Inspection on 06/12/06 for Beverley Court Residential Home

This inspection was carried out on 6th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beverley Court Residential Home 17/09/07

Similar services:

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Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Beverley Court Residential Home 334-336 Beverley Road Hull East Yorkshire HU5 1LH Lead Inspector Malcolm Stannard Unannounced Inspection 6th December 2006 09:30 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 DS0000067853.V322722.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. DS0000067853.V322722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beverley Court Residential Home Address 334-336 Beverley Road Hull East Yorkshire HU5 1LH 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) 01482 449296 Hestan Court Limited Dawn Marguerite Jones 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 DS0000067853.V322722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home must meet the requirements of the residential staffing forum. The home must increase its communal space to a minimum of 30 times 3.7 square metres per person within three years of registration. 2nd May 2006 Date of last inspection Brief Description of the Service: Beverley Court Residential Home is a purpose built home comprising of 3 floors and registered to care for 30 residents. It is situated on the corner of Sculcoates Lane and Beverley Road, which is one of the main roads leading into the centre of Hull. The Home is well served by public transport. Nearby there is a good range of shops and a local park. On the ground floor there are two dining areas and lounges and a small number of single rooms. On the first floor there is a further lounge / dining room and additional bedrooms. The remaining bedrooms are situated on the second floor. Access to the first and second floors is via two staircases or a passenger lift. To the rear of the Home is a car park and to the side and front, overlooking Beverley Road, are garden areas. The weekly fees stated by the manager during this visit are £340, this does not include the provision of newspapers and personal toiletries etc that must be paid for separately. The home changed ownership in July 2006. DS0000067853.V322722.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on an unannounced basis. A site visit was carried out which comprised of a tour of the premises, conversations with residents, staff and management and viewing of records held in the home. Relatives of residents were spoken with following the visit. Questionnaires were received in relation to the home from 2 residents, 3 care professionals, 3 relatives and 1 care manager. All the accumulated evidence has being used to say how well the home is doing. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services and their relatives were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure These findings will be used as part of a wider study that the Commission for Social Care Inspection are carrying out about the information that people get about care homes for older people. This report will be published in May 2007 Further information on this can found on our website www.csci.org.uk. What the service does well: Since taking over control of the home in July 2006, the new owners have invested a large amount of time and finances in to the setting to ensure the quality of provision is increased in a positive manner. The premises have being addressed throughout with new furnishings, decoration and carpets. The work is nearing the final stage and presently the ground floor is being improved with the previously mentioned furnishings and flooring etc, and also with a completely new kitchen facility on which work had started on the day of visit. The personal care offered is of a good standard and all relatives and residents spoken with were complimentary of the service received. A care manager from the local authority and a health care professional stated that the care in the home had improved greatly since being under new manager and ownership. A relative commented, “The manageress and key carers could not have being more helpful or concerned in regard to my fathers welfare”. DS0000067853.V322722.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Requirements have being made that the refurbishment work to the premises continues and that carpets etc, which require replacement, are actually replaced. In reality the majority of the work required has being carried out and the proprietor and manager of the home explained that the final piece of the work required is now underway. An improvement in the recording carried out was seen on this visit, however many records were let down in their presentation by not being signed or dated by the person compiling them. The medication system in use at the home requires attention to ensure that it offers safety for all concerned. DS0000067853.V322722.R01.S.doc Version 5.2 Page 7 The system for formal supervision of staff in the home requires to be developed to meet with the requirements of the standards. Evidence needs to be available that information in relation to the home and the terms of residence has being made available to prospective residents and their relatives. All involvement by residents in activities and leisure interests needs to be recorded formally. An internal quality assurance system is required to be in place in the home to allow all areas of the homes operation to be audited. 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. The summary of this inspection report can be made available in other formats on request. DS0000067853.V322722.R01.S.doc Version 5.2 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 DS0000067853.V322722.