CARE HOMES FOR OLDER PEOPLE
118-120 Dudley Street West Bromwich West Midlands B70 9AJ Lead Inspector
Mr Patrick Wright Unannounced Inspection 29th December 2005 09:00 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 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 118-120 Dudley Street Address West Bromwich West Midlands B70 9AJ 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) 0121 580 2573 0121 525 6257 N/K Lonsdale (Midlands) Limited Marie Grogan Care Home 8 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (5), Learning disability over 65 years of places of age (2), Physical disability (8) 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 5 LD, 2 LD(E),1 DE(E) and up to 8 PD. Date of last inspection 18/8/05 Brief Description of the Service: 118-120 Dudley Street is an 8-bedded nursing home for older adults with learning and physical disabilities. The home is situated close to local shops and amenities, is near to West Bromwich town centre, and is accessible by public transport. The service offers one shared and six single occupancy rooms, a communal lounge and dining area and assisted bathing facilities. None of the bedrooms currently offer en-suite facilities. There is a domestic style laundry and kitchen, and a garden/patio area to the rear. A lift services the first floor. A range of services are available including offering support and assistance to access healthcare facilities, various in –house and external recreational pursuits, and community inclusion. The home has its own transport. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted as a statutory unannounced inspection. The purpose of the inspection was to assess progress and compliance in meeting the National Minimum Standards and towards addressing issues identified at previous inspection visits. A range of inspection methods was used to make judgements and obtain evidence. The inspection included time spent examining documentation, reviewing how some of the care packages had been arranged and were being delivered, and having discussions the Registered Manager and residents. There was also a tour of the premises. The inspection was conducted with the full co-operation of the Manager and staff. The discussions and atmosphere throughout the inspection was positive and constructive. The home is registered to provide nursing care for adults with learning and physical disabilities, and other complex needs. There are eight residents currently living at 118 Dudley Street. The residents present during this visit stated or indicated their satisfaction about the level of care and support they receive at the home. Formal interviews were not appropriate. However informal discussion and conversations about daily life were appropriate, and some of the occupants of the home were willing to participate. Residents chatted about the recent Christmas festivities and one resident spoke about an accident he had had and the outcome of a visit to hospital. Overall the home continues to provide a comfortable and relaxed atmosphere. The inspector would like to thank staff and residents for their co-operation and hospitality during this visit. What the service does well:
The home provides stability and continuity of care for its residents and is run by an enthusiastic staff team. Staff actively support residents to enjoy a wide range of community based and in-house activities. The Registered Manager has purchased in house games for the residents to enjoy such as large-scale snakes and ladders and Ludo. Each resident has a series of comprehensive and individual care plans which incorporate specialist requirements and procedures designed to meet the needs of the person. All activities and care related issues are risk assessed and this includes a variety of activities and topics according to their individual abilities. The home uses a generic risk assessment system with interventions and guidelines for staff clearly described. Residents are provided with a positive lifestyle, including social inclusion, which strives to promote ordinary living, in an open and inclusive environment. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 6 Observations of staff and review of documentation confirmed that staff continue to have identified clear working relationships with each other, and this offers continuity of care in terms of meeting individuals needs. What has improved since the last inspection? What they could do better:
With the exception of minor shortfalls the home is meeting the majority of the National Minimum Standards for Younger Adults. With this in mind, the management need to ensure that the current service is maintained and progresses with regard to further good practice initiatives. The home still requires additional storage for equipment and aids, which should be of a good standard and fit for the purpose.
118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 7 It is recommended that the home obtains a computer, and is enabled to use email and web site facilities. Monthly visits to the home, under Regulation 26 of the Care Homes Regulations, by the organisations `Responsible Individual` or nominated representative must be conducted. The organisations training plan has not progressed recently and shortfalls are imminent in the provision of staff development opportunities. For example, staff are in need of training and direction in managing aggression and difficult situations. Similarly the level of NVQ level 2 trained staff is not meeting the proposed targets set by the Commission for Social Care Inspection and `Skills for Care`. 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. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4, 6 The home can demonstrate its capacity to meet the assessed needs of residents. Specialised services offered reflect current good practice and clinical guidance The home does not offer an intermediate care service. EVIDENCE: 118-120 Dudley Street offers a specialised service to people (including some younger adults and older persons) with Learning and physical disabilities, and other needs. The homes certificate of registration accurately reflects the primary care needs of those accommodated. The home provides nursing care through a group of staff whom collectively and individually have the skills and experience needed, and through this inspection process it was identified, communicated with residents in a positive and friendly manner. Through observations of staff and review of documentation it can be confirmed that at the time of the inspection, the home was meeting the assessed needs of the residents accommodated.
