Inspection on 16/11/05 for Bryony House

This inspection was carried out on 16th November 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

Bryony House 08/05/08

Bryony House 04/06/07

Bryony House 30/11/06

Bryony House 17/03/06

Bryony House 22/02/05

Bryony House 26/08/04

Bryony House 20/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bryony House 30 Bryony Road Selly Oak Birmingham B29 4BX Lead Inspector Brenda O’Neill Unannounced Inspection 16th November 2005 09:10 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 Bryony House DS0000016895.V265571.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. Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bryony House Address 30 Bryony Road Selly Oak Birmingham B29 4BX 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) 0121 475 2965 0121 680 1300 Bryony House Committee Ms Christine Hilton (Acting Manager) Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection February 22nd 2005. Brief Description of the Service: Bryony House is a purpose built residential home situated in a residential area within the Bournville Village Trust, providing care for up to 38 older people. There are shops and a church in the locality and easy access to the public bus service. Community facilities such as shops and churches are within walking distance. The home is a large three-storey building with a lower ground floor. The residents’ accommodation is situated on all floors of the home. There are toilets and bathrooms on all floors and several of the bedrooms have en-suite facilities. Lifts and stairs connect the separate floors. One shaft lift connects the ground floor with the lower ground floor and the other connects the ground floor to the first and second floors. There are also six flights of stairs throughout the home. On the ground floor are the main kitchen, a dining room and two lounges, office facilities and a hairdressing facility. There is also a lounge on the first floor. There is a large conservatory that leads out to the rear garden. At the front of the home there are parking spaces for several vehicles and there is a very attractive large private garden to the rear of the property. At the time of this inspection the home was undergoing extensive refurbishment to modernise and upgrade the premises. Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day in November 2005. This was the first of the two statutory visits for 2005/2006. During the inspection a partial tour of the premises was carried out, three resident and three staff files were sampled, maintenance records were checked and other documentation sampled. The inspector spoke with the deputy manager, four staff on duty at the time and seven of the twenty-five residents. What the service does well: What has improved since the last inspection? Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 6 A controlled medication cabinet had been installed in the home to ensure medication was stored safely. It was noted that the storage of accident records had improved, this was a requirement made following the last inspection. Storage complied with data protection guidelines. There had been several improvements in the environment and these were still ongoing. Assisted bathing facilities had vastly improved, bedrooms had ensuite facilities installed, there was a new heating system, new double glazing had been fitted and soft furnishings were also being renewed. 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. Bryony House DS0000016895.V265571.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 Bryony House DS0000016895.V265571.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): 3 and 5. The assessment procedures in the home were good ensuring the needs of prospective residents were known to staff prior to admission. Prospective residents were able to visit the home prior to admission to assess the suitability of the home. EVIDENCE: Three residents files were sampled during the course of the inspection. One of the files was for a resident who had been in the home for a considerable amount of time the other two were for fairly recent admissions. The two recently admitted individuals were known to the home as they had had respite care previously. There was evidence on the files that extensive assessments had been carried out and that the individuals concerned had been involved in these. The inspector was informed that the manager of the home visits any prospective residents and completes the documentation at that time. The areas assessed included, mobility, health and well-being, daily living skills and intellectual needs. The residents spoken with confirmed that they had visited the home prior to admission to see if they thought it met with their needs. Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 9 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 and 10. Care plans and risk assessments needed to be further developed to ensure they included sufficient detail to enable the residents’ needs to be met and ensure all identified risks were minimised. There needed to be improvements made to the medication system to ensure residents were not put at risk. The residents were satisfied that they were treated with respect and that their right to privacy was upheld. EVIDENCE: Three care plans were sampled during this visit. All the care plans had extensive assessment documentation included and there were several individual needs identified for each of the residents, for example, needs assistance with bathing, letters written may be helpful, help of carers to wash and dress. The care plans did not include, in most instances, specific details for staff of how they were to meet the identified needs of the residents. It was evident when speaking to one of the residents and some of the staff that she was receiving a lot more support with her personal care than was detailed in her file. There were care plan summaries but these had not been