Inspection on 04/11/05 for Bartlett House

This inspection was carried out on 4th November 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

Bartlett House 06/10/08

Bartlett House 15/10/07

Bartlett House 09/01/07

Bartlett House 13/05/05

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 Bartlett House Bartlett House Old Common Way Ludgershall Andover Hampshire SP11 9SA Lead Inspector Thomas Webber Unannounced Inspection 10:15 4 November 2005 th 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 Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bartlett House Address Bartlett House Old Common Way Ludgershall Andover Hampshire SP11 9SA 01264 790766 01264 791687 admin.bartletthouse@osjctwilts.co.uk 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) The Orders Of St John Care Trust Vacant Care Home 49 Category(ies) of Dementia - over 65 years of age (13), Learning registration, with number disability over 65 years of age (3), Old age, not of places falling within any other category (33) Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th May 2005 Brief Description of the Service: Bartlett House is a purpose built residential home offering accommodation and personal care to a total of 49 residents over the age of 65 who require care primarily through old age, although the home is registered to accommodate 13 residents 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 40 residents in situ, 3 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 managed by Rosemary Lusty acting manager. 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. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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 10:15 to 17:00. The inspection primarily focused on the direct care to the residents. A tour of the premises was undertaken and the views of twenty residents and the husband of one resident were sought on an individual and group basis, regarding the care and services provided by the home. The records in relation to residents’ contracts, assessments, care plans, menus, complaints and staffing were checked as well as a number of the core standards. What the service does well: Residents live in a home which is managed by a person who is suitably qualified and experienced to run the home and staff are working towards achieving a trained workforce who are competent to undertake their job. The home is run in the best interests of the residents with opportunities being available for them to comment on the care and services provided by the home. Residents spoken to commented very favourably about the care provided by the staff stating that the staff are excellent, kind, very good and will do anything for them and staff will purchase items for those residents who are unable to do it for themselves. Staff were observed to undertake their duties in an attentive manner and warm and positive banter existed between staff and the residents. Opportunities are available for residents to pursue social, religious and recreational activities of their choice. Residents, within their capabilities, can exercise personal autonomy and choice. Residents are treated with respect and their right to privacy is upheld. Residents receive a varied, appealing and balanced diet and the majority of them commented positively with the quality and quantity of food provided, confirming that choices are available and they receive plenty of food. Information is provided to residents on how to complain should they wish to and residents felt that any concerns they had would be listened to and acted upon. The home provides a safe environment, which is reasonably maintained to meet the residents’ individual and collective needs. Residents are provided with single bedrooms which they have personalised to their individual wishes. The home is maintained to a satisfactory standard being clean, tidy. Residents commented positively about the standard and cleanliness of their accommodation. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 6 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. These comments were endorsed in the recent minutes of a residents’ meeting and feedback received by the home from residents’ relatives. Residents are provided with a written contract and are normally assessed, at least by the home, prior to admission and opportunities are available for prospective residents and their families to visit the home to assess the suitability of it. Residents’ finances are suitably safeguarded. The health, safety and welfare of the residents and staff are promoted and protected. What has improved since the last inspection? 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. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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 Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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 the following standard(s): 2, 3 and 5 Residents are provided with a written contract or a supplementary letter whilst their level of contributions is being agreed. Residents are normally assessed, at least by the home, prior to admission and opportunities are available for prospective residents and their families to visit the home to assess the suitability of the home. EVIDENCE: All residents who are privately funded and those 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. Of the three residents case tracked, evidence was available to confirm that a copy of the home’s contract had been given to the resident who is privately funded and letters have been sent to the other two residents whilst their level of contributions is being agreed. The four residents referred to in the last inspection report have now received copies of their terms and conditions. The home completes its own assessment tool in relation to all prospective residents admitted to the home and normally obtains a copy of the community Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 9 care assessment or equivalent in relation to residents funded by social services, prior to admission. Documentary evidence available confirmed this, although a copy of the social services assessment in relation to one resident was not available. The care leader was advised to develop and implement a letter, which is sent out to all prospective residents once it has been agreed that their needs can be met. As part of the home’s admission process, prospective residents and their families are encouraged to visit the home prior to admission. However, in respect to the three residents most recently admitted to the home none of them made use of this opportunity by choice, although one was already familiar with the home. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 Residents’ care plans and associated documentation are not always recording sufficient information and therefore this potentially puts residents at risk. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Each resident is provided with a long term needs assessment and care plan. Residents’ short term care plans have also been established which are reviewed monthly or where the needs of residents change. Risk assessments have been established to all three residents case tracked by the Commission, although manual handling assessments had only been completed for two of the three residents. The care leader stated that this deficiency would be rectified that day. It was also noted that not all the sections of residents’ admission details forms were fully completed and therefore lacked significant information. Residents’ glasses and hearing aids are now being marked for identification purposes, where residents are in agreement. Nutritional assessments are now being completed in respect to any resident who is either prescribed a supplement or where obvious weight loss is noted. This process also generates the implementation of residents being now weighted weekly with food and fluid charts being completed. However, despite concerns raised as part of a previous complaint investigation, these charts do not always record Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 11 the resident’s food and fluid intake. The care leader reported that the output within these charts is only being recorded with the agreement of a medical professional. 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. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Opportunities are available for residents to pursue social, religious and recreational activities. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet. EVIDENCE: Observations and discussions with residents confirmed that they can choose how and where to spend their time and when to get up and go to bed. Residents have the opportunity to pursue their own individual interests as well as being able to choose whether to participate in the various organised activities and outings arranged by the home. An activities co-ordinator is now responsible for organising and overseeing the range of activities provided and residents commented positively about these. Activities are provided twice a day Monday to Friday. A hairdresser visits four times a week and communion and a separate evening service is provided monthly. Observations and discussions with residents indicated that they can exercise personal autonomy and choice according to their capabilities. 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. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 13 Regular residents’ meetings take place, which provide them with the opportunity to comment and contribute to the running of the home. 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 use the dining room for this meal. Drinks and snacks are also available at other times of the day. Residents can choose where to eat their meals and the majority of residents commented positively with the quality and quantity of food provided, confirming that choices are available and they receive plenty of food. However, some residents expressed less satisfaction with the meals provided particularly at teatime. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Information is provided to residents on how to complain should they wish to and residents felt that any concerns they had would be listened to and acted upon. However, an area of weakness lies within the recording of the outcomes to complaints investigated. 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 and investigated five complaints, which relate to food, staff conduct and money, glasses and clothing which have gone missing. All these complaints have been resolved. However, the form used by the home for the recording of these complaints does not record the outcome. The Trust has been advised of the need to implement a form that records all complaints received and their outcomes. Residents spoken to commented that they had no concerns or complaints about the care provided but they felt confident that they could discuss any issues with the manager and staff and these would be listened to and appropriately acted upon. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 and 26 The home provides a safe environment, which is reasonably maintained to meet the residents’ individual and collective needs, where improvements have been made and further improvements are planned. Residents are provided with single bedrooms which they have personalised to their individual wishes. The home is maintained to a satisfactory standard being clean, tidy and comfortable with suitable laundry arrangements are in place. EVIDENCE: The standard of redecoration within the home varies. However, the home has an ongoing maintenance programme with a number of improvements having already been carried out since the last inspection. These improvements have enhanced the residents’ living environment and have included the refurbishment to two bathrooms, the shower room has been changed to a wet room and carpets have been replaced in some corridors. Further improvements include the redecoration to the corridors, dining room and laundry room with new shutters being provided to the kitchen. The home provides sufficient lighting, heating and ventilation. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 16 The home provides all single accommodation for residents’ use. Married couples would either be provided with individual bedrooms or two bedrooms, one of which could be used as a lounge. Residents’ bedrooms are located on the ground and first floor levels and are serviced by a passenger lift. 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. 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. These comments were endorsed in the recent minutes of a residents’ meeting and feedback received from residents’ relatives. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 The current staffing levels are insufficient to meet more than the basic and immediate needs of the residents. The staff team are working towards achieving a trained workforce who are competent to do their job. 