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Inspection on 20/09/06 for Bedford Park Care Centre

Also see our care home review for Bedford Park Care Centre for more information

This inspection was carried out on 20th September 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is purpose built and well maintained providing a comfortable and safe place for people to live. It has good level access and extensive gardens that can be enjoyed by many clients. The matron manages a large group of staff and clients and strives to ensure that systems are in place to provide care using best practice.

What has improved since the last inspection?

The ordering, receipt, recording, storage, administration and disposal of medicines within the home has been reviewed following 3 drug errors ensuring the systems in place are more robust than previously.

What the care home could do better:

It is recommended that staff ensure all care plans are updated and reviewed to reflect the changing needs of the clients. The theme of the completed staff surveys indicated that staffing levels were low and that morale is therefore suffering. They also indicated that some staff are `clicky` and talking in groups when clients still needed care. It is recommended that the matron looks further into her ideas of rotating staff between units and using her staff resources to the full.The matron should implement the basic care training package developed by the home to complement the existing training that is offered. Ancyra Health is recommended to develop its current quality assurance (QA) system to include staff satisfaction and formally indicate how often QA activity is to take place to measure outcomes for residents.

CARE HOMES FOR OLDER PEOPLE Bedford Park Care Centre Pearn Road Mannamead Plymouth Devon PL3 5JF Lead Inspector Mandy Norton Unannounced Inspection 20th September 2006 10:00 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 Bedford Park Care Centre DS0000003573.V303112.R01.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. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedford Park Care Centre Address Pearn Road Mannamead Plymouth Devon PL3 5JF 01752 770477 01752 785090 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) Ancyra Health Limited Mrs Sally Anne Thornton Care Home 104 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (65), of places Physical disability over 65 years of age (39) Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. PD(E) Maximum registered 39 service users DE(E) Maximum registered 39 service users OP Maximum registered 65 service users Maximum of 104 service users accommodated at any one time Registered for 65 years and over Date of last inspection 12th January 2006 Brief Description of the Service: Bedford Park Care Centre comprises of three separate units (known as the ‘nursing unit’, ‘Compton Gardens’ and ‘the residential unit’; all are purpose built and laid out over two floors with wheelchair access via ramps or passenger lifts. The care centre is situated on the outskirts of Plymouth close to local amenities. The home provides 24 hour nursing care to a maximum of 39 people and personal care to a further 65 people over the age of 65 years of age of either gender with physical frailty, illness or disability 39 of those requiring personal care may also require care for dementia. Maximum number of service users to be resident is 104. Communal rooms are available in each unit and the home benefits from large landscaped and accessible gardens and patio areas including a raised fish- pond. The home is owned by Ancyra Health Limited, a national care home provider. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was carried out by 2 inspectors due to the size of the home. It was conducted with the matron and the deputy matron. The inspection included a tour of the home and examination of a variety of documentation. Views of the staff and clients spoken to and the information from the completed staff (15) and relatives /visitors comments cards (3), sent out randomly following the inspection, are reflected in the report. Information was also used from the completed pre inspection questionnaire submitted prior to the inspection. On the day of the inspection there were 37 patients in the nursing unit, 38 in the residential unit, most of whom have a degree of dementia, and 25 in Compton Gardens. All units currently have their own staff groups. The range of fees charged by the home are between £278.56 and £533.00 What the service does well: What has improved since the last inspection? What they could do better: It is recommended that staff ensure all care plans are updated and reviewed to reflect the changing needs of the clients. The theme of the completed staff surveys indicated that staffing levels were low and that morale is therefore suffering. They also indicated that some staff are ‘clicky’ and talking in groups when clients still needed care. It is recommended that the matron looks further into her ideas of rotating staff between units and using her staff resources to the full. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 6 The matron should implement the basic care training package developed by the home to complement the existing training that is offered. Ancyra Health is recommended to develop its current quality assurance (QA) system to include staff satisfaction and formally indicate how often QA activity is to take place to measure outcomes for residents. 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. Bedford Park Care Centre DS0000003573.V303112.R01.