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 & 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. No evidence is available that prospective residents or their relatives are provided with appropriate information to make an informed choice. Previsits to the home are enabled. There were no copies available of the statement of terms and conditions. Assessments are carried out however were found to be incomplete. EVIDENCE: A statement of purpose in regard to the home and a guide for service users are both available. There was no evidence on any of the residents files looked at that these had being made available to residents and their relatives. One relative spoken with said that she had being given information in relation to the home prior to the admission of her relative taking place. Evidence of assessment of resident’s individual needs, which had being carried out prior to admission to the home, was available on individual files. Of the three files looked at however two of the assessments had not being signed or DS0000067853.V322722.R01.S.doc Version 5.2 Page 10 dated, this not allowing evidence to be available that the home were able to meet the persons needs at the time of admission. Relatives of service users spoken to said that they had had the opportunity to visit the home prior to their relative entering the home and had opportunity to speak to the manager about the needs of their relative and how the home can meet them. There was no evidence that residents had being given a written statement of terms and conditions, there were no copies available on the files of the three/ residents which were looked at. One relative said that they had had the fee structure explained to them. The home does not offer intermediate care and standard 6 does not therefore apply. DS0000067853.V322722.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The medication system needs attention to ensure safety and protection for all. Plans of care and health information is available for residents. EVIDENCE: Individual plans of care, which covered all aspects of a residents needs, were available to view on two of the three files viewed. The file, which did not contain a plan of care, was that of a newly admitted resident. Monthly updating sheets are also available however these did not always record where a change to the plan of care had being required or not. Short and long term goals were identified, however due to the lack of dating and signing of these records it was difficult to see where any changes to a residents needs had occurred. Health care plans for each of the residents whose files were viewed were available and these contained details of health care appointments, visits by community nurses and any medication changes. Two residents stated that they always received the medical support they needed. Weight charts were also available on the files viewed. DS0000067853.V322722.R01.S.doc Version 5.2 Page 12 Comments received from a health care professional stated that staff were now much more open to advice on health care issues and another said, “Improvements continue to be made and a vast improvement has being noted”. Information in relation to any statutory reviews, which had being undertaken, was held on the individual files. The medication provision in the home utilises the Nomad system for which new medication is delivered weekly. There was one resident who holds his own medication and this has being assessed and recorded. Medication storage and administration was checked, whilst the stock of medication held in the cassettes was correct, some were difficult to audit as not all cassettes had being started on the same corresponding day marked on the cassette. It is recommended that all medication is started to be dispensed from the cassettes on the same marked day. The storage of controlled medication was also checked, whilst in a secure store, the medication held did not correspond to the record book for controlled medication. The record of receipt, administration and running total of this medication must be correct. Nutritional risk assessments are presently being compiled for all residents and the manager explained that it was intended to complete weight charts for all residents on a monthly basis. Observation during the visit to the home showed that residents were treat and spoken to with dignity and respect. Comments received from staff members were that they always attempted to motivate residents to make their own choices and respect these whilst having regard to the impact on their own and others care. DS0000067853.V322722.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A range of activities are carried out, however recording needs to be improved. Contact with relatives is encouraged and enabled. EVIDENCE: New staff members have recently being employed to facilitate the provision of activities in the home. As part of their plans of care, relatives are being asked to bring in photographs etc relating to residents so that reminiscence/life albums can be produced. An activity sheet template was available to view, this allows a plan of activities, which are to be undertaken to be compiled. Many of these sheets were however blank and hat not being completed. The records which are compiled of activities undertaken and of contact with the local community were looked at, it was found that no entries had being made since October 2006, this does not enable evidence to be available that a range of leisure interests had being undertaken. A record must be held of all activities undertaken and developed to meet the needs of residents. Residents are able to receive visitors at all reasonable times and also have access to a telephone. Some of the residents have the availability of their own telephone. Visitors are able to be seen in private in one of the communal DS0000067853.V322722.R01.S.doc Version 5.2 Page 14 rooms or in a resident’s own room should this be required. A visitor’s book is available at the entrance to the home. Residents are able to make choices about their daily lives, including what they would like to do during the day and what time to rise or go to bed. The food provision at the home was difficult to assess as the kitchen was being totally refurbished at the time of visit and food was being prepared using temporary equipment. Despite this the main meal seen was of a good quality. A set menu is available for all meals and alternatives are available should these be required. Any special diets required can be catered for and nutritional risk assessments were in the process of being compiled for all residents. Residents spoken with were complimentary of the food provided at the home s stating, “ The foods lovely, I have no complaints”, “Always a choice”, “we get cooked meals three times a day” and “The food is usually good”. Menus are displayed in each of the resident’s rooms. DS0000067853.V322722.R01.S.doc Version 5.2 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. 