Inspection on 29/10/06 for Belvedere House

This inspection was carried out on 29th October 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.

Other inspections for this house

Belvedere House 31/01/08

Belvedere House 14/11/05

Belvedere House 18/05/05

Belvedere House 08/11/04

Belvedere House 07/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Belvedere House Belvedere House Weston Acres, Woodmansterne Lane Banstead Surrey SM7 3HA Lead Inspector Deavanand Ramdas Unannounced Inspection 26th October 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 Belvedere House DS0000033885.V312343.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. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belvedere House Address Belvedere House Weston Acres, Woodmansterne Lane Banstead Surrey SM7 3HA 01737 360106 01737 353436 home.bns@mha.org.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 Royal Alfred Seafarers` Society Ms Bridgette Anne Kasey Care Home 56 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Old age, not falling within any other category (56), Physical disability (2), Physical disability over 65 years of age (15), Sensory impairment (2), Sensory Impairment over 65 years of age (5) Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Out of the 56 (FIFTY SIX) beds registered 12 (TWELVE) may be for Dementia Care of the elderly DE (E) Out of the 56 (FIFTY SIX) beds registered 15 (FIFTEEEN) may be used for Physical Disabilities/Elderly (PD(E)) Out of the 56 (FIFTY SIX) beds registered 5 (FIVE) may be used for Sensory Impairment/Elderly (SI (E)) Out of the 56 (FIFTY SIX) beds registered 2 (two) may be used for service users under the age of 65 (SIXTY FIVE) Out of the 56 (FIFTY SIX) beds registered 3 (THREE) may be used for Respite Care 18th May 2005 Date of last inspection Brief Description of the Service: Belvedere House is registered with the CSCI (Commission for Social Care Inspection) as a care home with nursing for fifty six service users. The home is purpose built and located in Banstead in Surrey and close to public amenities. Accommodation is on two floors accessed by stairs or a lift and comprises of lounges, dining rooms, a kitchen, laundry room, bathrooms, toilets, showers and single bedrooms with en-suite facilities. The home has a large garden which is private, secure, and accessible with private parking available. The fees charged by the home are £640 per week and the registered manager is Ms. Anne Kasey. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s key inspection by the CSCI (Commission for Social Care Inspection) henceforth referred to as the CSCI. The inspection was carried out by one inspector over a period of six hours starting at 11:00hrs and finishing at 17:00hrs. A partial tour of the premises took place, staff, service users and relatives were spoken to, and documents and records were examined. The inspector noted some service users had memory impairment and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the manager, deputy manager, staff, service users and relatives for their contribution to the inspection. What the service does well: The home has an experienced registered manager who provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘the manager is excellent, she is excellent at information and updating’’ and a relative commented ‘‘I am very happy with the care provided at Belvedere House and the home care manager is excellent’’. Activities at the home are well planned and organised with information about activities readily available in the home. The home promotes social contact and employs an activities co-ordinator to support service users in a range of valued and fulfilling activities. During discussions a relative stated ‘‘the home had a garden party with a marine band’’ and ‘‘service users are blessed with entertainment’’. The home has excellent community links and volunteers are involved in fundraising through the Relatives and Residents Group at the home. Further evidence indicated the home had a minibus and employed a driver to promote community presence and the local authority mobile library service visited the home. Meals at the home are good and offer variety and choice. During discussions a service user commented ‘‘the food is very good, I am enjoying mine’’ and ‘‘you always get a choice’’. Care at the home is good and it is recorded by a relative ‘‘I am very pleased with the level of care afforded both my father and mother. I have no complaints on the contrary, I am very satisfied’’. The home is committed to staff development and staff have NVQ (National Vocational Qualification) training and other specialist training to meet the needs of service users. A relative recorded ‘‘staff are patient, kind and caring’’ and ‘‘I am very impressed with the quality of care, especially nursing care’’. Recruitment and vetting practices at the home are excellent and a relative recorded ‘‘staff are absolutely fine and follow through requests’’. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 6 The home promoted equality and diversity and service users participated in community life and activities. Further evidence indicated staff have value based training and upheld the privacy and dignity of service users. The inspector noted the home arranged communion at the home to satisfy the religious beliefs and needs of service users. 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. Belvedere House DS0000033885.V312343.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 Belvedere House DS0000033885.V312343.