Inspection on 31/10/06 for Broadoaks

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broadoaks 12/08/08

Broadoaks 17/09/07

Broadoaks 16/01/06

Broadoaks 03/08/05

Broadoaks 20/01/05

Broadoaks 20/09/04

Broadoaks 24/03/04

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

CARE HOMES FOR OLDER PEOPLE Broadoaks 2 Southend Road Rochford Essex SS4 1HA Lead Inspector Ms Vicky Dutton Unannounced Inspection 31st October 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broadoaks DS0000018064.V317710.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. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoaks Address 2 Southend Road Rochford Essex SS4 1HA 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) 01702 545888 01702 546442 Eastwood Hall Limited Mrs Agnes Stubbings Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Broadoaks is a large detached 19th century Manor House situated close to Rochford town centre. Care and accommodation is provided for twenty residents. The home is not registered to admit service users who are diagnosed as suffering from dementia. Accommodation is provided on two floors with a shaft lift to enable access. Bedrooms are all single rooms with en suite facilities. The Home has two lounges, a pleasant dining room and a visitors room. There is parking to the front of the building and a secure garden with seating available to the side of the building. The Home shares a minibus with three sister homes, and this is available to provide transport and outings for service users. The registered providers have a website that can be accessed on www.crollgroup.co.uk The home has a statement of purpose and service users guide available. Information about the home and most recent inspection report are available to residents/visitors in the lobby area of the home and copies. An information pack including a copy of the most recent inspection report is provided to each new resident. It was confirmed at the site visit that the current fees at the home are £486.00 to £560.00. There are additional charges for chiropody, hairdressing, personal items, newspapers/magazines, some transport costs and any privately arranged therapies. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced ‘key’ site visit. The inspection was undertaken over a five and a half hour period. At this inspection all the key standards, and the homes progress against their previous agenda for action were assessed. Prior to the site visit the home had submitted a well completed pre-inspection questionnaire, and provided additional information that assisted with the inspection process. At the site visit a partial tour of the premises took place, care, staff, and other records and documentation were selected at random and various elements of these assessed. A notice was displayed in the home advising all visitors that an inspection site visit was taking place with an open invitation to speak with an inspector. During the site visit residents, and some of the homes staff were spoken with. As part of this key inspection questionnaires were sent out in the post to relatives and health and social care professionals. Staff, residents and relatives/visitors surveys were left at the home to be completed by any who wished to do so. The views expressed at the site visit and survey responses have been incorporated into this report. The inspector was assisted at the site visit by a senior member of staff, and other members of the staff team. Feedback on findings was given throughout the day, and summarised at the end of the day. The opportunity for discussion or clarification was given and a feedback card left with the home. What the service does well: Those residents spoken with and feedback received all expressed a high level of satisfaction by the service offered at Broadoaks. Comments such as ‘This is a very well run home’ and ‘I am pleased with the care my relative receives at Broadoaks.’ Were common from relatives and ‘I love it here’ and ‘Lovely girls, lovely food, just press a button and they are there’ were common from residents. Broadoaks provides a comfortable, well maintained and furnished environment for residents. The registered manager at the home has a ‘hands on’ approach, and has a good knowledge of all the residents and their needs. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 6 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. Broadoaks DS0000018064.V317710.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 Broadoaks DS0000018064.V317710.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, 3, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given sufficient information before they decide to move into the home. Prospective residents have their needs assessed before moving into the home. Staff at Broadoaks have received appropriate training to help them to meet residents needs. EVIDENCE: When an initial enquiry is made regarding an admission. An information pack is sent out to the enquirer by the organisations head office. A further pack is available in a resident’s room when they are admitted. The home completes a post admission questionnaire with each new resident. Those viewed showed that people felt that they had received very good information about the home, that their questions had been answered very well, and that the admission process had been well managed. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 9 Files of recently admitted resident’s showed that their needs had been assessed before they moved into the home. Staff records sampled showed that they had received appropriate induction and general training to meet the needs of residents. Residents spoken with felt that staff cared for them well and attended to their needs. Although the home is not registered to admit residents who suffer from dementia the home has some residents who show signs of dementia and confusion. Staff at the home have completed training in dementia awareness, further training is due to take place within the next few weeks. Intermediate care is not provided at Broadoaks. Broadoaks DS0000018064.V317710.