Care Home: Millcroft

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What has improved since the last inspection? The inspector examined the service user guide and service users` information pack and can confirm that they are clear document which contain relevant information. The drug stores keys are maintained in a safe and risk free manner. Evidence was supporting to confirm that staff no longer use white correction fluid and pencil to maintain documentation in the home. The service employs staff from outside the home to provide activities such as card games, hairdressing, a visiting magician, and singers. Following on from comments received at a service users meetings the service now holds a B B Q party in the summer, and an Easter bonnet party during Easter, as well as the initial Christmas party. Service users have use of a mini bus which takes them out twice a week. Evidence was supporting to confirm that the Registered Manager has engaged the services of a company to progress the quality assurance systems in the home and collated the relevant information to produce a plan to move the service forward. Quality assurance questionnaires were not available to view on the day of the inspection. What the care home could do better: MillcroftDS0000021165.V375219.R01.S.doc Version 5.2 Page 8No requirements or recommendations were made as a result of this inspection. However the Registered Manager should ensure the work on the quality assurance systems are progressed, information collated and available to view in the home. Key inspection report CARE HOMES FOR OLDER PEOPLE Millcroft Vines Cross Road Horam East Sussex TN21 0HF Lead Inspector Alexis Reilly Unannounced Inspection 29th April 2009 09:30 DS0000021165.V375219.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millcroft Address Vines Cross Road Horam East Sussex TN21 0HF 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) 01435 812170 bozena@millcroft.plus.com Millcroft and York Lodge Care Homes Ltd Mrs Bozena Bramble Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 24. Date of last inspection 15th April 2008 Brief Description of the Service: Millcroft is a care home providing care for up to twenty-four (24) service users, of either gender, over the age of sixty-five (65). Nursing care is not provided at this establishment. District nurses will provide nursing input when required. Conditions of registration may undergo review by the South East Registration Team as part of the Modernising Registration Agenda. The home is a detached property and is located in a quiet service userial area a short distance from Horam village. There is access to public transport in the town. There is a mini bus available for use at the home. There is a large garden at the rear of the building and parking facilities at the front of the home. Rooms are located over two floors. There is a passenger shaft lift available to assist service users to access all areas of the home. Sixteen rooms are for single occupancy of which 15 have en suite facilities. Two of these are less than 10 sq. m in size. There are four double rooms that are provided with an en suite. There are six communal toilets located throughout the home and four bathrooms, of which three have assisted facilities. There is a good-sized combined lounge room and dining area. There are grab rails placed throughout the home in areas where service users may require some assistance with mobilisation. Weekly fees range between £420 and £575. There are additional fees for Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 5 Hairdressing (£6 basic cut), Chiropody (£10 per session), Newspapers and magazines and dry cleaning (prices vary). Potential new service users can obtain information relating to the home by word of mouth, CQC inspection reports, placing authorities, local newspaper advertisements, Social Workers and GP lists. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection began at 10am and finished at 2pm. The inspector spent time with service users in the home and individually with the three service users who were part of the case tracking, the inspector also had the opportunity to meet with one relative. The inspector case tracked three service users, examining the care plans and the associated documents such as risk assessments and activity plans for these individuals. Other documents examined were copies of notifications, accidents and appointments, evidence of external reviews, the complaints procedure, copies of service users meetings, care plan meetings and staff meetings. Staff recruitment files and staff induction training sheets were also examined, as were a sample of the sheets which record the administration of medication and the duty rota. The plan of staff supervisions and the services Service user guide were also viewed. A partial environmental tour was carried out which included all communal areas, lounge, dining area, conservatory, kitchen and the three bedrooms of the service users case tracked. The inspector spent time with the Registered Manager, senior carer, and spoke with the cook. The inspector also observed other staff interacting in a positive manner with service users during the inspection. In the report the inspector has included comments from people met on the day of the inspection. Information was also taken from the AQAA which was comprehensively filled in and returned by the due date. What the service does well: Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 7 The Registered manager has worked hard on achieving the requirements set out in the last inspection report. They have ensured they have a team of staff on duty who provide a consistent approach to the delivery of care; they have achieved this by organising staff into teams who work the same hours over a weekly rota. Service users appeared happy and relaxed in the home, and evidence was supporting to confirm that they are involved and consulted on the activities on offer in the home. Comments received on the day of the inspection included, ‘I enjoy it here’ ‘staff are lovely’, ‘there are always lots of people around who go out of their way to be friendly’, ‘we go out in the mini bus all over the place’, ‘ trips twice a week’, ‘ I go for a walk round the block with x’, What has improved since the last inspection? What they could do better: Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 8 No requirements or recommendations were made as a result of this inspection. However the Registered Manager should ensure the work on the quality assurance systems are progressed, information collated and available to view in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 9 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 Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Evidence was supporting to confirm that service users benefit from receiving relevant and up to date information, which enables them to make an informed choice about the home prior to moving in. The service carries out Pre Admission Assessments and obtains the relevant information so as to ensure that an appropriate level of care can be offered and that service users needs can be met. EVIDENCE: As part of the inspection the inspector case tracked three service users in the home and spent time with these people individually, other service users were seen during the course of the inspection and staff