Inspection on 17/10/05 for Chipstead Lodge

This inspection was carried out on 17th October 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

Chipstead Lodge 03/04/08

Chipstead Lodge 04/04/07

Chipstead Lodge 29/07/05

Chipstead Lodge 25/11/04

Chipstead Lodge 23/06/04

Similar services:

Insight - Eastchurch

Southfields

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Dovedale Court

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Chipstead Lodge Chipstead Lodge Hazelwood Lane Chipstead Surrey CR5 3QW Lead Inspector Susan McBriarty Unannounced Inspection 17th October 2005 09:30 X10029.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 Chipstead Lodge DS0000013602.V259337.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 and Care Homes for Adults 18 – 65*. 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. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chipstead Lodge Address Chipstead Lodge Hazelwood Lane Chipstead Surrey CR5 3QW 01737 553552 01999 999999 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) Care Unlimited Ms Christine Margaret Dewan Care Home 36 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (14), Learning disability over 65 years of age of places (2), Mental disorder, excluding learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14) Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The age/age range of the persons to be accommodated will be: OVER 65 YEARS, 10 OF WHOM MAY BE WITHIN THE AGE RANGE 50 TO 65 YEARS Up to 10 of the younger adults accommodated may have a mental disorder (MD) or dementia (DE). Up to 14 (fourteen) of the older people accommodated may have a mental disorder MD(E) or dementia DE(E). Up to 2 (twp) of the older people accommodated may have a learning disability LD(E). Mental Disorder or Dementia over 50 years of age (5). Mental Disorder and Learning Disability over 65 years of age (5). Date of last inspection 25th November 2004 Brief Description of the Service: Chipstead Lodge is set in a rural area of Chipstead within walking distance of a few local shops. The property is an older style building that has a ground floor extension to provide further accommodation. There are two floors to the main part of the property and the first floor is reached by a shaft lift. A number of the rooms, including a few on the ground floor, require service users to have reasonable mobility to reach them as they need to access several steps to reach them. The home is one of three owned by the company and caters for a range of service user needs. The area to the front of the home has recently been re-surfaced and provides ample car parking. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005-2006. The Inspector arrived at 9.20am and the inspection took four hours. During the inspection four (4) residents and three (3) staff were spoken to by the Inspector excluding the owner, quality control manager and the manager of the home. The Inspector toured the communal parts of the home, the kitchen and the grounds. A number of documents were sampled these included; health and safety records, staff supervision records and Criminal Record Bureau (CRB)s checks. What the service does well: 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. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Following changes at the home during the course of 2005 further work is required to ensure that prospective residents have the information they need to make a decision about moving to the home. Standard 6 does not apply. EVIDENCE: The home has expanded to provide for up to thirty six (36) residents from twenty six (26). The statement of purpose and service user guide must be reviewed in order to recognise the changes that have taken place. A requirement was made to ensure that the necessary documents were updated. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 8 The Inspector sampled a number of contracts for residents and found the majority to have been provided by local authorities. The organisation does have a contract that can be used for those people who are purchasing their own care. The home encourages trial visits to the home to view the services available. In addition the statement of purpose notes that residents first month is a trial period. The Inspector spoke to some of the new residents and found that none had visited the home prior to moving there; this was due to personal circumstances. However those spoken to felt they were settling in well and found the staff helpful. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 9,11 The home has policies and procedures in place to ensure that residents needs regarding medication and to ensure support at the time of their death is sensitive to their needs. EVIDENCE: The Inspector sampled the medication administration records and the medication held in the controlled medication cabinet. The home procedures were found to meet the standard. The home manager informed the inspector that they are waiting for photographs of some of the new residents for the medication administration records. A requirement was not made as the home had the matter in hand. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 10 The home has a policy and procedure in place to assist those who wish to remain at the home at the time of their death. Some of the residents have made known their preferred options following their death and these are recorded by the home. It was recommended that the home seek to record the wishes of al the residents at the home. Where this is not possible to document the outcome on the resident’s care plan. The requirements made at the inspection on the 29th July 2005 regarding updating and reviewing the care plans and risk assessments had not been met. Some progress had been made. Further requirements were made to ensure the home meet this standard. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 The home has a good regard for the social and cultural needs of the residents. Activities are provided to enable residents to maintain a level of independence wherever possible. EVIDENCE: The home employs an occupational therapist to provide regular activities. The activities for the week were posted in home in a colourful and clear manner in order to assist residents to make a choice regarding taking part. The records sampled by the Inspector documented religious beliefs and preferences. Wherever possible residents are offered a choice of opportunities Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 12 and the Inspector was given an example of one of the residents moving on from the home having made enough progress to wish to consider a more independent lifestyle. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Further work is required by the home to ensure that policies and procedures are clear and safeguard the residents. EVIDENCE: The home’s complaint procedure must be updated to include the Commission for Social Care Inspection. The policy may also benefit from a review of the timescale, at the time of the inspection the completion of an investigation was stated to be within seven days. The home was dealing with a complaint at the time of the inspection, their first for over twelve months. The manager and proprietor were dealing appropriately with the complaint. The manager informed the Inspector that all the residents had just been confirmed as eligible to vote in the area through the returns to the local borough council. The procedure for the protection of vulnerable adults must be reviewed. The procedure at the time of the inspection required staff to investigate to ensure that any allegation was an allegation of abuse. This is not the procedure required within the local guidelines for the protection of adults. A requirement was made for the procedure to be reviewed in line with local guidelines. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 14 The home’s whistle blowing policy did not make clear that information given by staff may lead to an investigation in line with the protection of vulnerable local guidelines. In addition the home guaranteed the confidentiality of staff, there may be occasions where this may not be possible. A requirement was made that the home review the whistle blowing policy. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection on the 29th July 2005. EVIDENCE: These standards were not fully assessed during the inspection of the 17th October, however the Inspector brought to the attention of the manager and the proprietor issues relating to articles being left outside the building that may be a trip or other hazard. For example a bed had been left against an outside wall and the proposed water feature area had a trailing wire on the lawn. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 16 In the period since the inspection on the 29th July the home had nearly completed the external works. The drive had been covered and improved parking spaces provided away from the front door of the home. An area outside the home was filled with broken bricks and required a safety cover to prevent injury if someone fell. A requirement was made to make safe the external areas of the home. The CSCI had previously been informed that the kitchen refurbishment would begin in August 2005. Little progress had been made with regard to this work and the manager and proprietor were reminded that the refurbishment was a requirement made by the Environmental Health officer early in 2005. It was disappointing to note that work had not begun in earnest. The proprietor informed the Inspector that work was now due to begin in November 2005. A requirement was made that the home inform both the CSCI and Environmental Health of any further delays in the start date of the work required. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 The homes staffing levels had been adjusted in line with changing provision. Further work is required to ensure the home can meet the target of 50 of staff having qualifying training. EVIDENCE: At the time of the inspection the home had thirty one (31) residents and five (5) vacancies. Five (5) care staff were on duty each morning, four (4) each afternoon and three (3) waking night staff. The home must continue to consider staffing levels as the vacancies decrease. The home employs ten (10) care staff of whom four have qualified to National Vocational (NVQ) Level 2. The home was required to provide the Commission for Social Care Inspection with an action plan of how they intent to meet the target of 50 of care staff being qualified to NVQ 2 by 2005. The Inspector spoke with members of the staff team, the manager and quality control manager regarding staff training. The staff spoke of having regular Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 18 training including manual handling, infection control and fire safety. The manager and quality control manager informed the inspector that training was also provided regarding mental health, dementia and challenging behaviour. Three of the staff team received nurse qualification abroad and are due to start their adaptation course in November 2005. The home has reviewed recruitment procedures to ensure they meet The Care Homes Regulations 2001 (as amended). Photocopies of the Criminal Record Bureau (CRB) checks were held at the home. A recommendation was made that the home review the CRB guidelines regarding the disposal of the original documents and the keeping of photocopies. A clearer record of the CRB documents was seen by the Inspector during the inspection. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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, 32,33,34,35,36,38 (Older People) and 37,39 42 of (Adults 18-65). The home has a regard for ensuring these standards are met. Further work is required to ensure that staff supervision meet the standard of six sessions per year. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 20 EVIDENCE: The manager has worked at the home for some time and is specialist nurse qualified and undertaking the registered managers award. The home has clear lines of accountability and a flow chart was provided within the homes statement of purpose setting out how the home and the organisation were related. The quality control manager informed the Inspector that the home undertakes regular audits of each department within their homes including resident and relative’s views. A copy of the outcomes was not available at the time of the inspection and a requirement was made that a copy be forwarded to the CSCI. Copies of the home’s business plan and financial audit were not available at the time of the inspection and a requirement was made that a copy of both be forwarded to the CSCI. The home does not support any of the residents with their finances. Wherever possible the residents look after their own finances or they are assisted by relatives. The Inspector sampled a number of staff supervision records and found that the home would not be able to meet the target of six supervision sessions per staff member per year. It was recommended that the home plan dates for the supervision sessions in order to meet the target. The Inspector evidenced that the home had undertaken checks regarding electrical items, fire risk assessment, lifting equipment, lift maintenance and water sanitation during the course of 2005. The information for the control of chemicals hazardous to health had also been updated. Fire drills were recorded as taking place monthly between April and September of 2005. Chipstead Lodge DS0000013602.V259337.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 2 3 3 X 4 X 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 X 25 X 26 X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 3 33 2 34 2 35 3 36 2 37 X 38 3 Chipstead Lodge DS0000013602.V259337.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 5 Regulation 4(1)(a)(b)(c) (2)(3) Requirement The registered person must ensure that the statement of purpose and service user guide are reviewed and updated. The registered person must review the care plans and, where appropriate, enable the service users to sign and date the agreed care plan. Timescale of 31st August 2005 not met. The registered person must ensure that the risk assessments are reviewed, updated and where appropriate, enable the service users to sign and date the agreed outcome. Timescale of 31st August 2005 not met. The registered person must ensure that the complaints procedure is updated to include the Commission for Social Care Inspection. The registered person must ensure that the procedure for the protection of vulnerable DS0000013602.V259337.R01.S.doc Timescale for action 12/12/05 2 7 15(1)(2) (c) 30/11/05 3 7 13(4)(b) (c) 30/11/05 4 16 22 12/12/05 5 17 13(6) 12/12/05 Chipstead Lodge Version 5.0 Page 23 6 17 7 28 8 29 9 33 10 34 11 38 12 38 adults is updated in line with local guidelines. 13(6) The registered person must ensure that the homes whistle blowing policy is reviewed to ensure there is no confusion when the issue relates to the protection of vulnerable adults. 18(1)(c)(i)(ii) The registered person must provide the CSCI with an action plan showing how the home will meet the target of 50 of staff having qualifying training. 19(4) The registered person must review the CRB guidelines regarding disposal of documentation including photocopies. 24 The registered person must forward a copy of the outcome of the quality audit regarding service users and relatives’ views of the home to the CSCI. 25(3) The registered person must forward a copy of the home’s business plan and audited accounts to the CSCI. 13(4)(a) The registered person must review those areas and items external to the home to reduce the risk to residents. 23(2)(a)(b)(c) The registered person must inform the CSCI and Environmental Health if there are any further delays refurbishing the kitchen. 12/12/05 28/11/05 28/11/05 28/11/05 28/11/05 31/10/05 17/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 24 No. 1 Refer to Standard 36 Good Practice Recommendations It is recommended that the home plan dates and times for staff supervision to ensure that the target of six supervision sessions per year are met. Chipstead Lodge DS0000013602.V259337.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Chipstead Lodge DS0000013602.V259337.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. 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