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health and care needs are identified and planed for to a degree but development is needed to ensure that care plans are comprehensive, current and used by staff. Medication practices at the home are generally well managed and ensure that residents are kept safe. EVIDENCE: A care plan was in place for each service user. Those viewed did not identify how resident’s holistic needs were to be met. The assessment for one resident identified that they liked to wear make up and nail varnish, they had also been a member of a local church. A district nurse had been attending a wound on their leg. None of these issues were identified on the care plan. For another resident a range of different medical conditions had been identified, the implications of which had not been addressed as part of care planning. Information was available in different elements of the care file such as moving and handling assessments, reviews and general risk assessments but this information had not been brought together in the care plan. Daily records often Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 11 identified that residents had received assistance with personal care; assistance required was not identified in care planning. Residents current daily records are still kept in a separate folder from their individual care plans. This is not best practice and will not encourage care staff to refer to and use care plans on a regular basis. Records, observations and discussions with residents showed that the home monitor and address their health care needs. Feedback from health care professionals was very positive. One GP said that ‘I am very happy with the care given to my patients at this residential home.’ Another medical professional said ‘This is a very well run home. I would be able to retire here knowing that everything would be done for me.’ Opportunities are provided for optical checks and regular chiropody. Since the previous inspection an improved nutrition record has been put in place and residents weight is now regularly monitored. Pressure relieving equipment was noted to be available to help residents in maintaining healthy pressure areas, or assist healing. The home uses a monitored dosage system of medication administration. (Blister packs.) Medication systems and records were sampled and showed that residents are kept safe by good practices being maintained. Best practice does however need to be ensured in by protocols being in place for the administration of medication prescribed as and when required (PRN). As raised at the last inspection entries handwritten on to the medication administration records should be double signed. During the inspection residents were treated with respect and their privacy and dignity upheld. A pay phone is available and many residents have their own private phone installed in their rooms. Broadoaks DS0000018064.V317710.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 good. This judgement has been made using available evidence including a visit to this service. Some activities are provided at the home to provide stimulation and occupation for residents. The food provided by the home is plentiful, but menus may need to be reviewed to provide greater variety. Residents are offered choice in daily routines, but the home need to make sure that practices around the use walking aids are in line with individual needs and assessments. EVIDENCE: The home employs two part time staff who provide activities with residents on four afternoons (two hours) each week. The senior carer assisting with the inspection said that care staff did provide activities at other times. It was noted that each activity co-ordinator keeps their own assessment sheets and record of activities undertaken on different formats. This means that each resident has two records for the same area of care. This practice needs to be reviewed by the home. Records showed that a good range of activities are undertaken by residents. Individual needs are taken into account and, for example, talking books/newspapers arranged for those with visual difficulties. It was reported that more outings have taken place this year and that entertainers visit the home on a regular basis. Social events, such as recent barbeque are held at the home that relatives are invited to. Residents spoken with were Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 13 generally happy with the level of activity provided. Feedback from staff said that they also felt that the home provided a good level and variety of activity for residents. Routines are flexible. Residents spoken with felt that they could choose their own routines such as getting up and going to bed. Preferred routines were identified to a degree on care plans. The home need to review within an individual risk assessment framework the practice of removing residents walking aids when they are in the lounge/dining area. Resident supervision in the lounge area was intermittent. Although the practice of removing aids is said to be in place to ‘keep residents safe’, it limits residents choices and is an infringement of their rights. The home also need to make sure that when residents choose to remain in their rooms, they have means of calling for assistance. Arrangements are in place for residents to meet their spiritual needs. Visitors are welcome at the home at any time and positive feedback was received from relatives who said that ‘the staff are all very kind.’ Information on advocacy services was available in the ‘Residents Information’ book in the entrance hall of the home. Bedrooms at the home were very personalised showing that residents are encouraged to bring in their own possessions. The dining room at Broadoaks is comfortable and airy. New furnishings have just been purchased these enhance the environment for residents and provide seating that is safer for residents and staff to use. The tables were nicely laid and presented. Residents were generally positive about the food provided by the home. It was noted however that the home only operate a two weekly rotating menu for lunch, with many items offered being similar across the two weeks. The home should consult with residents to gauge if this meets their need and expectations. Resident’s meals are served in their rooms if they do not wish to go to the dining room. When this occurred, trays used were nicely done and reflected resident’s preferences. The daily menu is written up on a whiteboard in the dining room. Lunch of the day of inspection looked appetising and was well presented. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place. Staff have received training in adult protection. EVIDENCE: The home has a complaints procedure in place. It was discussed with the senior on duty that the home may need to review this procedure in line with recent guidance given by CSCI. A copy of the newsletter outlining this was left at the home. The homes complaints record showed that no complaints have been received by the home. Feedback from residents and relatives showed that people were aware of the homes complaints procedure. Previous inspections have shown that the home has suitable policies and procedures in place to protect residents from abuse. Information about adult protection was available in the home. Staff training records showed that all staff, including housekeeping staff, have undertaken training covering adult protection issues. A senior member of staff spoken with showed an understanding of reporting procedures. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Broadoaks live in a comfortable and homely environment. The home is kept clean and well maintained. EVIDENCE: Broadoaks provides a comfortable and well maintained home for residents. The homes grounds are secure and provide a safe outdoor environment. Residents spoken with felt that the home was very nice and comfortable. Access to the front of the home is via two steps and this was raised as an issue by one relative. Ramped access is however available to the side of the home. Aids are available to assist residents but the homes corridors are not fitted with grab rails that may be of benefit for some residents. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 16 The home employs housekeeping staff during weekday mornings. On the day of inspection all areas of the Home were found to be cleaned to a good standard and were odour free. Feedback received showed that people were happy with this aspect of the service. ’Their room is always neat and clean.’ Was one comment received. The laundry area was clean and tidy. It was noted that the laundry was kept open by the use of a door guard. The home needs to ensure that this does not place any residents at risk. Training records showed that staff had been trained in relevant areas such as infection control and COSHH procedures. Management at the home need to ensure that knowledge gained in training is carried out in practice by staff. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Development is needed to make sure that residents are protected by robust and consistent recruitment practices being maintained at all times. Staff are offered induction and training opportunities to enhance their knowledge and enable them to care well for residents. EVIDENCE: Broadoaks minimum staffing levels are currently maintained at: • One in charge plus two care staff during the morning afternoon and evening. • One in charge plus one care staff at night. Staff spoken with felt that these levels were sufficient to meet the current needs of residents who they felt were low to medium dependency. At the time of the inspection the home also had three rooms unoccupied. Domestic cover at the home is only provided during weekdays in the mornings. On several days each week there is no cover in the kitchen after mid afternoon. Care staff must therefore undertake additional tasks at these times. The home must make sure that this does not detract from the consistency of care or supervision offered to residents. As stated earlier supervision of residents in the lounge area of the home was intermitient. The home has a history of a high staff turnover. Currently, the inspector was told that, there are no care staff vacancies, and that the home has reduced their dependency on agency staff. This will improve consistency of care for residents. Also since the Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 18 previous inspection a deputy manager has been recruited, to strengthen local management. Many positive comments were made about the staff at the home. ‘Lovely girls’, ‘Manager and staff all very nice.’ Identified on the home pre inspection questionnaire and confirmed at the site visit. Four staff at the home have NVQ level two or above. It was reported that approximately a further seven staff will commence NVQ training at the end of the year. Recruitment is mainly managed centrally and checks for the protection of resident’s are carried out by the organisation. The files of three recently recruited staff were viewed at this inspection. Each showed shortfalls in the levels of checks undertaken and information available to show that safe recruitment practices are maintained. One file had no Criminal Records Bureau (CRB) check in place, only one reference (not from most recent employer) and no proof of identification on file. Another did not have a second reference in place. Another had no recent photograph, and no evidence of a POVA 1st check or CRB, apart from a copy of a CRB from a previous employer. The files of two recently appointed staff showed that an induction programme was being undertaken. This programme is compliant with Skills for Care standards. Staff training records have been reorganised since the previous inspection. This made it possible to see that staff at the home are offered a good range of ongoing training opportunities to assist them in safely meeting the needs of residents. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home consults with residents and others about their views of the home. Where the home holds monies for residents, this is managed safely. The home is generally managed to ensure the safety of residents. EVIDENCE: Broadoaks has an experienced registered manager in post. The registered manager has undertaken relevant training, but has yet to undertake the currently recommended formal qualifications for this role. The registered provider has strategies in place to monitor the quality of the service provided. Annual surveys are undertaken using questionnaires. Residents are also asked about their experience of admission to the home. Regular residents meetings are held. The minutes of these identified that the Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 20 views of residents who did not wish to attend the meeting were sought on an individual basis. The registered provider arranges for regular visits to be carried out as required under Regulation 26 of the Care Homes Regulations. These visits check that the home is being run effectively and should seek resident and staff views. Copies of reports of these visits were seen to be maintained in the home. An annual development plan for 2005 was in place but none could be found for 2006. Residents’ finances are mostly managed by their families, or solicitors. Records of resident’s monies held for safekeeping and transactions were sampled. They were well maintained and accurate. The pre-inspection questionnaire completed by the home showed that systems and services are regularly serviced and maintained. The home has policies and procedures in place relating to all aspects of health and safety. Staff training records sampled showed that staff training in core areas such as moving and handling is maintained. Staff on duty were unsure if a risk assessment had been completed in respect of the prevention of legionella at the home. Fire records showed that only one fire drill involving five staff has taken place so far this year. It was also noted that all recorded drills had taken place in the mornings. Senior staff said that staff had fire training, and that theses issues were covered at induction and in supervision. However regular drills should be undertaken so that residents know that all staff have the skills to react appropriately in the event of an emergency. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X X 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement The registered person(s) must ensure that residents care plans reflect all of their health and welfare needs. Previous requirement dates of 01/10/05 and 01/04/06 not met. 2. OP12 12 (2)(3) The registered person(s) must make proper provision for the health and welfare of residents. This refers to the need to review the practice of removing residents walking aids. 01/01/07 Timescale for action 01/01/07 3. OP29 19 The registered person(s) must 01/01/07 demonstrate that robust recruitment procedures are in place and maintained. This refers to the need for all required checks to be carried out and for this information to be available for inspection. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person(s) should review the practice of keeping daily records separate from care plans to make sure that care staff make full use of important information about residents. The registered person(s) should review the format of current care plans to ensure that they are adequate to identify all residents needs and the actions needed by staff to meet theses needs. The registered person(s) should make sure that the best practice issues in relation to medication identified in the report are addressed. The practice of activity co-ordinators maintaining separate records should be reviewed to provide consistent and unified information on residents. The registered person(s) should consult with residents to make sure that the two week rotating menu meets with their needs and expectations. The registered person(s) should review access arrangements for the building to ensure that they meet the needs of all residents. To assist residents the registered person(s) should give consideration to the provision of grab rails in the corridor areas of the home. The registered person(s) should monitor staff practice and understanding of training in relation to infection control procedures. The registered person(s) should keep the level/designation/deployment of staff under review to be sure that they remain sufficient to meet residents needs at all times. DS0000018064.V317710.R01.S.doc Version 5.2 Page 24 2. OP7 3. OP9 4. OP12 5. OP15 6. OP19 7. OP19 8. OP26 9. OP27 Broadoaks 10. 11. 12. OP28 OP38 OP38 50 of care staff should be trained to NVQ level 2 or above. A risk assessment in relation to the control of legionella should be completed. The registered person(s) should make sure that staff receive adequate fire training, including the attendance of regular drills. Broadoaks DS0000018064.V317710.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Broadoaks DS0000018064.V317710.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. 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