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. A formal complaints procedure is available. A procedure in relation to the protection of vulnerable adults is available and staff have undergone training. EVIDENCE: A complaints procedure is available in the home and details of how to make known any concern are displayed on various notice boards around the home. One relative spoken with said that they did not remember receiving anything in writing in relation to making a complaint, but that the manager and staff of the home had being very open with them and had taken on board any comments they had made. It may be beneficial for the home to revisit complaints information and ensure all parties are provided with written information in relation to this. In discussion the manger explained that the majority of concerns are dealt with there and then negating the need for a resident or relative to make a formal complaint. All staff members have being or are shortly to attend training in the protection of vulnerable adults. Policies and procedures are available in relation to this area. Responses from staff members in regard to the protection of residents showed that there was a good understanding of the issues and practice surrounding this area. DS0000067853.V322722.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Much of the homes premises have now being addressed, completion of the planned work is needed to ensure safe, comfortable accommodation throughout. EVIDENCE: A vast investment has being made in improving the whole of the environment at the home. All first and second floor rooms have being totally refurbished, including redecoration, new beds and furniture, furnishings, carpets and bedding. All communal areas on the top two floors have also being recarpeted. Resident’s rooms on these floors are well presented and those residents who lived at the home during the work being carried out were able to have a choice of rooms. The manager explained that all carpets on the ground floor were to be replaced following completion of the building/refurbishment work. As this was a requirement of the previous inspection it must be ensured that this work is completed. DS0000067853.V322722.R01.S.doc Version 5.2 Page 17 At the time of visit the kitchen was being completely renewed to provide a high standard of provision. The large front lounge has also being completely refurbished, including new decorations, carpets, chairs and lighting. Residents spoken with said that they had had an opportunity to add some views to the choice of decorations and curtains etc. A new washing machine has being ordered for the laundry area and it is intended to redesign this area shortly, including the provision of new flooring. The passenger lift in the home has also being overhauled and is now part of a regular service agreement. The continuation of refurbishment work in the home obviously makes it difficult for the two domestic staff who are employed, to carry out their duties, however the home is clean and hygienic and there were no malodours. Residents spoken with were complimentary of the standard of the new provision of furnishings, one gentleman said he would like some softer pillows and this was mentioned to the manager of the home. Another resident said, “ The new furniture is nice”. A further resident spoken with said, “The home is clean and warm, with good furniture”. Comment was received from a visiting health professional that the environment and general approach to care was vastly improved. Some of the toilets in the home are too small to allow for privacy of residents to be protected when in use. The proprietor explained that residents are presently being encouraged to use the larger toilet facilities and that it is hoped to redesign some of the smaller ones to allow more dignity when the communal space in the home is increased. A new electronic keypad system has being fitted to all external doors in the home; this assists in keeping the residents safe and secure. The proprietor of the home explained that new fencing is planned for the whole of the grounds perimeter of the home to aid in security and safety. It must be ensured that the work planned to be carried out to the home is completed and that a programme of maintenance is available and followed when this has being concluded. Due to internal building work carried out by the previous owners, the communal space was reduced and does not meet the requirement of 3.7 metres of communal space per resident. The proprietor intends to add additional communal space as part of the programme of works carried out. This issue therefore currently remains a condition on the homes registration. DS0000067853.V322722.R01.S.doc Version 5.2 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. 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. Training and development opportunities for staff members have improved Recruitment practices are satisfactory. Formal qualifications of staff remain at a low level. EVIDENCE: The management of the home now have their own policies and procedures in place in relation to the recruitment of staff members. A range of checks are carried out on prospective employees, including CRB and POVA first checks, the taking of references, and a comprehensive application form. Completed CRB checks are held for a period of six months prior to bring destroyed. A record is then held of the individual reference numbers of the check. Three staff records were viewed and these had evidence of the recruitment checks having being carried out. One of the files seen had only one copy of a reference, however this recruitment had taken place some two and a half years ago prior to the present owners having responsibility for running of the home. On the files of staff seen there were records, which demonstrated that all had received an at least basic induction. The manager explained that a full day induction system was now in place and new paperwork was currently being refined. DS0000067853.V322722.R01.S.doc Version 5.2 Page 19 The level of formal qualification of staff remains low, the manager said that recently six further staff have commenced an NVQ, five have almost completed a qualification and one is presently undergoing validation. The standard in regard to formal qualifications of staff requires that 50 of care staff hold an NVQ level 2 qualification or equivalent and the home should continue to work wards this. Evidence of mandatory training was available on the staff