Inspection on 14/11/06 for Birchwood

This inspection was carried out on 14th November 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

Birchwood 13/09/08

Birchwood 18/09/07

Birchwood 22/02/06

Birchwood 07/05/05

Birchwood 29/12/04

Birchwood 05/10/04

Birchwood 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Birchwood 35 Birchwood Road St Annes Brislington Bristol BS4 4QL Lead Inspector Sandra Gibson Key Unannounced Inspection 14th November 2006 10:00a 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 Birchwood DS0000036679.V317950.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. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birchwood Address 35 Birchwood Road St Annes Brislington Bristol BS4 4QL 0117 9712266 NONE 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) Bristol City Council Miss Debra Jane Clifford Care Home 30 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30) of places Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 30 persons aged 60 years and over. Date of last inspection 22nd February 2006 Brief Description of the Service: Birchwood is a large purpose built residential home operated by Bristol City Council. It is registered by The Commission for Social Care Inspection to provide personal care to 30 persons aged sixty five years and over with dementia. There is a condition to the registration which allows the home to accommodate 30 persons aged sixty years and over. All rooms are single and have been tastefully furnished to meet the individual needs of the occupants. The home is alarmed and secured, with a door entry system. There are spacious bright lounges for service users and their relatives to relax in and the dining room is well proportioned with ample space for moving around. There is an attractive courtyard with shrubs, plants and sitting area. Within the home there are aids and adaptations to aid mobility and this also includes hoists in the bathroom. Birchwood is situated in the south of Bristol and is on a major bus route. Fees are £584.99 week and extra charges are made for chiropody, hairdressing etc. Currently this information is initially only provided verbally prior to admission. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place midweek between the hours of 10am and 4 pm. Evidence was gathered from: Examining previous correspondence with the home including Regulation 37 (Death illness, other events notifications) and Regulation 26 monthly reports complied by the nominated responsible individual, inspection reports, information from pre inspection questionnaire, information from an independent survey of the home conducted in October 2006,relatives comment cards (20 sent 13 received), other visitors comments card (5 sent 1 received) talking to/observing residents, talking to the manager and deputy manager /talking to and observing staff, talking to two relatives talking to and case tracking four residents, examining records, policies and procedures. What the service does well: The system in place to assess a prospective resident’s needs is good. This information ensures that an individuals care needs are fully identified prior to admission. Residents’ physical and mental care needs are fully met and there have been further improvements in the medication administration system since the last inspection so that residents are better protected from risk of harm. Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. Residents and their relatives continue to be confident that their concerns will be listened too and have been made aware of the complaints procedure. Arrangements for protecting residents from harm are satisfactory. This ensures that residents are protected from harm possible risk or harm. Birchwood continues to be a clean, comfortable, safe home, which ensures that residents are kept safe from harm. The residents and staff team benefit from an experienced manager who has encouraged an open style management approach. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 6 Support to staff is satisfactory. There are systems in place to ensure that residents benefit from staff that are appropriately supervised. There are satisfactory systems in place to ensure those residents’ financial interests and valuables are safeguarded by the homes record keeping, policies and procedures. 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. The summary of this inspection report can be made available in other formats on request. Birchwood DS0000036679.V317950.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 Birchwood DS0000036679.V317950.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Following the last inspection minor attention was made to the information provided to residents and their representatives. This information now ensures that new residents can make informed choices about the home and that they can be sure their rights will be safeguarded. The system in place to assess a prospective resident’s needs is good . This information ensures that an individuals care needs are fully identified prior to admission. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 9 EVIDENCE: The statement of purpose and service users guide was examined. Birchwood provides accommodation for men and women aged over 60 years and will reserve up to two beds as a respite and emergency facility for people who are aged over 60 years or in exceptional and extreme cases, not younger than 55 years. There is currently one permanent resident accommodated who is now 60 years and another resident who is 61 years. Following the last inspection information has been added to the service users guide about how the home meet the national minimum standards for younger adults for example, staff training provided and exactly what facilities and activities are available for any residents under sixty five years. Evidence seen at the time of the inspection confirmed that these younger residents individual needs continue to be met by the staff team based at Birchwood. The manager informed the inspector that following a decision made by the Director of Adult Community Care (Bristol City Council) all care homes that provide dementia care will now be known as Elderly Persons Homes (EPH) for people with dementia (PWD) as instead of Elderly Mentally Infirm (EMI). A letter confirmed this information. The inspector advised that the statement of purpose and service users guide would need to be up dated with this information to avoid any confusion. The assessment documentation in place meets the national minimum standards. There is also an admission procedure checklist to prompt staff. A sample of needs assessments were examined and it was noted that they were up to date and accurate. Birchwood DS0000036679.V317950.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The completition of care plans with residents and their represenatatives has improved further since the last inspection and there are plans to develop the care plans further to ensure that staff are fully aware of residents’ individual needs. Residents’ physical and mental care needs are fully met and there have been further improvements in the medication administration system since the last inspection so that residents are better protected from risk of harm. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 11 EVIDENCE: A sample of individual care plans were examined. There was some evidence of further development and increased involvement of residents and their representatives in drawing up individual care plans. The manager explained that there were plans in place to obtain pen pictures of residents which would help staff get to know individual residents better. This is good practice when working with residents with dementia. Comments received included “my husband does not like to be bathed by women. A male carer does this now and he is much happier”. Another relative said, “My….has only been in the home for a short time. At present everyone from top to bottom has been very kind and helpful. If I have asked for anything whilst visiting they have delivered where possible right away” There was evidence in place to confirm that General Practitioners, psychiatrists, district nurses, opticians, dentists and chiropodists are all contacted at the appropriate time. Records all confirmed that residents were assisted to attend hospital appointments where planned. A psychiatrist was a visiting resident on the day of the inspection. Evidence confirmed that communication with multidisciplinary teams was good. Equipment was observed to be in place to prevent pressure sores in residents who were at risk. The medication administration system was examined and a sample check of medication administered was carried out. The records were found to be up to date and accurate. There is a programme of medication training in place for all staff involved in medication administration. The home has clear and robust practices for the care of residents who are dying. This was confirmed in Regulation 37 notifications sent to The Commission for social care Inspection in respect of residents who had died since the last inspection. Birchwood DS0000036679.V317950.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. 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. The opportunities to experience a stimulating and varied life have reduced since the last inspection with a result that the residents’ quality of life has deteriorated slightly. Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. EVIDENCE: Evidence in place confirmed that social activities do take place in the home on a regular basis; a church choir, an organ player, a bingo organiser, three entertainers including a keyboard player were all noted to visit. There are also plans in place for a pantomime during the Christmas period. Some resident attend a local day centre. Residents also have access to an aroma therapist, a hairdresser and health and beauty sessions on a regular basis. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 13 Records also confirmed that two clothes shows visit on a regular basis so that residents can choose their own clothes. Comments received from a visitor to the home included “I find the residents of Birchwood very well cared for”. However during the course of the inspection evidence confirmed that staff have less time to spend with residents on a one to one basis either taking them to the local shops, chatting with the resident and some times their family, or spending time reminiscing. This is a result of a high level of agency staff particularly on an evening and weekends, which will be discussed, further in the section on staffing. Evidence also confirmed that there were plans in place to reduce residents’ key time (one to one) with staff by seven hours each week. This reduced time for individual activities was also highlighted in the independent survey conducted in the home in October 2006. One relative said, “The activities planned with my mother rarely happen. There are so many agency staff that routines get broken”. There is now a refurbished lounge in the home that has been made into a reminiscence room using posters and memorabilia. Residents can access this room independently or be escorted by staff when they have time. Evidence confirmed that one of the residents under 65 years is assisted to choose her / his own clothes, which are appropriate to her/his age. Staff accompany this resident to the video shop to choose videos s/he enjoyed and to buy take away curries or other fast food that was not provided in the home. On the day of the inspection residents were spending time listening to music or talking to members of staff or visitors. Visitors confirmed that they were made very welcome in the home and that staff were very approachable. One relative said I am pleased that mum is getting very good care. The staff are always friendly and nothing is too much for them” Evidence confirmed that a key objective for the home is for residents to maintain independence and be enabled to make their own decisions about how they whish to live. Menus were inspected and were found to be balanced and appetising. Meal times are also flexible enough to accommodate individual preferences. Evidence confirmed that some residents choose to eat in their bedrooms. The inspector joined in the relaxed communal lunch held in the dining room. Residents were seen being assisted by staff members to make choices about the meal they wanted. There was evidence of fresh fruit and vegetables provided on a regular basis. Residents were seen enjoying the food and the company. