Inspection on 05/06/07 for Ardtully Retirement Residence

This inspection was carried out on 5th June 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.

Other inspections for this house

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ardtully Retirement Residence Station Lane Ingatestone Essex CM4 0BL Lead Inspector Mrs Bernadette Little Unannounced Inspection 5th June 2007 9:00 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 Ardtully Retirement Residence DS0000069546.V347063.R02.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. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ardtully Retirement Residence Address Station Lane Ingatestone Essex CM4 0BL 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) 01277 353888 01277 355924 Mr Rajan Dhirjal Madlani Mrs Susan Hume Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Ardtully is a striking pseudo Tudor building, which was originally built in 1882 and offers personal care and accommodation for twenty five older people. The home has three double and nineteen single bedrooms. Refurbishment and alterations had taken place to make best use of the space. There is a passenger lift to all three floors. Due to its age and retained character there are a number of changes in floor level, with steps within private and communal areas. The home is not considered appropriate for service users with mobility problems, for example those that require the use of a wheelchair to mobilise indoors. There is the choice of two lounges and a dining room. Ardtully offers its own hairdressing room. There is an accessible garden with raised flower-beds, pagoda and seating area. The village shops, bus and rail services are all close by. Parking is available to the front of the home. Ardtully provides residents with the use of a minibus. The current rate of fees is between £500 and £800 per week. Additional charges are made for hairdressing, chiropody, newspapers and magazines. There were no charges made for escorts or transport. Ardtully had been registered as a residential care home for some years and has recently been registered under new ownership. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken over a seven-hour period as part of a routine unannounced inspection of Ardtully Retirement Residential Home. There were 19 residents living at Ardtully at the time of this site visit. Time was spent talking to residents, relatives and staff as well as looking at records and parts of the premises. Records for two residents were tracked and sampled for others. Written information was provided by the home. Written information in the form of surveys was provided by five relatives, by ten residents, some of whom were supported by staff to complete the documents, and by a healthcare professional and their comments are reflected throughout the report. Discussion of the inspection findings took place with the deputy manager throughout the inspection and guidance and feedback given. The assistance provided by the residents, visitors, relatives, staff and the deputy manager was much appreciated. What the service does well: What has improved since the last inspection? While this home has been recently registered to a new provider, it is pertinent to note that the home have complied with the majority of the requirements identified at the last inspection and have implemented some of the recommendations, and difficult to determine the exact date that each item was addressed. Therefore, in the interests of fairness, information is being included in this section of the report. The home have complied with the majority of the requirements identified at the last inspection and have implemented some of the recommendations. The Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 6 recording of medication has improved providing a safer system for residents. A copy of the gas safety inspection certificate was also available and records showed that staff were being more regularly involved in fire drills, all of which safeguards the people at Ardtully. The home is asking residents, staff and relatives about various aspects of the service and ways to improve, and a report is to be available once the information is collected and analysed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ardtully Retirement Residence DS0000069546.V347063.R02.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 Ardtully Retirement Residence DS0000069546.V347063.R02.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, 3, 5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Users of the service can expect good information about Ardtully to help them to make a decision about living there and a detailed assessment to make sure that their needs can be met by the home. EVIDENCE: All surveys from residents and relatives confirmed that they had enough information about the home to help them make decisions. The home has a service user guide and statement of purpose that are provided to interested parties. The deputy manager confirmed that the documents will be amended to include information on the commissions current policy relating to the investigation of complaints. Appropriately detailed pre-admission assessments were available on the two files requested for sampling. The acting manager confirmed that 99 of residents or their representatives visit prior to admission and are actively encouraged to do this. The home was expecting one person on a guest basis Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 9 for day-care on the day of the site visit, and this was part of the assessment process. Ardtully Retirement Residence DS0000069546.V347063.R02.