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Inspection on 12/12/07 for Dr French Memorial Home Ltd

Also see our care home review for Dr French Memorial Home Ltd for more information

This is the latest available inspection report for this service, carried out on 12th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Dr French Memorial Home has a friendly, inclusive and supportive atmosphere. The manager and staff are committed to providing a very good level of care to all residents. The staff understand the needs of residents and work hard to meet these needs in a way that respects their privacy and dignity. One resident told us, " They are very good to me"". Residents are encouraged to be as independent as they wish. The manager of the home is professional and committed to providing a caring and supportive environment. Staff are appropriately trained for the work they carry out. The home is decorated and maintained to a very good standard.

What has improved since the last inspection?

What the care home could do better:

Four new requirements and three good practice recommendations have been issued as a result of this inspection. It is important that a reference from the potential staff member`s last employer is obtained so that the home has the most current employment history to make a judgement about the suitability of any new staff. The results of any quality monitoring assessments must bemade available to all existing residents, their representatives and potential residents so that they know how well the home is doing to meet its aims and objectives. Fire records must be kept up to date to provide evidence that the required tests and drills are taking place. The views of people who use the service should be sought when care plans are being reviewed so that people have a say in how their care is being delivered. Practical information about how to reduce risks to residents should be recorded on individuals` care plans to give staff practical examples of how risks can be reduced. A comments and suggestions form would give people who use the service and other stakeholders the opportunity to make suggestions about improvements as well as to raise concerns. The CSCI is confident that the registered person will comply with these requirements within the timescales given.

CARE HOMES FOR OLDER PEOPLE Dr French Memorial Home Ltd 13 Nether Street Finchley London N12 7NN Lead Inspector Mr David Hastings Key Unannounced Inspection 09:30 12th December 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dr French Memorial Home Ltd DS0000010424.V343104.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. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dr French Memorial Home Ltd Address 13 Nether Street Finchley London N12 7NN 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) 020 8445 4353 020 8445 4353 Dr French Memorial Home Limited Florence Somers Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th September 2006 Brief Description of the Service: Dr. French Memorial Home is a care home, which is registered to provide care for 30 older people, some of whom may have dementia. The home has charitable status and is run by a voluntary committee. The stated aim of the home is; To support residents to continue living as independently as possible by receiving care and support consistent with their incapacities and disabilities. The home consists of a large two-storey, detached building. There are 24 single bedrooms and 3 double bedrooms, located on the first and second floors. Fifteen single bedrooms have en-suite facilities, and there are eight toilets, three bathrooms and a shower. On the ground floor, there are two lounges, a dining room, a hairdressing salon, an activities room and two offices. There is a large, secluded, attractive garden at the rear of the premises and a car park at the front. The home is situated near the busy Tally Ho Corner in Finchley, North London and there are good public transport links. The fees charged at the home range between £459 and £526. A copy of this report can be requested directly from the home or accessed via the CSCI website (web address on page 2 of this report) Dr French Memorial Home Ltd DS0000010424.V343104.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 took place on 12th December 2007 and lasted seven and a half hours. The registered manager, who was very open and helpful, assisted throughout the inspection. We spoke with six staff, two visitors and twelve residents of the home. We inspected the building and examined various care records as well as a number of policies and procedures. The home has also sent us their Annual Quality Assurance Assessment (AQAA), which has provided us with important information about the service. All of the residents we spoke with said they were very happy with the care and support they received. One resident told us, “They are very, very good”. What the service does well: What has improved since the last inspection? What they could do better: Four new requirements and three good practice recommendations have been issued as a result of this inspection. It is important that a reference from the potential staff member’s last employer is obtained so that the home has the most current employment history to make a judgement about the suitability of any new staff. The results of any quality monitoring assessments must be Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 6 made available to all existing residents, their representatives and potential residents so that they know how well the home is doing to meet its aims and objectives. Fire records must be kept up to date to provide evidence that the required tests and drills are taking place. The views of people who use the service should be sought when care plans are being reviewed so that people have a say in how their care is being delivered. Practical information about how to reduce risks to residents should be recorded on individuals’ care plans to give staff practical examples of how risks can be reduced. A comments and suggestions form would give people who use the service and other stakeholders the opportunity to make suggestions about improvements as well as to raise concerns. The CSCI is confident that the registered person will comply with these requirements within the timescales given. 