Inspection on 14/06/05 for Acorns

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acorns 29/11/07

Acorns 06/09/06

Acorns 02/12/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Acorns 29-31 Welholme Road Grimsby DN32 0DR Lead Inspector Theresa Bryson Unannounced 14 June 2005 09:30 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 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. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Acorns Address 29-31 Welholme Road, Grimsby, DN32 0DR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01472 340129 Pindy Enterprises Ltd Ms Jane Wressell CRH 27 Category(ies) of OP 27 DE(E) 27 registration, with number of places Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None apply. Date of last inspection 07/01/05 Brief Description of the Service: The Acorns is a large Victorian house, which although retains many of its period features has been adapted to meet the needs of service users. The home is in the centre of a large residential area of Grimsby, overlooking Peoples Park, a well-known beauty spot. Local shops and other amenities are close to the home. The home is three-storeys, accessed by stairs and a passenger/chair lift. There are a number of sitting rooms and a large dining room. The house has parking to the front and rear and an adequate sized garden. The staff have their own working areas and there is also a large kitchen and outside laundry room. The home provides for the needs of service users from minimal needs to more complex needs. It is supported by the local district nursing service and local GPs. The manager is a professionally trained nurse. Staff are encouraged to attend training courses and there appears to be good input from other health professionals. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2005, present were both owners and the Registered Manager. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the owners, manager, 4 staff members and 6 people who live in the home. Paperwork kept in the home was also seen to make sure the checks to make sure staff are safe to work in the home were done before they started and they are trained to do their job safely. Paperwork was looked at to make sure that the home and the things used in it were safe and were checked often. Due to the change of ownership a couple of months before this inspection some outstanding requirements had not been completed by the previous owner. What the service does well: The home was clean and had a friendly feeling and all staff were very welcoming. It has lots of room for people to sit and relax both inside and outside the building. The staff were friendly and knew about the care the people living in the home needed. The care people needed was written down. The people living in the home told the inspector how kind and caring all staff were to them and they felt confident the manager would sort out any problems they may have at any time. The people living in the home said how much they liked the meals and there was plenty to eat and also plenty of different things to eat. If they did not like something they could ask and the staff would get it for them. They said there were always a lot of fresh vegetables and fruit and home baking. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The owners know they have to make sure that the paperwork telling people who are in the home and who wish to come in to the home is up to date. The staff do not always write down how care must be given and what has happened day to day to people living in the home. This is important to make sure that all staff understand the care that everyone needs and can make sure the care they are giving is working or not. The cupboard for strong drugs needs securing to a wall. This will prevent it falling on someone. Some parts of the home looked uncared for and in need of decoration, but the home needs to make sure this is completed around a plan and people living in the home are aware of when work will start. Staff could help by keeping the home looking tidier and making sure that the little things such as straightening bedcovers and making sure wash hand basins look clean and tidy are done each day. The manager must also make sure that all parts of the home meet health and safety guidelines, such as having carpet edging replaced, a bath panel repaired and windows are secure, for the safety of those living in the home. Staff in the home need to know what hours they work and on what other terms Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 7 they are employed. The owners must make sure each person has a contract of employment. The manager must make sure that she knows how staff work, any problems they have or she may have with them and what training each person needs. She needs to keep supervision and training records up to date. This will ensure that all staff feel valued and can contribute to the running of the home. The staff at the home complete some audits each month to check needs of people living in the home are met, staff are happy and the home is safe for people to live in each day. This now needs to be in written form and show, with an action plan how the home is going to give good quality of care in the future. 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. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 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 standard(s) 1,2,3 and 6. The statement of purpose and service users guide did not reflect the current ownership of the home. Service users were provided with information regarding the home before admission and were always seen by a senior staff member prior to admission. Staff were well informed of the service users needs on admission, which assisted the service user in feeling secure and welcome in the home. The home does not provide intermediate care and therefore Standard 6 is not applicable. EVIDENCE: The owners are aware that the statement of purpose and service users guide needs alteration as neither document reflects the current new ownership details. All other parts of the document remain the same and the owners stated that they have seen no reason to change the format as it still reflects the actual service provided by the home. The format was found to be comprehensive and Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 10 user- friendly. The company has provided the service users with a contract/statement of terms and conditions, but service users spoken to were not aware if they had signed this document. The manager stated that she assesses all service users prior to admission to the home and was able to provide evidence of completed assessments and care plans. The majority of service users stated that family or the local Social Services department had assisted them in coming to the home and helping them in the decision making process. All service users made positive comments on how well they had been welcomed to the home. The home does not provide intermediate care and therefore Standard 6 was not assessed. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9. Although care plans were not always followed through and there were some gaps in the recording details, which could leave service users at risk from unidentified health problems, there was sufficient evidence that health care needs of the service users were met. Service users are involved in the development of the care plans and staff were knowledgeable about the care needs of service users, and carried out tasks in a manner that respected the privacy and dignity of service users. The controlled drug cupboard needs attaching to the wall as staff, service users and other visitors could be at risk of it falling on them and the cupboard could be easily taken out of the home in the event of a burglary. EVIDENCE: 6 service users were talked to in depth and all stated that their care needs were being met and described how care was provided in a way that respected their privacy and dignity. Some were aware that records are kept on them and there was written evidence in the care plans that service users had input to the review process. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 12 Case tracking of 4 service users was completed. This included examination of care records, other related documentation such as accident records and discussion with service users and staff. Care plans were generally well developed, but some gaps and inconsistencies were seen. There were no photographs on the care plan folders and the documentation in use was not consistent in each file. Most care plans had been evaluated on a monthly basis, but some gaps were seen. The professional persons’ visit sheets were not always completed. The daily reports sheets had been completed on a regular basis, but the written comments were very repetitive in each care plan. It was therefore difficult for the inspector to see what the daily programme was for each service uses and how they wished to conduct their lives. Some staff were able to state their involvement of the care planning process and all stated that they felt able to approach the manager for help if they should need it, especially when documenting care. The manager stated that she audits the care plans and accident records on a regular basis, but no evidence could be produced to support this statement. The care plans were well presented in separate folders and the writing legible and clear. The medication records have improved since the last inspection and the drugs trolley was attached to the wall. Some training of staff administrating medication has yet to be completed. A reference book could not be found on the day of the inspection. Written evidence was seen that the home’s chemist had completed an audit last month. The store cupboards were carrying limited stock and all areas where drugs were stored were clean and tidy. There were only antibiotics and cough linctus stored in the fridge and temperature records had been kept. The controlled drugs were all checked and found to be correct and all written documentation had been signed correctly. The storage cupboard for these drugs has still not been attached to the wall and could present a hazard from falling and could also be easily carried away in the event of a burglary. This has meant that the recommended storage for controlled drugs has not been followed from legislative guidelines. All policies for drug administration and the use of homely remedies remains unchanged from the last inspection. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15. The meals provided in the home were of a good quality offering choice and variety. The kitchen area was clean and tidy. EVIDENCE: The service users spoke positively about the meals provided and described the quality, choice and variety of the meals as good. The kitchen was catering for 4 diabetic diets and 4 who required soft diets. The menus remained unchanged from the last visit. There was evidence in the storerooms that fresh fruit and vegetables are in use. Staff were seen to assist service users at the lunchtime meal with dignity and respect and in a calm relaxed atmosphere. The dining area is light and airey and new chairs with sliding feet had recently been purchased. New tablecloths were on each table, but the presentation on the tables of the tablemats and general laying of the tables was poor. Due to new ownership some suppliers had changed, but staff stated that they were coming to terms with the new arrangements and the stock cupboards showed adequate supplies of all types of foods. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 14 All equipment was in working order and the temperature control records were seen and showed regular checks had been made. The last environmental health officer’s (EHO) report, made in March 2005, was seen and indicated that some new checks be made for temperature control. The EHO report also stated that some minor adjustments had to be made to a hand-washing sink, but commended the home on the cleanliness seen in the kitchen area. All staff certificates for food handlers were seen and found to be still valid. One member of kitchen staff had completed an NVQ in Catering and another was about to complete. The kitchen was fully staffed at the time of the inspection and the rota seen. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 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 standard(s) 16 and 18. The relationship between the manager, staff and the service users enabled the service users to feel confident in making a complaint if it was necessary. This was supported by the policy on display. Training had yet to be completed for all staff in the protection of vulnerable adults and staff awareness of this topic was poor. The policy and procedure was not up to date. EVIDENCE: The policy was on display outlining the process for making a complaint and forms were available through the senior staff and on the reception table at the entrance to the home. Service users spoken to all understood that they could make a complaint if the need arose and stated they were happy to do so and confident that the senior management would address any issues raised. There was evidence to support that 4 staff members had attended up date training in the protection of vulnerable adults and two had certificates. The manager has yet to go on her training. Staff responses to questions about adult protection were mixed and indicated that there was an inconsistent approach and knowledge base in the home. Some staff stated they had undergone some training whilst completing their NVQ in care awards and 2 staff members stated they had attended a Mental Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 16 Health Awareness day. The manager needs to ensure that all staff are aware of this topic and also know how to refer a case through the correct channels so all service users can remain protected against any form of abuse. The up to date referral chart issued by the local Adult Protection Team was not in place and the manager needs to ensure that the file on display is up to date which outlines current legislation and local guidelines in adult protection. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26. 19,23,24 and The home was clean. Some areas did need more attention regarding a redecoration programme and renewal of some furniture and fittings. Individual service users rooms seen were untidy and more attention to detail needed by staff. Equipment in use in these areas had been assessed as to service users needs and appeared appropriate. The laundry area was clean and all equipment in working order. EVIDENCE: The home was clean but untidy in places and needs maintenance programme in place to ensure that areas identified during the tour of the premises, in the presence of the owners and the manager, can be identified as priorities. The provision of a maintenance and renewal programme has remained an outstanding requirement since the beginning of 2004. Some areas seen as needing urgent attention were a damaged bath panel, carpet strips on the entrances to two downstairs areas and attention to a Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 18 paved area outside of the service users dining area. During the tour of the building a number of windows were checked and some found not to have window restrictors in place, this was identified to the owners has needing urgent attention. The manager produced documented evidence to support that general furniture and fittings in service users rooms had all been assessed. Individual equipment for service users use was addressed through the assessment process in the care plans. One person’s needs were identified by direct observation by the inspector at the time of the visit. The manager was asked to ensure an assessment was obtained and suitable mobility aids found for this particular service user as the records showed an unacceptable length of time had elapsed for assessment of these needs and the service user was being transferred in an unacceptable manner. The laundry facilities are in a room just outside the dining area. This was tidy and clean and all machines in working use at the time of the visit. Staff stated that the laundry staff member takes out the baskets of washing to service users rooms and this was in practise at the time of the visit. All policies to support good practise in health and safety and cross infection remain unchanged since the last inspection. Hand held soap appeared to be in common use and the manager was asked to instruct staff not to use this type of communal hand washing material and ensure that each service user had their own supplies and other supplies were in place for staff use to prevent cross infection. Some areas of the outside of the building needed attention. There were cobwebs and waste paper around the front door and broken and unused furniture in areas which can either be seen or accessed by service users. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. The staffing levels were appropriate for the current dependency of the service users accommodated and had been revised after the last inspection. The home has still not reached the target for numbers of NVQ trained staff. The recruitment practises in the home had been adequately implemented and the new owners are to issue new contracts. The staff-training programme was adequate to meet the needs of service users and to record competence of all staff to complete their jobs. EVIDENCE: The service users dependency levels had been revised since the last inspection and the rota put in place to ensure adequate staff were on duty at all times. The rota was seen and staff interviewed stated they felt that all work can be completed with the numbers on each shift. Staff confirmed that the only time there were difficulties in the staff rota was when some staff took sick level. This was being addressed by the manager. The home could evidence that 6 staff members had completed their NVQ level 2 in care award and some others are going forward. The inspector was offered a copy of the training matrix, which showed that all Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 20 mandatory training was up dated and some service specific training had taken place. The 4 personal files of staff tracked during the course of the inspection showed the certificates in place and some were on display in the main entrance. The home produced evidence to support that all criminal investigation bureau checks had been completed. 