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, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Ardtully can expect to be involved in identifying their individual care and health needs, and having care plans available that generally inform staff of the support needed to meet these. Users of the service can also expect to be treated with dignity and respect. EVIDENCE: Care plans were sampled for four residents of Ardtully, two fully and two for more specific issues. They covered the majority of areas of identified needs with detail that supported staff to manage these effectively. They need to include general issues such as medication and finance for all and also include specific identified needs such as aggression/agitation, current footcare needs or a management plan for an ongoing skin tear, where individual residents conditions indicate this. A full risk assessment was not available for a resident who was regularly being found on the upstairs landing during the night. Care plans were written from the approach of maintaining residents’ choice and independence and staff were aware of this in discussions. Care notes were written regularly and contained good detail. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 11 Inspection of records relating to health care indicate that residents are supported to access all primary health care services required including GP, district nurses, chiropodist, optician, flu jabs, medication reviews etc. Discussions with residents confirmed this. Observation of medication administration demonstrated good practice. Medication Administration Recording (MAR) sheets had a photograph of each resident to assist with identification. No omissions were seen in the records, a clear improvement from the last inspection. A list of staff deemed competent to administer medication was available along with a sample of their signature. Information was available for staff regarding the homes homely remedy policies, the names of drugs used, what they were used for and how to use the MAR sheets effectively. The senior carer confirmed that there were no controlled drugs in use at the home or ‘as required’ medications except for creams. It was noted positively that the latter were referred at individual cream charts. It was recommended that the date of opening be written on medications that had a limited ‘shelf life’. The senior carer advised that all staff did the basic medication training but were expecting to have more detailed training in the near future. Discussion with five residents confirmed that they felt that their privacy and dignity was respected at Ardtully, be it in the choices that they make each day, being able to spend time alone, during personal care or in the way that they are spoken to. Observation of staff practice also positively supported this approach. A policy and procedure was available to staff on care of the dying that included pain control, companionship, involvement of family etc. The deputy manager advised that a letter has been prepared to send to either residents or their relatives to gather information on any specific wishes for end of life care, including religious rituals. Ardtully Retirement Residence DS0000069546.V347063.R02.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): 11, 12, 13, 14 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents of Ardtully can expect to exercise choice and individual preferences in the style of their daily living and have these respected and responded to. EVIDENCE: Residents advised that they chose where and how to spend their time, whether or not to join in activities, what time to get up and go to bed or where they decided to take various meals each day. A resident’s care plan confirmed the information provided in discussion that they had a varied wardrobe and liked to be consulted on what they wore each day. The hairdresser visited regularly. The home provides a range of activities including regular outside entertainers, in-house crafts, a weekly seated exercise session with a therapist, weekly religious services and quizzes, one to one chats, nail care sessions and trips in the minibus. There was ‘putting’ on the lawn at the time of the site visit and a plan to introduce bowls as a resident is keen on this. The home was in the process of undertaking a quality assurance survey on social activities, which will influence the development of this aspect of the service. One relative survey received advice that in the evenings, the television is on in both rooms and suggested that residents should be offered the opportunity for some activities at this time, including for example table games. The home should take this into Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 13 account, none of the social activity co-ordinated hours are planned for the evening and the staffing levels reduce on the late shift. Residents and visitors spoken with confirmed that visitors are welcomed at the home and this was observed during site visit. Several residents go out regularly with relatives and friends. Residents spoken with were satisfied with the meals served and one advised as having put on weight because of the good food at Ardtully. Dining tables were pleasantly set with condiments, cloths etc. Where a resident was supported to the in the lounge, staff were encouraging and patient. On the day the site visit, there was a clear choice of meals being exercised by residents including chicken casserole or steak and the meal was well presented. Residents were offered a choice of drinks including sherry, beer, or Guinness depending on preference. A relative suggested that residents could occasionally be offered a gin and tonic or glass of wine in the evening. Surveys from residents varied from one person who always liked the meals, to three people who sometimes liked the meals, to five people who usually liked the meals and one who never liked the meals. Comments included “ at times would like a little more variety”, “ we need more green vegetables like salads to be on offer” and “ there is always a willingness to give me an alternative to the set menu”. The menu demonstrated choices and this was confirmed in the record of food served. This record did not include breakfast meals. The deputy manager confirmed that residents did not have an active choice of cooked breakfast currently but that he had already identified this as an area for development. Care notes indicated how much food residents had eaten. Where a resident clearly was not eating a great deal and missing several meals, a record of food served did not include that supplement drinks were being offered. A nutritional assessment was not in place to support a care plan for this resident. Ardtully Retirement Residence DS0000069546.V347063.R02.