Inspection on 08/11/06 for Clifden House

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Clifden House 14/05/08

Clifden House 23/05/07

Clifden House 08/05/06

Clifden House 25/11/05

Clifden House 17/06/05

Clifden House 03/12/04

Clifden House 11/06/04

Clifden House 19/05/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Clifden House HistoGrange Ltd 82-88 Claremont Road Seaford East Sussex BN25 2QD Lead Inspector Gwyneth Bryant Unannounced Inspection 8th November 2006 07:30 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 Clifden House DS0000021423.V312953.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. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clifden House Address HistoGrange Ltd 82-88 Claremont Road Seaford East Sussex BN25 2QD 01323 896460 Telephone number Fax number Email address Responsible Individual Web address Name of registered Responsible Individual(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) office@clifdenhouse.co.uk Mr Nial Joyce Sheila Collins Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users must not exceed thirty six (36). Service users accommodated must be aged sixty-five (65) years or over on admission. Service users with a diagnosis of an early onset of dementia only to be accommodated. 8th May 2006 Date of last inspection Brief Description of the Service: Clifden House is a large detached house on two floors and provides two passenger lifts to access the first floor accommodation. The home is registered to care for 36 older people with Dementia. It is situated in a residential area of Seaford, with the seafront and town centre within short walking distance. The home is a member of the Alzheimer’s Disease Society. The home provides a light and airy dining room and four lounge areas. There is a large wellmaintained rear garden. The home provides 26 single bedrooms, 24 of which have toilet en-suite facilities and 5 double bedrooms with toilet en-suite facilities. Plans are in place to fit en-suite facilities to the remaining two single rooms. There are four bathrooms with assisted bath seats and six communal toilet facilities. Toilet riser seats, hand and grab rails are fitted as required. The service provides prospective service users and their families with a welcome pack which includes a copy of the Service Users Guide, a contract, terms and conditions, the Statement of Purpose, complaints policy, a copy of the latest inspection report and details of the trial periods offered. Fees charged as from 1 April 2006 range from £365 to £525, which includes toiletries, outings, activities and small items such as tights. Additional charges are made for hairdressing, chiropody and newspapers. Intermediate care is not provided. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over 8.75 hours. There were thirty-three service users in residence on the day. The inspector spoke with five service users, the registered Responsible Individual, two care staff, a visiting community nurse and the registered manager. One relative was spoken with at the time of the site visit and two others were contacted via telephone following the site visit. A meeting was convened with the registered Responsible Individual since the last inspection to discuss the shortfalls identified at the last inspection and a programme of improvement was agreed. Therefore part of the inspection was to check that requirements of previous inspections had been met and to inspect additional standards. A tour of the premises was undertaken and a range of documentation viewed including care plans, personnel and medication records. Seven service users surveys were returned having been completed on behalf of service users by family or friends. Comments in surveys included: ‘Overall, excellent standard of care, food and cleanliness’. ‘No complaints at all’. ‘my husband is very happy at the home’ ‘The staff are kind to my wife, look after her well’. ‘I am well satisfied with the way my wife is looked after’. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. This was returned and information detailed is used in this report. What the service does well: What has improved since the last inspection? Systems for the safe handling, recording and storage for medication have been maintained. Staff have received appropriate training to enable them to provide consistent and quality care to service users. Meal choices are routinely offered for all meals. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 6 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. Clifden House DS0000021423.V312953.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 Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to service users moving into the home which ensure that their needs can be met. EVIDENCE: Pre-admission documentation was viewed for recent admissions and it is evident that these documents are used effectively to ensure the home is able to meet the needs of prospective service users. At the time of admission information is sought from social and healthcare professionals to ensure all needs are clearly identified and planned for. Two relatives confirmed that a pre-admission assessment was carried out prior to the service user moving into the home. Intermediate care is not provided. Clifden House DS0000021423.V312953.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 at least once during a 12 month period. 