Inspection on 11/06/07 for Coumes Brook

This inspection was carried out on 11th June 2007.

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

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

Other inspections for this house

Coumes Brook 04/06/08

Coumes Brook 05/10/05

Coumes Brook 24/05/05

Coumes Brook 08/03/05

Coumes Brook 12/10/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Coumes Brook Cockshutts Lane Oughtibridge Sheffield South Yorkshire S35 0FX Lead Inspector Sue Turner Key Unannounced Inspection 11th June 2007 08:00 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 DS0000002950.V330933.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. DS0000002950.V330933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coumes Brook Address Cockshutts Lane Oughtibridge Sheffield South Yorkshire S35 0FX 0114 286 2211 0114 286 2211 none 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) Coumes Brook Home Limited Mrs Wendy Jane Newman Mrs Amanda Jill Crookes Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places DS0000002950.V330933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Coumes Brook is a purpose built care home providing personal care for up to 24 older people of both sexes. The home is located in the village of Oughtibridge. All of the accommodation provided is on the ground floor. A communal lounge, dining room and conservatory are provided. A central kitchen and laundry serve the home. Twenty-one single and two double rooms are provided. All of the rooms have en-suite toilet facilities. Seventeen bedrooms have en-suite shower facilities. The entire home is accessible to residents. The gardens are landscaped and a patio area is provided. The home has a car park. The manager confirmed that the range of fees from 1st April 2007 were £400 £410 per week. Additional charges included newspapers, hairdressing and private chiropody. DS0000002950.V330933.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 key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 8.00 am and 4:30 pm. Both registered managers Jill Crookes and Wendy Newman were present during the visit. The managers had submitted a pre inspection questionnaire and five people living in the home, two professionals and four staff members had returned care home surveys to the CSCI prior to the actual visit to the home. Their views and some information from the questionnaires are included in the main body of the report. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to five staff, three relatives and seven people living in the home. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was good. They made comments such as “this is one of the best there is” staff are very helpful” “the staff are marvellous” and “staff are very good at listening. The information received from questionnaires and from talking to relatives and people was in the main positive with some suggestions for improvements. Health professionals made comments such as “the staff are quick to point out peoples worries and concerns”, “staff are approachable and consistent” and “the staff are friendly and there is a pleasant atmosphere”. Relatives said, “when mum was poorly the staff cared for her very well”, “staff do a marvellous job” and “I think the home is perfect”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. People’s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. DS0000002950.V330933.R01.S.doc Version 5.2 Page 6 People said they enjoyed the activities available at the home, which included quizzes, gentle exercise and coffee mornings. People said that the activities programme had “dropped off” in the recent months and they were looking forward to a trip out into Castleton in July. People differed in their opinions about the food provided. Everyone said it was of a “good quality” and some described the food as “very good” and “very satisfactory”. Others said there wasn’t enough choice available, particularly at lunchtime. One person said that the main lunchtime meal was rotated on a weekly basis, which did not provide enough variety. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes managers and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. People living in the home and their relatives said that the home was always kept “immaculately clean” and “very tidy”. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. Staff supervision took place, to support and give guidance to staff on an individual basis. Mandatory training took place, to equip staff with the essential skills needed. Records within the home were stored securely, to safeguard confidentiality. What has improved since the last inspection? What they could do better: To ensure that people are fully aware of the service provided at Coumes Brook the Statement of Purpose needs to include more information and be updated at regular intervals. Some care plans need to be updated so that they reflect the current health, social and personal needs of people. To ensure that people are protected all medications and substances that could be hazardous to health must be kept locked away and footplates must be in situ on all wheelchairs unless risk assessed otherwise. DS0000002950.V330933.R01.S.doc Version 5.2 Page 7 People would benefit from a wider range of activities and meals. People should also be made more aware of the choices available to them about where they can take their meals. All staff should have undertaken training in adult protection and further staff should be trained in NVQ Level 2 or above. At staff recruitment full information must be sought in order to ensure the protection of people living in the home. So that improvements to the service continue to be made the homes quality assurance systems should be developed further. Confirmation that gas and electrical installation checks have been undertaken should be forwarded to CSCI. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000002950.V330933.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection DS0000002950.V330933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had not provided sufficient updated and relevant information to inform people about their rights and choices. Trial visits were encouraged to enable people to look around the home, meet other people living there and give them the information needed to make informed choices. EVIDENCE: The home had a brochure, which gave some brief information about the home. The homes Statement of Purpose was a printed sheet, which gave very brief details about the service provided at the home. This had been put together in 2004 and although the managers said they believed they had reviewed this since that date, it was not readily available and it did not include all of the information required by the regulations. DS0000002950.V330933.R01.S.doc Version 5.2 Page 10 Professionals and staff from the home prior to admission taking place assessed people. This either took place at Coumes Brook or at peoples own homes if they preferred. The managers said that assessments in hospitals were also possible if needed. This enabled staff to be aware of individual needs and to ensure that they could be met. One person said, “I came for lunch prior to being admitted, but I knew I wanted to come and live here before then”. A relative said, “it was important that mum was settled quickly and the staff helped this to happen”. This home does not provide intermediate care services. DS0000002950.V330933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main people’s health, social and personal care needs were documented in care plans and a range of health care professionals visited the home, which meant that individual needs could be met. Medication storage and procedures did not fully protect people’s health and welfare. People and their relatives were very complimentary about the way staff cared for them and the ways in which privacy and dignity was promoted. DS0000002950.V330933.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three plans of care were checked. Care plans contained a range of information, in an easy to read format. These contained information on aspects of personal, social and health care needs. The plans included information on the staff action required to meet any assessed needs. One care plan seen had not been updated since November 2006 and the plan was no longer a true reflection of the person’s needs and abilities. In the main monthly reviews had taken place, however for one person the last review was in April 2007 and for another March 2007. Staff were knowledgeable about peoples individual needs. Relatives said that although they could not remember being invited to contribute to their loved ones care plan staff were very good at asking and giving them updated information about any changing care needs. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. District nursing services visited the home several times a week to attend individual health needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. Relatives said that the staff were “helpful”, “friendly” and “nice” and provided a “good” or “excellent” standard of care. Medicines were kept in a locked trolley within a cupboard. On the morning of the site visit the medicine cupboard, which housed many medications had been left unlocked. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Senior staff administered medications; they said they had received in house medication training. Two people living at the home had chosen to self administer their medications. For ease of use, one person had “put out” his/her tablets on saucers, on the dressing table; their bedroom door was also left open. Another person was keeping his/her medications in a drawer in their bedroom; the drawer did not have a lock fitted. The risks associated with these practises were discussed with the managers immediately and action was taken to reduce and eliminate the risk. People said that staff at the home respected their privacy and dignity in a number of ways, for example, by knocking on their doors and waiting for a response before entering. The inspector observed this practice and many other good practise actions. Staff spoke to people in a respectful way and showed empathy and patience when providing personal care to them. DS0000002950.V330933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Contact with family and friends was supported and people continued to be involved in community life. Meals served at the home were of a good quality, however, people were not all aware of the choices of lifestyle within the home, at mealtimes. A limited range of activities was on offer. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. People were able to bring personal items with them into the home. All of the bedrooms seen were spacious, individually personalised and very homely. DS0000002950.V330933.R01.S.doc Version 5.2 Page 14 A friendly and welcoming feel was very evident in Coumes Brook. People said they enjoyed the activities available at the home, which included quizzes, gentle exercise and coffee mornings. The home did not employ an activities coordinator and relied on relatives and carers to provide indoor activities, people said they thought the staff were ‘too busy’ to offer activities. Some external entertainers were invited to carry out performances and people said they would benefit from more of this. The inspector sat with one person at breakfast and observed lunch being served in the dining room. The tables were pleasantly arranged with cloths, and matching crockery and cutlery. The ambience in the dining room at lunchtime was pleasant and relaxed and people were seen coming into and leaving the table as they wished. For most people breakfast and tea were served in their bedrooms, although this suited some people others said they would prefer to go into the dining room, so they could “mix” with other people. The managers said that people were free to decide where they would prefer to eat. These preferences were not referred to or recorded in care plans and the inspector suggested that it was made clear to people in the home that they were able to make their preferences known. People differed in their opinions about the food provided. Everyone said it was of a “good quality” and some described the food as “very good” and “very satisfactory”. Some people said that the staff were aware of their particular likes and dislikes and these were made available. Others said there wasn’t enough choice available, particularly at lunchtime. One person said that the main lunchtime meal was rotated on a weekly basis, which did not provide enough variety. DS0000002950.V330933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place to enable people to feel confident that any concerns they voiced would be listened to. Not all staff had been provided with essential training in adult protection procedures to ensure service users were safe, and to inform staff of the procedures to follow if an allegation was made. EVIDENCE: The homes complaints policy was on display in the entrance area of the home, it contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. The managers said that there were no outstanding complaints and since the last inspection CSCI have not received any complaints about the service. Staff spoken to were clear how to respond and record any complaints received. One relative said that several months ago they had “raised an issue” with the managers and this had been “appropriately responded to”. An adult protection procedure was in place, which contained information on the Department of Health guidance `No Secrets’. The majority of staff had DS0000002950.V330933.R01.S.doc Version 5.2 Page 16 undertaken training on adult protection to equip them with the skills needed to respond appropriately to any allegations. One domestic staff and two members of the night staff had not undertaken adult protection training, the managers said that they would enrol them on this as soon as possible. All people spoken to said that they felt safe living at the home. DS0000002950.V330933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was maintained to a high standard. The environment was very clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and people’s bedrooms were well decorated and personalised. Infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home is surrounded by impressive gardens, which have a variety of shrubs an array of wildlife, lovely views and pleasant outside sitting areas. Many DS0000002950.V330933.R01.S.doc Version 5.2 Page 18 rooms overlook these grounds and people said they got great pleasure from sitting outside in the nice weather. The home was very clean and tidy. Lounge and dining areas were furnished to a good standard. The managers had a programme of refurbishment and redecoration that ensured that the home was very aesthetically pleasing and free from hazards. The managers said that any work deemed necessary for the comfort and well being of the people living in, working and visiting the home was carried out. Bedrooms checked were comfortable, homely and reflected peoples personal tastes. People said their beds were comfortable and bed linen checked was clean and in a good condition. The home was clean and fresh smelling and relatives said that the home was always kept “spotless”. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. DS0000002950.V330933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers, recruitment procedures in the main promoted the protection of people, staff had completed training, including induction which ensured that they had the competences to meet people’s individual needs. EVIDENCE: Staff said that there was enough staff working at the home to ensure that people’s individual needs were met, however during holidays and sickness staffing levels could reduce. The manager confirmed that staffing levels were at the agreed minimum. The manager also said that this was kept under constant review and if there were a need to increase staffing levels then this would be implemented immediately. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Senior staff had also undertaken training in medication administration. DS0000002950.V330933.R01.S.doc Version 5.2 Page 20 Forty percent of the staff team had achieved their NVQ Level 2 or above, however this did fall below the recommended 50 trained staff. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Two staff files checked identified that the members of staff had received induction training when they commenced work. The recruitment records of three staff members were checked. Protection Of Vulnerable Adults (POVA) checks had been made and Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. The staff had provided employment histories and the home had obtained two written references for each of them. One person had left employment at the home and after a short while returned. For this person a reference had not been obtained from her most recent employer and she had not undertaken an updated CRB check. DS0000002950.V330933.