to participate in exercises such as stretching and throwing, sing a longs, memory games and quizzes. The manager advised that she had noticed that these sessions were very much enjoyed by the service users. Church services occurred once a month and involved songs, prayers, but also a tea and coffee morning. Service users, their family and other people from the local church attended these services. The manager identified that such services brought the ‘community’ into the home. Also a regular outing was arranged to the local Crown Green Bowling club for ‘tea’. Outings were planned on a monthly basis and the May and June outings were to Cleethorpes and Skegness. On discussing the activities with the service users, their opinions were that; ‘The film was good’. ‘Not sure what’s going on’. ‘We do things in here’. (Indicating the reception room) Regarding the meals, the manager advised that, as service users were often unable to remember what choice they had made, because of their medical condition, the service did not currently provide a menu. However two choices were available at dinner and each service user was asked their choice, before providing a meal. It was observed that each service user was asked for their choice and it was established that sufficient food had been prepared, as there was both choices left in the meals trolley, after everyone had eaten. Copies of four weekly menus were seen, within the kitchen, and the food on the date of the visit was being prepared according to this menu. Positive comments were received from the service users regarding the food provision. The general comments were that; ‘The food is good.’ ‘They give me what I like’. DS0000048425.V331760.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): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service had a complaints procedure in place, and it was operating according to the company policy, including the referrals to Safeguarding Adults team. This would provide confidence that complaints were taken seriously and acted upon to address any shortfalls in care or service provision. The service was able to evidence that the staff had received Safeguarding Adults training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: The service had a complaints procedure displayed at the entrance. The complaints book and the complaints file kept by the manager for her investigations were examined. There were two entries in June and July 2006 that were relating to care issues and both had been referred to the Safeguarding Adults team. The manager advised that both had been investigated and the necessary action taken, but the cases were yet to be ‘closed’ by the Safeguarding Adult team of Social Services. The Commission was aware of these cases. DS0000048425.V331760.R01.S.doc Version 5.2 Page 16 The regional manager examined the complaints as part of the monthly quality review. Regarding safeguarding adults, the safeguarding policies and procedures proved difficult to locate, however they were found in the training file. The manager expressed her concern that these documents were not readily available for staff and advised that she would copy the documents and place them in the policy file, that day. Staff had undertaken safeguarding adults training, and the manager was able to evidence this by showing computerised training records and certificates within staff files. DS0000048425.V331760.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): Standards 19 and 26. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment, monitored at the site visit, had not been maintained to a good standard and required a considerable amount of repairs to provide a safe, well-maintained environment for services users. EVIDENCE: On touring the building, the home was found to have reasonably decor in most areas but several areas of the service required redecoration and repairs. The following major areas required attention. The front lounge of the Hall had damp areas to the outside walls. This had caused the loss of décor and flaking plaster. No mould was apparent. DS0000048425.V331760.R01.S.doc Version 5.2 Page 18 The manager advised that a roof had leaked and this had caused damage to the lounge walls. The roof was now fixed but the lounge was yet to receive attention. On questioning when the work would be completed no timescale was offered. Bedroom 12, which was unoccupied at the time of the visit had sustained similar damage and was awaiting redecoration. Again no timescale was offered. Radiator covers had been fitted to the radiators, throughout the Hall and Court, The number of radiator was considerable and all these needed painting. Within the Court, a communal toilet and Bathroom 7 were without floor coverings. The manager advised that there had been a new bath fitted within the bathroom and the floor covering was the next work to be done. A shower room had newly tiled on the walls and new flooring fitted, but the sealing material between the flooring and tiling had not been fitted. It was established that service users were using this room. In its current state it did not create any difficulties or health risk to service users, but without the seals the room was at risk of leaking, which may cause damage elsewhere. Also many areas of the home required minor repair, examples; redecoration to a corridor, as a section of paper had been torn from the wall, repair and redecoration to some of the wooden boxing covering pipes in the en-suites, repairs to some the windows, replacement of some bulbs, and other work. It was recognised that if staff had not made the handyman aware of the minor repairs then he could not act on these, however there was a considerable amount of other major work that had been started but not completed. At the time