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 Bedford Park Care Centre DS0000003573.V303112.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and/or their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: The matron said that she and the other unit managers visit prospective clients in their current situation prior to admission to the home to ensure the home can meet the person’s needs. Care plans examined had pre admission information in them, which was used to begin the initial care plan. Social service care plans prepared for those who are publicly funded were also seen in the care plans used within the home. The home does not offer intermediate care. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a client receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Four (4) care plans were examined in detail from the nursing unit, two (2) from the residential unit and three (3) from Compton Gardens as well as a PreAssessment for a new client to the unit. The residential unit uses different care plans to reflect the needs of the clients who have dementia. All plans examined contained personal information, care needs, risk assessments for skin, manual handling and nutrition and use of bed rails, and daily statements about clients well being. Not all of the dependency scores had been updated and in one case it was not clear what action was Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 10 being taken following an assessment of the skin that had resulted in a high score (at risk of damage). One client had been admitted from the residential unit to the nursing unit and had not yet had her care plan transferred. Most of the plans seen had been regularly reviewed and had the care needs updated. The plans had information about clients’ GP, dentist and use of other community health services such as dieticians and chiropodists. A tour of the home confirmed that there is equipment available throughout the units for the promotion of healthy skin and prevention and treatment of pressure sores. The home has reported (via Regulation 37 notices to the CSCI) 3 drug errors made in the past 12 months. None of these were serious but the matron and the deputy carried out thorough investigations each time. Consequently changes in practice were recommended to ensure the reduction in risk of further errors. This included the way medicines are ordered and actual administration. The manager has yet to update the home’s policies and procedures to reflect the changes, but all staff who are responsible for giving out medications (trained nurses in the nursing unit and senior staff who have NVQ level 3 and have had specific medication training in the other 2 units) are aware of the changes that need to be made. During a tour of the home the staff were heard knocking on doors and talking to clients appropriately. Personal care was being carried out in privacy in bathrooms and individual rooms. Clients spoken to said the staff were kind and pleasant and called them by the name they preferred. Some clients spoken to had their own private phone (they are responsible for the cost themselves). 14 of the 15 completed staff surveys indicated that they had ‘received induction training (to help you understand the way your care home works and how to work safely and respectfully with service users’). Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities provided by the home help to meet residents’ expectations. Clients are offered a healthy, varied diet according to their assessed requirements and choice. EVIDENCE: Clients spoken to said that they could choose how to spend their day, when to go to bed and when to get up. One person said that they sometimes got up later than they would like but knew staff were busy and it was not a problem. Relatives were seen coming and going during the inspection, some were sitting outside with their relative, one person was being brought back after a day out with relatives, they were very happy with the care and support the home gives them and their relative. Other people were visiting their relatives in their own rooms or in one of the lounges. The completed relatives/visitors surveys (3) indicated that generally staff welcome them to the home and 2 out of the 3 said that they are aware that they can visit their ’relative/ friend in private’. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 12 No formal activities were taking place during the inspection, but the home does have two activities co-ordinators who work with clients in groups and individually. The pre inspection questionnaire states that the home facilitates quizzes, bingo sessions, a variety of games and accesses the wider community such as schools and church groups to provide singing, for example. The manager of the residential unit is trying to raise money for a ‘sensory room’ for clients with dementia to help with their relaxation. Clients spoken to said that the meals are nice and that there are choices offered. The cooks have a budget of £2.40 a day per person with which they provide a nutritious menu. Completed relatives/ friend comment cards indicate that staff sometimes leave some clients on their own in the dining room at meal times to attend to clients who need feeding and are in a different room. All food is prepared in the main kitchen and taken to the various units in heated trolleys. Each area also has its own kitchenette equipped with a fridge and microwave in which staff can prepare drinks and snacks 24 hours a day. A number of completed care workers surveys indicated that some of the dining room equipment (place mats etc) is in a poor condition. Some clients expressed anxiety about mealtimes because they preferred to sit in the same place yet staff had apparently told them that they could sit anywhere. One client was particularly agitated and staff on duty at the time did not seem to be aware that their responses were accelerating the anxiety. This was also reflected in the Residents Questionnaire given out by the home as part of its quality assurance. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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 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. Residents have access to an effective complaints procedure and the systems in place in the home help protect them from abuse EVIDENCE: The complaints procedure is displayed in each unit and is in information provided to each person prior to admission. One (1) of the three (3) completed relatives/friend surveys indicated that they ‘are aware of the homes complaints procedure’. The pre inspection questionnaire states that during the last 12 months they have had 6 complaints 4 of which have been substantiated and 1 adult protection investigation that was not substantiated. The complaints are detailed by each unit with the outcomes of the investigation and action required. The home’s adult protection procedures are robust and up to date and available to staff at all times. In the recent past some staff were not sure of the exact procedure for reporting any suspicion of abuse in the absence of the manager and it was recommended that a ‘check list’ be displayed in the office in each unit. Fifteen (15) of the sixteen (16) care workers surveys indicated that they ’are aware of adult protection procedures’. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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 the following standard(s): 19, 20, 21, 23, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The design and layout of the home enables residents to live in a safe, wellmaintained and comfortable environment. EVIDENCE: Bedford Park is a purpose built facility arranged in 3 separate units each with their own office, bathrooms and toilets and communal spaces. The whole home shares the laundry and kitchen and extensive gardens. The gardens are well maintained and have seating areas and extensive lawns with pathways to enable clients to access them. A tour of the home confirmed that the home is well maintained, safe and is suitable for the needs of the clients. The pre inspection questionnaire states that there have been ‘no changes to the premises’ since the last inspection. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 15 Clients spoken to liked their rooms, which they had been able to personalise with their own possessions. As well as many en suite facilities the units have a variety of adapted bathrooms and toilets for use by clients. The home was clean and tidy and hygienic. Hand wash facilities are sited in appropriate areas of the home. The matron said that the laundry is big enough to handle all of the linen and clothing needing to be washed. The machines have ability to wash at the required temperatures to meet disinfection standards. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 16 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, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to meet the assessed needs of the clients. EVIDENCE: Each unit is staffed separately at the moment, although the matron is considering rotating staff between units to encourage the staff groups to become more integrated. One unit in particular was found to be operating in isolation as though it was separate from the rest of the home. Its staffing arrangements reflected this. The manager of each unit is responsible for their own staffing levels but if agency staff are needed, this is arranged with the matron. The home tries to book the same agency staff in order to provide some consistency; this was confirmed by the list in the pre inspection questionnaire. The care staff are supported by catering, domestic, 2 administrative staff (although the care staff have to answer incoming calls) and maintenance staff. There is also a company operations manager who visits the home regularly and provides support and advice with a variety of areas including disciplinary matters. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 17 The completed relatives/visitors surveys indicated that generally there are enough staff on duty. Nine (9) completed care workers surveys (sent to night staff, day staff and ancillary staff) indicated that there are often staff shortages and they cannot do ‘their work properly’ resulting in people being woken early to be washed and dressed, and feeling that there is no time to spend quality time with the clients. Some surveys indicated that more equipment is needed so that instead of waiting for equipment to be finished with work can be ‘got on with’. Two (2) surveys indicated that staff often go to breaks together or stand around talking when there are clients to be seen to and that some staff are ‘clicky’. The Pre Inspection Questionnaire indicted that some staff work over 48hrs, including overtime, in any seven day period. Inspection of staff files on one unit found that staff who chose to work more than the hours recommended in the European Working Time Directive had signed an “opt out” agreement. One staff member stated that they were paid below the minimum wage so other staff regularly asked them to work extra hours because “ they knew X needed the money”. It was unclear if this was the same for other staff, and if they were all aware of the European