Inspection on 29/03/06 for Casa Mia

This inspection was carried out on 29th March 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 13/06/06

Casa Mia 08/09/05

Casa Mia 23/03/05

Casa Mia 27/07/04

Casa Mia 03/03/04

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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 Andrew Spearing-Brown Unannounced Inspection 29th March 2006 13:45 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.V287853.R01.S.doc Version 5.1 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.V287853.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Casa Mia Address Cleobury Road Far Forest Near Kidderminster Worcestershire DY14 9EH 01299 266317 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) Mr Martin James Winfield Mrs Michelle Dawn Winfield Mr Martin James Winfield Care Home 15 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.V287853.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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. 8th September 2005 Date of last inspection Brief Description of the Service: The home provides care for up to 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. Overall the home is able to accommodate 15 residents. 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. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by an inspector from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit lasted four and a half hours from early afternoon until early evening. The previous inspection, which was also unannounced, took place during September 2005 making this the second mandatory inspection during the 2005 – 2006 inspection year. The main focus of this inspection was to assess the progress made in relation to the requirements from the last inspection as well as assess some standards not inspected upon that occasion. Standards not assessed will form part of a forthcoming inspection. On the day of this inspection the registered manager was on duty, arriving shortly after the inspector. Other staff on duty included the deputy manager and a team of carers. A small representative number of residents were consulted. Many areas of the home were seen including some bedrooms and communal areas and facilities. The care records of a small sample of residents were seen, these included care plans, risk assessments and daily records. Other documents seen included medication records, staff records and some health and safety records. What the service does well: Casa Mia carry out pre admission assessments to ensure that care needs are able to be met. Potential residents and / or their relatives are able to visit the home prior to their admission. The atmosphere within the home remains relaxed. Staff were seen to respect residents privacy and dignity. Suitable activities are provided for residents by both staff and outside entertainers. Communal areas such as the lounge and dining room are well decorated and maintained. The grounds are well maintained; work on the outside decking continues to improve this area further. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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.V287853.R01.S.doc Version 5.1 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.V287853.R01.S.doc Version 5.1 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): Standards 1, 3 and 5. Standard 6 is not applicable to Casa Mia Potential residents are able to visit the home prior to their admission and are assessed by the home to ensure that care needs can be met. The assessment ensures that residents’ care needs can be effectively meet, improvements are however needed regarding the service users guide and other information available to potential residents. EVIDENCE: The previous inspection report stated that the home’s Service Users Guide covered the majority of the areas required and only needed a relatively small number of amendments. It was however highlighted that the Statement of Purpose required major amendments in order to bring it in line with the required standard. Since the last inspection the registered provider has obtained a new computer upon which it is proposed to complete the required information in the foreseeable future. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 9 A pre admission assessment was viewed for a resident who was recently admitted into the home. The assessment contained some basic information which was sufficient in its detail regarding individual care needs to ensure that an initial care plan could be implemented. This information needs to be built upon without undue delay into a suitable care plan ensuring that all identified care needs are covered. Residents and or their relatives on their behalf are able to visit the home prior to admission. A trail period is available before residents make a decision about becoming permanent. Intermediate care is not offered at Casa Mia and the home has no plans to provide such as service. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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): Standards 7, 8, 9 and 10 Limited progress has been made on improving care plans to ensure they are reviewed and up dated. However improvement is necessary to ensure that care plans and risk assessments are suitable detailed to ensure safe working practices and safeguard residents. In addition the storage and recording of medication need improvement to ensure systems are safe. EVIDENCE: A small representative sample of care plans and associated documents were viewed. Although some improvement was noted further improvement is necessary to ensure that care plans are specific to each individual and meet the National Minimum Standards. It was noted that new forms are to be introduced regarding activities and nutrition. The registered manager should refer to the associated standards to ensure that all areas of care and risk management are addressed. Evidence that care plans are reviewed was seen. The reviewing of care plans needs to be at least monthly or more frequent as necessary to reflect the individual changing needs and current care objectives in order to guide staff and enable the provision of a consist care package. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 11 Daily records were in place and detailed however these must be factual and not opinionated. As part of this inspection the safe management of medication was assessed. Since the last inspection the registered manager has introduced a system whereby keys to medication are signed for by the person responsible for their safekeeping, these records were well maintained and in good order. The medication trolley was not secured to the wall as necessary; this was also noted at the time of the last inspection. The current months MAR (Medication Administration Record) sheets were viewed. These were generally in good order although a small number of gaps were evident whereby no signature or code was entered. Allergies or an entry stating ‘none know’ was recorded on the vast majority of MAR sheets as required. Similarly the majority of hand written entries were double signed. A representative from the supplying high street pharmacy visited the home on the 9th February 2006 to carry out an audit and reported no concerns. It was noted that a drug, which is to be regarded as a controlled drug, was recently prescribed to a resident. This drug was not booked in correctly and was not entered into the controlled drugs book, as a result it was not double signed nor was a balance of the amount remaining recorded. Medication not held within the Monitored Dosage System (MDS) was not dated to show when it was opened. In the case of items such as painkillers it is not possible to undertake a full drug audit if the date of opening is not recorded. In the case of inhalers the date of opening is required as these items have a limited shelf life once opened. One inhaler held within the mediaction trolley had an expiry date of 03/06, as this inspection was on the 29th March 2006 this date had been reached. Since a previous inspection amendments to the homes medication policy have taken place. In order to ensure that this policy is now complete the registered manager should forward a copy of it to the CSCI for further examination. From observations made during the visit residents privacy and dignity was maintained by carers. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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): Standards 12, 13, 14 and 15 Activities within the home provide stimulation and interest for people living in the home. A balanced diet is provided to assist residents well-being. EVIDENCE: A notice board within the main lounge displayed a number of photographs taken during outings. Further information regarding entertainers and compliments received were also displayed. A relaxed atmosphere throughout the home was noted. A record of activities is held. It was evident that some activities are not recorded nevertheless it was clear that they are in place. During the inspection residents were engaged in colouring. The daily records of each resident were a further source of evidence that activities are in place. Outings have included trips to pantomimes and a local steam railway. Residents from Casa Mia have in the past gone on a holiday. The registered manager is currently considering options for this year. Links are established with local churches who visit to undertake communion as well as a religious service. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 13 Although no visitors were spoken to in any great extent it was evident that open visiting is in place and that visitors feel welcome. The registered manager was able to demonstrate an awareness of establishing community links while also maintaining residents rights to privacy within their own home. A small number of residents were consulted regarding food, the comments were generally positive. The registered manager and his deputy were confident that 5 portions of fresh fruit and vegetables are provided daily. Records of meals provided are maintained; these records did not however include breakfast. It was encouraging to note the wide range of different breakfast cereals available to residents. Cooked breakfast including items such as scambled egg was reported to be available every day. In addition it was pleasing to note that small tins of items such as corned beef and baked beans are available which suggests that these items would be made available to residents upon request. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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): None of the standards in this section were assessed in any great detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at Casa Mia. EVIDENCE: The registered manager stated that Casa Mia has received no complaints since the last inspection. No complaints have been made direct to the CSCI. Residents consulted expressed satisfaction with the care provided at the home. The complaints procedure was not viewed as part of this inspection. The homes procedures in relation to adult protection were seen during a previous inspection and were not viewed during this inspection. A previous inspection noted the need for some amendments to the homes procedures to ensure that they are in line with both national and local guidance. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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): Standards 19 and 21 Casa Mia offers a homely environment for people to reside. Bathing facilities are limited and therefore remove choice of facility EVIDENCE: The majority of environmental standards were not assessed during this inspection. It was nevertheless noted that the home had no unpleasant odours. The main lounge and dining area of the home are pleasant in appearance. A small sitting area is provided for residents who smoke. There have been no significant changes within the environment since the previous inspections undertaken by the Commission for Social Care Inspection. The registered manager has a number of plans for future improvement that need to be discussed further with the Commission. The lock to a bathroom door on the first floor was missing and as a result privacy is compromised due to a hole in the door. The bathroom near the main entrance on the ground floor remains to be in need of refurbishment as it Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 16 is unsuitable and out of use. This area is used as a store area, this must be reviewed and the bathroom brought back into use. The bathroom must be suitable to the current needs of residents. One toilet near to the lounge was out of order on the day of the inspection. Casa Mia does not have a passenger lift and has no lifting equipment such as hoists. The lack of equipment needs to be kept under review in line with health and safety regulations to safeguard residents and staff. It was noted that a freestanding wardrobe was not secured to the wall to prevent it falling over when opened. The grounds to the rear of the home are well maintained. A decking area, which is not yet complete, provides an attractive area for residents to sit. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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): Standards 27, 28, 29 and 30 The procedures for recruiting new members of staff are not sufficiently robust to fully ensure that residents are safeguarded and not potentially at risk. A sufficient number of staff were on duty and training continues to improve. EVIDENCE: On arriving for this inspection three carers were on duty. This level of staff is maintained throughout the waking day with the exception of a two-hour period in the afternoon when staffing is reduced to two carers. Additional staff undertake cooking and cleaning duties. The registered manager confirmed that currently three out of the twelve carers hold a NVQ (National Vocational Qualification). This equates to 25 of the care term. Additional staff are currently undertaking or about to embark upon this training and therefore the 50 level should be achieved in the future. The file of a new member of staff was viewed which indicated that the necessary recruitment checks to ensure the protection of residents had not taken place. This was of concern as similar concerns were highlighted following the last inspection. The file contained no references; it was evident that these had not been requested. Two written references must be obtained prior to the commencement of employment. The application form was dated the same date as the induction training sheet. A POVA first (Protection of Vulnerable Adults) check had been sought by the home however the Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 18 confirmation that the applicant was not included upon this list was dated three weeks after the employee had started work. A new employee may only start work once a POVA first is obtained and even then only under supervision. As a result of the serious shortfalls an immediate notice was issued at the conclusion of this inspection. The majority of staff have undertaken mandatory training. The gaps identified need to be filled as soon as possible to ensure full compliance. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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): Standards 31 and 38 Some shortfalls regarding health and safety need to be improved to ensure that residents are safe and not at risk of injury. EVIDENCE: The registered manager and his deputy have since the last inspection commenced upon the Registered Managers Award. It was reported that their assessor was due to visit the home later during the evening of this inspection. Previous inspections were unclear whether some chairs within residents bedrooms meet The Furniture and Furnishing (Fire) (Safety) Regulations 1988 (as amended 1989 and 1993). Progress on addressing this requirement will be assessed as part of a future inspection. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 20 It was evident that training shortfalls identified within the previous inspection are now part met. Moving and handling training has taken place. The majority of staff have received fire safety training, this training must be undertaken by all employees and regular refresher training must take place. It was previously reported that having 4 qualified first aiders would ensure that one is always on duty. On arriving at the home for this inspection none of the staff on duty were first aiders. The weekly and monthly fire check records were viewed and found to be satisfactory. The fire risk assessment document is in need of review. During the last inspection it was noted that wheelchairs within the smokers lounge were without footrests. It was recorded within the inspection report that the removing of these can be potentially dangerous in the event of wheelchair usage without them in place. It was of concern to note that a wheelchair with a corridor as well as two found in bedrooms had no footrests on this occasion. Other wheelchairs seen did have footrests however the concern that some are removed remains and the registered manager must take immediate action to prevent reoccurrence in the future. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 X 17 X 18 X 2 X 2 X X X X X STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 2 Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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 OP1 Regulation 4 (1) Requirement The registered provider must ensure that a Statement of Purpose is prepared which includes all the information detailed in Regulation 4 and Schedule 1. Timescale for action 30/06/06 2. OP1 5 (1) 30/06/06 The registered provider must ensure that the Service User’s Guide is ammended 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. 3. OP7OP8 15 (1) The registered manager must ensure that residents care plans and risk assessments are updated and must accurately reflect all service users care needs. 29/03/06 Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 23 4. OP7 15 (2) The registered manager must ensure that the daily notes are an accurate reflecting of the events surrounding individual residents daily events. The registered provider must ensure that policies and procedures relating to medication are reviewed. (Previous timescale of 31/05/05 and 30/10/05 part met - the timescale is extended.) 29/03/06 5. OP9 13 (2) 29/03/06 6. OP9 13 (2) 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. (Previous timescale of immidate and on going set on 08/09/05 part met – this requirement must now be fully met.) 29/03/06 7. OP9 13 (2) The registered manager must ensure that Medication Administration Record (MAR) sheets are signed after medication has been administered to residents. The reason for any nonadministration 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. 29/03/06 8. OP9 13 (2) 29/03/06 Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 24 9. OP9 13 (2) The registered manager must 29/03/06 ensure that all medication including inhalers are dated upon opening in order that a full medication audit can be carried out. The registered provider must ensure that adult protection policies and procedures are in line with Department of Health guidance and local procedures. (This requirement was not assessed as part of this visit and will therefore be assessed as part of a forthcoming inspection. The previously set timescale remains which is 30/10/05.) 29/03/06 10. OP18 13 (6) 11. OP19OP21 23 (2) (b) The registered provider must 30/06/06 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.) 12. OP29 19 The registered provider must operate a thorough recruitment system in accordance with the requirements of this regulation and Schedule 2 of the Care Homes Regulations 2001. Disclosure checks from the Criminal Records Bureau must be obtained for all new staff before their appointments are confirmed. (Previous timescales of immediate and on going following the last two inspections not met. Immediate action must be taken to prevent the consideration of enforcement action) DS0000018499.V287853.R01.S.doc 29/03/06 Casa Mia Version 5.1 Page 25 13. OP38 23 (4) The registered provider must ensure 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). (This requirement was not assessed as part of this visit and will therefore be assessed as part of a forthcoming inspection. The previously set timescale remains which is 31/12/05.) 29/03/06 14. OP38 13 23 The registered provider must ensure that all staff have received mandatory training including fire awareness and moving and handling. (The majority of staff have received training, those who have not must receive it. Refresher training must be provided as required.) 31/05/06 15. OP38 13 The registered provider must ensure that footrests on wheelchairs remain in place and are not removed. 29/03/06 Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 Page 26 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 OP9 Good Practice Recommendations The registered manager should supply a copy of the medication policy to the Worcester office of the CSCI in order that it can be fully assessed. Casa Mia DS0000018499.V287853.R01.S.doc Version 5.1 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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