of the visit no areas were receiving any attention, on raising this issue, the manager advised that the handyman was assisting another handyman at the other service, located in the grounds. It was agreed that the manager would undertake a quality monitoring of the environment of the service and identify all repairs both major and minor and produce a programme of maintenance work and a work schedule for the identified work, and a copy of the programme to be sent to the Commission. In future the manager should establish as part of the quality management a system of what work is required, who is to undertake the work and within what timescale it is completed. Since completion of the visit the manager has contacted the Commission, by telephone and advised that the quality monitoring has occurred and that the radiators will be decorated within the next week. Positive comments were received from the service users regarding the home. DS0000048425.V331760.R01.S.doc Version 5.2 Page 19 The general comments were that; ‘The place is nice’ ‘Its nice here’. The service users’ rooms had been personalised and contained photographs, personal belongings, which the individual or the family had provided, however these were limited in some rooms. DS0000048425.V331760.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager provided evidence that all staff had received training, which could reflect on the quality of care being delivered to the service users. The staff recruitment process should provide protection for the service users. EVIDENCE: On examination of the staff rotas and examination of staff on duty, the following was established: The Hall. Am. shift – Pm. shift– Night shift – The Court. Am. shift – Pm. shift– Night shift – 1 senior care plus 2 carers 1 senior care plus 2 carers 2 carers DS0000048425.V331760.R01.S.doc Version 5.2 Page 21 1 senior care plus 2 carers 1 senior care plus 2 carers 2 carers Plus A manager An administrator Activities Co-ordinator Ancillary staff included. Domestics and catering staff, and a handyman. Caring for a present occupancy of 31 service users. A full assessment of the dependency levels of the service users was not undertaken and compared with the indicated staffing levels. On examination of the three staff files, all contained the required documentation, including Criminal Records Bureau and POVA (Protection of Vulnerable adults) checks. On examination of the staff training records there were records and certificates that indicated the staff had received moving and handling, fire training and other relevant training. The members of staff with NVQ training at the time of the visit was: 5 staff had NVQ (National Vocational Qualification) level 2, 1 member of staff was near completing her NVQ level 2. The manager advised that 8 more staff were waiting to start the next course. On completion of the qualification the service should have 14 of the 27 care staff with a NVQ. Therefore achieving over the expected 50 of staff with NVQ. As this is yet to be achieved, but the service is moving positively on the issue, the requirement is restated with a new timescale. DS0000048425.V331760.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes, however the environmental shortfall should have been identified within this audit system. DS0000048425.V331760.R01.S.doc Version 5.2 Page 23 EVIDENCE: There was a registered manager in post. She advised that she had at least 13 years management experience and had attained the Registered Manager’s Award. Regarding the monies held by the company on behalf of the service users, there was a credit and debit system that had both hard copy (paper) documents and computer records. The importance of ensuring the use service user’s money to enhance their quality of life, and not being left accumulating in the account was discussed. Regarding Quality Assurance, manager and regional manager undertake the quality monitoring of the service. The system included analysis of the care and service provision, a scoring system / standard achieved was also included within the documentation. The information from these documents was forwarded to the head office of the company for analysis. The last quarterly audit undertaken achieved 86 . However the analysis of the monitoring was questioned, in view of the shortfalls in environment raised at this visit. Regulation 26 documentations, which are a record of the registered person’s monthly visits, was complied on a monthly basis, evidence of this was seen at the visit. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; have been received by CSCI (Commission for Social Care Inspection). The pre inspection questionnaire had been returned to the Commission prior to this visit. The information within the document confirmed that the necessary maintenance and servicing had occurred. DS0000048425.V331760.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 1 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 DS0000048425.V331760.R01.S.doc Version 5.2 Page 25 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 OP28 Regulation 18 (1) Requirement Ensure the target of 50 of staff with NVQ level 2 or above is achieved, so that the staff have received sufficient training to care for service users. Timescale for action 03/08/07 2. OP19 OP26 19 The service needs to be in good 03/08/07 state of repair. Attention should be given to the areas identified in Standard 19 and the audit undertaken by the service, so that service users have a well maintained environment in which to live. 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 DS0000048425.V331760.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000048425.V331760.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. 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