records seen, including in areas such as medication, food hygiene, protection of vulnerable adults, first aid and working with dementia. Staff members observed during the visit were attentive to residents needs, were polite and treat people with dignity. One resident stated, “ Staff are always happy and thoughtful”. Numbers of staff available at the home have steadily increased under the new ownership, with some staff having left and others being recruited. The rota demonstrated that sufficient staff were available at different points of the day to meet the needs of residents. The management of the home are aware that the staffing levels will need to be continued to be monitored to ensure that they meet the required level as the number of residents in the home increases. There is a mix of experience and gender within the present staff group, which enables residents to have a choice of whom provides any personal aspect of their care. DS0000067853.V322722.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management of the service is carried out by a suitable and qualified manager. An internal quality assurance system is lacking which would enable interests of residents to be safeguarded. Full completion of records would benefit the interests of residents. Staff members are not currently appropriately supervised. EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection, experienced in residential care and holds a qualification in care and management. A care manager from the local authority who replied to a Commission for Social Care Inspection questionnaire stated that since the new manager had being in place, there had being dramatic changes for the better. DS0000067853.V322722.R01.S.doc Version 5.2 Page 21 The home does not yet have an internal quality assurance process, it being felt more important to concentrate on getting the premises and staff numbers and training situation to a suitable position first. The proprietor of the home stated that an internal quality assurance process would be introduced when this former work was complete. The home do receive input from the local authority quality development department. Individual supervision records of staff records were looked at, it was noted that whilst there had being some sessions carried out with staff these had being infrequent with some senior and care staff not having received formal supervision for the previous six months. There were some records which showed supervision had being planned but had not taken place. The manager explained that they were in the process of revamping the whole system, with herself and a senior initially carrying out a formal supervision session with every staff member. It is then intended to create a cascaded system of supervision with senior staff members taking responsibility for the development of care staff. All staff must receive supervision, which covers all areas specified in the relevant standard. Whilst there has being a great improvement in the number and content quality of records held, many of these are let down by the fact that they are either not signed by the person making the entry, are signed with initials only and are not dated. All records must be signed and dated appropriately. It was noted during the visit that the fire lists displayed at all final exit doors were not consistent in their make up. It is recommended that all such lists are kept up to date with the correct information. A whole range of generic risk assessments have now being carried out, which comprehensively cover all areas of the premises. Many of these however were not dated, it is important that all risk assessments which have being carried out are dated, to enable identification of the time they are due for reassessment to occur. Fire detection and fighting equipment was available within the home, a check of the fire extinguishers showed that they had being serviced in September 2006. DS0000067853.V322722.R01.S.doc Version 5.2 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 2 1 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 3 2 DS0000067853.V322722.R01.S.doc Version 5.2 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 OP1 Regulation 4 Requirement Information regarding the home must be made available to prospective residents and their relatives, allowing them to make an informed choice. Evidence must be available that residents/relatives have being provided with a copy of the statement of terms and conditions. Assessments carried out on prospective residents must be dated and signed evidencing that the home can meet the needs of the resident at that time. The recording and storage of all medication must be carried out accurately and safely. TIMESCALE OF 01/08/06 NOT MET. It must be ensured that the work planned to be carried out to the premises is completed and a plan of maintenance is available following the conclusion. DS0000067853.V322722.R01.S.doc Timescale for action 31/01/07 2. OP2 5 31/01/07 3. OP3 14 31/01/07 4. OP9 13 01/01/07 5. OP19 23 31/03/07 Version 5.2 Page 24 6. OP20 23 7. OP33 38 8. OP38 13 9. 10. OP38 OP36 13 18 11. OP12 16 Carpets in the communal areas and corridors of the ground floor must be replaced. TIMESCALE OF 14/09/06 NOT MET. An effective quality assurance process must be in place to ensure the aims and objectives of the home are being met. TIMESCALE OF 01/09/06 NOT MET. All required generic and individual risk assessments must be completed and up to date. TIMESCALE OF 30/09/06 NOT MET. All records held must be appropriately signed and dated. All staff must receive supervision as per the requirements of the standard. All areas specified in relation to staff development must be covered. TIMESCALE OF 01/08/06 NOT MET. All involvement of residents in local community and internal activities must be recorded comprehensively to evidence that specific needs are being met. 28/02/07 31/03/07 31/01/07 31/01/07 31/03/07 31/01/07 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 OP38 OP28 Good Practice Recommendations It is recommended that lists of residents to be used in an emergency are kept up to date and are consistent. 50 of care staff should be qualified to NVQ level 2 or equivalent. DS0000067853.V322722.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000067853.V322722.R01.S.doc Version 5.2 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. 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