Inspection on 13/06/06 for Casa Mia

This inspection was carried out on 13th June 2006.

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

Casa Mia 23/02/09

Casa Mia 23/04/07

Casa Mia 29/03/06

Casa Mia 08/09/05

Casa Mia 23/03/05

Casa Mia 27/07/04

Casa Mia 03/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOMES FOR OLDER PEOPLE Casa Mia Cleobury Road Far Forest Near Kidderminster Worcestershire DY14 9EH Lead Inspector Y South Unannounced Inspection 13th June 2006 10:00 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 Casa Mia DS0000018499.V299031.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. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Casa Mia Address Cleobury Road Far Forest Near Kidderminster Worcestershire DY14 9EH 01299 266317 01299 266406 martin@casa-mia.org.uk www.casa-mia.org.uk Mr Martin James Winfield Mrs Michelle Dawn Winfield Mr Martin James Winfield Care Home 15 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) Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability over 65 years of age of places (15) Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may also accommodate a maximum of 3 people over 55 with a mental disorder, subject to discussion and agreement with the Commission prior to each admission. The home may also accommodate a maximum of 3 people over 55 with a learning disability, subject to discussion and agreement with the Commission prior to each admission. The home may also accommodate a maximum of 3 people over 65 years of age with dementia illness. The home may also accommodate one named person under the age of 65 years. 29th March 2006 2. 3. 4. Date of last inspection Brief Description of the Service: The home provides care for up to a maximum of fifteen older people who may also have a physical disability. Within that number the service can accommodate up to three people over 65 with dementia, up to three people over 55 years with a mental health need, and up to three people over 55 with a learning disability. In addition a recent variation was also agreed regarding the home accommodating one named resident under the age of 65 years. The home is located in a rural area of Far Forest near to Kidderminster. It provides level accommodation throughout the ground floor, and two bedrooms on the first floor. There are outdoor facilities on two levels, comprising of an attractive patio area and a lower garden - which is accessible to all residents via a ramp. The registered providers are Mr Martin Winfield and Mrs Michelle Winfield. Mr Martin Winfield has responsibility for management of the home. In the Documentation received by the CSCI on 26.06.06 Mr Winfield stated that the fees for accommodation and care were between £350 and £550. Additional charges were made for hairdressing, holidays, transport, toiletries, newspapers and magazines, reflexology and massage. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social care Inspection since 29.03.06 and the information obtained during a site visit on 15.06.06. The site visit extended over eight hours during which the inspector spoke to four residents, three staff and the manager. A tour of the premises was undertaken. Questionnaires were sent to the residents, relatives and health care professionals by the Commission for Social care Inspection and to date sixteen responses have been received. The focus of this inspection was on the key National Minimum Standards and the requirements and recommendation that arose out of the previous inspection. What the service does well: The service is family owned and managed. Several members of the family are involved and inconsequence the home has a family atmosphere. A relative has commented this on favourably. Other relatives commented that they are made to feel welcome, residents are comfortable and happy, senior staff take great pains to give residents time, attention and a listening ear, residents receive good home cooking, residents seem very well looked after and are very happy, and a large range of activities are provided for those who wish to join in. Staff receive the training they need to provide the care the individual residents’ need. The house s clean and well furnished. A redecoration and maintenance programme is currently underway. Casa Mia DS0000018499.V299031.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. Casa Mia DS0000018499.V299031.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 Casa Mia DS0000018499.V299031.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have access to the information they need about the home to enable them to make a decision regarding their future accommodation and care. Everyone is assessed before admission to ensure the home is able to provide the care they need. EVIDENCE: The residents confirmed that they had been given the information they needed to help them make up their minds and they had been able to visit the home before they made any decision regarding their future. This was endorsed in the questionnaire responses the Commission for Social Care Inspection had received. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 9 The residents also remembered that someone had visited them and asked ‘lots of questions’ before they moved in. Their records indicted that assessments had be carried out, they had visited the home and undertaken trial visits before making any decision regarding the home and their care. A contract with social services was in one file that was inspected and a copy of the home’s contract was in another. It was suggested that everyone should have a copy of the home’s contract, even if this was in addition to a social services contract, as the document clearly stated the terms and conditions under which the person agreed to be a resident, including the numbers if the room they were to occupy and the cost of their accommodation and care. Intermediate care is not offered in this home. Casa Mia DS0000018499.V299031.