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. All aspects of service users health, social and care must be identified and planned for, in order to clearly direct staff in the delivery of appropriate care. EVIDENCE: Eight care plans were viewed, including two for recently admitted service users and daily records for all service users were also viewed. While there has been improvements in all parts of the care planning process some shortfalls were identified. In order to ensure staff are clearly directed in the delivery of care, the plans need to be more specific. The care plans had general comments such as ‘monitor for changes’. These were discussed with the manager who agreed that not all staff would be sufficiently skilled to know what changes to report and she confirmed that she would address this. During the tour of the premises it was seen that a number of rooms had service users glasses, false teeth and Zimmer frames left in them although the service users were in the communal areas. The care plans of these service users were viewed and it was found that some should have had these aids at all times. One relative said that her mother did not always have her glasses but they were usually left in their room rather than being lost. Again this was Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 10 discussed with the manager and Responsible Individual who both agreed to address the issue with staff. Risk assessments had been carried out for all service users, including Waterlow assessments for those at risk of tissue breakdown, but they did not clearly identify the hazards nor include sufficient detail for the management of risks. For example, the daily notes showed that one service user who is at risk of tissue breakdown spends most of his day sitting in the lounge. Similarly risk assessments for those at risk of falls do not direct staff in how to reduce the hazards. Monitoring charts are maintained for those service users who present challenging behaviour and these are detailed and clearly show techniques for effectively managing these behaviours ensuring that neither staff nor service users are put at risk. Service users representatives are invited to join in the care plan reviews and all the returned surveys confirmed that they were consulted on the care given. The relative spoken with was evidently happy to speak to the manager and Responsible Individual and she said that she was happy with all aspects of the care given to her husband. The other two relatives spoken with confirmed that they are consulted in respect of the care given and that they were happy with the care provided by the home. Relatives comments included: ‘I am very happy with the care – very pleased with them’. ‘ they give good care, I think highly of it (the home)’. The visiting community nurse explained that she is frequent visitor to the home and that staff will redress wounds appropriately or seek advice from her as required. She also said she has provided staff with basic training on wound care which is put into practice. Service users weights are recorded but the records were erratic with some service users showing unlikely weight losses/gains. This was discussed with the manager who believes that the scales used may not be appropriate to this client group and is researching different types of weighing scales. Clifden House DS0000021423.V312953.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by service users does not always match their expectations, choice or preferences. Meals are satisfactory and service users benefit from a choice of meals. EVIDENCE: The home has developed an activity programme but on the day of the site visit the only group activity was a ‘sing a long’, initiated by the manager and some staff were observed to interact with service users on a one-to-one basis. Six of the returned surveys said that there are not always activities in which service users can take part and this needs to be addressed to ensure service users have both physical and mental stimulation. Daily notes on service users could be improved if they included any activities or interactions carried out with staff. This would provide a more accurate representation of how service users spend their day and provide evidence that social and leisure interests are fully met. One care plan said the service user should be encouraged to join in activities but the daily notes found she spent most of the day just sitting in the lounge and this needs to be addressed to ensure service users leisure needs are met. When the inspector and Responsible Individual arrived in the large lounge area, one carer was seen to be discussing a newspaper article with a service Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 12 user and it was evident that there was a good rapport between them. The same service user said that staff would get things from the shop for her but she would like to have her money and go into town herself. A carer said that she would be happy to do so when the service user felt like it. One survey comment was ‘visitors are welcomed at any time’. A number of people were noted to be visiting on the day including the one relative spoken with. Relatives spoken with all said they were made welcome by staff and that they were free to visit at all reasonable times. At the start of the inspection one service user was being taken to the bathroom wearing just a thin nightdress. This compromises her dignity and as she was barefoot this puts her at risk of injury or infection. Menus were viewed and a choice is routinely offered at each meal and care plans included information on service users food likes and dislikes. The home has developed food monitoring charts, however they were found to be inaccurate and insufficient detail was included to effectively monitor nutritional intake. This needs to be addressed to ensure all service users consume a well balanced and nutritious diet. The pre-inspection document showed that training in diet and nutrition has been booked. Although fresh fruit was not seen to be offered to service users the manager confirmed it is routinely offered both as an alternative to a dessert and as a snack. Meals were discussed with the manager who explained that she intended to use the training in nutrition to develop strategies for increasing food intake such as the introduction of finger foods and frequent, small meals. It was of concern that service users were seated in wheelchairs for the midday meal. This practice is unacceptable as service users are unable to get close to the table therefore food is spilt on their clothes. Clifden House DS0000021423.V312953.