Working Time Directive, and had signed it. A number of completed care workers surveys indicate that they meet with their manager regularly and receive supervision and support, however a number also say they do not meet with their manager regularly or receive supervision and support. It is difficult to identify if this is a problem in one unit only as the surveys are anonymous. It is recommended that the matron and unit managers meet to discuss a coherent approach to the subject of supervision and support. Staff receive mandatory training in fire safety and manual handling and staff files examined also contained certificates for other courses undertaken that are relevant to the role. The staff files inspected in Compton Gardens showed that all staff required Fire Safety training to be renewed as it was overdue since June 2006. Other staff files found that First Aid and Infection Control were also out of date and needed to be renewed. One staff file had no training recorded except Moving and Handling. Internal training sessions also take place and the manager is to implement inhouse training in basic care for all carers in the near future. The pre inspection questionnaire states that other training undertaken includes catheter care, dementia and challenging behaviour, hearing support and health and safety. It also states that 59 of staff have NVQ level 2 qualification or above. Staff files contain all of the relevant documents such as 2 written references, CRB check and an application form. The matron uses a standard recruitment procedure, collects all of the relevant documentation and sends it to the head office to be approved. The matron was conducting an interview on the day of the inspection and she continues to advertise current staff vacancies in the local press. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 18 Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The systems in place in the home ensure the health, safety and welfare of the clients and staff is maintained. EVIDENCE: The matron is experienced in managing the home and has done so for many years. She is based in the nursing unit and has a manager in the residential unit who is also the deputy manager of the home and there are two managers who job share in the Compton Gardens Unit. The matron meets with the unit managers regularly to try to ensure consistency of care and approach. She also meets with the company Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 20 operations manager and other managers from other homes within the company in order to keep up to date with her management skills. Some of the completed care workers surveys indicate that staff meetings are not held very often and not all staff hear relevant information at the same time resulting in ‘bits, here and there’ The company has a formal quality assurance system and monitors satisfaction amongst the clients. It is not clear how often this is carried out. Evidence was seen on two units of completed surveys received from clients. It was unclear what follow up there was after these surveys were collated, for example, clients had expressed dissatisfaction about seating arrangements at lunchtime, yet during the inspection clients had spoken about their anxieties that they could not sit in the same place each mealtime. The matron said that the 2 administrators deal with all of the clients money and any expenses such as hairdressing and chiropody are billed to the home and the administrators then take the money from the clients’ funds. This information is all kept on the home’s computer and can be crossed checked with receipts that are kept. For those clients who manage their own money (6) they have lockable facilities in their room. Records confirm that staff have mandatory training in fire safety, manual handling and food hygiene. Maintenance of the premises is carried out by maintenance staff and outside contractors are used as necessary for lifting equipment, the passenger lifts and servicing of boilers and central heating. Care plans examined had risk assessments included in them that were relevant to the individual including use of bed rails. The home has general risk assessments which are supplemented by policies and procedures such as missing persons policy. These are available to staff at all times. Data sheets are held for any chemicals that are used within the home. Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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. OP30 2. OP33 Refer to Standard Good Practice Recommendations The manager should start the training process she is developing to ensure all care staff have ongoing training in basic care issues. (Carried over from previous inspection). Ancyra should build on the existing quality assurance systems used in the home to ensure information contained in the Statement of Purpose can be measured effectively and desired outcomes are achieved. (Carried over from previous inspection). Care plans should reviewed and updated regularly to reflect the changing needs of the clients. The matron should build on the idea of rotating staff between the units in order to make best use of the staff they have and to avoid ‘clicks’ forming which can feel intimidating to other staff. Clients’ anxieties and concerns about seating arrangements for meals should be listened to and acted upon accordingly. DS0000003573.V303112.R01.S.doc Version 5.2 Page 23 3. 4. OP7 OP27 5. OP15 OP33 Bedford Park Care Centre Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Bedford Park Care Centre DS0000003573.V303112.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!