4 personal files of staff were looked at in depth. The home must ensure that if staff have been employed for a number of years that all references have been taken up or a statement is on file as to the home’s acceptance of them bring employed still. Service users stated that all staff were very caring and kind to them and allowed them as much independence as their conditions would allow. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 and 36. The new owners prior to the inspection had submitted an acceptable business and financial plan. It covered all the areas set under Regulation 25. An acceptable quality assurance plan was not in place or an annual development plan for the home and this standard could not be inspected due to the lack of evidence available. Records showing personal allowance money of service users had all been accurately recorded. Policies are in place to ensure no financial abuse can occur. Supervision records of staff were not up to an acceptable standard and there was not enough evidence produced to support that this occurs enough times each year as stated under Standard 36. EVIDENCE: Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 22 There was not enough evidence produced to indicate that an effective quality assurance system is in place and no annual development plan. This has been an outstanding requirement from early 2004. The new owners had submitted a new business and financial a short while before this inspection. The document covered all necessary parts to cover Standard 34. It was very legible and readable. The manager holds 10 separate accounts for service users personal allowance money, 3 of these were checked in detail. Each one showed the balance in hand, recorded all transactions, for which receipts were seen and had been audited recently. All money and balances totalled correctly. The new owners have put in a petty cash system for the manager to buy small purchases, up to a certain level of expenditure. The manager and owners both stated this system was working well. There was not enough evidence produced for the inspector to check whether all staff had received adequate supervision since the last inspection. Only 1 staff member spoken to understand what supervision means and each one could not remember when their last session had taken place. The manager was informed that this was unacceptable and she needed to have a system in place and this evidence open for inspection. This requirement has been outstanding from the beginning of 2004. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x 3 2 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 1 3 3 1 x x Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 24 yes 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. 1. Standard 1 Regulation 4(1ac,2)&5(1a -f),2 15 (1 & 2(a-d) 13 (2) Requirement The registered person must ensure that an up to date service users guide and statement of purpose is availablel at all times. The registered person must ensure that the serivce users care plan is kept up ot date at all times. The registrered person must ensure that the controlled drugs cupboard is secured to the wall. (Previous timescale of 30/03/05 not met.) The registered person must ensure that all staff have been trained in the protection of vulnerable adults and all guidelines in use are up to date. (Previous timescale of 30/03/05 not met). The registered person must must ensure that all windows are safe aned meet health and safety regulations. The registered person must produce a maintenance and renewal programme. (Previous timescale of 30/04/05 not met). The registered person must ensure that the care plan of one Timescale for action 30/11/05 2. 7 30/11/05 3. 9 30/08/05 4. 18 13 (6) 30/11/05 5. 19 23 (2b) 30/08/05 6. 19 23 (2b) 30/11/05 7. Acorns 24 15 (2b) 30/08/05 Page 25 v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 8. 9. 29 33 18 (1a) 24 (1a&b), 2 & 3) 10. 36 18 (2) particular service user identifed to them is up to date and all reassements completed. The registered person must ensure that all staff have contracts of employment. The registered person must develop and implement a formal qulaity assurance systme and takes into account the views of service users and measures the success in the meeting the aims and objectives of the home. (Previous timescale of 30/05/0/5 not met). The registered person must ensure that staff receive formal supervision at least 6 times a year and that this is recorded and covers all items in this standard. This is to include the Registered Manager). (Previous timescale of 30/03/05 not met). 30/11/05 30/11/05 30/11/05 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 28 Good Practice Recommendations The registered person needs to be aware of the deadline of 2005 to ensure that she meets the 50 target for NVQ level 2 trained staff working in the home. Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 OQF 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 Acorns v232960 j54 s63879 acorns v232960 14 june 05 stage 4.doc Version 1.30 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. 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