Inspection on 08/08/05 for Clarendon Hall Care Home

This inspection was carried out on 8th August 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

Clarendon Hall Care Home 22/05/08

Clarendon Hall Care Home 05/06/07

Clarendon Hall Care Home 18/05/06

Clarendon Hall Care Home 02/02/06

Clarendon Hall Care Home 28/10/04

Clarendon Hall Care Home 12/05/04

Clarendon Hall Care Home 15/03/04

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Hawkhills

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

CARE HOMES FOR OLDER PEOPLE Clarendon Hall 19 Church Avenue Humberston Grimsby DN36 4DA Lead Inspector Theresa Bryson Unannounced 8 August 2005 9:30 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 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. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Clarendon Hall Address 19 Church Avenue, Humberston, Grimsby, DN36 4DA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01472 210249 01472 210365 Southern Cross Healthcare Services Ltd CRH 52 PD(E) 46 PD 46 Category(ies) of OP 52 registration, with number of places Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None apply. Date of last inspection 28/10/04 Brief Description of the Service: Clarendon Hall is a 52-bedded establishment for older people and physically disabled, both under and over 65 years of age. The home is purpose built and is now owned by the Southern Cross group of homes. The accomodation is on 2 floors and accessed by a lift and various settings of stairs. There are some en-suite rooms and also a number of bathrooms and toliets, all within easy access to communal areas. There are a variety of sitting rooms and several dining areas, which are also used by the activities person. All garden areas are accessible for wheelchair users. The management team split the home into a unit for very ill service users and those who are more able, but each person can have access to the entire home, if they should so wish. The care staff and team are supported by a number of ancillary staff at the home and also a regional and head office team supplied by the parent company. The latter staff make frequent visits to the home and are accessible by telephone and e-mail. The home also has access, and uses a number of health care professionals in the locality including the health and social care co-ordinators, district nursing team, tissue viability nurses and continence advisors. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days on the 8th and 11th August 2005. This visit was prompted by an anonymous complaint over the provision of some care supplies to people who live in the home. The complaint was partially substantiated, but the manager had the situation under control within 24hours. To find out how the home was run and if the people who lived in the home were pleased with the care they got, the inspector spoke to the manager, 8 staff members, 8 service users, 1 relative and two other Company representatives. Paperwork kept in the home was also seen to make sure that the checks to make sure staff are safe to work in the home had been done. And that they had been trained to do their job safely. Paperwork was also looked at to make sure the home and the things in it were safe and checked often. The acting manager Maureen Broadhurst accompanied the inspector on both days. What the service does well: The staff looking after the people who live in the home were very friendly and knew a lot about each person. They showed dignity and respect to each person when they approached and assisted them through out the day, a variety of tasks. The home was clean and tidy and the grounds looked neat and inviting for the people who live in the home to relax in. The people who live in the home told the inspector how kind and caring the staff were and how much they enjoyed the variety, quantity and quality of meals. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The manager needs to ensure that all training needs for all staff working in the home are up to date and meet current guidelines. This is to ensure that staff can assist the people who live in the home with a good sound knowledge base. Now that it has a policy in place to ensure people who live in the home can exercise their legal rights the home must ensure that all permanent people living in the home are included on the local electoral register. This will enable them to vote in both local and National elections. The company needs to put in place a maintenance and renewal programme for the home, this will ensure the home is always looking its best for the people living in the home and it is maintained with safety in mind. The numbers of staff in the home on each day will depend on the assessed needs of each person living there, this was not all in place and needs to be open for inspection. People living in the home need to be assured that there are enough staff on duty each day to meet their needs. All staff working in the home should have received all the checks on them before commencing work, if this is not completed and audited the manager will not know if the people living in the home are being looked after by suitable staff. Staff should also be supervised and any failures or needs not met identified on Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 7 an action plan. People living in the home will then be protected from unsuitable staff. Quality audits need to be completed and a plan developed to ensure the service and facilities the people living in the home use meet their needs. 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. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 9 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 standard(s) 3,4 and 6. Service users are provided with comprehensive documentation before entering the home, to enable them to make informed choice. Staff are given preadmission paperwork to enable them to prepare for a person’s admission. EVIDENCE: The pre-assessment documentation was seen on each service users file tracked as part of the inspection. This remains unchanged since the last inspection and also incorporates an activities of daily living assessment. The manager completes all pre-admission documentation and instructions are left with her deputy and senior staff in her absence should the need arise to admit to the home. There was a lack of evidence to support that staff had received service specific training on their individual staff training files. This should be in place to ensure that staff are aware of the latest methods of caring for individual problems and needs to be included in the yearly training plan. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 10 The home does not provide intermediate care and therefore Standard 6 is not applicable. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7,8 and 9. The company provides comprehensive care documentation to enable all service users needs to be monitored and assist the staff to deliver the appropriate care to each person and administer all medication correctly. This documentation had not been correctly completed. EVIDENCE: 6 service users care plans were tracked in detail during the inspection. Staff spoken too were able to give a good verbal account of all their needs. The documentation provided by the company was comprehensive and if correctly maintained would give a good record of the delivery of care to each person and identify all their needs. Of the care plans seen the detail was very brief and there was very little attention to detail in the notes, so a satisfactory picture of their delivery of care could not be made by the inspector. Staff were also not recording all incidents as when tracking the accident books some events had been missed in the daily report sheets. One care plan identified to the manager needed a great deal of updating. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 12 Service users and a relative spoken to on the day did not have any recall of seeing a care plan or been asked to validate the documentation. Staff when interviewed did express they were aware of the need to do so, but had not offered the care plans, except than at a major review. On the second day of the inspection some new care plan documentation was received in the home by the manager and she stated at the feed back session she would use this opportunity to review each person’s care plan. The company has a system for auditing care plans, but the programme had slightly slipped in the absence of a manager. The new one will now recommence and is supported by the Director of Operations. The inspector went over the standards for this section with staff and manager and stressed how important it is to maintain accurate and clear records on all service users to ensure all needs are met, they are regularly evaluated and all agencies are aware of specific problems. Medication records were checked and the storage of all medication had much improved from the last inspection. The administration sheets were clearly written and the deputy manager and senior carer on duty were able to give a good account of their departments regime and needs. At the time of the visit there were 5 service users with PEG feeds and these appeared to be well maintained and all equipment was in working order. The controlled drugs were checked all found to be correct. Staff when questioned had a good knowledge of service users needs regarding administration of medication and which medication was required. This has resulted in a safe system being in place to meet service users needs. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 13 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 standard(s) 15. The home provided a varied menu to meet service users needs and all parts of the kitchen and storage areas had been effectively cleaned and maintained, which ensured a safe environment for the preparation of food. EVIDENCE: The inspector was given a tour of the kitchen and storage areas by the assistant cook. There appeared to be an effective system for cleaning in place and the ordering of food materials and other equipment. The kitchen had 2 days of rotas to fill due to long term sickness of one staff member, but the home was aware and using bank staff when required. There was evidence in the well laid out storage areas that fresh fruit and vegetables are used as well as frozen foods. This covered the 4-week cycle of menus. Suppliers have remained unchanged since the last inspection and these are authorised by the company head office. The majority of service users spoken to made very positive comments on the variety on the menu, the quantity and quality of the food supplied. Individual needs of a couple of service users were identified to the manager at the time. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 14 The kitchen does not keep a list of service users likes and dislikes, but this was documented in the individual care plans. The assistant cook was able to tell the inspector specific dietary needs of service users. Staff were seen to assist service users with dignity and respect at meal times and this took place in a relaxed environment. The home has three specific dining areas, the larger one needed some attention to the carpet, but new table linen and cloths had been provided since the last inspection. This has resulted in a homely atmosphere for service users to partake refreshment. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16, 17 and 18. A comprehensive complaints policy was in place for service users and other parties entering the home to see. Service users and their relatives were aware of how to make a complaint, were confident to do so and believed their concerns would be listened to and acted upon. There was a robust policy in place to ensure the service users were protected from abuse, but the training records were not up to date for staff, so this could not be fully implemented for service user safety. EVIDENCE: The procedure remains unchanged from the last inspection and service users and a relative spoken to were aware of the content and felt confident the company would deal with any problems. The complaints log was seen and there had been 3 since February 2005. Each had been investigated and the evidence was seen by the inspector. The manager completes an audit and this was also seen. This inspection had been prompted by an anonymous complaint over the provision of incontinence aids to service users. The manager had the situation under control before the visit and with in 24hours of the problem being identified to her, which was before this visit. Although the complaint was partially substantiated at no time were service users at serious risk to their health. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 16 The home had revised a policy for service users to exercise their legal and civic rights. No evidence could be produced to show that all permanent service users are on the local electoral role. Failure to have their names included could result in them not being able to exercise their voting rights. The local authority protection of vulnerable adults policy was in place as well as the company one. The manager was in the process of ensuring both policies were marrying up so staff were clear and what action to take, should the need arise. The staff files only showed a record of those nominated for training in protection issues. The manager was aware of the need to ensure all staff have received the correct training and was planning some cascade training through the Company networks. This will ensure that staff can identify needs if they should arise and be sure of a referral system to the correct agency. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 17 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 standard(s) 19 and 26. The home was clean and tidy and the environment safe for this category of service user. Planning of redecoration and refurbishment of the home was not evident. EVIDENCE: The home was clean and tidy and the inspector spoke to 2 domestic staff and one laundry staff who were able to give a good account of their working day and the process of cleaning in place. Their documentation was seen and appeared comprehensive. They had identified to the housekeeper certain problems with some cleaning products and the company was looking into this at the time of the visit. The gardens showed a marked improvement and were now more colourful and tidy. The handyman had put in a lot of hard work since the last inspection, which appeared to be appreciated by the service users spoken to. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 18 Staff needed to show a little more attention to detail when tidying service users room and also where they leave equipment, to ensure there are no hazards for service users and visitors. Due to changes in manager in the last year the home could not produce a maintenance and renewal programme for the home. Whilst touring the home some areas are now looking very unkempt, this was particularly so in one of the main lounges, the larger dining room carpet and a downstairs toilet area. Some doors were also sticking on closure, which could become a fire hazard for all persons in the building. The manager identified this to appropriate person during the course of the inspection. Service users spoken to expressed how they appreciated the work of the cleaning staff and no problems were identified in the laundry area. There was ample evidence in service users rooms of each person being able to personalize their own area. Many positive comments were received by the inspector from service users on how useful this had been to enable them to settle into a new environment. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. The company has a robust system in place for staff recruitment, but the documentation produced was not up to date, which could put service users at risk from inadequately employed staff. Training records for staff were incomplete and this would result in staff not having up to date knowledge of conditions to adequately care for service users. EVIDENCE: The rotas for all departments in the home were seen. The one for kitchen and domestic staff appeared adequate to the needs of those areas. Staff stated they were happy with their hours and the present schedules set for them. Care staff stated that the amount of hours set on their rota was not adequate to give quality time to the service users. This was further expressed by service users, who stated they did not always receive care when asked and felt they had to repeat requests. There were no dependency levels available in the home at the time of the visit for the inspector to ascertain if the correct numbers were on the rota. An immediate requirements notice was issued on the second day of the visit. The manager did not feel there were enough NVQ level 2 trained staff employed, but there were no records produced to show, how many were employed. The manager is aware of the deadline for 2005. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 20 6 staff files were tracked in depth. One file appeared to be very incomplete and the manager was asked to address this as a matter of urgency, but the person in question was not working at the present time. The inspector explained the need to ensure the recruitment process supplied by the company was adhered to, which will ensure that all staff are in place with adequate checks having been made to protect the service users. The training records for staff appeared to be incomplete. There was some evidence to support that staff had attended fire and first aid training in May 2005. The protection of vulnerable adults training had not been cascaded to all staff and service specific training had not been recorded in the last year for most staff. As the manager was new in post she had not had occasion to prepare a training plan, which would assist her in keeping track of all training and also ensure staff were kept up to date in all aspects of care, to help them deliver up to date processes to all service users. Staff in their comments to the inspector were very vague as to when they had last received training. Domestic staff in particular had received very little training. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36 and 38. The company has systems in place to ensure auditing of parts of the service take place, but there was not sufficient evidence produced to ensure that the quality of care delivered to service users is provided by supervised staff with a sound knowledge base. EVIDENCE: The manager seen at the time of the inspection was newly in post, but after discussion she appeared to have assessed the home well and identified for herself some urgent areas of need to tackle. This manager has not yet been interviewed by the CSCI and also not commenced her Registered Manager’s award. The company has a robust system of auditing certain aspects of the business, which is undertaken either by the Home’s staff or Regional/head office Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 22 personnel. Some audits such, as pressure sore management and home’s action plan had not been reviewed since May 2005. The care plan audit had not been completed since February 2005, but most others such as medication, facilities and accidents had been finished in July 2005. A full quality assurance programme is still not in place and the home could not produce a development programme. The CSCI needs to ensure that the home is aware of quality issues, which will benefit the service users in the monitoring of all aspects of care and facilities provided. The supervision records have still not been commenced by the home and this needs urgent attention by the manager. An immediate requirements notice was issued to this effect on the second day of the visit. The manager at present did not have sufficient knowledge of staff to ensure they were giving quality care to service users and had received all the training they personally needed to enable them to fulfil their roles. Policies are reviewed by the company head office and cascaded to all homes. All certificates were now in place to ensure the safety of the building and all maintenance records were in place. Staff when spoken to could state certain aspects of health and safety, which affected them, such as health and safety legislation, COSHH documentation and infection control policies. This has ensured that the facilities the service users are living in is well protected and safe. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 2 2 2 x 2 x x 1 x 3 Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 24 yes Are there any outstanding requirements from the last inspection? 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 4 Regulation 18.1c.i. Requirement The registered person must ensure that all service specific training is up to date and open for inspection. (Previous time scale of 30/04/05 not met). The registered person must ensure that each service user has an up to date care plan and this is reviewed regularly. (Previous time scale of 30/02/05 not met). The registered person must ensure that all service users are registered on the local electoral role to enable them to exercise their right to vote. The registered person must ensure all staff have received training in the protection of vulnerable adults. The registered person must ensure that a maintenace plan is in place for the building. The registered person must ensure that staffing levels are in place to ensure dependendcy levels can be met. (Previous time scale of 30/02/05 not met). The registered person must Timescale for action 30/01/06. 2. 7 15.2a,b,c, d. 12/09/05. 3. 17 16.2.m. 30/12/05 4. 18 13.6. 30/12/05 5. 6. 19 27 23.2b. 18.1a. 30/12/05 12/09/05 7. 29 19.1a,b,c. 30/12/05 Page 25 Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 8. 30 18.1c.i. 9. 30 18.1.c.i. 10. 33 24.1.a,b. 11. 36 18.2. ensure that all staff files are up to date and all checks have been completed for all staff. The registered person must ensure that all training records are up to date and a training plan in place to cover mandatory and service specific training. The registered person must ensure that all service specific training is in place. (Previous time scale of 30/04/05 not met). The registered person must ensure that a verifable tool is used for a`quality assurance programme and an annual development plan completed. (Previous time scale of 30/04/05 not met). The registered person must implement the supervision programme to all staff. (Previous time scale of 30/02/05 not met). 30/12/05 30/01/06 30/01/06 12/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 28 31 Good Practice Recommendations The manager is aware of the target date to ensure 50 of staff have completed their NVQ level 2 by 2005. The manager, who is a nurse, is aware of the target date for completing her NVQ level 4 in management in 2005. Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Clarendon Hall J54 2779 Clarendon Hall V236163 8 August 2005 05 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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