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): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide are good ensuring prospective service users have up to date information on which to make decisions about admission to the home. The systems for assessing needs are good ensuring the needs of prospective service users are assessed before admission to the home. EVIDENCE: The home has a Statement of Purpose revised in June 2006 and a Service User Guide which is written in plain English, nicely presented and available in the home for information which included fees charged by the home. The home has a policy on assessing the needs of prospective service users and further evidence indicated staff with professional qualifications carried out assessments to ensure service users needs were appropriately assessed. A review of records indicated assessments covered the areas of personal care, health care needs and social support and the home had a range of assessment tools including admission information, a pre-assessment report, daily living Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 9 profile and a cognitive assessment to ensure the mental health needs of service users are assessed before admission to the home. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 arrangements for care planning need strengthening to reflect the changing needs of service users. The systems for accessing healthcare are good and promote the health of service users. Medication management needs strengthening to promote health. The arrangements for privacy and dignity are good ensuring service users are treated with respect and their right to privacy upheld. EVIDENCE: The home has individual care plans which sets out in detail action to be taken by staff to meet the health, personal and social care needs of service users including a clinical fall risk assessment to promote the safety of service users. The inspector noted individual care plans and risk assessments needed reviewing at least monthly to reflect the changing needs of service users and a requirement has been made to address this shortfall. The home promoted the health of service users and a review of records indicated service users were registered with a GP and the home had contact with a dietician and a tissue viability nurse to promote health. The home was aware of the nutritional needs of service users and kept a record of nutritional likes and dislikes Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 11 including weight gain and weight loss and a review of records indicated a service user was prescribed nutritional supplements to maintain good health. The home has a policy on medications, a service level agreement with a local chemist and staff with professional nursing qualifications administered medications to safeguard the welfare of service users. A review of records indicated the home kept a record of medications received by and disposed of by the home including controlled drugs to prevent mishandling of medications. Observation confirmed two boxes of surplus controlled drugs dated 10/06/2006 and 19/07/2006 needs to be disposed of including eye drops that were out of date to promote health and action has been required in respect of this matter. The home has a policy on privacy and dignity and observations confirmed service users were treated with dignity and respect. Further evidence indicated service users have access to a telephone for use in private, the GP examined a service user in the privacy of the service user’s own room and care staff knocked on doors before entering bedrooms. It is recorded by a relative ‘‘I am very pleased with level of care afforded both my father and mother. I have no complaints, on the contrary, I am very satisfied’’. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for social contact and activities are excellent and satisfy the social, religious and recreational needs of service users. Community contact is excellent ensuring service users maintain family links and contact with the local community as they wish. The systems for autonomy and choice are good ensuring service users exercise choice and control over their lives. Meals at the home are good and offer variety and choice. EVIDENCE: The home promoted social contact and activities and employed an activities coordinator to plan and organise social and recreational activities. Further evidence indicated the home had a monthly planned programme of activities displayed in the foyer for information and a review of records indicated representatives from the local church visited the home to satisfy the religious needs of service users. The home had a minibus and employed a driver to enable service users to access community facilities and further evidence indicated the home had a visitors room where service users are able receive visitors in private. A review of records indicated a volunteer assisted at the home as secretary of the Royal Alfred Club to safeguard the interests of service users and during discussions a relative stated ‘‘the home had a garden party with a marine band’’ and ‘‘service users are blessed with entertainment’’. The Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 13 home had a visitors policy and relatives visited the home to maintain family links. The inspector noted written information in the service user guide about the home’s policy on maintaining family contact and friendships and a relative stated ‘‘visitors are welcomed at the home’’. Service users are helped to exercise choice over their lives and the home has arranged for relatives to handle the financial affairs of service users. Further evidence indicated service users are entitled to bring personal possessions to the home and the home has information on advocacy services to safeguard the interests of service users. The home employs a chef manager and a cook with a professional qualification in catering and the home has written menu plans which reflect variety, choice and healthy eating options. Observations confirmed meal time was relaxed and unhurried, and staff supported service users using verbal prompts to maintain independence. On the day of the inspection lunch was fish, with chips and peas, and dessert was cheesecake, ice cream or fresh fruits. The inspector noted service users had wine and beer at lunch for their enjoyment and during discussions a service user commented ‘‘the food is very good, I am enjoying mine’’ and ‘‘you always get a choice’’. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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. The complaint process is good with complaint information available to staff, service users and relatives. The arrangements for protection are good safeguarding the welfare of service users. EVIDENCE: The home had a complaints policy displayed in the foyer for information and the home kept a record of complaints about the home. The inspector noted eight complaints were recorded since the last inspection by the CSCI with two complaints in August 2006 and appropriate management action taken. During discussions a member of staff stated ‘‘I am aware of the complaint policy and procedures and I have no concerns’’. The manager stated the home had a policy on safeguarding adults and a review of documents indicated the home had a copy of the local authority (Surrey County Council) procedures on safeguarding adults to protect service users from harm. Further evidence indicated the home had a whistle blowing policy and staff have training in safeguarding adults. A review of records confirmed one incident reported under safeguarding adult procedures with appropriate management action taken. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 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&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the premises need strengthening to maintain a comfortable environment for service users. The systems for hygiene are good ensuring the home is clean, pleasant and hygienic for service users. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from mal odour with a good standard of décor in the communal areas of the home. Observations confirmed the home had adequate furniture and fittings and the gardens were well maintained, attractive, private and secure for the enjoyment of service users. Further evidence indicated the carpets on the first floor dining area needed replacement to make it nice for service users. The manager stated funding for the refurbishment of the home is being negotiated with management and based on this information a requirement has been made for the home to produce a renewal and redecoration plan to ensure the premises is well maintained and comfortable for service users. A review of records Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 16 confirmed the home had an environmental audit by the local authority (Surrey County Council) dated July 2006 with no recommendations made. The inspector noted the home needed an up to date fire safety risk assessment to ensure the safety of service users and action has been required in respect of this matter. The home had a policy on infection control and staff have training in infection control to prevent the spread of infection in the home. Further evidence indicated the home had adequate laundry facilities and a service level agreement with an approved contractor for the disposal of clinical waste. Observations confirmed the home had aprons, gloves and staff practiced infection control measures through regular hand washing to promote good hygiene. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 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): 27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing need reviewing to ensure adequate numbers of staff on duty to meet the needs of service users. Training in NVQ (National Vocational Qualification) is good ensuring service users are in safe hands at all times. Recruitment and vetting practices are excellent and safeguard the interest and welfare of service users. The arrangements for staff training are good ensuring staff are trained and competent to their jobs. EVIDENCE: The manager stated the home had adequate staffing levels and the home employed a registered manager, deputy manager, registered nurses, carers and cleaning, catering and laundry staff to meet the needs of service users. Further evidence indicated the home had an activities co-ordinator, a porter and a gardener reflecting the skill mix of the staff team. The inspector noted variations in staffing levels during the day which were in need of reviewing and action has been required in respect of this matter to ensure staffing levels are adequate to meet the needs of service users. The home is committed to staff training and development and staff working at the home have NVQ (National Vocational Qualification) training. Further evidence indicated a total of nineteen care staff have NVQ qualification to ensure service users are in safe hands at all times. The home has a policy on recruitment and staff working at the home are vetted before being employed by the home. The inspector sampled staff recruitment files which were in a locked cabinet in the manager’s office to Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 18 promote confidentiality