Inspection on 29/05/07 for Church Walk House

This inspection was carried out on 29th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Church Walk House 07/04/09

Church Walk House 04/07/08

Church Walk House 16/06/06

Church Walk House 08/12/05

Church Walk House 11/04/05

Church Walk House 06/10/04

Church Walk House 06/04/04

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

CARE HOMES FOR OLDER PEOPLE Church Walk House Church Walk Childs Hill London NW2 2TJ Lead Inspector Mr David Hastings Unannounced Key Inspection 29th May 2007 09:30 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 Church Walk House DS0000010421.V333435.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. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Walk House Address Church Walk Childs Hill London NW2 2TJ 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) 020 7794 2144 020 7794 2460 Hendon Old Peoples Housing Society Care Home 42 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (42), Old age, not falling within any other of places category (42) Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 42 service users who are elderly and may have dementia. Two specific service Two specific service users who are currently resident in the home and under 65 years of age can reside in this home. This condition will need to be reviewed when either one of these vacate the home. 16th June 2006 Date of last inspection Brief Description of the Service: Church Walk House is registered to provide personal care and support for 42 older people who may also have dementia. The home is operated by a charitable organisation, the Hendon Old Peoples Society, which manages the home through a management committee board of governors. The accommodation is provided in a building that used to be the vicarage. The building is on three floors. In the basement is the kitchen and laundry. On the ground floor are the main lounge, dining room, smokers’ lounge and a number of bedrooms. On the first floor are the rest of the bedrooms, a quiet lounge and the offices. Six of the bedrooms are shared and the rest are single. There are disabled accessible bathrooms and showers on both floors. There is a lift available in the home. There is a beautiful garden at the rear of the home. The staff team consists of a manager, a senior assistant manager, three assistant managers, two senior carers and a team of carers. There is also a team of ancillary staff including cleaners, cooks and laundry assistants. In the morning there are between 6-8 care staff and in the afternoon there are 5 care staff and 3 waking staff at night. The service also has a team of staff who organise a wide range of activities. The Purpose and Function Document and last inspection report are available on the notice board at the entrance of the home. Weekly fees are £450 This report is available through the internet. Copies may also be obtained from the provider of this service. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Tuesday 29th May 2007 and lasted eight and a half hours. I was assisted throughout the inspection by the registered manager who was open and helpful. I spoke with seven staff and eleven residents of the home. I inspected the building and examined various care records as well as a number of policies and procedures. I also spoke with two visitors to the home. The majority of residents I spoke with said they were very happy with the care and support they received. One resident told me, “They are good here”. What the service does well: What has improved since the last inspection? What they could do better: One requirement relating to checking the fire alarm weekly has not been complied with and is restated. A number of health and safety issues must be addressed in order to protect residents and staff. Water temperatures in residents’ wash hand basins are too hot. Fire drills need to be recorded and the fire procedures must be reviewed to ensure they are still up to date with current legislation. A number of people living at the home have dementia and Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 6 staff need training in this area so they can fully meet the needs of the residents. Some staff must have a new CRB disclosure to ensure the continued protection of residents. The recording of medication received by the home must improve. Bed rails must only be used when a resident is at risk of falling out of their bed. Bed rails must not be used to stop people getting out of bed. Bed rails can be very dangerous if residents are trying to get out of bed and climb over the rails. Ten new requirements have been issued as a result of this inspection. One good practice recommendation has been made that residents should be consulted about their plan of care when this is reviewed each month. 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. The summary of this inspection report can be made available in other formats on request. Church Walk House DS0000010421.V333435.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 Church Walk House DS0000010421.V333435.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents to the home have their needs properly assessed before making a decision to move in. EVIDENCE: I examined three assessments for residents who have recently moved into the home. The assessments were detailed and holistic and covered the elements required by Standard 3 of the National Minimum Standards for Older People. The manager of the home told me he always assesses potential residents after receiving assessments from the placing authority. There was evidence that residents review their placement at the home after 4 – 6 weeks. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals but risk assessments must e completed for everyone in relation to pressure care. Bed rails are not always being appropriately used. People are treated with respect and their right to privacy is being upheld. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Seven care plans were examined. These plans outlined the health, personal, social and emotional needs of individuals. Staff have recently undertaken care plan training and were generally positive about the process. Care plans were being reviewed monthly. Staff interviewed had a good understanding of the needs of the people they support. A requirement restated at the last inspection relating to care plans has now been complied with. Residents I spoke with said Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 10 they were satisfied with the care they received. One person told me, “They do their best”. A good practice recommendation has been issued in this report that the key worker reviews residents’ care plans with them and comments they make about their plan of care are recorded. This will ensure that care plans focus on the person receiving the care. There was evidence form the plans that residents have good assess to health care professionals including doctors, chiropodists, district nurses, opticians and dentists. One resident has a pressure sore and is being treated by the district nurses. Currently not all residents at the home are being assessed for the risk of developing pressure sores and a requirement has been issued relating to this in the relevant section of this report. The manager was able to clarify the procedure for calling out a doctor in the event that someone falls at the home. This was a requirement from the last inspection that has now been complied with. Risk assessments have been completed for all residents who have bed rails. This was a requirement from the previous inspection that has now been completed. It appears from discussion with the manager and senior staff that some residents are provided with bed rails in order to stop them getting out of bed at night. Bed rails must only be used if people are at risk of falling out of the bed and should not be used to restrain residents. Alternative arrangements must be implemented where residents are at risk of getting out of bed at night such as pressure pads next to the bed. A new requirement has been issued relating to this matter. Records in relation to the receipt, administration and disposal of medication were examined. The manager and a senior staff member were able to describe procedures for ensuring medication is ordered well in advance and to ensure that individuals do not run out if medication. Two requirements relating to these matters, issued at the last inspection have now been complied with. The receipt of medication was not accurate and some medication had not been carried forward to the next month. This means that an accurate audit of medication cannot take place. A requirement relating to this has been issued. A recent inspection from the home’s pharmacy provider (25/04/07) highlighted a number of recommendations. A requirement has been issued that these requirements are acted upon. Other records examined in connection with medication were satisfactory. People that I spoke with confirmed that they were treated with respect. I saw examples of this throughout the inspection. Staff I interviewed were able to give practical examples of how they respected residents’ privacy at the home. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from various social and recreational activities organised by the home meeting their needs and preferences. Family and visitors are welcome to the home, which residents appreciate and this benefits their emotional wellbeing. Residents are encouraged to exercise as much choice and control over their lives as they can to maximise their independence. Residents benefit from excellent quality meals, which are beneficial to their health. EVIDENCE: The activity programme was examined and offers a range of activities throughout the day to residents. I spoke with the activities organiser who described some of the activities arranged with residents. These include a clothes show, drama therapy, attending parties, trips out to the local shops, various clothing outlets and Brent Cross. This means that residents are supported to access a wide range of community- based activities which are linked to their needs and preferences and was evidenced by observations on the day of the inspection. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 12 Records and discussion with staff and residents indicated that people are supported to participate in religious services of their choice. Visitors that I spoke with said they were welcomed by staff and could visit at any reasonable time. Records seen indicated that visitors were encouraged at the home. The food seen in the home was fresh produce. It was of good appearance, nutritious and wholesome. Residents’ dietary needs are being met which benefits their health and wellbeing. The presentation of the food was excellent with fresh fruit and vegetables available. The cook showed me the list of peoples’ likes and dislikes and peoples’ personal choices were identified, which means residents’ wishes’ are being respected, which increases their selfesteem and quality of life. On the day of the inspection the kitchen was clean and tidy and well organised. The fridges were inspected and food was stored appropriately and was within its use by date. The food stored within the fridge was properly labelled minimising risk of ill health to residents. Residents have the use of two dining rooms; one of these is smaller and more appropriate for those people who need more assistance. The residents I spoke with expressed their satisfaction with the food available, saying ‘it was very good’. I was invited to lunch and I was very impressed with the standard of food and its presentation. People I spoke with said they were able to choose how they spent the day and staff I interviewed were able to give practical examples of how they supported people to exercise choice and control over their lives. These examples included choices of clothes and food. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Residents are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. The manager records all concerns and complaints and records examined indicated that all complaints were dealt with in an open and professional manner in line with the home’s procedures. Staff were able to describe to me how vulnerable people could be at risk of abuse in a residential care setting. All staff were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that I spoke to said they felt safe and well supported at the home. Records indicated that most staff have undertaken training in the protection of vulnerable people. Where staff have not yet received this training the manager has booked further training for them Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and maintained to a good standard. Residents are being put at unnecessary risk from inadequate health and safety procedures. EVIDENCE: The manager showed me round the home and I visited some residents in their rooms. The home is clean and decorated to a good standard and has a relaxed atmosphere. Residents that I spoke with said they were happy with their rooms. There is a fulltime handyperson who checks and ensures that the building and equipment are maintained and repaired. The home has sufficient domestic staff with a responsibility to clean bedrooms and communal areas. A laundry assistant ensures that peoples’ clothes are washed, ironed and folded. A requirement, issued at the last inspection that window restrictors are fitted where appropriate has now been complied with. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 15 Residents and visitors I spoke with said the home was always clean and there were no offensive odours detected throughout the home. One resident told me that the home was, “Clean and lovely”. I noticed that the temperature of a number of wash hand basins was quite hot. The water temperatures coming out of wash hand basins in residents’ rooms must be close to 43 degrees to reduce the risk of scalding. A requirement has been issued relating to this in the relevant section of this report. A requirement was issued at the last inspection that fire alarm tests must take place weekly. Although this has been happening there were a few weeks were the fire alarm had not been tested. The requirement has been amended and is restated. I also noted that there was no written evidence that fire drills had taken place on a regular basis. The manager and assistant head of home confirmed that two fire drills had taken place recently. A requirement has been issued under Standard 38 that all fire drills must be recorded. Another requirement has been issued under Standard 38 that the fire evacuation plan is reviewed with the local fire officer, as this has not taken place recently. Records indicated that staff have undertaken fire training on 18/04/07. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All the staff at the home work hard to meet the needs of residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are not sufficiently detailed in order to fully protect residents at the home. EVIDENCE: A staff rota for the home was inspected and found to be satisfactory, with staff on duty during the inspection matching those recorded on the rota, which meant there were adequate staff on duty to meet the needs of residents. It was noted that the staff group at the home was relatively stable with the majority of the existing staff having worked in the home for a number of years, which increases the sense of security for people living at the home. Both residents and visitors to the home were generally positive about the staff team. One resident told me, “They do their best”. Records of training that the manager showed me indicated that 71 of staff have now completed their NVQ level 2 or equivalent. This exceeds the requirements of Standard 28 of the National Minimum Standards for Older People. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 17 The manager is currently undertaking an audit of staff recruitment files to ensure that all files contain the information required by this Standard. Any staff employed after July 2005 must have a current CRB disclosure that clearly states they are working for this organisation. I saw a number of CRB disclosures that need to be updated. A requirement has been issued relating to CRB disclosures. The manager has developed a training profile for staff, which highlights any gaps in training as well as indicating when refresher courses are needed for staff. The vast majority of staff have completed the required mandatory training for the work they do such as moving and handling and medication training. There are some gaps and the manager assured me that training has or would be booked for these staff soon. A requirement relating to staff training issued at the last inspection has now been complied with. A new requirement has been issued at this inspection for all staff including the management and activities coordinator must attend training in dementia care. This training must include the “person centred” approach to care as well as supporting people with challenging behaviour. Records indicated that this training has not taken place for some time and this would be of benefit to residents at the home with dementia. Staff were positive about the training opportunities available to them. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager of the home is working hard to improve the quality of care provided to residents and meet the National Minimum Standards. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being properly safeguarded. In general the health and safety of residents and staff are promoted and protected. Some fire procedures and other policies will need to be reviewed to ensure residents continued protection. EVIDENCE: Residents and staff that I spoke with were positive about the newly appointed manager to the home. Staff commented that he was professional and fair. The Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 19 manager is in the process of being registered with the CSCI. He has an NVQ level 4 in business management. The manager has produced and published a quality assurance care audit following consultation with residents and other stakeholders in March 2007. This audit details the responses of questionnaires and clearly identifies the positive aspects of care at the home as well as the areas that need improvement. The audit has been made available to all interested parties and provides evidence that residents’ views are sought and acted upon. The home also holds residents and relatives meetings twice a year. Records were examined in relation to residents’ personal finances. Money is not held at the home and residents are invoiced for minor purchases. An account is held on behalf of some residents and although this is a joint account, outside auditors regularly calculate the interest on this account and share out the interest between the residents concerned. Clear audit trails were seen of items purchased on behalf of residents. Two requirements were issued at the last inspection that all staff must be regularly supervised and that this supervision must be recorded. The manager has worked hard to ensure these requirements have been complied with. Staff confirmed that they received regular supervision and records of supervision sessions were being maintained. As detailed in Standard 19 a number of fire procedures and systems must be addressed in order to maintain staff and residents continued safety. A requirement was issued at the last inspection that cleaning chemicals must not be left unattended. During the inspection there were no cleaning chemicals left lying about the home and all chemical cupboards were locked. The manager told me that he was in the process of reviewing all risk assessments at the home. The requirement relating to his has been complied with however risk assessments must be carried out for all residents regarding pressure care. I examined satisfactory records I relation to gas safety, electrical safety and Legionella. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 2 Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 21 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 OP19 Regulation 23 (4) Requirement The Registered Person must ensure that there is a weekly record of fire tests available. (Timescale of 06/02/07 not met) This requirement has been amended and is restated. The Registered Person must ensure that all residents are assessed for the risk of developing pressure sores and preventative action taken where needed. The Registered Person must ensure that residents’ beds are only fitted with bed rails were a risk has been identified of the individual falling out of bed as apposed to getting out of bed, which can be seen as a form of restraint. The Registered Person must ensure that accurate records are maintained of the receipt of medication coming into the home. This also includes the accurate recording and monitoring of medication carried forward from the previous month. DS0000010421.V333435.R01.S.doc Timescale for action 01/07/07 2. OP8 12(1) b 01/07/07 3. OP8 13(7) 01/07/07 4. OP9 13(2) 01/07/07 Church Walk House Version 5.2 Page 22 5. OP9 13(2) 6. OP19 13(4) 7. OP29 19 8. OP30 18(1) 9. OP38 23(4) 10 OP38 23(4) The Registered Person must ensure that all the recommendations from the recent pharmacist visit (25/04/07) are complied with. The Registered Person must ensure that water temperatures of wash hand basins in all residents’ rooms are maintained close to 43 degrees. Water temperatures in the kitchen and laundry must be unaffected. The Registered Person must ensure that all staff employed by the home after July 2005 have a current CRB disclosure that clearly states they are employed by the organisation. The Registered Person must ensure that all staff including the manager and management team attends dementia training. This training must include the “Person centred” approach to care as well as supporting those people with challenging behaviour. The Registered Person must ensure that all fire drills undertaken by staff are properly recorded. Night staff must undertake fire drills every three months. The Registered Person must ensure that the fire risk assessment and fire emergency evacuation plan are reviewed in line with current legislation and a copy given to the local fire officer for information. 01/07/07 01/08/07 01/08/07 01/09/07 01/07/07 01/07/07 Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should ensure that care plans are reviewed each month with the individual resident and that the person’s views about this care provision are recorded on the care plan. Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Church Walk House DS0000010421.V333435.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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