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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Users of the service can expect their views to be listened to and to be safeguarded by staff knowledge and skills. EVIDENCE: The acting manager confirmed that no complaints had been received by the home since the last inspection. A folder was available complete with separate sheets for logging individual complaints and maintaining confidentiality. Additional information regarding the complaints procedure is included in the first section of this report relating to the statement of purpose and services of guide. A card was available thanking the home for the care that had been provided to a user of the service. Information on advocacy services was also clearly displayed. The acting manager confirmed that no issues had been referred under pova since the last inspection. A policy and procedure on elder abuse advised staff of different types of abuse and the reporting procedure. The whistleblowing policy was attached. A policy and procedure on restraint was also available. The training matrix indicated that staff are provided with training on protecting vulnerable adults and the acting manager said that providing this for all the staff was high on the list of priorities for the home. Staff spoken with were aware of appropriate identification and reporting procedures. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 15 There was no record of any staff attending training on management of challenging behaviour/positive responses. As this is a current issue at the home, it is advised that this be provided for staff. Ardtully Retirement Residence DS0000069546.V347063.R02.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, 20, 23, 24, 25, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at Ardtully enjoy a particularly pleasant, homely environment that is maintained to a high standard. Individual accommodation provides comfortable surroundings with many bedrooms being highly personalised. EVIDENCE: Residents spoken with confirmed that they found the premises clean and fresh. This was also confirmed in all of the surveys received. Other comments from residents about the premises included “pleasing” and that their own rooms were “comfortable” and “suitable for their needs”. One relative commented that seating is all round the edges of the room rather than in groupings. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 17 The conservatory dining room no longer has blinds fitted but the glass has been covered with a film deflect the light. This did not seem to be particularly effective, and staff advised that sometimes this was not the most pleasant place for residents to sit. The gardens were well maintained and accessible. The bedrooms seen were personalised and many residents had their own telephone installed. Bedrooms are still not provided with appropriate style locks to ensure residents have an active choice in promoting their right to privacy, while protecting their safety. Since the last inspection the new kitchen has been finished and is in operation and new flooring was laid in this area. No health and safety issues were noted at the site visit. Ardtully Retirement Residence DS0000069546.V347063.R02.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): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents of Ardtully can expect to be cared for by kind, caring and supportive staff, who with exceptions in some areas, are well-trained and safely recruited. EVIDENCE: The deputy manager kindly provided copies of the staff rosters. These should indicate the hours worked by the manager and deputy manager. Ardtully has historically provided good staffing levels and these were maintained at the time of this site visit. Five care staff were rostered on the morning shift, three on the afternoon shift and two on the night shift, including one senior on each. Discussions with staff and residents, observations of practice and surveys from both relatives and residents indicate that care staffing levels provide a satisfactory level of support to residents. Ardtully also employs a range of ancillary staff including activity co-ordinators, cooks, laundry and housekeeping staff. Relatives and residents spoken with had only complimentary comments to offer regarding the staff, how “nice” they were. One resident wrote in their survey “ I would like to express and congratulate staff at all levels for their caring and support”. Another resident wrote “ I find all the staff are very responsive”. A relative commented “they always seem to be available and kind to individuals when needed”. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 19 The deputy manager advised that all but the newest member of staff have achieved at least NVQ level 2 but evidence of this was not checked for all staff. Two senior staff have completed NVQ level 3. The deputy manager advised that only one new staff had been appointed recently. A Povafirst check was in place although the criminal record bureau check was not yet available at the home. No photograph, health declaration relating to the persons physical and mental fitness or full employment history was on file. Ardtully employs its own trainer and files were well organised. A first-day induction session was recorded that included a training plan. Additionally TOPSS induction and foundation workbooks were available. Staff training records/certificates indicate that the new starter had been provided with the trading on fire, death and dying, managing challenging behaviour, medication awareness, concerns/whistleblowing/pova, safer people handling, emergency response first aid, age-related conditions and dementia awareness. The staff training matrix demonstrated that staff are provided with training in all the basic subjects such as moving and handling, food hygiene, health and safety, infection control, first aid, abuse and conditions that affect older people. The matrix demonstrated that staff have not had updated training in fire since January 2005 and several staff have never received this training. This was identified at the last inspection and it was disappointing that it had not been addressed. It was noted previously in this report that staff are awaiting more detailed training relating to medication. Ardtully Retirement Residence DS0000069546.V347063.R02.