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have access to care plans that describe the care each person needs. Health care is monitored and appropriate responses are made. Medication is generally well managed in a safe way and residents receive their medication as prescribed. EVIDENCE: Two care records were inspected and although one care plan was not dated and signed, they were detailed and informative. Risk assessments had been carried out and documented and the daily records were very well maintained. All documents had been appropriately reviewed. However detailed pressure care and nutritional risk assessments had not been undertaken and kept under review. This should be done on admission and regularly reviewed thereafter. Especially where there are concerns. Concerns should trigger a care plan. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 11 Two requirements were made of the manager in the previous report; that residents care plans and risk assessments must be up-dated and must accurately reflect all residents’ care needs and the daily notes must be accurate, reflecting of the events surrounding individual residents daily events. Both of these requirements had been met. Residents were most complimentary regarding the care they received and this was endorsed in the questionnaire responses seen and observations made during the site visit. Relatives described the care as very attentive, and considered residents received a very good level of care. A doctor said that the residents were well looked after. However one relative had concerns regarding the detail of information that passed between one shift and the next as her questions regarding her mother could not always be answered. The records demonstrated that appropriate responses had been made to health concerns. Residents said that they saw the doctor when necessary and the staff gave them their medication. None of the current residents managed their own medication. Medication records were well maintained. Storage facilities needed to be increased as the controlled drugs cupboard was also used to store stock of other medicines. Requirements were made in the previous report as follows; • The registered provider must ensure that policies and procedures relating to medication are reviewed. • The registered provider must ensure that medication is suitably secured. This includes the medication trolley chained to the wall and the safekeeping of the keys upon a nominated person. • The registered manager must ensure that Medication Administration Record (MAR) sheets are signed after medication has been administered to residents. The reason for any non-administration of prescribed medication to service users must be clearly entered onto the MAR sheets. • The registered manager must ensure that accurate records are maintained within the controlled drugs register for all medication which is controlled or those needing to be regarded as controlled. • The registered manager must ensure that all medication, including inhalers, are dated upon opening in order that a full medication audit can be carried out. Observation and inspection confirmed that these tasks had all been attended to. Staff and their training records indicated that training in the management of medication had been undertaken. Casa Mia DS0000018499.V299031.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 at least once during a 12 month period. 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. Residents are able to live the lives they choose as individuals, having opportunities and support to make choices regarding their care and social events. A good standard and choice of meals is provided that residents enjoy. EVIDENCE: Residents confirmed in the questionnaire responses that a range of activities were provided. The arts and craft activities organiser said in the questionnaire response that everyone was encouraged to join in and she was introduced to everyone who moved into the home. The residents showed the inspector a range of personal activities they had undertaken. These included painting, patchwork, crochet, knitting, gardening and bird watching. One resident said that she was able to visit the local shop, help with house keeping tasks, visit the local town and go out for a meal. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 13 The inspector observed residents enjoying the garden, watching the fish on the pond, quizzes, singing, having a massage, doing crochet and knitting. The residents confirmed that the vicar called at least each month and Communion was served to those who wished to participate. The daily records gave a good account of involvement. The manager said that a holiday had been booked for eleven residents and five staff this summer together in Tenby. Social events were being organised to raise money for a minibus. The next event was to be supper with entertainment. Casa Mia DS0000018499.V299031.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have confidence to raise their concerns with the staff and manager. There is a complaints procedure, whistle blowing procedure and Protection of Vulnerable Adults procedure available to advise and guide staff to respond appropriately to any issues that may arise. The lack of structured training puts residents at risk as staff may not be able to identify concerns. A recording system is necessary to enable an audit of the management of complaints, and should it be necessary improve the service. EVIDENCE: The complaint procedure in the Statement of Purpose was seen. Three relatives said in the questionnaire responses that they did not know the complaints procedure. It is suggested that when the review of the Service Users’ Guide is completed and all residents are given their copies all principle relatives are informed and their attention is drawn to the complaints procedure. The Commission for Social Care Inspection had received no complaints and the manager said neither had the home. A file needs to be set up in which to record complaints received and investigations and actions taken when they are received. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 15 It was observed that staff were very responsive, attentive and caring. None the less they need to undertake training related to the Protection of Vulnerable Adults. This was required following the previous inspection and still had not been carried out. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 16 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, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a comfortable house that suits their needs but some of the facilities are not available for their use and there are risks as infection control procedures needed to be improved in the laundry, and the bathroom after use. EVIDENCE: Work was in progress to redecorate and furnish one of the bedrooms and the manager said that the next task was to combine a small bathroom and a small toilet to make a sizeable bathroom that would be fitted with a bath hoist. Currently the bathroom was not in use. One resident said that she had been able to choose the décor for her bedroom and another said that she would discuss the matter with the manager’s wife who had ‘good taste’. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 17 The garden was extensive with a large level decking. Residents were able to enjoy their lunch outside and many remained outside enjoying the good weather. The decking was well decorated with colourful hanging baskets. Many of the bedrooms had french doors on to the decking and two people had potted plants and bird feeders, which they attended to. The tour of the home indicated that, with the exception of the laundry, everywhere was clean and there were no offensive smells. The laundry was a tiny room that was untidy and needed cleaning behind the machines. It was observed that one bedroom needed a light shade, two en-suite door locks needed to be repaired or replaced, one bedroom door lock had been put on back to front. This must be attended to as a matter of urgency as there is a risk the resident could become trapped in their room. In one bathroom it was observed that personal toiletries and face cloth had been left behind after use. This is not acceptable as others could use them. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient suitable staff to provide the care the residents need. They receive the training they need to develop their knowledge and skills EVIDENCE: The files were inspected of two staff. They both contained relevant recruitment documents, references and checks undertaken by the Criminal Records Bureau. Therefore the requirement, made following the last inspection, was being met. The manager and senior care assistants said that the new Skills for Care Induction programme was being used but an example was not available for inspection. The manager stated in the pre inspection documentation that the staff had received training in NVQ level 2, managing abusive behaviour, moving and handling, and induction and foundation training. It was observed that the files contained a range of training certificates and staff recounted courses that they had attended. The two senior care assistants who assisted the inspector had both undertaken all core training and qualified to NVQ level 3. They both intended continuing studying and do the level 4 course. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 19 A full staff training analyses would assist the manager in planning to meet future training needs. Individual training profiles are needed to assist in drawing up the analyses. Such an analyses could also be used to ensure the information held in the Statement of Purpose and the Service Users’ Guide are updated annually. The duty roster that was seen indicated that the home was adequately staffed to meet the current needs of the residents. Only one of the questionnaire respondents considered the staffing levels to be low. The person ‘sleeping in’ must be named on the rota. During the inspection staff were observed to relate well to the residents. They sat with them chatting and encouraging them. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 20 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, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and provides the care the residents’ need. A detailed quality assurance system ensures weaknesses are identified and addressed and the service is continually developing and improving. Improvements need to be made to the documentation regarding money held in safe keeping so that the interests of the resident and manager are safe guarded. There are several health and safety risks in the home that put residents in danger. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is well qualified and experienced. A detailed quality assurance manual indicated that systems were regularly audited and surveys had been undertaken. It was suggested that a record be made on any questionnaire that had triggered a response. Analyses of the responses should be made and published as is required. This could be updated annually in the Service Users’ Guide and Statement of Purpose. Staff meetings and residents’ meetings were regularly held and minutes were seen. In September 2005 the home was awarded a certificate for achievement in the ‘Having your Say’ project that enabled and supported people to speak out. The manager said that money was held in safe keeping for only one resident. Storage was acceptable and receipts were retained but a balance sheet was not maintained. This must be addressed. Some health and safety matters had been attended to and others identified that needed to be addressed. A requirement had been made in the previous report that all soft furniture such as chairs provided by the home meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended in 1989 and 1993). The staff said that all home purchases met the requirements of the legislation and, as far as possible, they checked to ensure private pieces of furniture brought in by residents were also acceptable. When this was not clear a risk assessment was undertaken and responded to. It was also required that all staff should received mandatory training including fire awareness and moving and handling. The records indicated that moving and handling training had been undertaken and staff had attended a training session on fire safety from an external trainer. Fire safety training must be renewed every three months. However it can be done in-house by a competent person. The manager was advised that close monitoring of attendance was necessary to keep control and ensure all staff were included. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 22 A requirement was made in the previous report that footrests on wheelchairs must remain in place and are not removed. It was observed that notices were posted to this effect and all the wheelchairs that the inspector saw were fully equipped. The upstairs windows needed to be fitted with retainers to prevent them being fully extended and posing a risk to residents. A freestanding supplementary radiator must be covered to prevent the risk of burns from the hot surface. Freestanding wardrobes must be attached to the walls to prevent the risk that they might fall onto someone. It was observed that a cupboard in a bathroom containing chemicals was unlocked. This put the residents at risk of harm. An immediate requirement was made for it to be attended to. The Fire Log indicated that the appropriate checks of fire detection and safety systems were being made and a Fire Risk Assessment had been made of the home. Notifications were not always made to the Commission for Social Care Inspection as required by Regulation 37. Information was made available regarding this. Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 2 17 X 18 2 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 (1) Requirement The registered provider must ensure that the Service User’s Guide is amended to include all the information detailed in Regulation 5 and Standard 1. It must be available in the home and copies must be given to all current, and any prospective, service users. The time scale to meet this requirement was 30/06/06. Following this inspection it has been extended. 2 OP8 12, 13, 14 All residents must have a detailed pressure area assessment and nutritional assessment as soon as possible after they have moved in. These must be regularly reviewed and generate care plans if necessary. 31/08/06 Timescale for action 31/07/06 Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 25 3 OP9 13 General medication stock must not be stored in the controlled drugs cupboard and internal preparations should be stored separately from external preparations. Therefore the amount of suitable storage space must be increased. Facilities must be available to enable a record to be maintained of all complaints that are received that includes details of investigation and any action taken. 31/08/06 4 OP16 17 13/06/06 5 OP19 23 (2) (b) The registered provider must 30/08/06 ensure that all areas of the home, including bathrooms and toilets are well maintained and in good and sound order. (Previous timescale of 31/08/05 and 31/12/05 - the timescale is extended but must be met.) There is little likely hood of the new timescale of 30/06/06 being met. However the manger expects the work to be completed within one month. Therefore it has been extended for the last time. Enforcement action may then be considered if the work has not been carried out. 6 OP26 13, 16 The home must be well maintained. Specifically the laundry must be kept clean and tidy Personal toiletries must not be left in a communal bathroom A light shade must be hung in the bedroom identified All bedroom and en-suite locks must be repaired or replaced. 13/06/06 Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 26 7 OP38 13 Issues relating to health and safety must be addressed. Specifically the freestanding radiator must be taken out of use until it is fitted with a cover. Chemicals must be stored securely Issues relating to health and safety must be addressed. Specifically upstairs windows must be fitted with retainers. Free standing wardrobes must be secured to the walls Notifications must be made to the Commission for Social Care Inspection in accordance with the requirements of Regulation 37. 13/06/06 8 OP38 13 31/07/06 9 OP37 17 13/06/06 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 OP16 Good Practice Recommendations When the Service Users’ Guide has been updated and the residents have been supplied with new copies it is suggested that the residents and all principle relatives are informed and their notice drawn to the complaints procedure. Individual training profiles should be maintained for all staff to enable their training to be calculated each year and enable a full training analyses to be maintained that can up date the information in the Statement of Purpose and Service Users guide each year and provide the information necessary to draw up an annual training plan. 2 OP30 Casa Mia DS0000018499.V299031.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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