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a positive style of management in the home, which had a positive affect on the quality of the service that people received. Some of the homes policies and procedures did not fully promote the health, safety and welfare of people, relatives and staff. EVIDENCE: Both registered managers were experienced in the care of older people and one had achieved their NVQ level 4 Award in Management. The registered DS0000002950.V330933.R01.S.doc Version 5.2 Page 22 managers were hard working, competent and carried out their role to a high standard. They were both clearly very committed to ensuring that people living in the home were well cared for, safe and happy. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the managers at any time for advice, guidance or to look at any issues. They all said that they were confident that they would respond to them appropriately and swiftly. The managers said that in the past, but not for quite a while, they had sent out questionnaires to people and their relatives asking their opinions of the home. The inspector saw that a residents meeting had taken place in February 2007 and the last staff meeting minutes were for September 2006. The home handles money on behalf of some people. Account sheets were kept, receipts were seen for all transactions and a second individual witnessed all transactions. Formal staff supervision, to develop, inform and support staff took place at regular intervals. All staff regardless of their role were offered formal supervision and staff said that they found this useful and beneficial. On the day of the site visit the managers were unable to produce any certificates to confirm that the gas and electrical installations had been serviced, although certificates were seen regarding the electrical PAT (portable appliance testing) checks. The manager said that this work had been carried out and she would chase-up the certificates. Fire records evidenced that weekly fire alarm checks took place. Staff said and fire records confirmed that fire drill training took place on a regular basis. At the previous inspection people were observed using wheelchairs without footplates fitted. At this site visit people were also seen without footplates on their wheelchairs. A cupboard that contained hazardous substances had been left unlocked by the staff. The accident records seen were fully completed and a management review, which identified whether accidents were occurring at similar times and involving the same people were undertaken and then referred to the falls management clinic. DS0000002950.V330933.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 4 17 X 18 2 4 X X X X 4 X 3 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 2 X 3 3 X 2 DS0000002950.V330933.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 (1) (c) Requirement There must be an up to date Statement of Purpose that includes the matters listed in Schedule 1 of the Care Homes Regulations. Care plans must be updated to ensure that they reflect the current health, social and personal needs of each person. People must be protected by the homes policies and procedures for dealing with medications therefore: People self administering their medications must keep their medications in a lockable facility. All cupboards and drawers that house medications must be kept locked. People must be consulted regarding the variety of activities offered. Further activities and trips out of the home must be provided. People must be made aware of DS0000002950.V330933.R01.S.doc Timescale for action 01/08/07 2. OP7 15 01/08/07 3. OP9 13 11/06/07 4. OP12 16 01/08/07 5. OP14 12 01/08/07 Page 25 Version 5.2 6. OP15 16 7. OP18 18 8. 9. OP28 OP29 18 19 10. OP33 24 the choices available to them in regard to where they eat their meals. A wider range of food choices must be available to fully ensure that people are receiving a healthy and balanced diet. To further ensure the protection of all people, staff must be trained adult protection procedures. There must be 50 of the care staff trained to NVQ Level 2 or equivalent. To fully protect people two written references, one from the previous employer, must be obtained for all prospective members of staff and a CRB check must be undertaken. The homes quality assurance system must be developed further. The performance of the home must be monitored against the Statement of Purpose and The Care Homes Regulations. Any identified patterns or issues requiring action must be dealt with appropriately. Adjustments to improve the service must be made if necessary. Certificates to confirm that the gas and electrical installations have been serviced as required by the health and safety and insurance policies must be provided. People must not be moved in wheelchairs without footplates in place unless a written risk assessment has been undertaken. All care plans must be audited to ensure they contain this information. (Previous timescale of 01/12/05 not met). Substances that could be DS0000002950.V330933.R01.S.doc 01/08/07 01/08/07 01/12/07 01/08/07 31/12/07 11. OP38 23 01/08/07 12. OP38 13 11/06/07 13. OP38 13 11/06/07 Page 26 Version 5.2 hazardous to health must be kept locked away at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000002950.V330933.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000002950.V330933.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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