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 inspected at least once during a 12 month period. 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. There is a satisfactory complaints system with evidence that service users, via their relatives felt confident their views would be listened to. All staff have been trained in the protection of adults to ensure that everyone is familiar with procedures so that service users are not at risk of harm or abuse. EVIDENCE: The home has detailed policies and procedures on complaints and surveys received showed that the registered manager and her deputy listened to any concerns raised and took appropriate action although all said that they had not needed to make a complaint. The complaints book was viewed and it showed that all complaints are recorded and handled in line with the homes policies and procedures. The home has detailed policies and procedures on adult protection and the registered manager and her deputy have undertaken a training course, enabling them to cascade this training to all staff. In addition all staff are required to sign a statement agreeing that they have read and understood the Protection of Vulnerable Adults training. The one carer spoken with demonstrated that she has a reasonable understanding of protecting service users. Clifden House DS0000021423.V312953.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 at least once during a 12 month period. 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. Some parts of the home are well maintained providing a homely and comfortable environment for service users; improvements need to be made in respect of on-going maintenance to ensure all areas of the home are pleasing and safe. EVIDENCE: The Responsible Individual toured the premises with the inspector and it was agreed that there were a number of repairs that needed to be carried out in addition to the repairs needed to the hot water tank. All service users are able to access a call bell while in bed ensuring they can summon help when required. There is a written maintenance plan and the Responsible Individual has developed a comprehensive refurbishment plan, which includes upgrading the entire plumbing system as this presents a number of problems in respect of maintaining comfortable hot water temperatures. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 15 Two surveys returned mentioned that sometimes there were offensive odours during the week. One survey mentioned the stickiness of banisters and that the upper floors ‘need a good clean’. All rooms had clear signs with the name(s) of the occupants but these did not always match with the names on internal cupboards and towels. This mismatch may add to the confusion of service users and the manager agreed to attend to this immediately. All communal bathrooms, toilets and en-suite toilets need to have paper towels and toilet paper as required to reduce the risk of infection. Some areas of the home are malodorous and this needs to be addressed to ensure the home remains pleasant and reduce the risk of infection. Staff were observed to be working in ways that minimised the risk of infection by the wearing of gloves and aprons as required. The garden area is attractive, well maintained with appropriate seating and provides an accessible and safe area for service users. . Clifden House DS0000021423.V312953.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 at least once during a 12 month period. 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. Staff training continues to improve and there are sufficient staff deployed, but service users would be better protected by robust recruitment practices. EVIDENCE: The home continues to provide six carers on the morning shift and at least four during the afternoon and evening shifts. Four night waking staff are also employed. Domestic and laundry staff are also employed along with a gardener, cooks and kitchen assistants. On the day of the inspection two agency staff were on duty to ensure staff numbers were maintained when regular carers are unwell. However, at one time the service users in the large lounge area were left unsupervised. This was discussed with the manager and Responsible Individual who agreed to review this and develop a policy requiring staff not to leave service users unsupervised. Two relatives spoken with confirmed that ‘there are usually plenty of staff around to talk to’. A trainer has been employed since the last inspection to facilitate meeting the required 50 of staff with National Vocational Qualification (NVQ) in care at level 2 by April 2007. The trainer also provides a range of care related training to ensure all staff have the skills and competency to meet service users assessed needs. The manager maintains a staff training matrix to ensure all staff receive the required training and that training is updated as required. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 17 Pre-inspection documents showed that of the twenty three care staff currently two have achieved NVQ level 2 in care but four are in the processing of gaining this qualification and a further five are working toward NVQ level. One newly recruited carer who’s first language was not English was still able to confirm that she had received basic training as part of her induction in manual handling, fire safety and protection of vulnerable adults. There are induction and foundation training programme that meet care skills sector guidelines. Recruitment practice remains an area for improvement with one employee who provided just one reference. All new staff need to provide a full employment history and a written explanation given for all gaps. New staff should also confirm they are in good physical and mental health. Protection of Vulnerable Adults first checks had been carried out for all new staff. When there are delays in obtaining Criminal Record Bureau checks new staff only work when there is a member of staff with a full check on duty. Clifden House DS0000021423.V312953.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although adequate systems are in place to protect service users financial interests, all aspects of service users health, welfare and safety need to be protected and promoted. EVIDENCE: A number of issues in respect of some staff practices were discussed with the registered manager and while she is clear about her management role she needs to provide more direction to staff and create a system to ensure they follow good practice guidelines on a day-to-day basis. One survey comment was ‘the manager is eminently approachable and acts on any complaints as does the deputy (manager).’ Both the relatives spoken with following the inspection and the returned surveys stated that the management style is open and friendly. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 19 As part of the quality monitoring system the Responsible Individual has produced an annual business/development plan and has developed a system whereby he intends to monitor compliance with each of the National Minimum Standards during the monthly visits. In addition the Responsible Individual has agreed to keep the CSCI informed on the progress of the refurbishment programme, also as part of his monthly visits. These systems will enable the management to objectively evaluate the service and ensure it is run in service users best interests. Service users relatives and or solicitors handle their finances. The home holds a bank account for small amounts of service users monies and full records of all transactions are kept. Information in the pre-inspection document confirmed that safety checks are carried out on all electrical and gas systems and appliances and that they are serviced annually. In addition documents relating to safe working practices and Health and Safety are available and are regularly reviewed. Accident records were viewed and found to be satisfactory. An annual fire risk assessment is carried out and the manager intends to review this document in line with the latest fire safety regulations. During the tour of the premises a number of wheelchairs were seen and none had footplates and they were subsequently used to transfer service users. This puts service users at risk and needs to be rectified. It was also noted that a number of fire doors did not fully close and this also needs to be addressed to protect service users in the event of fire. Clifden House DS0000021423.V312953.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Clifden House DS0000021423.V312953.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 Responsible Individual(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4bc) 15(1) (2bc) Requirement Risk assessment for those at risk of tissue breakdown or falls need to be more detailed and include the management of the risk and direction to staff on minimising the risk. (timescale of 02/02/05 and 08/07/06 not met). That care plans include information on how service users leisure preferences are to be met. (timescale of 08/07/06) That action is taken when it is noted that service users have lost or gained weight as required under Regulation 17 (1) (a) Schedule 3 (o). ( timescale of 08/07/06 not met). That service users dignity and privacy is respected at all times. That service users preferences in respect of getting up, going to bed and mealtimes be recorded and met as required. (timescale of 08/07/06 not met). That service users nutritional intake accurately monitored. Paper hand towels need to be DS0000021423.V312953.R01.S.doc Timescale for action 08/01/07 2 OP7 OP12 OP8 16 (2) (mn) 14 (1a) (2ab) 08/01/07 3 08/01/07 4 5 OP10 OP14 12 (4) (a) 12 (2)(3) 08/12/06 08/01/07 6 OP15 7 OP26 Reg. 17(1)(a) Schedule 3 (o) 16 (2)(j) 08/12/06 08/12/06 Page 22 Clifden House Version 5.2 8 OP26 16 (2jk) 9 OP29 19(4c)(5) 10 11 OP38 OP38 23(4a) (c)(i) 13 (4) (a)(b)(c) provided in all bathroom and toilet facilities and in the kitchen. (timescale of 10/09/05, 16/02/06 and 26/06/06 not met). That all parts of the home are to be kept clean and free from offensive odours. (timescale of 08/07/06 not met). All staff need to provide the required documentation listed in Schedule 2 (as amended) of the Regulations prior to appointment. (timescale of 17/07/05, 02/12/05 and 08/07/06 not met) That that all fire doors close properly. That footplates are used on all wheelchairs when transferring service users. 08/12/06 08/01/07 08/12/06 08/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Responsible Individual/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations That a plan is developed to ensure 50 of staff achieves NVQ level 2 by April 2007. Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Clifden House DS0000021423.V312953.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!