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, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents of Ardtully can expect their views to be taken into account in a service that is well-managed, and well maintained in terms of health and safety. EVIDENCE: The registered manager continues to undertake NVQ level 4/Registered Managers Award. The file indicated that the manager has continued to undertake other relevant training such as management of challenging behaviour, raising concerns and whistleblowing, safer people handling, dementia, pressure care and infection control. All indications from surveys and discussions with relatives, residents and staff indicated that they find the management team approachable and supportive. Ardtully undertakes regular surveys of residents, relatives and staff on various different subjects to monitor the quality of care provided and offer regular residents meetings. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 21 Other audits undertaken included in relation to medication and health and safety. Monthly reports by the registered person were available as required under regulation 26. Records of money looked after by the home were sampled for two residents. Amounts tallied and receipts were available. Some residents after their own money, while other residents’ relatives are invoiced for services such as hairdressing and chiropody. Staff files sampled demonstrated that formal supervision has not been provided to staff on a regular basis, for example there were two recorded sessions for one staff member during the year 2006. Some staff files show a recent appraisal but no supervision sessions in this year. The deputy manager advised of the plan to introduce five supervision sessions and one appraisal for each staff member annually. Record sampled included accident records and those others identified in this report. Records were generally well-organised and readily available. Policies and procedures were sampled which showed a forthcoming review date of August 07. They had not been signed by the registered manager. The deputy manager was advised that the siting of the MAR sheets on the top of the cabinet on the main staircase did not protect resident confidentiality. Current safety inspection certificates were available in relation to the electrical fixed wiring, portable appliances, fire equipment, emergency lighting, gas and the lift. Weekly fire checks had also been undertaken and fire drills were being held quarterly. Monthly checks were being undertaken of the hot and cold water. Ardtully Retirement Residence DS0000069546.V347063.R02.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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 2 3 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 2 3 Ardtully Retirement Residence DS0000069546.V347063.R02.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 OP7 OP8 Regulation 15 12(1)a Sch3 Requirement So that residents are cared for consistently and safely, care plans must identify all their assessed needs and all aspects of health care and must provide staff with sufficient information to enable them to offer residents proper and consistent care and assistance. This includes issues identified in the report such as nutrition, skin tears, medication, aggression/agitation foot care and finance. To support monitoring to ensure that residents are having a suitable, nutritious diet, the nutrition record must contain information on all food/drinks served to residents The person registered must ensure that any identified risks are eliminated as far as possible. This refers to the safety of the locks used on resident bedrooms. To safeguard residents, records must be maintained in the care home, as required by regulation and schedule to show that all DS0000069546.V347063.R02.S.doc Timescale for action 15/08/07 2 OP15 Sch 4(13) 15/08/07 3 OP24 13(4)c 15/08/07 4 OP29 17(2) & Sch 2 15/08/07 Ardtully Retirement Residence Version 5.2 Page 24 5 OP30 18 appropriate references and checks on staff have been obtained. To benefit residents and the quality of support offered to them, all staff must be provided with training appropriate to the work they are to perform, including those identified in the report, for example medication, managing challenging behaviour and fire training. 15/08/07 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 4 5 6 Refer to Standard OP6 OP31 OP36 OP37 OP37 OP38 Good Practice Recommendations The home should implement a dependency assessment tool that would inform the home’s training plan and staffing levels. The registered manager to achieve NVQ Level 4, Registered Managers Award. Staff to be provided with formal supervision at least six times annually. Records should be stored more securely. Policies and procedures should be signed and dated by the registered persons. Regular checks of the cold water system should be undertaken to ensure the safety of residents. Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Ardtully Retirement Residence DS0000069546.V347063.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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