Care Home: Highgrove Care Home

Similar services:

• Snydale Care Home
• Abbey The
• Larchfield Manor
• Hawkhills
• Beeches The - North Yorkshire County Council
• Carentan House
• Ravensworth Lodge

What the care home does well The home has a very stable staff group, which ensures continuity of care by staff who know the people within the home. Care plans seen were found to be of a good standard and people were assisted and supported by staff to make decisions and choices about all daily living needs. People were provided with stimulation and interesting activities. These were varied, for people to participate in if they wished also opportunities for people to have trips out whenever possible. Heather Hudson (Expert by Experience) had the opportunity to speak to six people within the home and three relatives. All comments received are contained in this report. There was a good atmosphere within the home and feedback from people within the home and relatives was positive about the care and staff. None of the people had any negative comments about the care they received. What has improved since the last inspection? The home has addressed all the requirements made at the last inspection for example, medication issues had been addressed. Staff have had updates on moving and handling and staff that work on the EMI unit have received dementia training. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Highgrove Care Home West Rd Mexborough Doncaster South Yorkshire S64 9NL Lead Inspector Janet McBride Key Unannounced Inspection 18th March 2008 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highgrove Care Home DS0000058632.V361010.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. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highgrove Care Home Address West Rd Mexborough Doncaster South Yorkshire S64 9NL 01709 578889 01709 578842 paulhulbert@ntworld.com www.winniecare.co.uk Winnie Care (Highgrove) Ltd 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) Mrs Christine C McDonnell Care Home 78 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (57) of places Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. One named Service User under 65 years old to reside on the residential unit. Highgrove Care Home provides a separate 21 bedded EMI residential unit. The Registered Manager, Christine McDonnell, must undertake and complete further training on Dementia Care conversant with her professional status. One named service user to be admitted to the unit on rolling respite. Date of last inspection 27th September 2006 Brief Description of the Service: Highgrove Care Home provides residential and nursing care accommodation for older people, it is registered for 78 beds on three units, comprised of a nursing and residential unit, on the ground floor, residential unit on the upper floor and a separate 21 bedded residential EMI unit. All the bedrooms are single and the home has two specific bedrooms for high dependency nursing service users. Highgrove Care Home is located in the town of Mexborough and is in within walking distance to local shops, public houses and other community amenities. Highgrove was first registered in July 2002,and since 2005 as been owned by Winnie Care, who has other homes in the area. Fees range from £380:62 to £426:30:00 per week, as at March 2008. Additional charges are made for hairdressing, chiropody, newspapers and magazines. For further information contact the home. The Statement of Purpose and the Service User Guide, which is available on request, this as information about the services available to residents and their families. The home last published inspection report was also available for resident and relatives to read. Highgrove Care Home DS0000058632.V361010.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. One inspector carried out this key unannounced inspection, which took place on the 18 March 2008 for seven hours fifteen minutes. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We currently use a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. Heather Hudson (Expert by Experience) accompanied the inspector for three hours and spent time speaking to staff and people who use the service. Prior to the inspection the home submitted an Annual Quality Assurance Assessment this gives information regarding the home and services provided. Pre-inspection work was carried out on the information received and other relevant documentation, for example analysis of statutory notifications and complaint records. During the inspection, documentation and records were examined, for example medication, complaints, accident records, staff rotas and staff training files. Five care plans were cross-referenced with other relevant documentation relating to those people who use the service, to evaluate how well their care needs were met. A tour of the premises and direct observation of staff interaction with people who use the service was carried out throughout the visit. Information was gathered from as many different individuals as possible that had contact with people within the home, including individual interviews with the manager and five members of staff. We sent out surveys prior to the inspection, twenty were sent to people within the home who received the services, eight were received back. Six were sent to professionals who had contact with the home and one was received back. They were asked to comment on the standard of care, staff skills, attitude, and how the needs of people using the service needs were met. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 6 We would like to thank all the staff, relatives and people receiving services within the home for their co-operation in the inspection process. Any issues or concerns that were raised were discussed with the manager at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: A number of issues raised with regard to the premises. • The designated smoke room must have a ventilation system to ensure smoke drift does not affect other communal areas of the premises. • A new bath must be fitted in the identified bathroom, to ensure bathing facilities are kept in a good state of repair to meet the needs of people using the service. • Identified carpets must be cleaned or replaced in these areas, • Smoke room • EMI corridor • One identified bedroom. Highgrove Care Home DS0000058632.V361010.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. Highgrove Care Home DS0000058632.V361010.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 Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 &6. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People that use the service had information about the home and services provided. People were individually assessed prior to admission to ensure their needs could be met. EVIDENCE: The home offers nursing and residential care including dementia care they also offer respite care but not intermediate care. All surveys received confirmed that people who use the service were provided with sufficient information before moving into the home, and that they had the opportunity to visit and stay prior to admission. Records showed that people who use the service were fully assessed prior to moving into the home, management assessments had been completed for Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 10 people placed by funding Authorities, and people who were self -funding had a written assessment prior to admission completed by the management of the home, involving other professional if involved in their care. The scale of charges was discussed with the manager and any extras that people pay for, are documented on page 5 of this report. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Care plans provided staff with sufficient information to meet the needs of people who use the service. People were assisted and supported by staff to make decisions and choices about all daily living needs. Medication policies and procedures were well managed, this ensured the safe administration of medication. EVIDENCE: Four care plans were checked these set out in detail healthcare, personal and social care needs in an individual plan of care. All contained up to date information that reflected people’s needs as detailed in their assessments. This ensured that staff know the care required and that peoples needs were identified and met. People were nutritional assessed and weighed on a regular basis, and when weight loss had been highlighted they been referred to a dietician. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 12 Risk assessments had been completed based on individual needs, these were incorporated into each persons care plans. Records showed that people had been assessed for pressure care, and fall risks. This helps to safeguard their health and safety. Good health records were maintained and it was evident that people within the home were registered with a GP and had access to health care facilities. This included any specialist health services that were required. GP and health professionals’ visits were recorded. The home has a comprehensive policy on the safe receipt, storage, handling and administration of medication, which complies with the requirements of the Medicines Act. Medication records were discussed with the manager and the nurse in charge of the unit. Examination of records, storage and recording of medication was completed. All were found to be satisfactory with any issues raised on the last inspection had been addressed. Surveys and people spoken to said they were encouraged to make everyday choices, for example what to eat and what to wear. This promoted the choices and dignity of people living at the home. Feedback from relatives, visitors and observation on the day of the visit showed that staff treat people with respect and spoke with courtesy, and treated them in a dignified manner. Typical comments included: “ I would like to commend the matron and staff who promote the home and develop ways of improving the residents quality of life”. “I find that staff communicate well with residents”. “Staff are always available when you need them”. None of the people had any negative comments about the care they received. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. People who use the service experience excellent outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People within the home were provided with stimulation and interesting activities. They were offered a wholesome and appealing balanced diet with a varied selection of food available to meet people’s tastes and choices. EVIDENCE: The home as two activity organisers who work four days a week, and social activities were co coordinated across all the three units within the home. Heather Hudson (Expert by Experience) remit was to speak to people and relatives, to get an insight into the quality of life and the standard of care and dignity given to the people, as well as looking at the quality of food and activities the that people received at Highgrove. Activities were really varied, these included crafts, and at the moment they were making Easter chicks and bunnies. Other activities include knitting, jigsaws, making cards and bingo. On a monthly basis they have reminiscent days, this is organised in conjunction with Doncaster Museums, and this is a Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 14 very popular activity. Emphasis is also given to outdoor events during the warmer weather. They have their own mini-bus and go out into Mexborough and further a field