completed in all cases and where they had did not include sufficient detail for staff. The documentation being used for care planning was very good for assessments but not for concise care plans that staff could refer to easily. The residents had Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 10 been involved in drawing up the documents and there was a statement saying they would be reviewed three monthly. The requirement is that care plans are reviewed monthly. None of the files sampled included manual handling risk assessments and the only personal risk assessments were what the residents had perceived themselves as their risks when the assessment was being carried out. All residents needed to have manual handling risk assessments that detailed any handling methods to be used and also what actions were to be taken by staff in the event of a fall if the resident were not injured. Personal risk assessments needed to identify all risks and how these were to be minimised by staff. It was also noted that at least one of the residents had some challenging behaviours which needed to have some management strategies in place for staff to follow. There was good documented evidence of residents’ health care needs being identified, followed up and monitored by staff. There was evidence of visits from health care specialists including doctors, district nurses and chiropodists. Daily records evidenced personal care needs being met and residents were being weighed regularly. One of the residents spoken with confirmed she had been able to keep the doctor she had known for many years when admitted to the home. All the residents spoken with were satisfied there health care needs were being met and that they could see the doctor if they wished. The manager needed to ensure that all residents had simple tissue viability and nutritional screenings when admitted to the home to highlight any issues that may need monitoring or following up with the relevant professionals. The medication at the home was being administered via a 28-monitored dosage system. The inspector was informed that only senior staff administered medication and they had all received training. Two of the residents were self administering their medication and risk assessments had been undertaken for this and some compliance checks were being carried out. There was controlled medication in the home which was being stored and administered correctly. Copies of prescriptions were being kept and all medication was being acknowledged when it was received into the home. Any balances of medication carried forward at the end of the month were entered on to the medication administration records (MAR) ensuring the system was auditable in most cases. It was noted that staff had used tipex on the MAR charts on several occasions. Any errors made needed to be lined through not totally covered. Where variable doses of medication could be administered staff needed to identify how many tablets had been administered to ensure the medication could be audited. Several discrepancies in the amounts of tablets remaining in the home were noted when auditing some of the medicines and it was not possible to determine how this had occurred. The manager needed to ensure that regular staff drug audits were undertaken to ensure staff competency when administering medication. Any discrepancies in medication audits needed to be fully investigated and appropriate actions taken. It was also noted that Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 11 some PRN (as and when necessary) medication, other than painkillers, was being administered. The manager needed to ensure there were written guidelines for staff to follow to ensure they were consistent when administering. Residents spoken with were satisfied that staff treated them with respect and their right to privacy was upheld. The inspector spoke to some residents who chose to spend a lot of time of their bedrooms and staff respected this. All the bedrooms in the home were of single occupancy and all residents could have keys to their rooms if they wished. There were several areas in the home where residents could meet their visitors in private if they wished. There was a telephone for the use of the residents in the conservatory and several residents had their own telephones in the bedrooms. Staff were heard to address residents appropriately and there were friendly relationships evident. Bryony House DS0000016895.V265571.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 and 15. There were no rigid rules or routines in the home and there were activities on offer for residents if they wished to take part. The meals served in the home were good. EVIDENCE: The residents spoken with confirmed there were no rigid rules or routines in the home and they could spend their time as they chose. A programme of forthcoming activities was posted on the notice board so that residents knew what was available to them. Detailed activities included bingo, keep fit, films and visiting entertainers. Residents also commented on recent activities including a fireworks display and a visit to Walsall illuminations. Residents were observed to wander freely around the home, spend time in their bedrooms writing letters and reading, watching television, meeting with visitors or chatting in small groups. Several residents had newspapers delivered on a daily basis. Residents did comment on the disruption in the home due to the extensive refurbishment work that was ongoing however they were accepting of this and stated staff had tried to minimise the disruption to them as much as possible. Visitors were seen to come and go throughout the course of the inspection and all appeared to be made welcome by staff. There did not appear to be any restrictions on visitors to the home within reasonable hours. Residents spoken Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 13 with stated they could have visitors at any time and staff always informed them when their visitors had arrived. There was also the option for residents to have a meal with their relatives/friends in a smaller dining area if they wished. The menus seen at the home were varied and nutritious and although there were no stated choices at lunchtime there was an extensive list of alternatives available to the residents on display in the dining room. All the residents spoken with were satisfied with the catering arrangements at the home and confirmed they were asked prior to meal times what they would like to eat. Meals were seen to be served to residents in their bedrooms if they were unwell or did not wish to go into the dining room. Bryony House DS0000016895.V265571.