Inspection on 24/05/05 for Brooklands House

This inspection was carried out on 24th May 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

Brooklands House 11/11/08

Brooklands House 30/07/07

Brooklands House 24/04/06

Brooklands House 10/10/05

Brooklands House 18/10/04

Brooklands House 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brooklands House 3 Woodville Terrace Lytham St Annes Lancashire FY8 5QB Lead Inspector Denise Upton Announced 24 May 2005 th 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 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. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brooklands House Address 3 Woodville Terrace Lytham St Annes Lancashire FY8 5QB 01253 736 393 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) GilliganPJ22@aol.com Mrs Carol Gilligan Mrs Carol Gilligan Care Home 25 Category(ies) of Old Age (OP0) 25 registration, with number of places Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for a maximum of 25 service users in the category of OP (Older Persons over the age of 65 years). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 18th October 2004 Brief Description of the Service: Brooklands House is situated in a quiet residential area of Lytham but in close proximity to Lowther Gardens, the promenade, the main shopping area of the town and community facilities and resourses. The home is arranged over two floors with the majority of service users accommodated in single bedroom accommodation. Only one bedroom is for shared occupancy. The home is registered to accommodate up to 25 older people who do not require nursing care. Mr and Mrs Gilligan are the registered providers and a new manager has recently been appointed. At this present time, Mrs Gilligan oversees the running of the home and directs all professional issues and care practices. Training is viewed as a positive tool to improve standards and to provide a high quality service. All staff are expected to undertake revelant training including nationally recognised N.V.Q. training and become accredited to a minimum of Level 2. Personal care is provided as required and specialised needs can be catered for. Any nursing needs are referred to the community district nursing team. In house activities are arranged and service users can choose whether to participate or not. Visitors are welcome at any time of the service users choice and can be entertained in the privacy of the residents individual bedroom accommodation or any communal area of the home. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a day and a half and in total spanned a period of 11 hours. The inspector spoke individually with the home’s owner and manager and individual ‘in depth’ discussion took place with five of the residents living at the home, and three relatives of service users who visited during the course of the inspection. In addition, individual discussion took place with three members of the care staff team and a college tutor who was also visiting the home regarding a nationally recognised training course for care staff. A number of records and policies and procedures were also examined and a partial tour of the building took place. What the service does well: What has improved since the last inspection? Some of the suggestions made at the last inspection regarding medication issues have now been put into practice however there are still some outstanding things that need to be done. The staff have also made improvements to the recording of some of the written information held. Further staff are now undertaking nationally recognised training for care staff that will help increase the skills they need to look after older people in the best Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 6 way possible. Staff morale has improved recently since the appointment of a new manager and staff are working well together to provide a good service. Residents spoken with said they got on well with other people who lived at the home and the support of the staff group. 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. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 standard(s) 3 The pre-admission assessment form used to identify what the prospective resident can do well and what help may be required, is completed by the proprietor to supplement the information provided by other professionals in respect of the individual’s medical, personal and social care requirements. This process enables an informed decision to be taken as to whether the prospective service users current strengths and needs could be met by the home. However the information written on the home’s pre admission assessment form could be more detailed, especially with regard to prospective service users who have not required a further professional assessment in order to provide staff with sufficient information to devise a comprehensive initial individual care plan. EVIDENCE: Service users are only admitted to the home following a pre admission assessment by the proprietor of current strengths and needs. Evidence was also available of multi disciplinary assessments from health and social care professionals that had been provided prior to admission. Whilst collectively this provided sufficient written information in respect of prospective users who had Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 9 been assessed by other professionals, information recorded on the home’s pre admission assessment document was limited and not recorded in sufficient detail to provide a holistic account of the prospective service users needs in order to evidence if current requirements could be met or to inform the care planning process. Whilst it is acknowledged that the pre admission assessment document itself is comprehensive and staff spoken with were clearly aware of the needs of the most recently admitted service users, their immediate requirements were not necessarily clearly reflected in the written pre admission assessment. Following the pre admission assessment process, it was evident that each newly admitted service user had a plan of care for daily living based on the care management assessment and care plan or on the home’s own strengths and needs pre admission assessment outcomes. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10 Although each service has an individual plan of care, there is only limited detail recorded that does not provide staff with the written information they need to satisfactorily meet service users needs in a consistent way. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. Although some improvement was noted in the management of medication, staff have still not been provided with medication training despite this being made a requirement following the last inspection visit. This could potentially place service users at risk or harm. EVIDENCE: All service users at Brooklands House have an individual plan of care based on current assessed strengths and needs that is developed from the initial assessment process. However the development of the care plan is poor and does not reflect the holistic needs and requirements of service users accommodated. In addition, although an individual risk may have been identified, a formal written risk assessment is not routinely undertaken with outcomes incorporated in the care plan. There was no evidence to suggest that care plans had been formally reviewed on at least a monthly basis or amended as required. One service user recently sustained a broken hip, but on discharge from hospital the care plan had not been revised and amended to inform staff Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 11 of changing needs and did not provide a detailed record of the current requirements of the service user. Whilst there is no suggestion that service users needs and requirements are not been adequately addressed in practice, care plans should be expanded and further developed to ensure they provide a full and accurate account of current strengths, needs and requirements. Care plans should also be reviewed on at least a monthly basis and signed by the service user where-ever possible as their acknowledgement of and understanding of the content of the care plan. In instances where the service user does not have mental capacity to understand and sign their care plan, with the service user’s permission, the content of the care plan could be discussed with a family member(s) who may wish to sign the care plan on their relatives behalf. If the service user does not sign the individual care plan, the reason should be identified on the care plan. Service users and a relative spoken with were, in the main, vague as to the existence of their individual care plan. It is recommended that the content of the care plan is discussed with the individual service user at each review especially if amendments are required, in order to keep the service user informed and to elicit their views. It was evidenced through discussion with service users, relatives and staff and observation of documentation that service users health needs are fully met. There is a good relationship with health and social care professionals in order to maintain service users health and social well-being. It is understood that opportunities are given for appropriate exercise and physical activity for service users who wish to participate and one to one visits out of the building are arranged with family or members of staff. Although some improvements were noted in response to the requirements and recommendations made in respect of medication issues identified at the last inspection, further progress and development is still required. In particular, as identified in the last inspection report, staff with responsibility for medication administration must receive suitable certificated medication handling training in order to provide staff with the appropriate skills, knowledge and understanding of medication issues and to protect service users from potential harm. Please advise in the action Plan of the date this training has been arranged. Recording of medication administered should be routinely monitored on a regular basis to advise staff quickly of any incorrect procedure and it is recommended that the person who ‘audits’ the medication administration records sign and date the documents to provide a permanent record. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 standard(s) None of the four Standards were assessed at this inspection. EVIDENCE: None of the four standards were assessed at this inspection. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 & 18 The home has developed a satisfactory complaints system and adult abuse policy and procedures for the protection of service users. However as recommended in the last inspection report, staff have yet to receive formal training in the area of abuse and protection. By undertaking specific training in respect of these issues, staff would be provided with increased knowledge and understanding that would further protect service users. EVIDENCE: Since the last inspection, the Commission For Social Care Inspection received one anonymous complaint in respect of Brooklands House. This was investigated by the proprietor and found to be unsubstantiated. There is a satisfactory complaints procedure that is displayed in the entrance hall and also incorporated in the Statement of Purpose and Service Users Guide to inform service users and their relatives of how to make a complaint. It was however recommended that a structured complaint record form be developed to record the nature of the complaint, detail of the investigation, the outcome of the investigation, any action taken as a