CARE HOMES FOR OLDER PEOPLE
Coppelia House Court Street Moretonhampstead Devon TQ13 8LZ Lead Inspector
Clare Medlock Unannounced Inspection 1st November 2005 10:00 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 Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Coppelia House Address Court Street Moretonhampstead Devon TQ13 8LZ 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) 01647 440729 01647 440884 www.peninsularcarehomes.co.uk Peninsula Care Homes Ltd Vacancy Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th April 2005 Brief Description of the Service: Coppelia House is a Care Home registered to accept 30 residents of either gender who require personal care. The Home is one of five owned by Peninsular Care Homes. Coppelia House is a home that has been extended and adapted over the years to meet the needs of the residents. The home is situated in the rural town of Moretonhampstead, which is close to Dartmoor National Park. Some Rooms have views of Dartmoor and the surrounding countryside. The home is situated within a close distance of the town and local amenities. The town has a post office, coffee shop, shops, pub, doctors surgery and small cottage hospital. The Home is arranged over several floors. There are two passenger lifts which access the main floors. There are additional rooms that are accessed by extra steps, but resident mobility is assessed prior to admission to these rooms. All rooms are meant for single occupancy, however the home does have some large rooms and flats that could be used for those who chose to share. The home has a large dining area and separate lounge area which overlooks the well maintained gardens. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Tuesday 1st November 2005 between the hours of 9.50am and 16.00pm. Two inspectors (Clare Medlock and Megan Walker) conducted the inspection. One inspector focused on speaking with residents, their visitors and staff and the other inspector focused on documents, records and speaking with the Area Manager for the organisation and the Team leader of the home. A full tour of the building was conducted. Care Records, staff files, policies and procedures, the home diary and other records were inspected. There have been no questionnaires, complaints or letters received by the Commission for Social Care Inspection regarding this home since the last inspection. Coppelia House have been subject to many changes over the past three years, including change of ownership and five changes of management. This inspection was unannounced and did not look at all standards. All standards were looked at during the last inspection in April 2005, it is therefore recommended that the reader obtains this report to have a full picture of events within the home. What the service does well:
The staff at Coppelia provide a very good level of Personal care. A dedicated staff group ensure that Residents have all their needs met and ensure residents access all the services they need despite having many changes in leadership. Residents and their families are given information and opportunities to visit the home and residents are assessed prior to making a decision to move into the home. Residents spoken to were happy living at the home and praised the care staff within the home. The staff group are keen to maintain the high standard of care despite the many changes that have occurred within the home. Residents speak highly of the team leader, speaking of how approachable she is and how efficiently she sorts problems out. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 6 Staff have a good understanding of the needs of Residents and importance of choice and respect. The staff team organise the activities programme and encourage residents to maintain contact with friends, family and the local community. The home is well maintained and decorated to a high standard. The home is equipped to ensure Residents are helped to maintain as much independence as possible. The Peninsular Care Homes senior management team communicate well with the Commission for Social Care Inspection. What has improved since the last inspection?
Peninsular Care Homes appear to be dedicated in improving the homes in which the residents live. Coppelia House is no exception. The carpet in the lounge area has been replaced and gives a clean fresh appearance. Building work is ongoing at the home. Since the last inspection, an unstable chimney block has been removed, the garden has been tidied and an old lift shaft has been removed providing more space within the kitchen and upstairs bathroom. New flooring was in the process of being fitted in the kitchen. In the upstairs bathroom, work was being done to produce a useable bathroom rather than a bathroom that was previously used as storage. Despite the home having an unsettled management, staff have acted on many of the previously set requirements and recommendations. New Care Plans have been introduced which are easy for all staff to use and on the whole reflect the high standard of care that is given. Residents are now thoroughly assessed before they come into the home. This now means that both the residents, their families and the staff are confident that Coppelia is the right place for them to be. Changes in the way the medication system has begun to improve with the introduction of a ‘record of receipts’ of all medication coming to the home and ensuring prescribed products are only used on the residents they are meant for. The way resident personal monies (known as pocket money at the home) are handled have also improved. Staff now get two signatures and ensure separate receipts are obtained. This ensures resident money is protected and provides evidence of what the money has been spent on.
Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 7 What they could do better:
Although staff within the home have made many changes and improvements since the last inspection these changes need to continue. The main focus needs to be the introduction of a stable manager and clear sense of leadership and organisation within the home. Residents and staff need to feel secure and confident in who is running the home. The Team leader has done a tremendous job in this role and she now needs time to reflect on her role and support the new Manager. The new Manager must make her first job to ensure training is introduced, completed and kept up to date. The training record at Coppelia has been poor over the last two years and needs to be addressed as a matter of urgency. All staff must be trained in fire safety, moving and handling, infection control, food hygiene and first aid. This will make sure staff have the skills needed and are able to work and care for the residents in a safe manner. Staff training in adult protection issues must be completed so all staff know how to prevent, recognise and correctly report any signs of abuse. Staffing levels need to be settled following the long period of staff absence and sickness. Ensuring there is enough staff in the home will help maintain the standard of care that is currently given but will also help make sure records are up to date and staff receive the right supervision. It will also ensure agency usage is kept to a minimum and residents know who is caring for them. The way in which staff are recruited must also change. Staff need to have all the right checks performed which include a Protection of Vulnerable Adults (POVA) check and making sure two references are obtained prior to working at the home. This will help to keep residents safe. Feedback from residents must also continue. Staff within the home must make sure residents are fully aware of what is being said at the meetings. Any feedback or requests from residents must be addressed regardless as to who is on duty. Food remains to have a mixed response at the home, although the general feeling is that it has improved. The home must continue to seek the views from residents. The manager must ensure residents are aware of the full menu at tea time. Staff must ensure food and drinks get to residents when they are still hot and make sure requests are carried out regardless as to who is on duty. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 8 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. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 9 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 Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 10 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 Residents are thoroughly assessed prior to admission which means staff now have the correct information to decide if they can care for the individual before they move. EVIDENCE: All Care Plans of new admissions seen at inspection contained completed assessments in addition to social services care plans and health care professional updates. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 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 the following standard(s): 7,8, elements of 9, 10,and elements of 11 The general and specific care needs of the residents are well met by a dedicated established team of staff who promote the privacy and dignity of residents. The improved system for recording residents needs and reporting how they have been met reflects the level of care that is given. The improvements in the way medications are managed within the home protects the home, staff and residents from risk. EVIDENCE: Residents spoken to on the day of inspection said they felt well cared for. All residents seen on the day of inspection appeared well cared for, with the finer details of care attended to. This included clean shoes, new hairstyles and nail care. Residents who were being cared for in bed appeared warm, comfortable and pain free. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 12 A visiting healthcare professional spoken to on the day of inspection stated that the change from being a nursing home to a care home had gone well and that care staff make appropriate referrals and follow instruction well. The homes diary confirmed that staff within the home access a full range of health care services depending on the need of each resident. These included General Practitioner, District nurse, out patient appointment and other health care professionals. Care Plans have greatly improved since the last inspection, but still require improvements to reflect the level of care given. A new system has been introduced which staff say was easy to use. Care Staff are now encouraged to use these documents and key workers have a separate dedicated page to record changes and reviews in care. Six care plans were inspected on this occasion. Three documents had not been signed or dated, two care plans had been reviewed in the last month, one plan contained no care plan for night times, two family details charts were not complete. However overall the care planning system has greatly improved since the last inspection. Discussion with the team leader confirmed that due to low staffing levels, staff have concentrated on giving hands on care and some records needed to be updated. Four of the six care plans did not contain requests regarding terminal illness and dying Observation confirmed that staff within the home access the services of General Practitioners, but residents also access the General Practitioner directly if they prefer. Communication with the General Practitioner and Team leader was excellent with the team leader demonstrating a good knowledge of residents at the home. A folder within the office show past and present resident and relative thank you cards and letters. These letters thank staff for their care and dedication in the care that is given throughout their stay and in the final days. Observation confirmed that there have been improvements to the way the medication is received into the home. This now makes sure the home and staff are safeguarded. Staff on the day of inspection were discussing how one residents medication could be ordered to ensure the supply did not run out. The Team leader stated that the home do not have a policy for staff to follow to ensure the system can be used in her absence. Direct and Indirect observation confirmed that staff are kind, sensitive and respectful. Observation confirmed that staff knock on Residents doors prior to entering and prevent entry when care was being given to protect their privacy. Observation confirmed that Residents are able to receive visitors in private, receive their post unopened and use the telephone in private. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 13 Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 14 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): 13,14 and 15 Residents have choice and control over their lives whilst living at the home and receive visitors in private. The variety of the menu is good, and the standard of the food provided has overall improved, however feedback from residents remains mixed. EVIDENCE: Most residents spoken to felt they had enough choice whilst living at the home, however one resident stated that the amount of bathing has reduced recently. Discussion with the team leader confirmed that due to the building work there has been a temporary reduction in the supply of hot water, but once this has been completed the numbers of baths residents chose can return to normal. Residents stated staff will help them with what they choose to do. Feedback regarding food remains mixed at the home. Overall, residents stated that they thought the food had improved. But feedback has become more specific rather than the standard of food or its delivery. Some residents stated food was too salty, others stated it was not salty enough and lacked flavour. Some residents commented that teatime food is often dull and repetitive. Residents stated that it was always soup and sandwiches. The area manager for Peninsular and Team meeting stated that there is always other items on the
Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 15 menu. One resident stated that breakfast is sometimes served cold, but it depended who was on duty. Observation confirmed staff within the home have introduced a morning requests for morning drinks, wake up calls and getting up. One resident stated that the request did not always happen and depended who was on duty. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 16 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 The improved way complaints are dealt with ensures Resident’s views are listened to and acted upon. The training of adult protection procedures is incomplete. These issues are placing Residents at risk. EVIDENCE: A complaints procedure is displayed within the hall and within the Statement of Purpose and Service User Guide. All documents contain timescales and information on how to contact the Commission for Social Care Inspection. Residents spoken to confirmed that they find the Team leader will sort out any issues within the home. A complaints register has now been commenced but could not be located at inspection. A record of events was kept in the resident file and demonstrated what action had been taken by staff at the home. When asked, the Team leader was aware for the correct reporting procedures should staff, residents or relatives report abuse. Discussion and Records confirmed that adult protection training is being performed but is incomplete. A new timescale was agreed. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 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 the following standard(s): Elements of 21 and elements of 26. The standard of the environment with Coppelia is good, providing residents with a safe attractive homely place to live. EVIDENCE: During the inspection, building work was in progress at the home to convert an unused bathroom that was too small into a new useable bathroom. The old lift shaft had been removed to provide more space in the kitchen area and new flooring was being laid in the kitchen. New carpet had been laid in the communal lounge area. This provided a bright fresh appearance to the home. Outside the building an old chimney has been removed and the garden tidied. Some areas within the home were identified during the inspection that needed attention. These included a extractor fan that had been removed a year ago and stuffed with paper towels to prevent a draft. The area manager stated that
Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 18 she was unaware of this and would address it whilst the builders were at the home. A tour of the building confirmed that Coppelia House was generally clean, tidy and free from offensive odours on the day of inspection. Some staff stated that they thought there were no enough staff to keep the home clean. There were areas where the carpets were dirty with building dust, however it was agreed that this would be inspected at the next inspection when builders were not in the home. Communal areas provided a variety of furnishings which promoted a homely feel. A tour of the building confirmed that residents are encouraged to bring personal items with them to the home. Records confirmed that a list of these possessions are now made. A tour of the building confirmed that the décor within the home is generally good, providing residents with a homely place to live. Some carpets are beginning to look worn and will need replacing in the future. The home has been adapted to encourage the independence of Residents and provide safe working environments for staff. All radiators seen were covered and all first floor windows checked had been fitted with restrictors. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 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 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 and 29 The recent shortage of staff at the home has meant staff can not fully meet the needs of the residents and residents are sometimes cared for someone they do not know. The staff files are incomplete and do not show staff have had necessary checks and references performed. This is placing residents at risk. EVIDENCE: Observation and discussion with residents and staff confirmed that there has been a shortage of staff at the home. Shortfalls are made up by the use of agency staff, but this means residents are not always cared for by staff they know and staff do not always have time to give the level of care they expect. Residents said the care was very good but they had noticed the care ‘is going downhill’ and staff ‘do not talk about my needs’ and ‘there is a lot of agency staff’. Agency staff stated that there is not enough time to read the care plans so staff verbally give instructions. Discussion with the Area Manager and Team Leader confirmed staffing has been disrupted because of long term sickness, absence and staff annual leave, but that this was being addressed. Two new staff files were inspected on this occasion. Neither files were complete. Neither files contained a Protection of Vulnerable Adults (POVA) check, or second reference. These lack of checks have the potential to place residents at risk. Discussion with the administrator confirmed existing staff files are being checked to ensure they contain all documents.
Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 20 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): Elements of 31, Elements of 32, 33,35,36 and elements of 38. The day to day management of Coppelia House relies heavily on Senior care staff within the home. This leadership is not in the best interests of the residents, staff and service as a whole. EVIDENCE: There have been many changes in the Management at Coppelia House. In the last three years there have been two changes to the ownership and five different Managers. This has been a very unsettled time for residents and staff. At the time of inspection there was no Manager in place. He day to day management has been performed very well by the Team Leader with the Support from the area manager. Residents comments included: ‘My main concern is the lack of management’, and ‘They don’t seem to be settled with their management’ and ‘It needs somebody in charge.’
Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 21 Discussion with the Area Manager confirmed that a new Manager has been appointed and will start at the home soon. Residents spoken to confirmed a questionnaire had been sent round asking what they liked and disliked and what they wanted in the morning. These questions were seen. Residents confirmed that they had attended resident meetings but it was difficult to hear what was being said. Records confirmed discussions about the food were made and positive feedback about the care given. Records confirmed that staff meetings have been conducted and letters written by the Provider updating staff about the changes in the homes. Records kept have improved since the last inspection and were found to be generally secure and up to date. It was not clear whether Policies and procedures seen had been updated which could result in residents not getting up to date care or services. The administrator holds a small amount of petty cash for events such as the hairdresser and chiropodist. Relatives deposit money into these separate accounts. Inspection of these records confirmed improvements have been made which include obtaining two signatures when a deposit or withdrawal is made and obtaining separate receipts so residents, relatives or solicitors can see proof of spending. Training records continue to be poorly maintained. Not all staff have received all mandatory training which potentially could place residents and staff at risk of living and working within an unsafe environment. This shortfall has been an on going issue at Coppelia House and must be addressed as a matter of urgency. Staff spoken to confirmed that they had received fire training, but when questioned staff did not demonstrate a clear idea of what to do after reaching the fire panel. One resident expressed concern over the fire evacuation procedure and staff gave assurances that his concerns would be addressed. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 22 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 2 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 x x 2 X X X X x STAFFING Standard No Score 27 2 28 X 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 2 1 Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 23 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 OP11 Regulation 12(2&3) Requirement The Manager must ensure the wishes regarding terminal illness and death is recorded in each care plan. Carried forward The Manager must ensure there is a medication policy written and maintained. The Manager must ensure: 1. Residents are aware of the full range of menu at tea time 2. The food is delivered to all residents hot at all times. 3. Any food and drink requests are carried out at all times and not when certain staff are on duty. Carried forward The Manager must ensure all staff receive adult protection training The Manager must ensure no staff are employed without a POVA check and two written references relating to them Carried forward
DS0000040423.V251591.R01.S.doc Timescale for action 31/03/06 2 OP9 13(2) 31/03/06 3 OP15 16(2i) 31/03/06 3 3 OP15 OP15 16(2i) 16(2i) 31/03/06 31/03/06 4 OP18 13(6) 31/03/06 5 OP29 19(1bi) Schedule 2 18(2) 31/03/06 6 OP36 11/02/06
Page 24 Coppelia House Version 5.0 7 OP38 18(1i) 13(4) The Manager must ensure staff receive clinical supervision. Carried forward The Manager must ensure all staff receive mandatory training in respect of fire, manual handling, food hygiene, infection control and first aid. 31/03/06 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 3 4 5 6 Refer to Standard OP8 OP14 OP21 OP37 OP38 OP38 Good Practice Recommendations The Manager should ensure the improvements in the care plans are maintained, and contain up to date complete documents. The Manager should ensure baths are no longer restricted once the building work has been completed. The Manager should ensure repairs are made to the removed extractor fan from the bathroom identified at inspection. The Manager must ensure that all policies and procedures are up to date. The Manager should reassure residents who have concerns regarding the fire evacuation procedure The Manager should ensure all staff are aware of the full fire procedure and what to do after reaching the panel. Coppelia House DS0000040423.V251591.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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