Care Home: Willoughby Grange

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What the care home does well Residents now live in a more attractive, comfortable and safe home. Residents were well cared for by a well managed and competent care team. Those residents and visitors we spoke with expressed satisfaction with the care and service provided by the home. All residents were assessed before entering the home and there was an improved recreational and activity programme which provided stimulation. There was a thorough assessment and review of care and efforts had been made in involving residents in their care. Efforts have been made to make the care and support more person centred. What has improved since the last inspection? Since the last key inspection a great deal of improvements have taken place in the home. This has included providing new carpets in all the ground floor and first floor corridors, new wooden flooring at the entrance, and in the dining room in the main home, new carpets in lounges. In addition, 6 bedrooms had also been redecorated with new carpets and 2 bedrooms had new furniture. The corridors had been painted in brighter colours and 8 new profiling beds had been provided. The ground floor corridor outside the dining room had a large colourful mural, which had been created by the residents. New signage had been introduced for toilets and bathrooms to identify them better. This had greatly improved the overall impression when coming into the home.A new menu had been introduced in line with the Department of Health nutritional guidance. Menus are now on the tables and both dining rooms had been made more attractive. Care records on the dementia unit had been made more person centred. This will be introduced to the rest of the home in the future. Each resident had a key worker and for those who were receiving nursing care had a named nurse. New linen had been introduced. Staff have been trained to understand the needs of the residents especially those with dementia. What the care home could do better: There were no requirements or recommendations from this key inspection. The manager and company should continue to maintain and further develop the considerable improvements seen in the home. The manager should also continue to develop opportunities for staff to study for formal qualifications in care (National Vocational Qualifications). CARE HOMES FOR OLDER PEOPLE Willoughby Grange Willoughby Road Boston Lincs PE21 9EG Lead Inspector Tobias Payne Unannounced Inspection 17th January 2008 08:30 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 Willoughby Grange DS0000002575.V356623.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. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willoughby Grange Address Willoughby Road Boston Lincs PE21 9EG 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) 01205 357836 01205 356756 willoughby.grange@fshc.co.uk www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Ann Patricia Houston Care Home 44 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (33) Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users with dementia only to be admitted to those rooms designated on the ground floor for the category DE(E) The home is registered to provide personal care with nursing for service users of both sexes whose primary needs fall within the following categories: Old age not falling within any other category (OP) (33) Dementia (over the age of 65 years) (DE(E) (10) Dementia (DE) (1) The maximum number of service users to be accommodated is 44. The category Dementia (DE) applies to the person named in the Notice of Proposal to Register dated 4th February 2005 only. 4th April 2007 3. Date of last inspection Brief Description of the Service: Willoughby Grange Nursing Home is situated within half a mile of the town centre of Boston. The home is owned by Four Seasons Health Care and is registered to provide nursing and personal care for 44 service users. On the day of our inspection visit there were 30 residents. It is a purpose built twostorey home, with accommodation on the first floor accessed by a shaft lift. The home has its own mini bus and is also close to a bus route and the centre of Boston. Car parking facilities are at the front of the building, and a courtyard with garden furniture is situated to the side of the home The home has a self-contained wing, which provides 11 places for residents with dementia. There are 6 double rooms and the remainder are single rooms. Four of the rooms have en-suite facilities. Fees at the inspection visit of the 17/1/2008 ranged from £380 to £550 per week. Extras were hairdressing which ranged from £5 to £22, chiropody £8 and personal newspapers and magazines. Information about the home including the service user’s guide and statement of purpose can be obtained from the administrator or manager of the home. There is also detailed information about the home and company in the entrance to the home. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection started at 8.30 a.m and took place over 7 hours. It was undertaken using a review of all the information available us about Willoughby Grange. We spoke with 9 residents, 6 visitors, 5 staff and the manager. The main method was called “case tracking”. This involved selecting 2 residents and tracking the care they received. This was done through the checking of records, discussion with them, the care staff and observation of how care was delivered. We also received before this inspection visit an Annual Quality Assurance Assessment completed by the manager and four comment cards. An annual quality assurance assessment (AQAA) is a self assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we get information from providers about how they are meeting outcomes for people using their service. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. What the service does well: What has improved since the last inspection? Since the last key inspection a great deal of improvements have taken place in the home. This has included providing new carpets in all the ground floor and first floor corridors, new wooden flooring at the entrance, and in the dining room in the main home, new carpets in lounges. In addition, 6 bedrooms had also been redecorated with new carpets and 2 bedrooms had new furniture. The corridors had been painted in brighter colours and 8 new profiling beds had been provided. The ground floor corridor outside the dining room had a large colourful mural, which had been created by the residents. New signage had been introduced for toilets and bathrooms to identify them better. This had greatly improved the overall impression when coming into the home. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 6 A new menu had been introduced in line with the Department of Health nutritional guidance. Menus are now on the tables and both dining rooms had been made more attractive. Care records on the dementia unit had been made more person centred. This will be introduced to the rest of the home in the future. Each resident had a key worker and for those who were receiving nursing care had a named nurse. New linen had been introduced. Staff have been trained to understand the needs of the residents especially those with dementia. 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. Willoughby Grange DS0000002575.V356623.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 Willoughby Grange DS0000002575.V356623.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): Standards 1, 2, 3, 4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents coming into the home received detailed and up to date information about the home. This enabled them to make a choice about whether or not to come to this home. They also receive an assessment and know their needs can be met. EVIDENCE: Since the last key inspection the statement of purpose and service user’s guide had been reviewed and included information about the new manager and operational manager and regional director of Four Seasons Health Care. A copy of the service user’s guide was given to each new resident. The information was also available at the front entrance to the home. The manager using a new comprehensive dependency assessment form, which was the base of the care plan, assessed each resident coming into the home. Written confirmation was now sent to them to confirm that based on the Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 9 assessment the home could meet their needs. Each person received terms and conditions when being admitted to the home. The home does not provide an intermediate care service. Willoughby Grange DS0000002575.V356623.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good and improved care planning in this home, which helps ensure that the general health and welfare of residents is addressed. Procedures relating to the delivery of personal care are sufficient. Medication is safely given by staff who know what they are doing. EVIDENCE: Since the last inspection visit efforts had been made to make care records more person centred with the emphasis on involving residents in their care and support. Together with this initiative has been the introduction of a key worker and named nurse. Each resident had a care plan. Records showed a photograph, medical history, a daily living skills assessment covering all aspects of daily living with a mental health assessment. There was also a dependency rating tool which was reviewed monthly, nutritional assessment, malnutrition screening tool, continence assessment, body map, oral assessment and risk assessment (moving and handling). Care plans contained information about each resident’s assessed needs, the expected outcome of the plan of care and progress sheet. Each entry was dated with the signature of the member of staff. There was also information about the key worker and Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 11 named nurse system. We also saw a new person centred care plan which had been introduced initially on the dementia unit. This was more detailed and less clinical. This initiative is also to be introduced throughout the home. Staff were seen to have evident pride in their work and attended to people promptly and with little fuss. All the residents and visitors we spoke with were very complimentary about the staff and the way they attended to them. No one had any complaints and all spoke about the way the staff were polite and respected their dignity. A comment card stated, “Care is very good although sometimes I feel more support could/should be more available, when I ask or query anything they are acted upon, they do help my father extremely well, when I need to see a staff member they are always available. They always inform me when a doctor or nurse has been called”. The last pharmacy inspection was in December 2007. There were no concerns. Nurses and senior care assistants give medication. Each person had been trained by Boots as well as formal training by Four Seasons. We saw a medication round taking place. Staff identified the resident, checked the medication against the medication card, gave the medication and signed the card to confirm this. We had no concerns about the way medication was given. The manager also undertook a monthly audit of the medication. Residents felt there privacy was respected and this was shown by staff knocking on doors before entering rooms and talking to people in a calm and friendly manner. Willoughby Grange DS0000002575.V356623.