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. These staffing levels include those hours worked by care leaders. There are also three members of waking night staff on duty each night. In addition, the home employs a number of ancillary staff. A minimum number of agency staff are being used to maintain these staffing levels. Two additional staff members are on duty throughout the day to manage the day centre. Residents spoken to commented very favourably about the care provided by the staff stating that the staff are excellent, kind, very good and will do anything for them and staff will purchase items for those residents who are unable to do it for themselves. Staff were observed to undertake their duties in an attentive manner and warm and positive banter existed between staff and the residents. Concern continues to be expressed by the Commission about the need to ensure that there is a sufficient number of care staff on duty at all times providing direct care to the residents. This needs to be based on the size and layout of the building, the changing and high dependency needs of the Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 18 residents together with the existing staff structure and various responsibilities/tasks undertaken by staff. 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. The staffing resources available may also be a contributing factor to the deficiencies within the maintenance of residents’ records. All new staff receive an induction programme and staff then receive a variety of mandatory and NVQ training to equip them to perform their duties. At the time of the inspection four staff had completed NVQ 2 and thirty staff from a variety of disciplines were in the process of completing NVQ training, some of who were waiting for their work to be verified. The senior carer is also in the process of completing her NVQ 4 course. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Residents live in a home which is managed by a person who is suitably qualified and experienced to run the home. The home is run in the best interests of the residents with opportunities being available for them to comment on the care and services provided by the home. Residents’ finances are suitably safeguarded. The health, safety and welfare of the residents and staff are promoted and protected. EVIDENCE: The acting manager has appropriate management and supervisory experience in the relevant care setting to the client group she manages. She is a first level registered nurse and undertakes periodic training to update her skills and knowledge. The acting manger is in the process of undertaking her NVQ level 4 and will subsequently complete courses in Dementia and the registered managers’ award. Since the inspection, she has successfully completed her registered manager’s interview with the Commission for Social Care Inspection. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 20 A quality assurance system has been introduced and consists of an annual quality survey involving residents and their relatives. On completion of the surveys a report will be produced which will identify both the positive and any negative aspects relating to the care provided by the home. The results of the survey undertaken in September 2005 have not yet been received. However, once obtained, it should be made available to all who took part in the survey as well as a copy being sent to the Commission for Social Care Inspection. The timescale for completion of this task to be undertaken has been extended to allow for this process to be completed. In addition to the annual quality survey, other monitoring systems include residents’ meetings which now take place on a monthly basis and enables their views to be sought as well as for them to raise and discuss any issues pertaining to the running of the home, one to one sessions between residents and their key workers, regular staff meetings and daily handover meetings. The home has secure facilities for the safe storage of residents’ money. A spot check of the system of money held by the home on behalf of some residents showed that it is, in the main, being suitably maintained. However, there is a need to ensure that receipts are established for all purchases made, in line with good practice. Safe working practices have been established within the home, which comply with the relevant legislation. Full health and safety policies and procedures are in place to ensure a safe working environment. The manager is the health and safety officer for the home and holds health and safety meetings twice a year from a representative from each discipline within the home. Health and safety training is programmed for all staff to attend. Risk assessments have been completed in relation to all residents, the premises and fire prevention. Radiator covers and window restrictors have been fitted for the protection of residents. Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 and 5 Timescale for action The registered individuals must 06/01/06 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 was not met. This requirement was not checked at this inspection therefore the new timescale of 30/09/05 has been extended) The registered individuals must 06/01/06 confirm in writing to the resident that, having regard to the assessment, the care home is suitable to meet their needs. The registered individuals must 06/01/06 always obtain a copy of the social services assessment prior to admission. The registered individuals must 06/01/06 ensure that the admission details form is always fully completed. The registered individuals must 06/01/06 ensure that food and fluid charts DS0000028275.V257746.R01.S.doc Version 5.0 Page 23 Requirement 2. OP3 14(1)(d) 3. OP3 14(1)(b) 4. 5. OP7 OP7 14 17(3)(m) Bartlett House 6. OP16 22(3) 7. OP27 18(1)(a) 8. OP33 24 are being fully completed The registered individuals must 06/01/06 ensure that all records of complaints investigated clearly record the outcomes. The registered individuals must 06/01/06 ensure that there are sufficient numbers of care staff on duty providing direct care to meet the needs of the residents. The Trust must submit a written proposal to the Commission for Social Care Inspection detailing how this will be achieved. (Previous timescale of 30/06/05 has not been met and has been extended to ensure compliance) The responsible individuals must 06/01/06 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 Commission for Social Care Inspection and available to residents. (Previous timescale of 30/09/05 has not been met and has been extended to ensure compliance) 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 OP29 OP35 Good Practice Recommendations The responsible individuals should consider obtaining a full employment history for newly appointed staff. The responsible individuals should ensure that receipts are established for all purchases made by residents. DS0000028275.V257746.R01.S.doc Version 5.0 Page 24 Bartlett House Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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 Bartlett House DS0000028275.V257746.R01.S.doc Version 5.0 Page 25 - 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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