Care Home: Court Regis

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What the care home does well The home has a new manager with new ideas and a positive approach. She is supported by her deputy, assistant general manager and senior staff. Many staff have worked at the home for a long time providing stability for the residents. It had been proposed that the number of shared rooms be reduced thus providing more privacy to the residents. The residents confirmed that they felt comfortable and relaxed in the home and that they felt well cared for. The home is friendly and homely. Health needs are well managed and a good relationship is enjoyed with the local District Nurse team. Residents are encouraged to maintain contact with their loved ones and visitors are made very welcome. Residents spoken with said that the food was good and there was always a good choice. Staff training is well organised and provides staff with the competences to fulfil their roles at the home. The residents enjoy an excellent level of activities and social events within and outside the home. All staff contribute to the well running of the home and the friendly and warm environment. The home promotes equality and diversity for all residents and staff in accordance with company policy and procedures. What has improved since the last inspection? The corridors have been redecorated and all hallway carpets replaced. Some bedroom carpets have been replaced. The "toilets block" on the lower floor has been refurbished and sinks replaced. An activities room has been created and equipment purchased. Flat screen televisions have been installed in the lounges. Improvements have been made to the clinical room. What the care home could do better: The statement of purpose and service user guide need further refinement to ensure that the care of dementia clients is included. Care plans could be further improved by making sure that nutritional needs are evaluated. Some recommendations in respect of medication practices were made. Some bedroom carpets are in need of replacement. The gardens should be made user friendlier and allow the residents free access. Rubbish and miscellaneous objects need to be removed. Plans are in hand to build raised flowerbeds and to relay the paths. CARE HOMES FOR OLDER PEOPLE Court Regis Middletune Avenue Sittingbourne Kent ME10 2HT Lead Inspector Lisbeth Scoones Unannounced Inspection 25th February 2008 10:15 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 Court Regis DS0000023918.V357769.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. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Court Regis Address Middletune Avenue Sittingbourne Kent ME10 2HT 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) 01795 423485 01795 471348 www.kcht.org Kent Community Housing Trust vacant post Care Home 54 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (34), of places Physical disability (2) Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care for one person with a physical disability is limited to one person whose date of birth is 19/09/1942. Care for one person with a physical disability is limited to one person whose date of birth is 04/05/1947 30th January 2007 Date of last inspection Brief Description of the Service: The home occupies detached premises, which was custom built initially for the local authority, and offers accommodation on the ground floor only, although there are staff facilities on the first floor. There are 32 single rooms and 10 shared rooms, all of which have call bell and television points. Some of the shared rooms are used as singles. The home is located on the edge of a large residential estate and adjacent to a junior school, to the north of Milton Regis. It is close to a bus route and about a mile from the main line railway station of Sittingbourne. Local shops are within a short walking distance. The home employs 45 care and 19 non-care staff. These include activities, domestic, catering, cleaning, laundry, gardening, maintenance and administration. The recently appointed manager has wide experience in the provision of care. She has attained qualifications in management and care and oversees a skilled competent team who are trained in working with older people and those suffering from dementia. The duty rota includes 3 carers on waking night duty, with a senior member of staff on-call for emergencies. There is also a full time activities co-ordinator. The unit within the home that offers care for those people suffering from dementia is self-contained, but shares the catering and domestic services within the main building. It has access to a large secure garden. Weekly fees range from £318.99 to £525 depending on whether the resident has dementia or residential care needs, is private or local authority funded and has a single or shared room. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key unannounced inspection that took place on 25th of February 2008 and comprised discussions with the manager and her deputy, members of staff, many residents and three visitors, a tour of the building and examination of care and other records. The assistant general manager for KCHT was present at the feedback session. The inspection was further informed by an AQAA (annual quality assessment and audit) completed by the manager prior to the inspection. Comment cards completed by 11 relatives, 2 residents and 11 members of staff arrived too late to be included in this report. Comments received were complimentary and positive in all respects. Overall this was a positive inspection with generally good outcomes for the residents. What the service does well: The home has a new manager with new ideas and a positive approach. She is supported by her deputy, assistant general manager and senior staff. Many staff have worked at the home for a long time providing stability for the residents. It had been proposed that the number of shared rooms be reduced thus providing more privacy to the residents. The residents confirmed that they felt comfortable and relaxed in the home and that they felt well cared for. The home is friendly and homely. Health needs are well managed and a good relationship is enjoyed with the local District Nurse team. Residents are encouraged to maintain contact with their loved ones and visitors are made very welcome. Residents spoken with said that the food was good and there was always a good choice. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 6 Staff training is well organised and provides staff with the competences to fulfil their roles at the home. The residents enjoy an excellent level of activities and social events within and outside the home. All staff contribute to the well running of the home and the friendly and warm environment. The home promotes equality and diversity for all residents and staff in accordance with company policy and procedures. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 7 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 Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s updated statement of purpose needs to be further enhanced to ensure that all residents and families receive comprehensive information regarding services offered at Court Regis. A written statement of terms and conditions protects residents’ legal rights to occupancy. Residents benefit from a comprehensive needs assessment prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 9 EVIDENCE: Residents and their families have access to a written Statement of Purpose and Service User Guide. Both documents, though updated, need further refinement particularly in respect of the dementia care clients. All residents are provided with a written statement of terms and conditions with the home. The manager explained the process of admission, which was thorough and consisted of a home visit where possible and a phased admission to the home. Residents spoken with confirmed that they had visited the home prior to their admission and had been able to bring in a few personal items with them. Pre- admission assessments were examined. These provided comprehensive information from which to write a care plan. Whenever possible the new resident’s key worker would be present on admission to help the resident to settle in. All resident have a full review after four weeks to ensure his or her needs continue to be met. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 10 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 from having clear person-centred care plans that identify their individual needs and give clear guidance to staff. Staff should ensure that planned care is evaluated at review. Health needs are well met and residents benefit from having full access to all professional health care services as required. Residents are mostly protected by the home’s policies and procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy is upheld. Residents benefit from having the issue of aging and illness handled sensitively. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 11 EVIDENCE: A sample of care plans was viewed and provided staff with good information and guidance to staff. They set out the action needed to ensure that residents’ health and personal care needs were met. Care plans are supported by a range of risk assessments such as risk of falls and the risk of skin breakdown. Where such a risk is identified, residents are provided with a pressure relieving mattress and chair cushion. In relation to nutritional risk, staff should ensure that weights are recorded and related care needs evaluated. Many care plans are signed by the residents or their relatives which is good practice. All residents are registered with a local GP and had access to other professionals such as opticians and chiropodists ensuring health care needs were met. One resident said that her doctor visits regularly and that she often sees the district nurse. All staff who administer medication have completed appropriate training. Some time was spent with a team leader who demonstrated a good knowledge of the residents’ medication needs. Good records are maintained of administration and disposal. These could be further improved by ensuring that all hand written entries on the medication charts are signed by two members of staff: that eye drops bottles and medicated ointments are dated when opened ensuring that these are not used for more than 28 days: that only those medications requiring it are stored in the fridge. Staff practices seen on the day indicate that residents are well respected at all times and that preferred terms of address are used. Good interaction between staff and residents was observed. Many residents commented on the kindness of the staff. The home has a policy on illness and palliative care which as far as medically possible enables residents to remain in the home for as long as possible. Support would be sought from the local District Nurse team. Spiritual needs would be addressed at this time. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Residents, who wish to, have excellent access to organised activities. Residents benefit from the appetising meals and balanced diet offered by the home and those residents requiring specialist diets are well catered for. EVIDENCE: Residents spoken with confirmed that routines are flexible , that life is very relaxed and that they choose when they get up and go to bed. Breakfast time is flexible. Residents can have their meals in their own room if they wish, although they are encouraged to come to the dining room to ensure they enjoy the company of the other residents. Several notices were seen around the home informing the residents of future activities and entertainments. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 13 The level of activities in the home is excellent. An activity coordinator who has worked at the home for many years spoke with enthusiasm and dedication about the activities she provides. She works 30 hours a week including alternate weekends to ensure that residents are entertained at the weekend. Residents are given a choice whether they wish to attend and those who do not receive a one to one session where possible. Good records are kept to evidence this was happening. Activities range from indoor and some outdoor visits. Some craftwork is done but only if residents requested it. Other activities include raffles, bingo, quizzes, reminiscence work, fish and chips suppers, wine and wisdom evenings. A designated activities room has been made available. A mini oven has recently been purchased to allow residents to bake cakes. Residents spoken with confirmed how much such sessions are enjoyed. One to one sessions include trips to beer festivals, pub lunches, and shopping as well as hand massages and games such as scrabble and draughts. The activities programme was seen on wall and it was confirmed it changed weekly according to what was required. An outside entertainer visits each month. Large photo boards were seen throughout the home evidencing residents’ enjoyment in activities offered. The home has access to a ‘Bright Day’ minibus once a month for trips out such as seaside visits, places of local and historical interest, lunches out and country drives. A resident said she much enjoyed these opportunities. The activities coordinator uses a rota system to ensure as many residents who want to go out are accommodated. The home has an amenity fund and monies raised from social events are used for the benefit of the residents. On the day of the visit, an Easter raffle was seen on display. Residents are rewarded with prizes at the Bingo and quiz sessions. Families are always made very welcome at these events and they have proved very popular. To promote residents’ independence, the home provides a laundry room for those residents who wish to do their own washing. The home provides care for two residents under 65. Comments made by some residents included ‘I have plenty to do’ and ‘there is always something to do’. ‘I like my own company’. Several families spoken with on the day confirmed they were always made welcomed and could visit at any time. A relative said this is a nice home and my relative is well looked after. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 14 With the levels of dementia and confusion within the home it is not always easy to ensure full choices were given at all times, however staff were seen to offer choices where possible and where not possible gave full support and consideration. All residents spoken with confirmed the food was very good and a choice was always given. Comments like ‘the food is lovely’. A lunchtime session was observed. The atmosphere in the dining room was friendly and relaxed and the food looked appetising and well presented. Records confirm that choices are given. Drinks are freely available. As a result of listening to people, Kentucky fried chicken suppers are now provided weekly and other evenings are being planned such as fish and chips, seafood and pie and mash. Court Regis DS0000023918.V357769.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 are protected by a clear complaints procedure and residents and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The home’s complaints procedure complies with all the requirements of the regulations. Neither residents nor a relative spoken with raised a complaint during this inspection. They confirmed that they knew whom to speak to if they wished to raise a concern. The home receives many compliments and letters of thanks. The complaint file was examined. One complaint had been received which was acted upon within the policy’s timescale. The training matrix confirmed that staff have received Safeguarding Vulnerable Adults training. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to safe and comfortable indoor communal areas. The gardens should be improved for residents’ to enjoy. Residents are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. Whilst residents’ rooms are homely and comfortable, not all residents benefit from living in rooms that meet the requirements for space. Residents benefit from living in a clean, pleasant and hygienic home. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 17 EVIDENCE: Residents live in a clean, well- maintained and safe environment. CCTV has been installed outside the building for security purposes. The general environment has improved considerably since the previous inspection. Corridors have been repainted and re-carpeted. The manager confirmed that the maintenance man usually decorates vacant bedrooms ready for a new admission. The toilets in the block to the front of the building have been redecorated and upgraded now providing a clean and spacious environment. The laundry area has been upgraded. It was noted that several residents have been supplied with pressure relieving equipment to prevent skin breakdown. Other specialist equipment is provided following assessments from visiting professionals. Several bedrooms were viewed and all were clean and well personalised. It was noted that the carpet in room 20 had a hole in it. The manager said this carpet is soon to be replaced. Residents have full access to several comfortable lounges and grounds. Plans are in hand to tidy up and enhance the gardens for residents to enjoy. None of the rooms have an en-suite facility though all have a washbasin. The home is proposing to reduce its number of shared rooms. Currently there are 10 such rooms, 3 of which are used as singles. Some of the shared rooms do not meet the minimum requirement of at least 16 sq m of usable floor space. On the day of the inspection the home was clean and fresh. Several visitors said that it was always clean. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 18 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. The residents benefit from staff who are trained and competent to do their jobs and who enjoy good morale. Residents are protected by the home’s employment procedures and practices. EVIDENCE: The home is divided into two separately staffed units. In the residential care unit care was provided by 4 staff and the deputy manager. In the dementia care (Cherry Tree) unit by 3 staff. Evidence seen on the day including rotas and observations of working practises confirm that the residents’ needs are met by sufficient numbers of staff and that they have the necessary skills. Families should be confident their relatives are in safe hands. Several members of staff were spoken with and all said that they did not feel under any pressure and were well supported by the management. A sample of staff files was seen and evidenced that the home follows its written policies on the recruitment of staff. All new staff complete a Skills for Care compliant induction programme and a three-day in house induction course. All required checks are carried out. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 19 Staff are well trained and currently 75 of the care staff have an National Vocational Qualification (NVQ) level 2. Team leaders are encouraged to obtain a level 3 qualification. The other 25 are working towards the qualification. In addition to all mandatory training (see also standard 38), the Trust provides other training in house including medication, infection control, dementia care and adult protection. Colleges in Kent validate these courses. All staff are to undertake a 16-week course on MRSA. Mental Capacity Act training is being organised for all home managers. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 20 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, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having a manager who is well supported by senior staff and management in providing leadership throughout the home and from staff who demonstrate an awareness of their roles and responsibilities. Residents benefit from a service that is run in their best interests. Current arrangements are sufficient to protect the health, safety and welfare of residents and staff. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 21 EVIDENCE: Since the previous inspection a new manager has been appointed. She has all the necessary qualification to manage the home in a professional and efficient manner. Her application to become registered with the CSCI is currently being processed. Residents and staff said they like her open door policy and calm personality. The atmosphere amongst both the staff and senior team is one of commitment and all enjoy a homely environment. Policies and procedures are in place to ensure resident’s finances are well protected and secure. Records for two residents were examined and in order. Evidence was seen and was confirmed by staff that regular supervision is ongoing. Several staff said that they felt well supported by management and felt the supervision process was helpful. The home has achieved the Investors in People Award and ISO 9001 accreditation. The manager said that there are good monitoring systems in place to ensure that residents are satisfied and practices up to date. A ‘quality circle’ is operating well encouraging residents to have a say in how the home is run. Residents are regularly asked to complete a satisfaction survey. Care plans are reviewed monthly. It was noted that some polices and procedures had not been reviewed since September 2005. The manager acknowledged that these are due for review. Information contained in the AQAA confirms that home and its equipment are well maintained. Accident records were examined and well maintained. Risks of falls are assessed, monitored and steps taken to minimise such risks. The CSCI is informed of reportable incidents in accordance with Regulation 37. An in depth policy and procedures around fire safety is in place and contained the required fire risk assessment. Regular fire drills were held. As already referred to in standard 30, all staff receive mandatory training. On the day after the inspection staff were to attend nutrition and Food Hygiene training. Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 22 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 2 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x 2 x x 3 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 2 x 3 3 x 3 Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 23 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 OP1 OP7 OP19 OP33 Good Practice Recommendations That the statement of purpose and service user guide be further revised to ensure that the care of dementia clients is included That nutritional risk assessments are evaluated to evidence the action taken That the gardens and outside areas be improved for residents’ benefit That all policies and procedures are regularly reviewed Court Regis DS0000023918.V357769.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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