on shopping trips. On the day of the inspection a group were going to the pantomime in Goldthorpe. Family and friends can visit at any reasonable time and can see their relative in private if they wish, relatives seen confirmed they can be involved in peoples care for example attend reviews and discuss care plans. Meals were served in a number of dining rooms and lunchtime was indirectly observed on all three units. Menus were on display in two of the units, but not in the EMI unit. On checking the menus, which are on a four weekly rota, there was a good selection of meats and vegetables. Lunch served on the day was Gammon, pineapple, seasonal vegetables, roast and mashed potatoes. On speaking with the cook people can have a lighter option if they prefer, lunch is served 12.00 – 12.15. Tables were nicely set with condiments available, the tablecloths were clean and glasses were on the table, with jugs of orange squash and water. Kitchen staff either directly served meals from the kitchen or from a hot trolley, meals looked appealing and appetizing, even liquefied meals were well presented. Staff was available to give assistance and people had sufficient time between courses to eat their meals. People were asked about food at the home, they stated they had a choice. There is not a set time for breakfasts, people can have there breakfasts when they get up, and they can have just what they want, a hot breakfast or cereals and toast. The kitchen provides home baked cakes for morning coffee and tea and afternoon tea and supper. No complaints about the standard of food from any of the people within the home. Heather Hudson (Expert by Experience) had the opportunity to speak to six people within the home and three relatives. The husband of one of the residents who was ‘tube fed’ said, “I am delighted with the care they give my wife, they really look after her”. A woman I spoke to had a mother in the home and she said “She was very pleased with the home and her mother had improved immensely since she had been at Highgrove, and was now able to eat food again, when she came in she wasn’t able to”. Her mother had to go back into hospital when she first came into the home because she was dehydrated, and she was very pleased with the way the nurse at the home had dealt with this. Comments from the other people were very positive, one lady said “they would do anything for you” and pointing to one of the carers said “especially that one”. One resident said “one night she wasn’t feeling very well, and asked one of the carers if she could go to bed?” The carer took her upstairs at teatime and waited with her until she got undressed and was in bed, before she left her on her own. Highgrove Care Home DS0000058632.V361010.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The complaints procedure was accessible and displayed within the home. Policies and procedures were in place on adult protection, this promoted and protected people who use the service. EVIDENCE: There was a comprehensive complaints procedure, which was on display. Complaint records showed that all complaints had been recorded, responded and investigated in an efficient and thorough manner. All surveys confirmed that people were aware of the complaint procedure and knew how to make a complaint. People were asked if they had raised concerns to the home and whether they had they responded appropriately, most people said they had. Some comments were made, for example “ I see matron if I have a complaint and she soon puts things right”. We don’t have to complain very often”. Policies and procedures were in place regarding the protection of vulnerable adults. Staff confirmed they were aware of abuse polices and procedures, they were able to describe the action they would take on receiving any allegations. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 16 Management are proactive in referring any allegations or incidents to adult safeguarding and keeps the Commission for Social Care Inspection informed of any issues. Highgrove Care Home DS0000058632.V361010.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): 19,20,21,24&26. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People who use the service live in a safe and comfortable environment. The home was clean and tidy, however some areas of the premises required some minor refurbishment. However comments from people who use the service and relatives thought the home was a comfortable environment. EVIDENCE: A tour of communal areas on all three units found the reception area of the home quite a popular place to sit. Quite a number of people were sitting in this large area, either people living in the home or a relative, apparently they like to see who is coming and going through the main doors. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 18 The home had a selection of small lounge areas giving people a choice of sitting quietly, meeting family and friends in private or being with other people in the larger lounge. All communal areas were found to be clean and tidy and in good decorative order with ongoing general maintenance taking place. However some issues were raised for example, on the emi unit the corridor carpet very stained and sticky underfoot and the carpet in the smoke room was full of burn marks. This designated room for smoking also requires a ventilation system to prevent smoke drifting into the communal areas of the premises. Comments from people who use the service and relatives thought the home was a comfortable and accessible environment. All bedrooms are single rooms, including two specific bedrooms on the nursing unit for people who have high dependency nursing needs these are very large bedrooms for any equipment that may be needed. Bedrooms looked very comfortable and it was confirmed people could bring personal furnishings with them on admission, some were found to be homely or personalised by individual people, including own phones and fridges in their bedrooms. All were clean and tidy, however one bedroom carpet very stained. There are assisted baths and showers on each unit. A tour of these areas confirmed they were satisfactory, with the exception of one bath that was split on the top, when this was pointed out to the manager a new bath was ordered that day. Laundry facilities at the home are satisfactory, it was found to be well organised. Highgrove Care Home DS0000058632.V361010.