were observed interacting in a positive manner with service users. The inspector also had the opportunity Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 11 to speak with relatives, the senior carer and the Registered Manager. As part of the case tracking the inspector examined the person centred care plans and the associated documents such as risk assessments and activity plans for these individuals, also evidenced were the external reviews from the placing team to ascertain if the needs identified in the assessment are used as a basis for a comprehensive care plan. The inspector examined the service user guide and service users’ information pack and can confirm that they are clear document which contain relevant information. The home has had five new admissions since the last inspection, evidence was supporting to confirm that service users are involved in the admissions process and are given choice, the service had comprehensive assessment document in place which were used to assess someone referred to the service. Also available to view was collated information with regard to service users in the home, and their referring documents. This highlighted that the Registered Manager obtains background information and up to date CPA and mental health assessments if applicable prior to offering a place in the service. Intermediate care is not offered by this home. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Care plans and procedures are in place and are sufficient to ensure that a good provision of health care and personal support is provided to service users by the home. Evidenced was supporting to confirm that care is administered in a way that protects service users privacy, and dignity, and that peoples independence is promoted. Medication procedures are in order. EVIDENCE: As part of the inspection the inspector case tracked three service users in the home and spent time with these people individually, other service users were seen during the course of the inspection and staff were observed interacting in a positive manner with service users. The inspector also had the opportunity Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 13 to speak with relatives, the senior carer and the Registered Manager. As part of the case tracking the inspector examined the person centred care plans and the associated documents such as risk assessments and activity plans for these individuals, also evidenced were the external reviews from the placing team to ascertain if the needs identified in the assessment are used as a basis for a comprehensive care plan. Care plans examined were clear and easy documents to follow. The service has also introduced a ‘passport to the past’; evidence was supporting to confirm that staff are completing this with service users and using it as an aid in the home. Evidence was supporting to confirm that service users are respected and personal care is delivered maintaining individuals privacy and dignity. Medication procedures have improved and the key to the medications cupboard is now kept securely. Staff training in medication is conducted as part of the induction process, refresher training is also provided. Staff records viewed confirmed this. The inspector evidenced through out the care plans good practice examples in the way service users were to be encouraged and their independence promoted and maintained. The service has policies in place in respect of anti discrimination, equal oportunities, racial harasment and bullying. The policies are introduced to staff during their induction and also at staff meetings to ensure that staff fully understand the meaning of these policies. The Chiropodist attends the home every six to eight weeks and on an as required basis. Service users are registered with one GP from one of four local surgeries. GP’s visit the home usually, though service users can attend the surgery if able. The local dentist is utilised for all dental treatments and there are arrangements in place for the dentist to conduct home visits. The Continence Nurse and District Nurses attend the home as required, care staff contact the District Nurse team directly or service users are referred via the GP. The Visiting Optician makes annual and as required visits to the home. Audiologist appointments are arranged via the GP, service users then attend the hospital for appointments. Speech and Language Therapist, Physiotherapist and Occupational Therapist are arranged via the District Nurse (if required). The home has a Visiting Dentist to make minor repaires to dentures for the service users if they so wish. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Evidence was supporting to confirm that a range of social, cultural and recreational activities are on offer with the wishes of the service users being central to the provision. The menu is varied and specialist diets are provided for service users, with service user’s choice and wishes being respected. EVIDENCE: As part of the inspection the inspector case tracked three service users in the home and spent time with these people individually, other service users were seen during the course of the inspection and staff were observed interacting in a positive manner with service users. The inspector also had the opportunity to speak with relatives, the senior carer and the Registered Manager. As part of the case tracking the inspector examined the person centred care plans and the associated documents such as risk assessments and activity plans for these individuals, also evidenced were the external reviews from the placing Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 15 team to ascertain if the needs identified in the assessment are used as a basis for a comprehensive care plan. Evidence was supporting to confirm that relatives feel welcomed into the home. Menus are varied and larders, fridges and freezers were well stocked with food on the day of the inspection. The service is currently producing pictorial menus for service users. Activities are on offer in the home, and evidence was supporting to confirm that individual’s wishes with regard to activities are taken into consideration, and that staff have a good understanding of individual service user’s likes and dislikes and indeed their history, this information they use to encourage service users to be involved in activities. The service runs trips out twice a week, and alternative service users go on these. Others walk in the grounds of the home together. Service users clearly enjoyed the Easter party at the home, and photographs of this were seen on the notice board and shown to the inspector by service users. Service user’s views are taken into consideration with regard to the activities’ and this was evident through minutes of the service users meetings and actions planned with regard to future parties in the home. The Registered Manager has also brought more outside activities into the home since the last inspection. The Registered Manager of the home believes in promoting an equal and diverse culture amongst staff and service users. Service users are encouraged to attend local community events service users religious wishes are observed and arrangements are in place for service users to receive Holy Communion, if they wish. Non-denominational Holy Communion is held every fortnight and service users who are able are assisted to attend church. Friends and family are welcome at any time and in accordance with service users wishes. Personal relationships and family relationships are encouraged if these are helpful and appropriate. Evidence was supporting to confirm that the service has updated their policies regarding Equality and Diversity. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Service users benefit from a robust and efficient complaints procedure, whilst the homes procedures and processes protect service users. Staff are trained in the Protection of Vulnerable Adults. Evidence was supporting to confirm that service users felt there views were taken into consideration. EVIDENCE: During the inspection the inspector examined copies of notifications, and accidents and appointments, evidence of external reviews, and the complaints procedure. The inspector also discussed individual complaints with the senior carer. Evidence was supporting to confirm that all staff bar three has received training in POVA, and that the Registered Manager completed train the trainer for POVA update in February of this year. The service has had eight complaints and one safeguarding referral since the last inspection. Outcomes of the safeguarding ensured that the home improved policies and procedures. The service now has a Tissue Viability Nurse assessement for all service users with regular monitoring of service users at Risk of pressure tissue damage. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 17 Evidence was supporting to confirm that complaints are dealt with effectively and that staff have knowledge and understanding of complaints raised in the home. In addition evidence was supporting to confirm that residents and relatives felt able to raise concerns with the Registered Manger or staff and that these would be dealt with. The service deals with complaints within two weeks of receiving them. The service ensures that Concerns and Complaints are encouraged at service users and relatives meetings. Service users relatives are reminded to attend the service users meetings by writen reminders Staff are made aware of the Whistle Blowers policy on Induction. All accidents and incidents are recorded by the carer involved or present at the time. The record is then checked by the senior carer. If no specialist treatment is needed the carers on the following shift carry on observation of the service user, recording finding, dating and signing after each episode of observation. All accidents are regularly analysed for possible causes and findings are discussed at handover or care meeting. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Evidence was supporting to confirm that accommodation at the home is provided in such a manner that it is safe, hygienic and odour free. Appropriate infection control procedures are in place, in order to reduce or eliminate the risk of infection to staff and service users. EVIDENCE: As part of the inspection the inspector carried out a partial environmental tour of the home, which included all communal areas, dining room, lounge, conservatory, kitchen, larder and store cupboards. The service user’s bedrooms who were involved in case tracking were also inspected. The home Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 19 is well maintained and all areas of the home, including the garden, and all areas are accessible to service users. The home has an ongoing plan of refurbishment in place. The size, location and layout of the home are suitable for its stated purpose. The home was clean and odour free throughout. There is a daily cleaning schedule in place. The home has an infection control policy in place and staff are trained in infection control procedures, staff training records viewed confirmed this. The home has recently had an inspection from the health and safety executive which was also positive. Millcroft DS0000021165.V375219.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Sufficient staff are on duty to meet the needs of the service users placed, Staff receive appropriate training and supervision. Staff recruitment procedures are effective and protect service users from potential harm or risk associated with poor recruitment practices. EVIDENCE: As part of the inspection the inspector examined the recruitment files of two newly recruited staff to the service these were found to be in good order. The service uses the skills for care induction booklets, and a list of staff training was also seen as were copies of staff meetings. New non-English speaking staff attend English classes so they fully understand the necessary policy and procedures. Evidence was supporting to confirm that staff are well trained, supervised and attend regular staff meetings. Out of the 23 staff employed, one has NVQ Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 21 level 4, eight have NVQ level 3 and eight have NVQ level 2, making a total of 17 staff with NVQ qualifications. Staff are also trained in areas relevant to the needs of service users such as dementia training, prevention of falls, risk management, and hoist training. Members of staff were seen on the day of the inspection interacting positively with service users in an encouraging manner. Millcroft DS0000021165.V375219.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 Registered Manger has ensured that service users live in a safe and well manager service which is run in their best interests. EVIDENCE: Evidence was supporting to confirm that the Registered Manager has engaged the services of a company to progress the quality assurance systems in the home and collated the relevant information to produce a plan to move the service forward. The completed quality assurance questionnaires had been Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 23 taken by this company to collate therefore was not available to view on the day of the inspection. Evidence through out the inspection was supporting to confirm that service users received a good level of service. Care plans and risk assessments were informative, activities are provided and service user’s dignity and independence is respected. Staff are well managed, supervised and trained. Service users are protected by the homes policy on recruitment and handling of finances and valuables. The Registered Manager has worked hard to address the shortfall of the last inspection and the requirements have been met, however they must ensure that the work on quality assurance continues in the home. The Registered Manager has arranged her staff teams to ensure continuity of staff and a competent senior care team member is in place. New non-English speaking staff attend English classes so they fully understand the necessary policy and procedures. The service has introduced compulsory written fed-back on all courses the care staff attend, whether in-house or outside. Evidence in the AQAA confirmed that policies and procedures are in place with regard to health and safety. Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X N/A 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 3 3 X X 3 3 3 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 3 3 Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Millcroft DS0000021165.V375219.R01.S.doc Version 5.2 Page 26 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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