of information. The inspector noted recruitment files contained completed application forms, two written references, personal information, training records and certificates, a recent photograph of the employee, statement of terms and conditions, job descriptions and CRB (Criminal Record Bureau) disclosure information. The home has a checklist to ensure staff are fully vetted before being employed by the home and the registered manager notifies the CSCI of new employees to the home to safeguard the welfare of service users. The home had a policy on staff induction and a structured induction and foundation programme. The inspector sampled induction training records which were dated and signed by the employee and supervisor and the manager confirmed staff have named supervisors to provide advice and support. The inspector noted the induction and foundation training programme needed reviewing to reflect Skills for Care common induction standards and a recommendation has been made in respect of this matter to ensure staff are trained and competent to do their jobs. During discussions a relative stated ‘‘I am very impressed with the quality of care, especially attention to nursing care’’ and ‘‘staff are absolutely fine and always follow through requests’’. Belvedere House DS0000033885.V312343.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 arrangements for the day to day management of the home are good ensuring the home is run by a person fit to be in charge of the home. The systems for quality assurance are good ensuring the home is run in the best interests of service users. Policies and procedures are good and safeguard the financial interests of service users. The systems for health and safety are good and promote safe working practices. EVIDENCE: The home has a registered manager who holds a professional nursing qualification and completed the RMA (Registered Manager Award) qualification to ensure the home is run by a person fit to be in charge of the home. The manager is aware of her role and responsibilities and there are clear lines of Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 20 communication and accountability in the home reflected in the management structure in the statement of purpose. During discussions a member of staff stated ‘‘the manager is excellent, she is excellent at information and updating’’ and a relative recorded ‘‘I am very happy with the care provided at Belvedere House and the home care manager is excellent’’. The home has quality assurance procedures and regular Regulation 26 (monitoring visits) with appropriate management action taken. Further evidence indicated the home had regular Relatives and Residents meetings and used questionnaires to obtain feedback about the home. A review of records indicated the home regularly reviewed policies and procedures to maintain standards at the home and the inspector noted the home met the requirements made by the CSCI to improve practice at the home. During discussions a relative commented ‘‘everything is absolutely fine’’ and a staff stated ‘‘it is a nice place to work’’. The home has a statement on Residents Property and a review of records indicated service users financial affairs were handled by relatives who had power of attorney to safeguard the interests of service users. Further evidence indicated the home provided secure facilities for the safe-keeping of money and valuables. The home had a policy on health and safety and staff have training in fire safety, food hygiene, first aid, moving and handling, and COSHH (Control of Substances Hazardous to Health) training to promote health and safety in the home. Further evidence indicated the home had a current gas safety certificate, service inspection records of fire equipment, hoists, lifts and emergency lighting equipment to safeguard the welfare of service users. The kitchen appeared clean and hygienic, food was appropriately stored and fridge and freezer temperatures were within normal limits to promote food safety. Belvedere House DS0000033885.V312343.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(2)(b) Requirement The registered person must ensure care plans and risk assessments are reviewed regularly to reflect the changing needs of service users to promote health, personal care and social support. The registered person must ensure eye drops which are out of date are disposed of by the home to promote health. The registered person must ensure surplus controlled drugs are disposed of by the home to prevent mishandling of medications. The registered person must ensure the home has a fire safety risk assessment in place to promote the health and safety of staff and service users. The registered person must undertake a review of staffing levels at the home to ensure it is adequate to meet the needs of service users. Timescale for action 01/11/06 2. OP9 13(2) 01/11/06 3. OP9 13(2) 01/11/06 4. OP19 12(1)(a) 13(6) 01/02/07 5. OP27 18(1)(a) 01/02/07 Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 23 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 OP19 OP30 Good Practice Recommendations The registered person shall do a development plan outlining renewal, refurbishment and decoration of the home to safeguard the interests of service users. The registered person shall review the homes induction programme to reflect Skills for Care common induction standards. Belvedere House DS0000033885.V312343.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Belvedere House DS0000033885.V312343.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. 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