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff had the skills and knowledge to fulfil their roles within the home; a stable staff group ensured continuity of care for people who use the service. Recruitment policies were followed promoting the safety and protection of people who live at the home. EVIDENCE: The home has a very stable staff group, staffing was discussed with the manager and the duty rota examined. This clearly identified staff within the home and their role, gave a clear line of accountability of management and ancillary staff. The manager is supernummary with identified deputy managers for all the units within the home. Observation on the day of inspection and checking of duty rotas confirmed there were sufficient staff to meet the needs of people who use the service. There were robust recruitment and selection procedures including an equal opportunities policy. New staff recruitment files were examined, these confirmed that all the required employment checks had been undertaken prior to staff being employed, including Criminal Record Bureau (CRB) Protection Of Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 20 Vulnerable Adults (POVA) checks. This ensured people who use the service were safe and protected. All registered nurses have to re-register their pin numbers with the Nursing and Midwifery Council (NMC). The home provided evidence to show they monitor this practice. Training and development of staff was discussed with the manager and staff, who confirmed what training had been completed. Training records indicated that a number of the staff team had accessed various courses since the last inspection, for example dementia, adult protection, moving and handling, infection control and first aid courses. Development of staff was evident by 50 of staff achieving National Vocational Qualification (NVQ) level 2 or 3 in care with other members of staff continuing to work towards attaining this qualification. Highgrove Care Home DS0000058632.V361010.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): 31,33,35,36 &38. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Good policies and procedures were in place to protect and safeguard people who use the service. The financial interests of people were safeguarded, good health and safety procedures ensured they were protected. EVIDENCE: Management structure at the home consisted of a registered manager, and deputy managers on each unit and an administrator. The homes registered manager has completed the Registered Managers Award. She his fully aware of her responsibilities and provides leadership, guidance and direction to staff to ensure that people receive consistent quality care. Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 22 Staff and people receiving care spoke freely and positively about the manager saying she was open and approachable. Quality assurance systems were in place and the manager could evidence they monitor the quality of care and services within the home. The company’s operations manager continues to carry out monitoring visits, and completes regulation 26 reports (copies were available at the home). These state what she found during her visit and who she spoke to. Staff said they received supervision on a regular basis and that staff meetings are held with minutes taken. Discussion with the administrator and checking of records confirmed that people’s finances were recorded, receipts kept and audited on a regular basis, this also included a recent audit carried out by Doncaster Metropolitan Borough Council (DMBC) the report was available to read. Some people control their own finances, with the help of their families. Maintenance and service records were examined, these were up to date with current certificates. The required health and safety policies and procedures and the relevant notices were displayed throughout the home. Fire safety procedures were in place, records examined showed they were current and up to date. This keeps people living and working at the home safe. Highgrove Care Home DS0000058632.V361010.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 3 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 3 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 3 X 3 3 X 3 Highgrove Care Home DS0000058632.V361010.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. 1 Standard OP19 Regulation 23(2)(p Requirement The designated smoke room must have a ventilation system to ensure smoke drift does not affect other communal areas of the premises. Identified carpets must be cleaned or replaced in these areas: 1) Smoke room 2) EMI corridor 3) Bedroom. A new bath must be fitted in the identified bathroom, to ensure bathing facilities are kept in a good state of repair to meet the needs of people using the service. Timescale for action 01/06/08 2 OP20 23(2)(b) 01/06/08 3 OP21 23(2)(b) 01/06/08 Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 25 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 Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Highgrove Care Home DS0000058632.V361010.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!