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 There was an appropriate complaints procedure in the home. Residents were satisfied that if they raised any issues they would be addressed promptly by the staff. EVIDENCE: There was an appropriate complaints procedure on display in the home and residents spoken with confirmed they had received a copy of this. The complaint records were not inspected during this visit however it is known from the previous inspection that the staff at the home did investigate complaints as necessary. The residents spoken with confirmed that if any issues did arise they would have no hesitation in speaking to the manager or deputy manager and were confident that the issues would be resolved. Bryony House DS0000016895.V265571.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, 20, 21, 22, 24, 25 and 26. The home was undergoing extensive refurbishment, when this is complete the premises would offer a very high standard of accommodation for the residents. EVIDENCE: At the time of the inspection the home had been undergoing extensive building works and refurbishment and redecoration for a considerable amount of time. A partial tour of the premises was made. The home was found to be safe and well maintained. The home had ample communal space for all residents with two large lounges and a conservatory. One of the lounges had had all new armchairs since the last inspection. There were extensive very well maintained grounds to the rear of the home that were accessible to the residents. There were numerous toilets, bathing and showering facilities throughout the home. All bathrooms and some of the toilets had been upgraded and provided residents with a variety of facilities many of which allowed for full staff assistance. When all the building works are completed all bedrooms will have Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 16 en-suite facilities of toilet and wash hand basin and some had already had floor level showers fitted. The aids and adaptations throughout the home appeared to meet the needs of the residents and these included, shaft lifts, level entrances and exits, grab and hand rails, assisted bathing and toilet facilities, emergency call system and there were mobile hoists on site for use as necessary. The inspector viewed some of the completed bedrooms and spoke to some of the occupants. The residents spoken with were very happy with the newly refurbished rooms. Although they had had to move out of their rooms for a while whilst work was undertaken all stated it had been worth the disruption. All bedrooms were having en-suite facilities installed, new double glazed windows had been fitted, a new heating system installed and all were having new flooring, curtains and linen. All bedrooms were lockable and residents could have keys if they wished. The heating, lighting and ventilation appeared to meet the needs of the residents and were safe. At the time of the inspection the home was found to be acceptably clean, considering the amount of building work being undertaken, and odour free. The laundry had been refurbished and was appropriately equipped with washing machines with sluice facilities and tumble driers. There was also a newly installed commode pot washer/disinfector in a separate room. The kitchen had been refurbished and although not fully inspected on this occasion was seen to be well organised and very clean. Bryony House DS0000016895.V265571.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 and 29. Good staffing levels were being maintained by a stable staff team which was good for the continuity of care of the residents. The recruitment procedures were robust and offered the residents adequate safeguards but needed to be applied consistently across all staff. EVIDENCE: The home was well staffed on the day of the inspection and extra staff were on duty to assist with the moving of residents either back to their newly refurbished rooms or to another room so work could commence. Minimum staffing levels were being maintained at four care assistants throughout the waking day with the managers’ hours as supernumerary as well as numerous ancillary staff to undertake catering, domestic, reception and maintenance duties. All the residents spoken with were very positive about the staff team and comments included: ‘Staff are very pleasant.’ ‘Staff have been very kind, they bring my meals to me.’ ‘We have a core group of very loyal staff.’ ‘Staff are very nice they’re very kind.’ Several of the staff had worked at the home for a considerable amount of time which was very good for the continuity of care of the residents. One of the newer staff employed was spoken with and she stated the home was a nice place to work and staff were very friendly and worked well together. Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 18 The recruitment files for the three recently employed staff were inspected. Two of these included all the necessary documentation including, completed application forms, two written references, proof of I.D., medical declarations and POVA first checks. The third file included only one reference, the inspector was informed that a verbal reference had been obtained but there was no evidence of this on file. The POVA check for this person had been obtained after employment commenced but this had been based on a risk assessment as it was for an ancillary worker who would never be alone or have access to the residents unsupervised. It was noted that the application being used at the home had been changed. The one in use did not allow applicants to enter all the necessary information, for example, the names of two referees and there was little space for past employment history. This was discussed with the manager the day after the inspection when giving feed back to her and the newer form was part of a quality assurance system that was being implemented in the home. It was strongly recommended that the home either use the previous application form or a combination of both but ensuring all the necessary information is included. It was also strongly recommended that interview notes are kept and if gaps in employment were questioned notes were also retained. Bryony House DS0000016895.V265571.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 and 38. The manager ensured the smooth running of the home in a competent manner with the support of a senior team. Health and safety of the residents and staff were well managed. EVIDENCE: The acting manager was not on duty at the time of the inspection as she was at college. The inspector did contact her by telephone after the inspection to provide some feedback. She was aware of the shortfalls in the home particularly in relation to the care planning system and was committed to addressing this. The application for registration of the acting manager had been received by CSCI and was being processed. The inspector met with the deputy manager who had worked at the home for a considerable amount of time and had a very good knowledge of the residents’ needs and the running of a residential home. She had taken a lot of responsibility in organising the movement of residents and the refitting of the Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 20 rooms throughout the home during the ongoing refurbishment. Despite being very busy on the day of the inspection she managed the inspection with confidence. Considering the amount of building works going on at the home health and safety were being very well managed. Staff demonstrated how they were constantly aware of the dangers of having builders in the home who may not know the potential risks for the residents. There was evidence on site that all the required in house checks on the fire system were being carried out and that staff had received fire training and a drill had taken place. The maintenance operative had set up a folder for the fire officer detailing all alarm points, where extinguishers were located and all fire exits in the home. There was evidence that he had completed a fire safety manager’s course. There was evidence on site of the servicing of all equipment with the exception of the gas boilers. There were extensive risk assessments in relation to the premises that had been regularly reviewed and updated. There was also an extensive COSHH folder that included numerous data sheets for the products used in the home and COSHH substances were kept securely. Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 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(1)(b) (c) Requirement All residents must have care plans that detail how all their current needs in relation to health and welfare are to be met by staff. (Previous time scale of 31/05/05 not met.) Care plans must be reviewed monthly. All residents must have personal risk assessments that detail how any identified risks are to be minimised. Where any challenging behaviours are identified there must be strategies in place for managing these. All residents must have manual handling risk assessments that include details of the actions to be taken by staff in the event of a fall. All residents must have tissue viability and nutritional screenings. Staff must not use tipex on MAR charts. Where variable doses of DS0000016895.V265571.R01.S.doc Timescale for action 01/01/06 2 OP7 13(4)(b) (c) 01/01/06 3 OP7 13(5) 01/01/06 4 5 6 OP8 OP9 OP9 12(1)(a) 13(2) 13(2) 01/02/06 17/11/05 18/11/05 Page 23 Bryony House Version 5.0 7 OP9 13(2) medication can be given the amount administered must be indicated. Any discrepancies found in medication audits must be fully investigated. Regular staff drug audits must be undertaken to ensure the competency of staff. (Previous time scale of 28/02/05 not met.) There must be written protocols in place for the administration of PRN medication. Two written references must be obtained for all staff prior to their commencing their employment. The acting manager must ensure that all members of staff urgently receive moving and handling training. (Previous time scale of 31/05/05 not assessed for compliance at this visit.) The acting manager must complete her Care Manager’s Award by the end of 2005. (Timescale had not lapsed.) The registered manager is required to establish and maintain a formal system of Quality Assurance for reviewing and improving the quality of care. (Previous time scale of 31/05/05 not assessed for compliance at this visit.) There must be evidence on site that the gas boilers have been serviced. 24/11/05 8 9 OP9 OP29 13(2) 19(1) sch 2(5) 18(1)(c) 14/12/05 14/12/05 10 OP30 31/12/05 11 OP31 9(2)(b)(i) 31/12/05 12 OP33 24(1)(a) (b) 31/01/06 13 OP38 23(2)(c) 14/12/05 Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP29 OP29 Good Practice Recommendations It is strongly recommended that records are retained of staff employment interviews and discussions undertaken in relation to gaps in employment. It is strongly recommended that the application for employment form that was formerly used by the home be put back into use. Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bryony House DS0000016895.V265571.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!