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. Dr French Memorial Home Ltd DS0000010424.V343104.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 Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home carries out a comprehensive assessment of individual’s needs so that they know that the home is suitable for them before they decide to move in on a trial basis. EVIDENCE: We looked at the “Service User Guide”. This gives people information about the home and services and facilities available. The guide was detailed and included a clear statement that people from different backgrounds and cultures were welcome and that any discrimination would not be tolerated at the home. This ensures that Dr French has an inclusive approach to the care of everyone at the home. We examined assessments of people who have recently moved into the home. These assessments were detailed and covered all the requirements of Standard 3.3 of the National Minimum Standards for Older People. Residents we spoke with said that the staff knew them well and understood their needs. It was Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 9 clear from discussion that the manager understood the importance of making sure the home could properly support the person before a decision to move in was made. There was evidence that people moving into the home have a review of their placement after four to six weeks to see if they are happy at the home and whether they decide to move in on a permanent basis. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Six care plans were examined. These plans were holistic in approach and set out the plan of care for each individual for staff to follow. The plans set out the health, personal and social needs of residents. Staff we interviewed had a good understanding of the needs of the people in their care. Although plans were generally being reviewed and updated regularly residents did not appear to be involved in the review of their plans. A recommendation has been issued that residents views about the care provided to them are sought and recorded when care plans are reviewed. This will ensure that people have a say in how their care is provided. Risk assessments were seen in all care plans, which Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 11 highlighted a potential risk for the individual. Risk assessments covered moving and handling. The use of bed rails, pressure care and other risk associated with dementia. In some cases there was not much practical information for staff on how to reduce the risks identified. A good practice recommendation has been issued that all risk assessments include useful, practical information for staff on how to reduce identified risks. From records and discussions with the manager it was evident that people have been supported to access health care. Residents told us that their health care needs were being met by the home. Records indicated that doctors, dentists, chiropodist, opticians and district nurses regularly saw residents. We were able to speak to a district nurse who was visiting the home on the day of the inspection and she confirmed that communication between staff and the district nurse team was very good. Satisfactory records were examined in relation to the receipt, administration and disposal of medication. Medication was being stored appropriately and the temperature of the medication storage area was being monitored and recorded. Only those staff who have completed the medication training are permitted to administer medication. The manager carries out regular medication audits to ensure that residents get the right medication at the right times and that staff are maintaining accurate records. No one at the home currently deals with his or her own medication administration. Throughout the inspection we saw examples of staff treating people with respect and upholding residents’ privacy. For example staff were seen to be knocking on people’s doors before going in. People we spoke with confirmed that they were treated with dignity and staff upheld their need for privacy. One person told us that staff are, “Respectful and friendly”. Staff we interviewed were able to give practical examples of when they have upheld peoples’ privacy. Dr French Memorial Home Ltd DS0000010424.V343104.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): 12, 13, 14 and 15 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can choose from a range of activities at the home and are kept suitably occupied and engaged. Visitors to the home are made to feel welcome and can visit at any reasonable time. Residents are helped to exercise choice and control over their lives. The food provided is of good quality and mealtimes are relaxed and enjoyable. EVIDENCE: There is an activities programme available, which includes exercise, arts and crafts, Bingo, card games and creative writing and poetry. Music tapes, videos and books are also available. One resident told us she really appreciated the home’s library and enjoyed reading the books. She also told us, “I join in with everything”. Occasional group outings take place and two residents were out and about on the day of the inspection. There is an activities coordinator and in house entertainment is also arranged from time to time. There is a monthly Church of England service for those interested and one person is taken to church by a relative. Other faiths and beliefs would be and have been assisted in the past by the home. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 13 The record of visitors indicated that residents could have visitors at any reasonable time. The visitors we spoke with said they were always made welcome and offered tea or coffee when they visited. Visitors were very positive about the staff and management of the home. One visitor told us, “You couldn’t get any better”. Residents we spoke with confirmed that visitors to the home were welcomed. Residents confirmed that they were able to have choice and control over their lives at the home. Residents told us they could do what they liked and were not “bossed about” at all. Staff we interviewed were able to give examples of how they ensure people are able to exercise choice and control within their daily routines. We did not see any institutional practices taking place during the inspection. The kitchen was inspected. The cook on the day of the inspection was aware of individual’s likes and dislikes as well as any special diets people may require. The kitchen was clean and there was a good selection of fresh food. Fridge and freezer temperatures were being monitored and recorded. The home has recently been awarded 5 stars from the local environmental health department for food hygiene standards at the home. People we spoke with were positive about the food provided by the home and confirmed that a choice of menu was always available. The cook was helping to serve the meals and was getting feedback from residents about how they enjoyed their lunch. People were being offered “seconds” and there appeared sufficient quantities of food for everyone. Lunchtime was relaxed and staff were providing discreet assistance when required. Dr French Memorial Home Ltd DS0000010424.V343104.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): 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Residents are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. No complaints have been received by the home since the last inspection. All the residents we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. Minutes seen of residents meetings showed that any minor issues were dealt with promptly. A good practice recommendation has been issued that a comments and suggestions form be made available for all residents and visitors to the home so that people have an opportunity to have a say about the standard of care in the home and to make any suggestions about improvements. Staff were able to describe to us how vulnerable people could be at risk of abuse in a residential care setting. All staff were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 15 Records indicated that staff have undertaken training in the protection of vulnerable people. There was evidence from the returned Annual Quality Assurance Assessment that the adult protection policy and procedure had been reviewed in June 2007. This was a good practice recommendation that has now been complied with. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is safe and cleaned and maintained to a very good standard. EVIDENCE: We toured the building with the assistant manager and visited a number of residents’ rooms. The building is well maintained and decorated to a very good standard. Peoples’ rooms have an individual feel and contained their pictures, ornaments and small pieces of furniture. All rooms can be locked by residents for their privacy and staff were respectful about people’s personal space. A requirement was made at the last inspection that wash hand basins are maintained at safe temperatures so that residents are not put at risk from scolding themselves. The manager told us that the mixer valves have now been adjusted in all rooms and when we tested the temperatures they were within safe limits. All rooms, bathrooms and toilets have thermometers so that staff can check water temperatures. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 17 The home had appropriate infection control policies and procedures in place and staff have had training in this area. All toilets and bathrooms had antibacterial soap and paper towels to minimise the risk of cross infection. Alcohol liquid was also seen throughout the home. One person at the home has MRSA and appropriate measures were in place to manage this issue including the provision of red bags that dissolve in the washing machine. Both washing machines have a sluice function to deal with soiled laundry. Residents and visitors we spoke with said the home was always clean and there were no offensive odours detected throughout the home. A resident told us, “It’s extremely clean”. There appeared to be sufficient domestic staff employed at the home to maintain high levels of cleanliness. Dr French Memorial Home Ltd DS0000010424.V343104.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): People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. All the staff at the home work very hard to meet the needs of residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are generally sufficiently detailed in order to protect residents at the home. EVIDENCE: On the day of the inspection there were four care staff and the assistant manager on duty. The manager told us that there were between four and five care staff on duty during the day and three waking night staff on duty throughout the night. The manager or assistant managers take it in turns to sleep in the home so they can respond to any potential problems quickly. People who use the service told us that they felt there were enough staff on duty to meet their needs. One resident told us the staff, “Work very hard”. Satisfactory staffing rotas were examined. There are a number of people at the home with dementia and staff have had dementia training in order to provide “Person centred” care. Training records provided by the home indicated that 9 staff out of 25 have obtained NVQ level 2 or equivalent. The manager told us that all care staff who do not have this qualification have now enrolled on NVQ level 2 training. It is clear that the manager is working hard to meet the requirement of this standard. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 19 Three staffing files were examined. These files were generally satisfactory and contained all the information needed for the protection of people who use the service including proof of identity, two written references and a satisfactory CRB disclosure. However we noted that the references from one staff member did not include their most current employer. It is important that the home is provided with the reference from the person’s most recent employer to ensure that the most current information about the person is obtained. The manager told us that this was an oversight and other files seen did contain a reference from the most recent employer. A requirement has been made regarding this matter in the relevant section of this report. Staff were positive regarding the opportunities for training at the home. Records of staff training indicated that the majority of staff have completed the required training. A good practice recommendation, issued at the last inspection, that an, “At a glance” training record is kept for staff has been complied with. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are generally being promoted and protected. EVIDENCE: The registered manager has completed the Registered Managers Award and there was evidence that she also attends other training on a regular basis. Both staff and residents that we spoke with were very positive regarding the manager and it was clear that everyone at the home benefits from her hands Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 21 on approach and commitment to improving the service. Both residents and staff commented that the home is well run. Although the home has a quality assurance system, which includes regular questionnaires given to people who use the service and other stakeholders, the results of these quality monitoring reviews must be published and given to all interested parties. It is important that people who use the service are given feedback about how well the home is doing to meet its aims and objectives. A requirement has been issued relating to this matter in the relevant section of this report. Some monies are kept by the home on behalf of a number of residents. A number of records were checked against cash held and found to be correct. Clear audit trails were seen for all money examined and a good practice recommendation that individual receipts for purchases are numbered has been complied with. The home has a range of health & safety policies, including manual handling, fire safety, first aid, food hygiene and infection control. Maintenance checks had been made on the home and follow up work completed. Test certificates for gas, electrical installation, electrical appliances and fire were inspected. There were a few gaps in the record of weekly fire alarm testing and a requirement has been issued relating to this. Although a fire drill had taken place recently it was not clear if night staff had been included in the drill as recording was a bit patchy. A requirement has been issued that fire drills take place on a regular basis and that night staff undertake fire drills every three months so they are confident about what action to take if a fire occurs at night. COSHH substances were kept in a locked cupboard and the requirement issued at the last inspection relating to this has now been complied with. All bedroom doors that residents want to keep open are now fitted with a selfclosing mechanism that will close in the event of a fire. This was also a requirement from the last inspection that has now been complied with. Dr French Memorial Home Ltd DS0000010424.V343104.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 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 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 2 Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19(1) c Requirement The registered person must ensure that the two written references obtained for all potential staff at the home includes a reference from the person’s last employer. This should ensure that the most current information is obtained about the prospective candidate. The registered person must ensure that the results of any quality assurance surveys are published and made available to all interested parties. This includes residents and potential residents to the home. The registered person must ensure that the record of fire alarm testing is being accurately recorded to provide evidence that the fire alarm is being tested weekly. The registered person must ensure that the record of fire drills is being accurately recorded and that night staff undertake fire drills every three months. Timescale for action 01/02/08 2. OP33 24(2) 01/04/08 3. OP38 23(4) c 01/02/08 4. OP38 23(4) e 01/02/08 Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP7 OP8 OP16 Good Practice Recommendations The registered person should ensure that the views of residents are sought every time care plans are reviewed. The registered person should ensure that risk assessments contain practical information for staff to enable them to reduce the identified risk. The registered person should ensure that a comments and suggestions form is available to all residents and visitors so that they may be able to make suggestions for improvement of the service or to raise any concerns. Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Dr French Memorial Home Ltd DS0000010424.V343104.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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