Inspection on 13/05/05 for Bartlett House

This inspection was carried out on 13th May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bartlett House 06/10/08

Bartlett House 15/10/07

Bartlett House 09/01/07

Bartlett House 04/11/05

Bartlett House 26/01/05

Bartlett House 19/05/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Barlett House Old Common Way Ludgershall Andover Hampshire, SP11 9SA Lead Inspector Thomas Webber Unannounced 13th May 2005 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. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bartlett House Address Old Common Way Ludgershall Andover Hampshire SN11 9SA 01264 790766 01264 791687 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) The Orders of St John Care Trust Vacant Care Home 49 Category(ies) of DE(E) Dementia - over 65 (13) registration, with number LD(E) Learning Disability - over 65 (3) of places OP Old Age (33) Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2005 Brief Description of the Service: Bartlett House is a purpose built residential home offering accommodation and personal care to a total of 49 service users over the age of 65 who require care primarily through old age, although the home is registered to accommodate 13 service users with dementia and 3 with learning disabilities. Five of the 49 beds are also used for respite care. The home also provides day care facilities for a further 20 clients. On the day of inspection the home had 41 residents in situ, 2 in hospital and 6 vacancies. The home is one of a number of homes managed by the Orders of St John’s Care Trust. At the time of the inspection, the registered managers post was vacant and the home was being run by Alice Mansfield, Acting Head of Care. The home is situated in a residential area close to the centre of the small town of Ludgershall on Salisbury Plain. Ludgershall is situated on the A342 between Andover and Tidworth. The home provides all single accommodation which is located on the ground and first floor levels and is accessed by a passenger lift. Married couples would either be provided with individual bedrooms or with two bedrooms, one of which could be used as a lounge. There is a large, enclosed rear garden. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 10:00 to 16:45. The inspection was undertaken earlier than originally intended as a result of complaints received, which are currently under investigation. These relate to a resident not being accompanied to hospital, the loss of his hearing aids and alleged neglect leading to his loss of weight. The inspection primarily focused on the direct care to the residents rather than the underlying administration of the home including policies and procedures. A tour of the premises was undertaken and the views of thirteen residents were sought on an individual basis, regarding the care and services provided by the home. The Commission received one anonymous comment card from a resident. The records in relation to medication and recruitment of staff were checked and contracts and staffing levels were discussed with the acting head of care as well as the majority of the outstanding requirements from the previous inspection. Requirements relating to the home establishing an effective quality assurance system and improvements to the recording of withdrawals for residents’ finances were not checked at this inspection. What the service does well: What has improved since the last inspection? The home continues to strive to address the outstanding requirements previously identified. There have been a number of improvements to the physical environment of the home, which is appreciated by the residents. The monitoring of complaints has been reviewed to provide a more robust system. The home has taken positive action to ensure that all residents have a signed contract in place. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 6 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. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 All but four residents are provided with a contract or a set of teams and conditions either by the home or by the palcing agency. EVIDENCE: The Trust and home have developed two documents: The Resident’s Handbook which is used as the home’s service users’ guide and the home’s statement of purpose that relates specifically to Bartlett House. However, these documents still need improvements to meet all the criteria as set out in Regulations and National Minimum Standards. To avoid duplication of some information, it might be beneficial to produce a combined document which covers all aspects required. All service users have been provided with a copy of the Resident’s Handbook, which covers all homes, run by the Trust. All residents who are privately funded and placed by local authorities other than Wiltshire County Council are provided with a copy of the Trust’s contract. Residents placed by Wiltshire County Council would be provided with a copy of their terms and conditions. The acting head of care reported that, despite chasing Wiltshire County Council, the home is still waiting for four residents’ terms and conditions to be signed and returned by them. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 9 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) 8, 9 and 10 The health care needs of the residents are being appropriately met. Suitable procedures are in place to enable residents’ the opportunity to be responsible for their own medication where capable. Systems are in place for the receipt, recording, storage, handling, administration and disposal of residents’ medication. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Discussions with residents confirmed that their health care needs are being suitably met. Residents tend to be registered with the local surgery situated in close proximity to the home and tend to visit the surgery for any appointments. However, where GPs or other health professionals make home visits, these and any treatment would be undertaken in the privacy of residents’ bedrooms. Residents confirmed they can and do access other health care services such as dental, opticians, chiropody and hearing, as and when required. Appropriate aids are provided for those residents who require aids for incontinence and mobility. However, there is a current complaint being investigated which relates to a resident’s hearing aids being misplaced and the resident being provided with a pair found in the office. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 10 Discussions with residents confirmed that some of them, who have been risk assessed as being capable, are responsible and handle their own medication. Suitable and lockable facilities have been provided within residents’ bedrooms for this purpose. Alternatively, staff administer medication to those residents who are deemed not capable. Staff receive training in the administration of medication from the acting head of care before being deemed competent to undertake this task. A medication policy and procedure has been established by the Trust but this is currently under review. A spot check of residents’ medication records showed that they are being appropriately maintained. Suitable systems have also been established for the receipt and return of unwanted medicines. Observations and discussions with residents confirmed that they are provided with their own bedroom where they can conduct all their personal affairs in complete privacy. They can also choose who and where to see any visitors. Residents are offered a key to their bedroom door and staff knock and wait for a reply before entering. Residents have access to the home’s mobile phone, which they can use in the privacy of their bedrooms, or they can also use the home’s payphone. Alternatively, residents can have a telephone installed in their bedrooms and some of them have availed themselves of this facility. Residents’ mail is given directly to them unopened. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 11 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) 12, 13, 14 and 15 The lifestyle experienced by the residents matches the residents’ expectations and preferences apart from the need to improve the range and frequency of activities available. Suitable arrangements are in place for residents to maintain contact with their families and friends. Residents are enabled to exercise choice and control over the various aspects of their lives, with support provided where required. A satisfactory and varied menu is provided which gives residents a choice and caters for their preferences. EVIDENCE: Observations and discussions with residents confirmed that they can choose where and how to spend their time and when to get up and go to bed. A hairdresser visits four times a week. Communion and a separate evening service is provided monthly. Residents have the opportunity to pursue their own individual interests as well as being able to participate in the various organised activities and outings arranged by the home, should they wish to do so. A designated member of staff is responsible for overseeing the activities provided by the home. An activities file has been established but this did not indicate that activities are organised on a daily basis. Residents did not express any concerns about the lack of activities, although an anonymous comment card did state that the home does not provide suitable activities. The issue of activities was raised at a recent residents’ meeting which referred Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 12 to the need to provide more outings and this has been addressed. The acting head of care is also aware of the need to strive to improve and develop the range of activities provided to the residents. Visitors are welcome at all reasonable times and the policy refers to importance of residents maintaining contact with their families, relatives friends in a variety of ways. Residents can choose whom and where to visitors either in the privacy and comfort of their own bedrooms or communal rooms available. the and see the Observations and discussions with residents indicated that residents can exercise personal autonomy and choice. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose where to spend their time, where to eat, and what activities to participate in. Residents, who are capable, can handle their own financial affairs in the privacy of their own bedrooms. Residents’ meetings take place on a bi-monthly basis and provide them with the opportunity to comment and contribute to the running of the home. Residents can access their personal records, if they choose to, and staff would facilitate this process. A satisfactory and varied four weekly menu is in operation, which provides a choice at breakfast and lunch with a selection of food provided at tea and suppertime. A cooked meal is provided at breakfast time for those residents who tend to use the dining room for this meal. Drinks and snacks are also available at other times of the day. Residents’ food preferences are recorded and available in the kitchen. Residents can choose where to eat their meals. Residents spoken to commented that they were happy with the quality and quantity of food provided, confirming that choices are available and they receive plenty of food. However, one resident and an anonymous comment card received by the Commission stated that the quality of meals can vary. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 13 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 Information is provided to residents on how to complain should they wish to and the residents felt that their complaints would be listened to and acted upon. Appropriate procedures are in place to protect the residents from abuse. EVIDENCE: Residents are provided with a copy of the home’s complaints procedure, which specifies how and who would deal with any complaints. Since the last inspection, the home has received one complaint, which relates to a resident not being accompanied to hospital, alleged neglect with regard to his weight and loss of his hearing aids. This complaint has been referred to the vulnerable adults panel for investigation as is still ongoing. The acting head of care reported that the recording and monitoring of complaints received has been reviewed and updated since the last inspection to provide a much more robust system. Residents spoken to commented that they had no complaints or concerns. However, if they did have any, they felt confident in discussing them with the acting head of care who would listen and act accordingly. An anonymous comment card from one resident stated that they did not know who to speak to if they were unhappy with their care, although the 13 spoken to during the inspection did know who to speak to. The Trust’s policy and procedure regarding abuse has recently been reviewed. The home has appropriate procedures for responding to suspicion or evidence of abuse. Copies of the full and shortened version of the Wiltshire and Swindon Vulnerable Adults procedures have been obtained which are in line with the Department of Health Guidance “No Secrets” document. Copies of the shortened version of this document have been distributed to all staff. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 14 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) 19, 20, 21, 22, 23, 24, 25 and 26 The location and layout of the home is suitable for its stated purpose. It is accessible, safe and reasonably maintained to meet the residents’ individual and collective needs. An additional lounge has been created to improve the communal space available. Suitable individual bedrooms are provided for residents to enable them to personalise these to their individual wishes. Residents have adequate and suitable toilets and bathrooms facilities. Residents have appropriate equipment to maximise their independence. The home is maintained to a satisfactory standard being clean, tidy and comfortable. EVIDENCE: Although the standard of redecoration varies, the home has an ongoing maintenance programme and a number of improvements have been made since the last inspection to enhance the residents’ living environment. These have included the introduction of a new lounge, considerable redecoration to residents’ bedrooms as well as re-carpeting and replacement of dining room chairs and some new curtains and blinds. Funding has also been agreed to make further improvements. The home is maintained to a satisfactory Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 15 standard being clean, tidy, and comfortable and provides sufficient lighting and ventilation. The decoration and furnishing and fittings are also suitably maintained. The home provides a number of communal rooms including a large dining room together with a small sitting area. There is also a shop and a bar available within this area of the home. In addition, there are now three small sitting rooms, one of which is used as a library/ quiet room and another being designated as a smoking area. Some residents also use the sitting area by the front door. Residents can access the day centre facilities after 16:30 each day as well as at weekends and during holidays. Hairdressing facilities are also located on the first floor of the home. Residents have free access to the communal areas, including the garden and to their bedrooms. The home provides a passenger lift to enable residents to access the first floor of the building. In addition, items such as grab and hand rails, mobile hoists, assisted baths, zimmer frames, wheelchairs, raised foot rests and raised WC seats are provided, where appropriate, to meet the needs of specific individuals and groups of residents. A call bell system is installed in each room, which can be used by residents to call for staff assistance. On the day of the inspection this facility was in the process of being upgraded. The home provides a sufficient number of bathroom and toilet facilities to meet the needs of the residents. However, two bathrooms were out of action on the day of inspection due to a chair being broken in one of them and the home is still waiting for the delivery of parts ordered and the other could benefit from being converted to an appropriate shower room as the type of bath installed is deemed not suitable for the residents accommodated. One resident commented about the lack of heat to the bathroom used and this was brought to the attention of the acting head of care. The home provides all single accommodation for residents’ exceed the national minimum standard of 10 square metres couples would either be provided with individual bedrooms or provided with two bedrooms, one of which could be used Residents’ bedrooms are located on the ground and first floor serviced by a passenger lift. use which all each. Married they would be as a lounge. levels and are Residents’ bedrooms are suitably furnished and equipped to ensure comfort and privacy. Residents can and have brought items of furniture and personal possessions to make them homely and residents have personalised their bedrooms to their individual wishes. Locks have been fitted to residents’ bedroom doors and their bedrooms have been provided with a lockable storage space, which can be used by residents to store their personal effects. Residents commented positively about the standard and cleanliness of their accommodation. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 16 Residents’ accommodation provides suitable lighting and ventilation. Prior to the fitting of radiator covers, residents could regulate the temperature to their bedrooms by either turning the valve on or off. However, due to the type of construction now used residents are no longer able to adjust the valve as it is encased within the cover, although there are plans to modify the radiator covers by the end of August 2005. The home is maintained to a satisfactory standard being clean and tidy. Suitable laundry facilities are available to meet the needs of the home and residents’ clothing is labelled to ensure that their garments are appropriately returned. Residents, spoken to, commented that they are satisfied with the laundry arrangements in place stating that their clothing is returned in good condition. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 17 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 and29 The current staffing resources within the home are insufficient to enable staff to provide a high quality of care to the residents. Adequate recruitment procedures are being followed for the protection of the residents. EVIDENCE: The deployment of staff ensures that throughout the week there are five members of care staff on duty during the day with four care staff on duty in the evenings. There are also three members of waking night staff on duty each night. In addition, the home employs a number of ancillary staff. On the day of inspection the home continued to have a number of vacancies, despite active recruitment. Two additional staff members are on duty throughout the day to manage the day centre. Despite concerns expressed at previous inspections, the number of care hours allocated has only recently been increased by 10 hours per week. Given the size and layout of the building, the changing and increased dependency needs of the residents now being accommodated, together with the existing staff structure and various responsibilities/tasks undertaken by staff, this is still insufficient. Given the resources available, the staff are only able to meet the immediate care needs of the residents and cannot provide the type of quality care the staff would wish to aspire to and which would be endorsed by the Commission for Social Care Inspection. Residents spoken to commented very favourably about the care provided by the staff stating that the staff would do anything for them, although some Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 18 residents also stated that staff are very busy. The one anonymous comment card received by the Commission stated that the home needed more cleaners and care staff. The resident also didn’t feel well cared for. Staff were observed to undertake their duties in an attentive manner. A sample of three newly appointed staff files checked showed that appropriate recruitment practices are being followed. However, the Trust could still benefit from obtaining a full employment history as opposed to the current system of only requesting information relating to the last ten years of the person’s employment. The acting head of care is in the process of establishing and placing a recent photograph on each staff file where these have not already been achieved. Evidence was available to confirm that two satisfactory references and POVA first checks and CRB enhanced checks have been obtained in respect to staff employed. Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 19 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) This area was not examined at the inspection. EVIDENCE: Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 20 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 x 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 3 4 3 2 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 21 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&5 Requirement Timescale for action 30/09/05 2. 2 5 3. 27 18 (1)(a) 4. 33 24 The registered individuals must ensure that the service users’ guide meets all the criteria of Standard 1.2 or alternatively produce a combined document of the home’s statement of purpose/service users’ guide that meets all the criteria of Schedule 1, Standard 1.2 and Regulations 4 and 5. (Previous timescale of 31/05/05 not met) The registered individuals must 31/08/05 ensure that all residents are provided with a copy of their contract of residency. (Previous timescale of 30/04/05 not met) . The registered individuals must 30/06/05 ensure that the numbers of staff on duty are sufficient to meet the needs of the residents and a proprosal is required to show how this will be achieved. The responsible individuals must 30/09/05 establish an appropriate and effective quality assurance system, which consults with all residents and their representatives at appropriate intervals. A report must be established of any such reviews with a copy being sent to the Version 1.30 Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Page 22 Commission for Social Care Inspection and available to residents. 5. 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. Refer to Standard 12 21 Good Practice Recommendations The registered individuals should strongly consider improving and developing the range of activities provided to the residents. The registered individuals should strongly consider converting one of the bathrooms that is deemed not suitable for the residents accommodated into an appropriate shower room. The responsible individuals should strongly consider obtaining a full employment history for newly appointed staff. 3. 29 Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham WIltshire, SN15 2BB 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 Barlett House D51_D01_S28275_BARTLETTHOUSE_V227428_130505_Stage4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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