CARE HOMES FOR OLDER PEOPLE
Bethany 434/436 Slade Road Erdington Birmingham West Midlands B23 7LB Lead Inspector
Brenda O`Neill Announced Inspection 31st October 2005 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 Bethany DS0000016765.V252446.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. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bethany Address 434/436 Slade Road Erdington Birmingham West Midlands B23 7LB 350 7944 624 7311 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) Mr Joseph Alphonse Rodrigues Mrs Helen Rodrigues Mr Joseph Alphonse Rodrigues Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That one named person, who is under 65 years of age at the time of admission can be accommodated and cared for in this Home. 11th May 2005 Date of last inspection Brief Description of the Service: Bethany House is a registered care home for 30 elderly people and is located North of the City Centre in Erdington and close to the M6. It has easy access to community facilities and public transport which runs directly outside the home. The home was originally four houses that have been tastefully converted into one large care home offering a very good standard of accommodation. Accommodation is offered over two floors with six double and eighteen single bedrooms all with en-suite toilet and wash hand basins. There are three lounges and a large dining room located on the ground floor, toilet, bathing and showering facilities are located throughout the home. There is also a hairdressing room, large kitchen with a small area attached for residents to prepare drinks, medical room, laundry and office space. The front of the home has been block paved and has ramped access and ample parking space. To the rear of the home is a very large patio area that has been block paved to match the front and offers ample space for the residents with a water fountain feature, raised flower beds and seating available. Access to the grounds is via the dining room and two bedrooms on the ground floor have direct access to the grounds. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and carried out over one day in October 2005. This was the second of the two statutory visits for this home for 2005/2006. To get a full overview of all the standards assessed during this inspection year this report should be read in conjunction with the report written following the inspection on May 11th 2005. During this inspection a partial tour of the building was made, three resident and three staff files were inspected as well as some policies and procedures and other care and health and safety records. The inspector spoke with the manager, three staff members, five of the twenty one residents and several relatives at a meeting arranged by the owner/manager. What the service does well:
The home continues to offer a good service to the people who live there and this was evidenced by the numerous comments that were received prior to the inspection, on completed comment cards, from visitors to the home. These were all very positive about the home, the staff and the service offered to the residents. Comments included: ‘Staff always pleasant, care and attention has been excellent.’ ‘More than happy with the care, staff are welcoming, helpful and supportive.’ ‘This is my mother’s third home and by far the most caring both of residents and relatives.’ ‘The staff are always kind and helpful.’ ‘It is a very welcoming home. All the residents seem well cared for and staff are friendly and approachable.’ ‘Good food, clean bed and clothes, she has a bath frequently and has her hair done by the hairdresser. Staff are always friendly.’ ‘Could not wish to find a better home.’ ‘Staff are very helpful.’ The home had a visiting policy which asked people not to visit at meal times. However, this was flexible depending on circumstances. The home was to be commended on its links with relatives/representatives of current residents. The enthusiasm and involvement of relatives was demonstrated at a meeting the inspector had with them when they had nothing but praise for the home and it was very evident how welcome they were made whenever they visited. The residents spoken with stated the staff were kind and helpful and that there were no rigid rules or routines in the home. Friendly relationships were evident between staff and residents. Residents spoken with were satisfied their Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 6 needs were being met and there were some activities on offer. Residents were happy with the food served to them at the home. Although the home had had considerable turnover of staff since the last inspection they had managed to retain a core group of staff who had worked there for a considerable amount of time and this was very good for the continuity of care of the residents. The staff at the home record and address any minor issues that are raised by the residents very promptly. The home offers residents a very well maintained, good standard of accommodation. What has improved since the last inspection? What they could do better:
The manager needed to ensure that a full assessment was carried out on any prospective residents so that staff were able to determine if the home could meet any identified needs. To ensure that staff had all the necessary information and worked consistently the manual handling and pressure risk assessments needed to clearly detail any handling techniques or equipment to be used. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 7 The manager needed to ensure that there was a complete audit trail for all medication and that any discrepancies were fully investigated. To ensure the residents were fully safeguarded the manager needed to ensure that all the required documentation was obtained prior to employing new staff. There needed to be evidence that staff had received some initial induction training in relation to their roles and the running of the home. The home needed to have a formal quality assurance system based on seeking the views of the residents with a view to continuously improving the service on offer. 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. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 8 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 Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 9 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, 2 and 3. There was adequate information available for prospective residents to ensure they could make an informed choice about where they lived. The assessment procedures needed to be developed to ensure staff knew the needs of the residents prior to admission. EVIDENCE: The statement of purpose and service user guide for the home were viewed. Both these documents had been further developed since the last inspection and included all the relevant information only some very minor amendments were needed. The assessment documentation for two residents was sampled. One of the residents was privately funded the other funded by social care and health. One resident had been assessed by a social worker and there was a copy of the initial care plan on the individual’s file but no copy of the assessment. The other resident had been assessed by the home on the pre admission visit however the documentation for this was brief and did not cover all the required aspects of the individual’s life. It was difficult to see from any of the
Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 10 documentation how the staff had determined they could meet the needs of the individuals. There was evidence on the files sampled that the residents were being issued with a contract at the point of admission to the home and this detailed the terms and conditions of residence at the home. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 11 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 and 9 There had been a vast improvement in the care plans which detailed how the individual needs of the residents were to be met and the strategies for managing risks were generally clear. The health care needs of the residents were being met. The system for the administration of medication was good with the exception of one tablet where there was a discrepancy in the audit trail. EVIDENCE: Three care plans were sampled, two for recent admissions to the home, the other for a long standing resident. There had been a vast improvement in the care planning system since the last inspection. The care plans included routines on waking, routines on retiring to bed, daily routines and interests, social needs and relationships and personal hygiene. The plans included very good detail of the needs of the residents and how staff were to meet the needs, for example, how to prepare the bathroom prior to bathing, how to respect the individuals privacy whilst offering personal care and what choices to offer. A lot of attention had been paid to detail, for example, the frequency of hair done, likes hot chocolate at night, has tea with one sugar, prefers to sleep with the lamp on and has two pillows plus a ‘v’ shaped one. There were
Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 12 care plan summaries that evidenced they had been discussed with the resident or their relatives. All the files sampled included manual handling and personal risk assessments. The manual handling risk assessments needed to be more specific about the assistance to be given as they stated ‘appropriate techniques and equipment to be used’. These needed to be detailed for each individual to ensure consistency by staff. One of the care plans included very good detail of how the individual was to be moved by staff to enable the hoist sling to be used. All the files sampled had nutritional screenings and tissue viability assessments which were appropriately completed. There were also pressure risk assessments however where any action was needed by staff in relation to these the actions were not adequately detailed, for example, important to encourage her to move regularly, this referred to an amputee and it was difficult to see how staff would interpret this. They also needed to include details of any pressure relieving equipment that was being used. There were separate records for the residents detailing any professional visits in relation to health care. These included evidence that when new residents were admitted they were registered with a doctor who came out to meet them and gave them a medical check up. District nurses visited the home twice daily to administer insulin and there was evidence that the chiropodist and optician also visited. All the relatives spoken with were very happy that the residents health care needs were being met and stated they were kept fully informed of any illnesses or falls. One relative was very happy with the care his relative was receiving as she becoming frail and spent much of her time in bed. There had been no changes to the medication administration system since the last inspection. Medication was only administered by senior staff who had undertaken accredited training. The medication system was generally well managed with only one discrepancy noted in relation to warfarin tablets. It appeared from the balance brought forward onto the medication administration record and the numbers administered that there were too many tablets left in the box. The amount over was equivalent to one week’s supply of tablets but it could not be determined how this had happened. The manager needed to ensure that there was a complete audit trail for all medication and that any discrepancies were fully investigated. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 13 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 and 15. There were no rigid rules or routines in the home and residents were encouraged to make choices and maintain control over their lives and there were activities on offer. There were no restrictions on visitors to the home within reasonable hours and they were made very welcome. The meals offered in the home were good. EVIDENCE: There did not appear to be any rigid rules or routine in the home and the residents spoken with confirmed they could spend their time as they chose. Residents were seen to wander freely around the home, spend time in their rooms, reading, chatting and watching television. One of the residents continued to go out to a day centre twice a week which he told the inspector he thoroughly enjoyed. Some of the other residents went out with their relatives. Recorded activities included board games, tea dance, exercise sessions, knitting, reading and walks in the garden. It was strongly recommended that the record of activities was developed to include comments from the residents about the suitability of the activities, if they were enjoyed and who had declined to take part. It was evident from the comments received from the visitors at the meeting the inspector had with them that they were made very welcome regardless of when they visited the home.
Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 14 Residents appeared to be able to exercise control over their lives and make choices. There was evidence on care plans of the choices residents were able to make for themselves, to what extent they were able to self care and they got up and went to bed when they pleased. There was also evidence on daily records that residents could have their breakfasts in their bedrooms or the dining room if they preferred and this could be changed as they wished. The bedrooms seen were appropriately personalised to the occupants choosing and residents were encouraged to bring possessions in from home to help with this. The residents and relatives were positive about the meals served in the home. The food records seen evidenced the meals offered were varied and nutritious. The records had been further developed since the last inspection and evidenced that medical diets were being catered for. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 15 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 and 18. The complaints records evidenced that any issues raised by the residents, no matter how minor, were listened to and acted upon. There were policies and procedures on site for the prevention of abuse and staff received training in this topic ensuring the safety of the residents. The manager needed to develop a concise step by step procedure for staff to follow in the event of or suspicion of any abuse taking place which was accessible to them at all times. EVIDENCE: There was an appropriate complaints procedure on display in the home. The pre inspection questionnaire detailed the home had had six complaints. The records for these were seen and all were very minor ‘grumbles’ and included such things as newspapers not being delivered and laundry going missing and all were resolved very quickly. The home had an adult protection procedure which covered the majority of expected areas. There was also a copy of the most recent multi agency guidelines for adult protection on site. The manager needed to develop a concise step by step procedure for staff to follow in the event of or suspicion of any abuse taking place. This needed to be kept accessible to staff at all times. The majority of the staff at the home had undertaken training in adult protection. The home had a comprehensive procedure on restraint and physical intervention. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. The standard of the environment within this home was very good providing residents with a safe, attractive and homely place to live. EVIDENCE: There had been no changes to the layout of the home since the last inspection. It was safe accessible and very well maintained by a permanently employed handyman. The home had a very good standard of furnishings and fittings throughout that were domestic in character. The lounge carpets and several armchairs had been replaced since the last inspection. The bedrooms were a mix of singles and doubles and all had en-suite facilities of a toilet and wash hand basin. There were ample toilets, bathrooms and shower rooms throughout the home some of which allowed for full assistance from staff. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 17 The home had a variety of aids and adaptations including handrails, assisted bathing facilities and ramped access to the home. There was a very large shaft lift which gave easy access to the first floor. There were grab rails in all the ensuite toilets. Doorways were wheelchair accessible and wheelchairs were available in the home. Some of the bedrooms had pressure pads installed that triggered the call system when residents who were at risk wandered around thus alerting staff. The bedrooms seen were appropriately personalised. There was evidence on the resident’s files that discussions had taken place with them in relation to their requirements for the furniture in their rooms. All bedrooms had locks that enabled residents to lock their rooms if they wished but staff would be able to gain access in an emergency. All double bedrooms had appropriate screening. The home was clean, hygienic and odour free with an appropriately located and equipped laundry. The kitchen was not inspected during this visit. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29 and 30. The recruitment process for new staff had improved. Further improvements were needed to ensure that the residents were fully safeguarded. There was ongoing training for staff at the home to ensure they were equipped with the necessary skills and knowledge to fulfil their roles. There needed to evidence that staff had received some initial induction training in relation to their roles and the running of the home. EVIDENCE: There had been quite a big turn over of staff since the last inspection, however the home had managed to retain a core group of staff who had worked there for a considerable amount of time. The recruitment records for the three most recent employees were sampled. Two of these staff had been recruited from abroad. The files for these staff included police checks, references, proof of I.D., work permits, photographs, job descriptions and contracts of employment. Neither of the files included a declaration of medical fitness. The other staff member had been recruited locally, this file included an application form, but this needed to be further developed as there was no space to include referees, there were two references but they had not been obtained prior to employment, again there was no medical declaration. A CRB check had been sent for and a POVA first check had been obtained. There was no evidence to suggest the person’s employment history or any gaps in this had been explored. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 19 Well in excess of fifty percent of the staff at the home were qualified to NVQ level 2 or above. There was evidence of good ongoing training for staff some that was facilitated by the manager and then test papers sent off for marking externally and some conducted by outside trainers. Topics included food hygiene, manual handling, adult protection, first aid, pressure ulcer prevention and dementia care. There were no records of any initial induction training into the home for two staff that had been employed for just over two weeks. The manager needed to ensure that there were records of all areas covered when staff first begin their employment. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. The manager ensures the smooth running of the home in a competent manner. The health, safety and welfare of residents and staff were very well maintained. EVIDENCE: There had been no changes in the management of the home since the last inspection. The owner of the home was also the manager and he had many years experience of running the care home. During the course of the inspection he produced evidence that the qualifications he has are the equivalent to those required for a registered manager. He had also updated a lot of his basic training as was recommended following the last announced inspection topics he had covered included, first aid, manual handling, adult protection, managing medication and dementia care. He had a very supportive senior team who he delegated responsibilities to and, in turn, they delegated tasks to care assistants and supervised their work.
Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 21 There were some informal ways of monitoring the quality of the service offered at the home, such as room audits, medication audits and contact with families. The manager was aware that there is a requirement to have a formalised tool for measuring the quality of the service with a view to continuous improvement. He had purchased an extensive quality manual that included an audit tool but this had not been used at the time of the inspection. The manager did not manage any of the finances for the residents they either managed their own or relatives managed them. The manager did give an example of how he had acted as advocate for one of the residents where he thought the person was treated unfairly. There was a system of staff supervision in the home. The manager supervised the senior staff and they supervised the care staff. It appeared that all staff were receiving the required six supervision sessions per year. It was recommended that the supervision records were further developed to include some of the comments made by both supervisor and supervisee as the records were really only tick boxes. The records required by regulation for the protection of the residents and for the effective running of the home were well maintained. There were numerous policies and procedures on site that were regularly updated and all records were held securely. Health and safety at the home was very well managed and no requirements were made in relation to this. The premises was very well maintained and staff had ongoing training in safe working practices. There was evidence on site of the regular servicing of all equipment. Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 3 3 Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 23 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 OP3 Regulation 14(1)(a) Requirement The manager must ensure that a full assessment is carried out prior to the admission of any resident and that individual needs are detailed. (Previous time scales of 01/12/04 and 01/07/05 not met.) Manual handling risk assessments must include detail of the equipment and handling techniques to be used. (Previous time scales of 16/11/05 and 01/07/05 partially met.) Pressure risk assessments must include specific detail of the actions to be taken by staff to avoid pressure sores and detail any equipment to be used. The manager must ensure that there is a complete audit trail for all medication and that any discrepancies are fully investigated. (Previous time scale of 13/05/05 partially met.) The manager must develop a step by step adult protection procedure for staff to follow in the event or suspicion of abuse. (Previous time scales of
DS0000016765.V252446.R01.S.doc Timescale for action 01/01/06 2 OP7 13(5) 01/01/06 3 OP8 12(1)(a) 14/12/05 4 OP9 13(2) 14/12/05 5 OP18 13(6) 14/12/05 Bethany Version 5.0 Page 24 6 OP29 19(1)(a) (b) Sch 2 01/08/04 and 01/07/05 not met.) The application form for new staff must be further developed to ensure it included space for all the relevant information. Two references must be obtained for staff prior to their commencing their employment. There must be evidence that staff are mentally and physically fit to undertake their roles. There must be records maintained of the initial induction training staff receive when commencing their employment. The home must have a formal quality assurance system based on seeking the views of the residents. (Previous time scales of 01/08/04 and 01/07/05 not met.) 14/12/05 7 OP30 18(1)(a) 01/12/05 8 OP33 24(1)(a) (b) 01/02/06 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 Refer to Standard OP12 Good Practice Recommendations It was strongly recommended that the activity records were developed to include comments from the residents on there suitability and include who had declined to take part. It is recommended that supervision records are developed to include some of the comments made by both supervisor and supervisee. 2 OP36 Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bethany DS0000016765.V252446.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!