result of the investigation and the date the complainant was informed of the findings of their complaint. Likewise written policies were evidenced in respect of abuse, risk taking and abuse, whistle blowing and bullying. It is understood that further policies in respect of physical intervention, physical restraint, service users monies and financial affairs, and staff involvement in the making of or benefiting from service users wills are also developed but could not be located at the time of inspection. There is an expectation that all staff should read and understand Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 14 the home’s main policies and procedures and staff sign a form to this effect indicating their understanding of the document read. As previously recommended, staff have still not attended formal abuse and protection training that would strengthen their knowledge and understanding of the topic despite this being made a requirement in several previous reports. It is understood that adult abuse training has now been arranged to take place in September 2005 and it is anticipated that all staff will attend. A relative spoken with at the time of inspection stated that a minor concern had been raised with the proprietor that had been immediately addressed to their satisfaction. Service users individually spoken with also confirmed that the management team respond to any concern immediately to try and resolve the issue as soon as possible. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 standard(s) 26 Brooklands House provides a comfortable environment for service users to enjoy that is maintained in a clean and hygienic condition and free from offensive odours. A number of staff have now attended infection control training. This training should continue for the remainder the staff to ensure the staff group have sufficient understanding of the topic and a consistent approach is taken in respect of the control of infection. EVIDENCE: The home is maintained in a clean, comfortable and hygienic condition that is free from offensive odours. Laundry facilities are appropriately sited in an area of the home that does not intrude on service users. Appropriate measures are taken for the removal of clinical waste. Policies and procedures have been developed for the control of infection and a number of staff have now undertaken infection control training. It is understood that all remaining staff will attend this training in the near future. It was very evident that service users can take personal items including small pieces of furniture into the home on admission to make their personal space Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 16 more familiar and to ease the transition into residential care. On relative spoken with described his relatives personal accommodation as ‘could not be better’ and another visitor stated the bedroom accommodation of his friend was very comfortable and ‘smack on’. Service users spoken with also said they were comfortable in their bedroom accommodation. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 Recruitment processes based on the amended Care Standards Act Regulations had not been followed resulting in service users receiving care from three staff members who had not been properly vetted. This potentially leaves people who use the service at risk. Staff training has been given priority to ensure staff have the skills and knowledge to provide a good quality service. Staff moral is high resulting in an enthusiastic workforce that work positively with service users to help maintain or improve their quality of life. EVIDENCE: Brooklands House has a positive staff group who support the proprietor to provide a good quality service and address the individual strengths and needs of service users accommodated. The relationship observed between staff, residents and relatives was comfortable and relaxed. The number of staff and skill mix is kept under constant review by the proprietor to ensure that service users individual needs and requirements can be fully met. Staff training is considered important in providing a well qualified workforce and currently six members of care staff team hold an NVQ Level 2 in care, another five members of staff are currently undertaking this course of study and a further member of staff is undertaking Level 3 of this award. In addition, further short course training has also been undertaken by a number of staff covering a variety of topics but further specific training, required by regulation, is required to be undertaken by a further number of staff. At the time of inspection an NVQ College Tutor was visiting the home who stated that the home had been chosen to take part in a pilot NVQ programme Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 18 because of a good and positive working relationship with the proprietor in the past. It was evident that induction training is made available to newly appointed staff however there was no indication that the current induction training programme had been evidenced against the TOPSS specifications to ensure compliance. Induction training to TOPSS specification should be provided to newly appointed care staff within the first six weeks of employment and foundation training to TOPSS specifications should be developed and introduced and provided to staff within the first six months of employment. Three new members of staff took up employment at the home in recent months however a Criminal Record Bureau clearance and POVA first clearance that is required by regulation had not be submitted as part of the recruitment process. These clearances should have been obtained and deemed to be satisfactory prior to the applicants taking up post. An immediate requirement notice was issued for the proprietor to ensure that these checks are taken up retrospectively and that all appropriate clearances are taken up prior to any further new members of staff starting work at the home. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35 & 36 The systems for service user consultation are good with systems in place to indicate that service users views are both sought and acted upon. All service users, wherever possible, are encouraged to remain financially independent enabling each service user to continue to manage their own financial affairs without the involvement of the home. The system of staff supervision has of late, been informal. Regular formal staff supervision should be reintroduced covering a variety of topics to ensure staff are fulfilling their role to the level expected and as a forum to guide their work practices. EVIDENCE: Anonymous questionnaires were developed and provided to service users, relatives and other visitors to complete approximately twelve months ago. It is understood that this process is to be repeated in the near future. In addition, newly admitted service users are also provided with a separate questionnaire about three weeks after admission to elicit their views on their admission to the home and staff also has opportunity to complete an anonymous Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 20 questionnaire. Service user meetings have taken place in the past however service users have stated that they do not feel formal meetings are useful and do not want any more to take place. To address the issue of consulting with service users, a new system is to be introduced whereby senior care staff will speak individually with a number of service users each week to enable residents to air their views and opinions. It is understood that residents have approved of this suggestion. Residents spoken with during the course of the inspection were clear however that if they had anything to say they could talk with the owner or the manager at any time that were both ‘very good’. In addition, Brooklands House has achieved the professionally recognised ‘Investor In People Award’ to supplement the internal quality assurance systems in place. Although all residents are encouraged to maintain control of their own financial affairs or assisted in this task by their family or an external advocate, appropriate systems are in place for the safe keeping if service users monies and valuables. However a policy and procedure document in respect of service users monies and valuables was not available at the time of inspection and should be developed. Over recent months formal staff supervision has been allowed to lapse. However following the appointment of a new manager, it is anticipated that formal one to one supervision will be reintroduced on at least a monthly basis for all staff covering at minimum all aspects of practice, philosophy of care in the home and career development needs. In addition, it is planned that bi annual appraisals will also be introduced. To supplement these formal processes, all staff is informally supervised as part of the normal management process on a continuous basis. The management team have already acknowledged that the existing policy and procedures will need to be amended to reflect the anticipated changes. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 2 2 x x Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement Timescale for action 31/08/05 2. 9 13 & 18 3. 4. 18 29 13 19 Care plans must be further developed to provide a holistic account of current strengths and needs and identify how these are to be addressed. Formal risk assessments must be undertaken as required with outcomes incorporated in the care plan. (Timescale of (31/12/04 not met) The manager to ensure that all 31/08/05 staff that administer medication have received suitable certificated medication handling training and ensure that refrigated items are securely stored. (Timescale of 31/11/04 not met) All staff must receive appropriate 16/09/05 Adult Abuse Training Newly appointed staff must only Immediate take up employment at the home when all the required references and clearances have been received and deemed to be satisfactory. Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 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. 2. 3. 4. 5. 6. 7. Refer to Standard 3 7 9 16 26 29 30 Good Practice Recommendations The pre admission assessment document completed by the home should be more detailed and initial risk assessments developed as required. Care plans should be a working document, signed by the service user and formally reviewed on at least a monthly basis. It is recommended that who ever undertakes the drug administration records audit sign and date the documents to this effect. A complaint record form should be developed to formally record information in respect of the complaint. Formal training in infection control should be provided to the remaining staff who have not undertaken this training. Copies of the General Social Care Council Code of Conduct should be obtained and made available to all staff. Current induction training should be evidenced against TOPSS induction training specifications to ensure compliance and foundation training to TOPSS specifications developed. Further policies and procedures should be developed including policies and procedures in respect of service users monies and existing policies and procedures kept under regular review. Formal documentated one to one staff supervision should be reintroduced. 8. 33 9. 36 Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit 1, Tustin Court Portway Preston PR2 2YQ 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 Brooklands House F57 F09 S9800 Brooklands House V204050 240505 Stage 4.doc Version 1.30 Page 25 - 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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