118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 The medication system at the home is well managed. The systems for the administration of medication are good and arrangements are in place to ensure service users medication needs are met. Personal support is offered in such a way as to promote and protect the service users preference and in a way that respects the individuals privacy and maintain their dignity. EVIDENCE: Procedures and practices with the home in relation to medicines and controlled drugs were found to be satisfactory. There are no residents who self administered at the time of inspection and specimen signatures were available of qualified staff who administer medication to service users. Staff signatures for the homes updated medication policy need to be obtained as an acknowledgement of its content/existence. Medication in the custody of the home is handled according to the requirements of legislation and records are available, of medicines received, administered and leaving the home. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 11 PRN, (when required) prescribed medication, is documented in the individuals service user plan, demonstrating frequency and under what circumstances to be administered etc. Records of administration are maintained accordingly. The current office is used for the storage of Oxygen. The temperature of the room is monitored but not recorded. The Registered Manager was advised that the temperature of the room should be documented, in addition to the maximum and minimum temperatures of the medication fridge. Resident’s privacy and dignity is respected at Dudley Street, with regards to personal care, entering toilets, bathrooms and bedrooms, and maintaining social contacts. Residents have access to a telephone, are spoken to using a preferred term of address, (which is documented) and arrangements are in place to ensure personal clothing/laundry is returned to its owner. The home provides one shared occupancy room for which there is a privacy screen provided. Items or equipment for the delivery of personal care are stored in a suitable and discreet manner, but this can prove difficult at times due to the lack of storage space available within the home. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Resident’s interests are recorded and they are given opportunities to experience leisure and recreational activities in and outside the home. Staff support the residents to maintain family links and friendships and they are able to receive visitors in private. The rights of individuals living at the home are respected and choices and preferences identified. Daily routines are modelled around the individuals choices. The meals in this home are good, with evidence that residents are offered quality meals and choice. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 13 EVIDENCE: The home provides flexibility in daily routines for residents, which incorporate exercising choice/control in their daily lives. Daily activities are documented and are available through utilising various sources, both in house and externally. Some residents have regular visits from relatives and if they so choose can take trips with families out into the community. Food, meals and mealtimes, personal and social relationships with families and friends, leisure and social activities (to include cultural interests) are flexible and varied. Care plans indicate that resident’s interests are respected. Where possible residents are supported and encouraged to pursue stimulation in and outside the home, which suits their needs, preferences and cultural interests. Resident’s likes and dislikes are identified and up to date information is available about resources available. Recreational activities include music/keyboard sessions, chair exercises, sensory sessions, foot spas, nail care/beauty, cookery, hobbies (e.g. knitting) videos and television. In addition, trips out to the cinema, theatre and church are provided plus shopping, meals out and accessing day care facilities. Residents spoke of how they enjoyed Christmas and the activities provided. One resident was recently supported to visit family in Coventry, and escorted there by care staff. Dudley Street operates an open visiting policy, and welcomes relatives and friends of service users at any reasonable time. There is no restriction with regard to visiting times. The home actively supports maintaining contact with friends and relatives. The Registered Manager keeps relatives regularly updated with any changes/incidents. Limited communal space is available where visitors can meet their relatives in privacy, but service users can access their own rooms with relatives if desired. An additional recreational area will be created once the current building extension is completed. Examination of the visitor’s book and conversation with service users confirmed that regular links within the community are maintained and encouraged. Examination of residents files and personal documentation such as care plans and reviews/assessment forms, confirmed that individuals are encouraged to exercise their right to handle their own financial affairs. Where appropriate advocates, relatives or a family member can act on behalf of a resident and all information is recorded as part of the consultation process. None of the existing residents currently manage their own financial affairs. Access to personal records (if requested) would be in accordance with Data Protection Act 1998. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 14 Residents can bring with them personal possessions, on admission, and inventories are kept of belongings. Residents/their relatives or representatives have been informed previously of how to contact external agents e.g. advocates who can act in their interest if needed, and literature has been obtained on the subject. Staff regularly consult with residents e.g.:- choice of meals to be eaten, and activities etc. Residents are helped to exercise choice and control over their lives at the home. Residents at Dudley Street continue to be offered a variety of meals taken from a menu produced weekly in consultation with those who live at the home, and based on their likes/dislikes. Menus offered drawings and a pictorial guide to accompany the written information to assist residents with communication needs, to make an informed choice. Regular meals, snacks and hot/cold drinks are available. Meal planning and mealtimes are flexible, and can be changed, as needed/requested. Residents are given a choice as to where to sit and eat, are not hurried and staff are available for assistance when necessary. It was also noticed that wherever possible, residents get up from sleep at a time to suit themselves. This is acknowledged as good practice and also demonstrates that choice and flexibility is available to residents in different lifestyle issues. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A EVIDENCE: No standards from this section were assessed at this inspection 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The standard of the environment within this home is good providing residents with an attractive and homely place to live. Satisfactory Infection control measures are in place. EVIDENCE: At this unannounced inspection Dudley Street was again found to be comfortable, well maintained and clean. There were no offensive odours and the premises offered adequate light and ventilation. The home continues to offer a good standard of furnishings and fittings and is well decorated. A maintenance and renewal programme has been formulated, although regular environment audits are being conducted. The premises are in keeping with the local community, and offers access to local amenities and transport. A passenger lift is provided. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 17 Am extension to the property was nearing completion at the time of this inspection, to provide two refurbished bedrooms with en-suite shower facilities. In addition, two existing bedrooms will be made larger. The existing office will transfer to the ground floor and a second lounge/recreational area will be created from utilising the remaining space available. At the time of this inspection the Registered Manager stated that she was waiting for a visit from the Fire Safety officer before confirming the rooms were ready for approval/registration by the Commission for Social Care Inspection. A new assisted bathing facility has been provided at the home, with a hydraulic seat. The home requires additional storage for equipment and aids, which should be of a good standard and fit for the purpose. This unannounced inspection identified that the home was again found to be clean, and free from odour. Laundry facilities are appropriate and are sited in a separate area designated for the purpose. Laundry products (i.e. washing powder and fabric conditioner) are kept locked away and the room is fitted with a lock to be used when unattended. Equipment provided ensures foul laundry is washed at appropriate temperatures, and the washing machine has a sluicing facility. Laundry facilities do not intrude on resident’s routines, and walls and floors are readily cleanable. The homes Infection Control policy states that laundry to be washed is not to be carried through the lounge, and must be transported in appropriate containers or disposable bags. `Designated` baskets are identified for sorting clean and dirty laundry. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 The home has an experienced staff team with sufficient numbers and skills to support the service users. The number of NVQ level 2 trained staff is not meeting the proposed targets set by the Commission for Social Care Inspection and `Skills for Care`. Staff will shortly require training updates, or initial instruction, to ensure the staff team are appropriately trained and the service benefits from a planned development programme. EVIDENCE: The home operates at staffing levels of one qualified nurse and three support workers during wakeful hours, and one qualified nurse and one support worker during the night time. These staffing levels are the minimum the home must operate at. The Registered Manager is advised of the need to monitor and adjust staffing levels to ensure the needs of service users are being met and where necessary contact the appropriate health professional to conduct a reassessment. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 19 The organisations training plan has not progressed recently and shortfalls are imminent in the provision of staff development opportunities. For example, some staff are in need of training and direction in managing aggression and difficult situations. Similarly several of the staff team will shortly need updates (or initial instruction for new staff) in mandatory courses such as manual handling and adult protection, in addition to specialist training such as Dementia care. The number of NVQ level 2 trained staff is not meeting the proposed targets set by the Commission for Social Care Inspection and `Skills for Care`. The Registered Manager has reviewed the training needs of the staff team and produced an updated matrix, which forecasts the training to be provided through the company training schedule for the coming year. The induction system for new staff is provided through the Black Country Partnership for Care organisation and is referenced to the `Skills for Care` induction standards. There was minimal progress identified that staff are to be enabled to access Learning Disability Award Framework accredited training, (LDAF). 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 The Registered Manager is experienced and qualified to run the home and meet its stated aims and objectives. There are elements of a Quality assurance system, but this needs to be formalised to ensure it is based on the outcomes for residents, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. EVIDENCE: The Registered Manager has appropriate qualifications and experience for the post, and undertakes periodic training and development to maintain her knowledge and skills. She is a Registered Nurse (Learning Disability), is a Learning Disability Awards Framework assessor, and has recently commenced working towards the NVQ level 4/Registered Managers Award qualification.