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): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s social and cultural needs are met at the home. The range of activities provided by the home continues to improve. There is a variety of nutritious food provided. The dining rooms are attractive and enhance the quality of the catering service provided. EVIDENCE: The way activities are provided in the home especially on the dementia unit continue to be further developed. When a new resident comes into the home their interests are written in the care records and the activities person tries to visit them to find out what they wish to do. There was a weekly activities programme displayed. The programme for the week of the 14/1/2008 was seen. This showed a varied programme, which included one to one, carpet, bowls, music and movement, resident shopping, art and craft, card and board games. The activities person was very enthusiastic about developing the activities further and had joined the national activities organisation NAPPA and was developing links. On the dementia unit the environment was more stimulating and residents were more alert, sitting in the lounge, in conversation with one another or Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 13 staff. There was no sign of distress, no calling out and a more relaxed atmosphere. Concerning catering, since the last inspection menus had been reviewed in line with the Department of Health nutritional standards. On admission, dietary information was sent to the kitchen. There was a weekly menu and daily menus were on each table as well as displayed on a board. At the previous inspection we were told that the manager hoped to introduce picture menus but this had not yet taken place. It was her intention to do this in the future. Boston Borough Council inspected the home on the 20/3/2007 and once again awarded a bronze award for catering which was the same as in 2006. The menu had 2 choices but an alternative could be provided. Residents had no complaints about the food. The manager also audited the catering every month. We saw lunch being served in the two dining rooms. Staff were correctly dressed, the tables had clean tablecloths, menus. Food was well served in a discreet manner and staff sat to assist those residents who needed help. No one had any complaints about the food. One visitor who was assisting her husband commented, “when ever I visit I receive lunch and refreshments. The food is always good and staff are very kind and respectful. Residents commented, “I like the food” and (to us) “would you like to stay to lunch it is very good”. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and feel that staff will listen to their views. Any complaint received is thoroughly investigated and lessons learnt as a result of investigations. Staff are aware of how to respond to a complaint or an adult protection allegation. EVIDENCE: There was a complaints procedure displayed at the entrance on the wall at the entrance to the home and each person received a copy of the complaints procedure in the service user’s guide. We had also been informed of 2 complaints, which we had asked the manager to investigate, using their procedures. The complaints register was examined and showed 5 complaints had been received by the home since the last inspection. There was a clear information and evidence to that each complaint had been thoroughly investigated by the manager. Issues ranged from a residents tea being too hot to management of health care needs. We had also been aware of 2 adult protection issues relating to staffing levels and the lack of information about how care needs are supported on some care records. These were investigated and concluded by Lincolnshire County Council and the manager fully co-operated in the process, which ensured residents continued to be supported in a safe way. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 15 During the inspection visit the manager showed how improvements had been made by introducing person centred training, provided training in infection control and ensured that at all times there were 2 staff working on the dementia unit. During our inspection visit no one had any complaints about the home and felt they could approach staff with any concerns. Adult protection training was provided for all staff during 2007. This was also covered in the new comprehensive induction standards for all new care workers. We spoke with 2 staff who confirmed this information and knew what abuse was and what they should do if abuse was suspected. Willoughby Grange DS0000002575.V356623.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): Standards 19, 20, 21, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Since the last inspection improvements have taken place to the decoration and water systems of the home. Residents live in comfortable, clean, bright and safe accommodation. This has improved their quality of life. EVIDENCE: Since the last key inspection a major improvement programme had taken place to improve the environment of the home. This had included new carpets in all ground floor corridors, new wooden flooring at the entrance, and in the dining room in the main home, new carpets in lounges, 6 bedrooms had also been redecorated with new carpets, and 2 bedrooms had new furniture. In addition, the corridors had been painted in brighter colours and 8 new profiling beds had been provided. The ground floor corridor outside the dining room had a large colourful mural, which had been created by the residents. New signage had been introduced for toilets and bathrooms to identify them better. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 17 This has greatly improved the overall impression when coming into the home. Residents and visitors commented positively about the improvements, which had taken place. New towels had also been introduced. At the previous inspection and as a result of conversations with Boston Borough Council’s Environmental Health Officer we had concerns about the suitability of the showers. We were told by the home-owners that the company would improve the shower systems. Since then the company has taken action to install 4 new water tanks and as a result the water pressure had improved and all bathing and shower facilities were now available. In addition 5 mixer valves had been replaced and a further 3 basin taps were planned for replacement. There was no noticeable odour during the inspection and all areas were clean. Domestic staff were seen to have pride in what they were doing. Willoughby Grange DS0000002575.V356623.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): Standards 27, 28, 29 and 30 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 robust recruitment practices. Improvements have been made to the number of staff working in the home and the training of staff to meet the needs of the people living in the home. However formal training in care and support needs to be increased. EVIDENCE: Since the last key inspection training and staffing has been addressed. The manager monitored dependency and was able to employ more staff where required. As a result of concerns about the levels of staff on the dementia unit 1 full time and 1 part time care assistant had been recruited and at all times there were 2 members of staff on this unit. There were no staff vacancies and a further 2 nurses were on the homes bank staff list. The rotas showed that staff were working 18 to 38 hours a week. There was no evidence to show staff were working excessive hours though we were told staff would ask to work extra shifts but the manager monitored this. Staff told us that morale had improved; and that there was more stability and better leadership under the new manager. Since the last inspection training had covered, dementia awareness, moving and handling, fire prevention, protection of vulnerable adults, managing behaviours, health and safety and infection control. In addition a senior care assistant had been on a course to learn about dementia care mapping in order to assess how residents react to Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 19 staff and how to further improve the contact between staff and residents who have a dementia. The manager also confirmed that some staff members who work at the home had achieved nationally recognised qualifications and that she was working to increase the opportunities for more staff members to increase their qualifications and skills. Each new member of staff received a comprehensive induction. The workbook/induction covered 12 weeks and staff work with a mentor. We spoke with one member of staff who confirmed she was correctly recruited. This included providing an application form, her references checked, a check by the criminal records bureau, interviewed and then received a 3 day supported induction. We could see individual staff files with well maintained records. Willoughby Grange DS0000002575.V356623.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): Standards 31, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. Residents, relatives and staff benefit from the positive leadership from the manager. EVIDENCE: In December 2006 a new home manager was appointed. She has had wide experience as a nurse and manager. Since July 2007 has been formally registered to manage the home. She had introduced monthly residents and staff meetings. She had also introduced formal staff supervision. Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 21 A customer survey was sent out to 30 residents/relatives in March 2007. The manager confirmed she had used feedback received to undertake an ongoing review of the service provided and how things can be improved. Four Seasons had also introduced a comprehensive Total Quality Audit Process in March 2007. This was a very comprehensive auditing system. Internal audits carried out by the manager included kitchens, care records, accidents and bed rails. The home received monthly monitoring visits by the area manager. These reports were available in the home. They were detailed and contained enough information to show that the company were up to date with progress in the home. Residents and relatives were satisfied with the care and approach of the staff. Comments were “It is very nice here”, “the home is brilliant”, the staff have been excellent, I am always kept informed of my husband’s condition” and “I find the manager very helpful”. Staff commented, “the home is more stable”, “Pat is approachable and supportive”, “I receive positive feedback during my supervision sessions” and “I enjoy working here”. There were very comprehensive maintenance records, which were well maintained and available. A care manual with updates was introduced in 2006. This included clinical procedures and comprehensive infection control. Staff had gloves, aprons and alcohol hand washes. There were also detailed health and safety policies. There was an equality and diversity policy. The manager did not feel there were any communication issues and this was confirmed by our observation during the inspection. There were no issues regarding equality and diversity. Accurate records were kept of resident’s monies, which were computer records with receipts and tallies. The records were well maintained and managed by the receptionist. Willoughby Grange DS0000002575.V356623.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 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X x 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 3 3 X 3 X 3 3 Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Willoughby Grange DS0000002575.V356623.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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