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 14 A relative said “I have not seen food as I go home at lunch time, but I had to buy new clothes for my husband as he has put weight on since he moved in”. Another relative said he was very pleased with the care. He said his wife looked well and that she enjoys the food”. Birchwood DS0000036679.V317950.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. Residents and their relatives continue to be confident that their concerns will be listened too and have been made aware of the complaints procedure Arrangements for protecting residents from harm are satisfactory. This ensures that residents are protected from harm possible risk or harm. EVIDENCE: Residents, visitors and staff told the inspector that they were comfortable talking to the manager or one of the management team about any concerns. Residents were seen actively seeking out the members of the management team on duty that day with any concerns they had. No complaints have been received either by the manager, complaints manager for Social Services and Health or The Commission for Social Care Inspection since the last inspection. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 16 The majority of residents surveys received confirmed that relatives were aware of the complaints procedure. A new residents relative said, “So far I have no complaints what so ever thank you very much”. Another relative said I feel that my … is well looked after and they are very friendly staff. They give the best care they can. The manager and deputy are always there to take care and listen”. Two relatives seen during the inspection confirmed that they were aware of the complaints procedure and said, “I would talk to officer if concerned about anything”. Another relative said, “I would go the office if I was concerned about No Secrets in Bristol (Local authority Adult Protection procedure) is in place in the home. And the majority of staff have now received adult protection training provided by the Local Authority Safe guarding Adults Coordinator. Staff are the home regularly inform the Commission for Social Care Inspection regarding any events that affect the welfare of a resident and any adult protection matters are dealt with appropriately. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 17 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): 20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Birchwood continues to be a clean, comfortable, safe home, which ensures that residents are kept safe from harm. EVIDENCE: The inspector was updated about the changes in the environment since the last inspection. Evidence confirmed that disabled access has improved through out the home. All lounges have been decorated and there is a programme of decoration in place to redecorate the bedrooms. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 18 In general, the environment is well maintained and suited to residents needs. Birchwood is decorated and furnished to a standard that creates a comfortable homely atmosphere despite it being a purpose built building. There are a number of small lounges through the home in the care home which residents were seen using and appeared comfortable and relaxed. The home smelt fresh and the rooms were cleaned to a high standard. Residents’ bedrooms looked homely and were personalised with residents’ personal possessions and furniture. The toilet and bathroom facilities are sufficient to meet the needs of the residents. The garden and courtyard at Birchwood are well maintained. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 19 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): 27,28,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The ratio of permanent staff at Birchwood is not satisfactory. Urgent attention must be given to the employment of permanent staff in sufficient numbers to ensure that residents’ needs are consistently met. The majority of permanent staff are trained and competent to do their job. However urgent attention is required to ensure that all agency staff have the necessary skills and knowledge to ensure that residents are in safe hands at all times. EVIDENCE: Rotas show that minimum staffing levels are met on the majority of occasions, but this is only managed with a high level of agency staff to fill the gaps in the rota. The inspector was informed that permanent staff are to be redeployed to the home following the closure of another local authority home. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 20 Evidence confirmed that the same staff were used where possible to ensure a consistency in the care provided to residents but sometimes this was not possible. From the information received there had been concerns raised by staff about the use of a high level of new agency staff on an evening/weekends who did not hold the necessary skills or knowledge to provide the personal care or domestic care required for the residents of Birchwood. Evidence confirmed that the manger monitored this use of agency staff and she had raised concerns with senior management about the training agency staff received prior to working at Birchwood. However relatives confirmed concerns raised by the permanent staff. Comments received included “There are so many agency staff routines are broken –this is very frustrating for everyone and does not help the running of the home”. Another relative said, “They are always understaffed and there are always new faces. It is not good for people with dementia. They do not like change it confuses them”. This information was also highlighted in the independent survey conducted in the home in October 2006 The manager ensures that all permanent staff receive relevant training that is targeted to meet the needs of the residents accommodated in the home. There is a programme of statutory training which includes basic food hygiene, first aid, manual handling and Protection of vulnerable Adults. Records confirmed that NVQ training is progressing well. Training in this care home also includes dementia care training, mental health training and loss and bereavement. Communication between residents and staff was noted to be very good and all staff observed were very sensitive to residents’ needs and spoke to with respect and understanding of residents needs. The recruitment procedure was not inspected during this inspection as the staff personnel files are held centrally by Bristol City Council Adult Community care personnel department. These files will be inspected separately following an agreement between Bristol City Council Adult Community Care Team and The Commission for Social Care Inspection. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents and staff team benefit from an experienced manager who has encouraged an open style management approach. Support to staff is satisfactory. There are systems in place to ensure that residents benefit from staff that are appropriately supervised. There are satisfactory systems in place to ensure those residents’ financial interests and valuables are safeguarded by the homes record keeping, policies and procedures. Minor improvements are required to ensure that all required records are available for inspection so that service users rights and best interest are protected at all times. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager was present during the inspection. Evidence confirmed that she has the required experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and transparent in all areas of running the home. All staff and relatives consulted confirmed that the manager continues to be very approachable and supportive. Regular staff meetings take place. Staff confirmed this information. Member of staff consulted said if you cannot attend the meetings any issues you wish to raise are brought up for you. Records confirmed that staff supervision is taking place for all members of staff. The care staff and domestic assistants on duty confirmed this that day that all said that they felt very well supported and that the officer responsible for their individual supervision was very approachable. However, the staff supervision records were not available for inspection. A sample of other records that are required to be available for inspection were found to be secure and well maintained. The fire log was examined. All periodic checks and tests were found to be up to date and that day and night staff receive fire safety training as out lined in the recommendations by Avon Fire Brigade The Commission receives regular reports for Social Care Inspection from the nominated responsible individual who conducts monthly visits to the home. The system in place for carrying out and reporting these visits is currently being reviewed. A programme of independent surveys conducted in the local authority home commenced in September 2006. This information supports the quality assurance system in place The financial arrangements for managing residents finances and valuables is satisfactory Birchwood is operated by Bristol city Council and the registered person has the skills and ability to deliver good business planning effective financial controls and provides a quality assurance and monitoring process. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 23 There was information in place to confirm that staff attend regular staff meetings and that supervision is provided on a regular basis. The staff and officers seen at the time of the inspection confirmed this information. Staff said, “They felt listened to” Records confirmed that the finances held on behalf of residents are well managed and there are systems in place to protect the resident best interests including their finances. Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 24 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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 25 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 OP12 Regulation 16(6) Requirement Arrangements must be made to ensure that all residents are provided with meaningful key working time (one to one on a regular basis each week. A review of the staffing team numbers must be completed. The staff vacancies must be addressed in this review and a plan sent to the CSCI demonstrating how the vacancies are going to be filled and what arrangements are in plan to ensure that residents receive consistent care from trained competent staff at all times. Timescale for action 15/05/07 2. OP27 18(1)(a) (b)(c) 15/02/07 Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 26 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 OP36 Good Practice Recommendations Supervision records must be available for inspection Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Birchwood DS0000036679.V317950.R01.S.doc Version 5.2 Page 28 - 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. 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