118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 21 At the time of this inspection the monthly visits by the company `nominated representative` under Regulation 26 of the Care Homes Regulations 2001 were not being conducted. The last visit was recorded as being conducted in July 2005. Monthly visits to the home, under Regulation 26 of the Care Homes Regulations, by the organisations `Responsible Individual` or nominated representative must be conducted and reports submitted to the Commission for Social Care Inspection. The Company holds the Investors in People Award and the Registered Manager has an annual development plan for the home. In addition, various audits take place in the establishments, for example, estates audits. The company complaints procedure is available to all residents and their representatives, and is in suitable formats. Regular reviews of care plans and systems are held, and various policies and procedures are being updated. The Registered Manager is aware of the need to involve the residents and staff at Dudley Street in the quality assurance process, but should continue to explore ways and methods of demonstrating the quality of service is appropriate, and include other stakeholders. The organisation needs to consider formalising the quality assurance process for the care home. The home must evidence an effective system for Quality Assurance is in place based on outcomes for residents, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. As previously recommended the Registered Manager may wish to consider reviewing the office filing system, streamlining the documents held and archiving relevant records no longer used on a daily basis. In addition it is recommended that the home obtains a computer, and is enabled to use e-mail and web site facilities. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 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 X X X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Timescale for action 30/06/06 2 OP19 13,23 3 OP30 18 The home should progress with the implementation of a system of Person Centred Planning. (Previous timescale of 31/12/05 partly met) • The company must ensure 28/02/06 that all unwanted items and debris is removed promptly, allowing staff to ensure the external recreational space is kept free of hazards. Increased safety measures should be provided around the pond. The home requires additional storage for equipment and aids, which should be of a good standard and fit for the purpose. (Previous timescale of 30/11/05 partly met) 28/02/06 The Registered Manager must submit an updated staff training and development programme, to the Commission for Social Care Inspection, for all mandatory and foundation training commensurate with staff duties. This must clearly identify
DS0000004771.V274858.R01.S.doc Version 5.1 118-120 Dudley Street Page 24 4 OP33 24 programmed dates of training, for completion. • Monthly visits to the home, 30/06/06 under Regulation 26 of the Care Homes Regulations, by the organisations `Responsible Individual` or nominated representative must be conducted and reports sent to the CSCI (by 31/01/06). • The service must adopt and evidence an effective system for Quality Assurance based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis (By 30/6/06). 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 Refer to Standard OP9OP38 Good Practice Recommendations The Registered Manager is advised that the temperature of the office where Oxygen is currently stored, should be documented when checked. • Staff signatures for the homes updated medication policy need to be obtained as an acknowledgement of its content/existence. That the home continues to work toward meeting Sector skills workforce targets of 50 of care staff having achieved an NVQ level 2 or above. That the Registered Manager continues working towards the RMA/NVQ IV in Management (to be achieved by 30/9/07) • It is recommended that the home obtains a
DS0000004771.V274858.R01.S.doc Version 5.1 Page 25 • 2 3 4 OP28 OP31 OP37 118-120 Dudley Street • computer, and is enabled to use e-mail and web site facilities. The Manager should consider reviewing the office filing system, streamlining the documents held and archiving relevant records no longer used on a daily basis. 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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 118-120 Dudley Street DS0000004771.V274858.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
