Inspection on 25/10/05 for Bramble House

This inspection was carried out on 25th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Bramble House 17/09/09

Bramble House 17/09/08

Bramble House 20/09/07

Bramble House 13/11/06

Bramble House 19/06/06

Bramble House 25/04/05

Bramble House 26/10/04

Bramble House 02/06/04

Bramble House 16/12/03

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

CARE HOMES FOR OLDER PEOPLE Acefield Care Home 96a & 98 Stroud Road Gloucester Glos GL1 5AJ Lead Inspector Mrs Janet Griffiths Announced Inspection 25th October 2005 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 Acefield Care Home DS0000016357.V253698.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. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Acefield Care Home Address 96a & 98 Stroud Road Gloucester Glos GL1 5AJ 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) 01452 521018 Forestglade Limited Mrs Vivian Dawn Grimes Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age (2) of places Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 Brief Description of the Service: Acefield Residential Care Home is situated on the outskirts of the city of Gloucester and is within easy walking distance of a local shopping complex. A major building project, completed last year, has joined the large detached house and an adjacent house via a link corridor. The first floor of the main house is accessed either by stairs, a shaft lift or a stair lift. In addition to the above work, by constructing a conservatory and improving the existing lounge/diner, the communal space has been increased. A small quiet lounge is currently being used by the activities co-ordinator and will be used for one to one activities and as a quieet room. With another extension at the rear of the building, the home is now registered to accommodate 30 elderly service users. This extension consists of four single en-suite rooms, new office space and an assisted bathroom. To complete this work, the kitchen has been enlarged and totally refurbished and a new laundry, sluice and shower room have been built. The area that was previously the adjacent house has also been refurbished and extended to provide two extra bedrooms, one en-suite, an assisted bathroom and toilet and the small activities/quiet lounge. Access to the first floor in this half of the building is via a stair lift. There are four assisted baths and a shower within the home and there are now fourteen rooms with en-suite facilities. The home still has extensive gardens at the rear of the building and adjacent to the conservatory, with orchards, vines and fruit that the cook is able to utilise. Additional carparking space has been created at the front of the building. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over seven hours of one day in October 2005. One inspector carried out the inspection with a regulation manager attending the first half of the inspection to look closely at the environment. The manager was present throughout the day and the registered individual for part of the day. In addition to a full inspection of the premises, residents and staff were spoken with and the records of some residents were looked at in detail as part of a case tracking exercise. New staff records and other relevant records were also seen. What the service does well: What has improved since the last inspection? An activities co-ordinator was appointed earlier in the year and is now well established providing a varied activities programme for both group and one to one activities and a much more stimulating environment was evident at the inspection. A new larger shaft lift has finally been fitted which provided much better access to the upper floor of the main home. Every resident, to include those admitted for respite care are now fully assessed prior to admission to ensure that the home is able to meet the needs of each resident before they are admitted. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 6 The recruitment process is now much more robust with all new files checked containing all the required paperwork and necessary checks before staff are appointed. The medication system is gradually improving, helped by separate storage for permanent and respite residents, better maintained records and a regular audit being carried out by the manager. 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. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 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 Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Residents are given clear information regarding the service but some amendments to the service users guide are still necessary. Progress has been made on improving the admission procedure and an assessment is completed for every service user prior to admission. EVIDENCE: There were three residents receiving respite care at the time of inspection. All had assessments completed by Social Services and these were checked and signed by the manager on admission. All three residents on respite care were seen and spoken with and all were satisfied with the care received and the facilities provided. However, there had been an unfortunate incident with the loss of some money from one resident and an investigation was underway and compensation was being organised. All had a copy of the service users guide in their rooms. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 9 Some amendments have been made but since the change of use from smoke room to activities room further amendments are required to inform everyone either that the home is now non-smoking or what provisions are being made for any smokers in the home. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents appear to be well looked after in respect of their health and personal care needs. There has been a marked improvement in the medication procedures. Service users feel that they are treated with respect and that their privacy and dignity is maintained. EVIDENCE: Records of one permanent resident and three residents receiving respite care were all looked at in detail. As before, other than an assessment/care plan from social services, a moving and handling assessment and daily records there is no other documentation for those residents on respite care but the assessment is checked by the manager on admission and if any changes were required or care needs identified that required a care plan then this would be completed. Records belonging to a resident on long-term care contained a pre-admission and admission assessment that are reviewed regularly, a moving and handling assessment also reviewed regularly and several care plans. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 11 This reflected most of the care needs of this resident but a care plan for pressure area needs for someone on permanent bed rest was missing. On the whole the standard of daily records has improved but the standard is variable with some being very brief and carelessly completed, not recording full names, and in one entry recording on another resident. Staff must be reminded that these are legal documents and must be carefully maintained. From records and discussions with the manager and service users it was confirmed that other agencies are referred to where necessary. For example the resident on permanent bed rest is monitored by the district nurse regularly for skin integrity; the continence advisor also visits regularly to assess new and all other residents for their continence needs; the community psychiatric nurses are called if advice or reassessment is necessary and dentist, optician, and chiropodist call regularly with doctors visiting on request. Reference to a visit for one resident from a psychiatrist and to another who had been terminally ill, from the Macmillan nurses was also seen. There are no residents at present with a history of wandering or of frequent falls and no serious accidents reported. A record of all accidents is maintained. One resident had previously been referred to the ‘falls nurse’ but is now less mobile. Only one resident currently requires a soft diet but several were observed receiving assistance with their meals and this was carried out in a sensitive manner. There have been serious concerns over recent months regarding the medication administration and storage practices and the home has received several visits from the CSCI pharmacy inspector and immediate requirement notices have been given. Although the medication storage area ideally needs a new secure door, the area was securely locked on this occasion. The home now has two medication trolley’s for permanent and respite residents which makes administration that much easier and safer. All medication seen had been dated on opening and records were well maintained. A new medication policy has also been compiled and each carer has received a copy. The manager also conducts two-weekly medication audits. Staff who administer medications are current undertaking distance learning medication training and records of their progress are sent to CSCI each month. Locks are not routinely fitted onto doors of residents’ rooms but they may have them fitted if they wish and this is indicated in the service users guide. One resident has requested a lock and now has one fitted; another room has a lock from a previous occupant. It was noted in one room that a safety chain was fitted inside the room (apparently a request of a previous occupant). This is now to be removed. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Residents are now experiencing a much more stimulating and varied life at the home with visitors and community links encouraged, various informal activities being made available and appetising food being provided. EVIDENCE: A new activities co-ordinator has been appointed over the last few months and has greatly improved the atmosphere in the home and the quality of life of the service users. A weekly programme of group and one to one activities is planned and a record is kept of the activities undertaken by each resident. The main conservatory area was a ‘buzz’ of activity during the morning of the inspection with approximately six residents making decorations in preparation for Halloween. During the afternoon, a lot more were engaged in a popular game of bingo. A montage of photographs of recent events were on display in the entrance to the conservatory, one such event being a ‘pink day’ fund raising event for breast cancer where the home raised £200. Another was a visit from ‘Pets as Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 13 Therapy’ and there was a very positive response to this from some resident who may not respond to many of the other activities. Music and movement and several visiting entertainers are booked regularly and another popular event was a cinema afternoon when a video of choice was shown and ice creams were served in the interval. The home has also restored their links with the local church and several resident visited for the harvest festival recently and monthly communion is held at the home. A choir also performed at the home the previous weekend and links with the local brownies and cubs are being sought, as is the mobile library, and the lobby to the conservatory is now attractively furnished as a quiet/reading area. One resident who at the last inspection had complained that he had not been out for months has recently been on a trip to town which he thoroughly enjoyed especially as he met a number of his acquaintances. Two ladies were out at a local club they visit weekly and another continues to attend her local WI. Visitors are encouraged and a number of residents go out regularly with their relatives. One gentleman said how lucky he was that his son and daughter took it in turns to take him out each week. One relative was helping her mother with the morning activities making Halloween decorations. Residents confirmed that they are given the choice of how and where they spend their days; two of those on respite care preferred to remain in their rooms most of the time although one did join the other residents for lunch; the third was taking a stroll round the garden during the morning. The majority of others tended to spend their days in one of the two lounges and have their meals in the dining area. All of the residents spoken with were very happy with the quality and quantity of food provided. They are not offered a choice at lunchtime but there is a list displayed in the kitchen of individuals preferences and alternatives are available. A list is kept of all the food provided although it was advised that when a ‘choice of sandwiches ‘ is listed, so should be what is used as sandwich fillers to ensure that residents are not being served the same food every day. Special dietary needs are catered for as was confirmed by one gentleman who is a diabetic, and supplements are provided where necessary. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a satisfactory complaints system in place, ensuring the protection of residents. EVIDENCE: Previously both the CSCI and Social Services have received and investigated a number of complaints about this home but there have been none over the last few months. There is a complaints procedure in place and this is clearly accessible in the service users guide in each resident’s room. A number of permanent residents and those receiving respite care were spoken with during the day and all were very happy with the care they received and the facilities provided in the home. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19; 26 The standard of décor within this home is slowly improving but varies between the older and newer buildings. There is still a great deal of room for improvement to ensure a consistent standard for all residents. The standard of cleanliness also needs to be more robust. EVIDENCE: A full inspection of the premises was completed both with the manager and responsible individual. A new shaft lift has finally been installed after many months of problems and has much improved the access within the home. New carpeting has been fitted throughout the ground and first floor corridors, with just one area adjacent to the conservatory still to be completed. New bedroom furniture has been purchased for one empty room, but more work is required before this room is ready to accept a new resident. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 16 However, it was obvious to the inspectors that there is not a regular thorough check of the building as there were minor/major maintenance jobs to be completed in almost every room, some rooms requiring redecoration and refurbishment and worn and stained furniture still being used. All of the inspectors’ findings will be listed individually in a separate letter to the responsible individual with a time scale given as to when these tasks must be completed, as many of these have been identified with the responsible individual at previous visits/meetings. The home has also undergone several changes of call bell systems over the years resulting in a number of now obsolete wiring systems that must be checked and removed. In addition to this although superficially clean in most areas, there were layers of dust pointed out in at least one room, toilets and baths needing cleaning, a number of sink plugs missing, some odorous areas and some stained carpets. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staff are employed in sufficient numbers to meet the residents needs. Staff morale remains high with a low staff turnover that ensures consistency for the residents. The procedures for the recruitment of staff have improved but must be maintained to protect the people living in the home. A staff training programme is now in place but needs to be developed to include NVQ training. EVIDENCE: There appeared to be adequate staff on-duty during the day of inspection to meet the needs of the residents and observations and residents comments confirmed this. In addition to care staff, the activities co-ordinator, two cleaners, a cook and a handyman were present. A new cook and a new carer for night-duty had been appointed since the last inspection and their records were checked. All the required documentation and checks were in place. All the criminal record checks completed since the last inspection were also seen and noted. However it was noted that someone appointed prior to the last inspection did not have a POVA check or CRB as the home was using the previous CRB check. This is not acceptable and a further check is to be made and CSCI advised when this has been returned, to be seen by the inspector. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 18 Since the last inspection the home has commenced a modular distancelearning programme for a number of topics to include medications. A monthly progress sheet has been sent to CSCI for monitoring and gradual progress appears to be taking place. This progress needs to be maintained by all the staff and audited for its effectiveness. However, despite enquiries being made into a source of NVQ training, no applications have been made as yet. The home has not met the standard for 50 of care staff with NVQ 2. It was reported that there are plans for 10 staff to be put forward and of these 5 are keen to commence. One the care staff has now completed a moving and handling trainers course (certificate seen) and has taken on the responsibility of training and updating staff on moving and handling and supervising staff on these practices. The manager has also completed a trainer’s course for Practical First-Aid and is now able to instruct staff on these procedures. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 The leadership, guidance and direction to staff has improved but could be made more formal through regular staff meetings and there still does not appear to be a clear development plan in place for the home. This still results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. There are processes in place to safeguard the financial interests of service users but problems have arisen where service users are not willing to follow these procedures. The systems for service user consultation have also improved but there is still little evidence that all their views have been acted upon. EVIDENCE: The deputy manager is currently on long-term sick leave and the responsible individual has been asked by CSCI to look at acting arrangements to ensure Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 20 that all the managerial responsibilities are met. This has not been addressed to date. Handovers take place at each shift change and handover records are kept, which is when daily communications between the staff take place but no formal staff meetings have been held, although the manager did report that she had met with both day and night staff two weeks before the inspection. Rotas now indicate which carer is responsible for medication administration and which carer takes charge of the shift in the absence of the manager to ensure accountability is maintained. The manager does not act as an appointee for any residents’ pension and does not deal with any financial transactions for the residents. This is the sole responsibility of the residents and their families. Money had been taken into safe- keeping for one resident on respite care and this was held securely and a record kept but this practice is discouraged. Another resident on respite care had unfortunately reported a sum of money missing during their stay, having refused to hand it in for safe keeping. This was reported to the police and was being investigated. It was also reported on a Regulation 37 to CSCI, who were told that the resident would be compensated for their loss. The registered provider is now carrying out Regulation 26 visits and has submitted some monthly reports to the CSCI. To date this has not been totally consistent. This must be maintained monthly. Although the home has commenced a quality assurance programme and sent surveys to each resident/their families, the results of these have not yet been collated and an improvement plan developed to indicate that the views given have been acknowledged and/or acted upon. A programme of staff supervision is now in place and records were seen to confirm this. This generally takes the form of supervision of specific duties such as medications, bathing, nutrition, infection control, night-duty and moving and handling procedures. Domestic staff are also supervised in their cleaning procedures. The home now appears to be maintaining all the required records to include care records, staff records, supervision and training records, photographs of all residents and a record of visitors and food (see standard 15) A policy for either no smoking or provisions to be made for smokers needs to be put in place within the home; the smoking room being no longer available. There was less evidence of doors being wedged open on this occasion but continues to be several potential health and safety risks identified during the tour of the building to include superfluous wiring; inadequate floor coverings, cracked glass and inadequate cleaning processes. There are also potential Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 21 hazards within the garden and a risk assessment is required for this to ensure that it is made safe and secure and could be an excellent further resource for residents and their families to spend their time when the weather allows. Again, al these will be identified in a separate letter to be addressed within an identified timescale. Records were seen to indicate that servicing of equipment such as the hoists, the sluice master and the water systems were being serviced/maintained regularly. Acefield Care Home DS0000016357.V253698.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 3 3 2 Acefield Care Home DS0000016357.V253698.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 OP1 Regulation 6 Requirement Ensure that the Statement of Purpose and Service Users guide are reviewed regularly and revised where necessary. Ensure that individual care plans reflect current needs of service users. A rolling programme of maintenance, redecoration and refurbishment must be implemented and maintained in accordance with separate letter to the responsible individual. Ensure that all areas are kept clean and odour free(timescale of 26/11/04 and 31/5/05 not met). The registered person shall not employ a person to work at the care home unless the person is fit to work at the home and the registered person has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of Schedule 2 (Timescale of DS0000016357.V253698.R01.S.doc Timescale for action 30/11/05 2 3 OP7 OP19 15 23 30/11/05 31/12/05 4 OP26 16 30/11/05 5 OP29 19 30/11/05 Acefield Care Home Version 5.0 Page 24 31/5/05 not met in full). 6 OP30 18 Ensure that persons employed by the registered person receive training appropriate to the work they are to perform and suitable assistance including time off, for the purpose of obtaining further qualifications appropriate (timescale of 26/11/04 and 31/5/05 not met) The registered manager shall undertake such training as is appropriate to ensure that she has the experience and skills necessary for managng the care home. A system is maintained for reviewing the quality of care an improving the care provided at the care home to include month submission of a report to the Commission. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated (timescale of 31/5/05 not met in full). 31/12/05 7 OP31 10 31/12/05 8 OP33 24 31/12/05 9 OP38 13 31/12/05 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 3 4 Refer to Standard OP1 OP7 OP28 OP31 Good Practice Recommendations Make necessary amendments to service users guide to reflect changes in the home. Daily records must be clearly written, accurate, completed in full and consistent. A minimum ratio of 50 trained members of care staff (NVQ 2 or equivalent) is achieved by 2005. Arrnagements are in place for an acting deputy manager to ensure that the manager can fulfil all the managerial DS0000016357.V253698.R01.S.doc Version 5.0 Page 25 Acefield Care Home duties and complete the necessary management training. Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Acefield Care Home DS0000016357.V253698.R01.S.doc Version 5.0 Page 27 - 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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