Inspection on 21/06/06 for Courtenay House Nursing & Residential Home

This inspection was carried out on 21st June 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

Courtenay House Nursing &... 27/04/09

Courtenay House Nursing &... 15/04/08

Courtenay House Nursing &... 18/04/07

Courtenay House Nursing &... 06/10/05

Courtenay House Nursing &... 04/05/05

Courtenay House Nursing &... 23/11/04

Courtenay House Nursing &... 18/05/04

Courtenay House Nursing &... 27/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Courtenay House Nursing & Residential Home Fakenham Road Tittleshall Norfolk PE32 2PF Lead Inspector Ruth Hannent Unannounced Inspection 21st June 2006 12:30 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 Courtenay House Nursing & Residential Home DS0000015629.V301344.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. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Courtenay House Nursing & Residential Home Address Fakenham Road Tittleshall Norfolk PE32 2PF 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) 01328 700646 01328 701320 County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Position Vacant Care Home 51 Category(ies) of Dementia (51), Old age, not falling within any registration, with number other category (51) of places Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Fifty-one (51) older people may be accommodated. Fifty-one (51) older people with dementia may be accommodated. The total number of services users not to exceed fifty-one (51). Date of last inspection 6th October 2005 Brief Description of the Service: Courtenay House is a large detached property in the village of Tittleshall. Bedrooms are on the ground and first floors and consist of six double and thirty-nine single bedrooms, some of which have en suite facility. The home has a variety of communal rooms for the use of residents. There are gardens with a car park to the rear of the property. Email Courtenay.house@fshc.co.uk Fees £385 - £537 Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report that has looked at accumulated information received at the commission since the last inspection followed by an unannounced inspection, which took place over a period of five hours. The pre inspection questionnaire had been completed by the Deputy Manager in the absence of the Manager and was filled in comprehensively. Two comment cards received after the last inspection, nine residents comment cards and eight relatives comment cards received recently were taken in to account when completing this report. (All but one was favourable). One card received from a health professional was concerned that there was little stimulation offered to residents. The Home has during the past few months, been managed on a temporary basis, by the Deputy Manager who phoned the commission twice for information and clarification on items of care while the Manager was away. Regulation 37’s were received appropriately. During the visit, residents, relatives and staff were spoken to, a tour of the building took place and records were looked at that included care, medication, assessments, health and safety and personnel. What the service does well: What has improved since the last inspection? The Home has improved the documentation in the care plans. The folders are neater and it is easier to find information with dividers and sections labelled. The content is more informative and reflects the individual person. The menu’s are now displayed on the tables for residents to make a choice. The Manager is slowly improving the documentation held on training, supervision, policies and procedures and information to ensure implementation happens. Courtenay House Nursing & Residential Home DS0000015629.V301344.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. Courtenay House Nursing & Residential Home DS0000015629.V301344.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 Courtenay House Nursing & Residential Home DS0000015629.V301344.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 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. The Management of the Home do visit and assess the suitability of the potential resident. Families and residents are invited to visit the Home. EVIDENCE: Two recently admitted residents both had completed assessments prior to admission that were signed and dated. Each one held details that would enable the Home to decide if the service could meet the need of those people. On discussion with the Manager the Home will also take along another nurse or senior carer to help with the assessment process to ensure the correct level of care/nursing is available. One resident spoken to, had the assessment in her folder held within her room and was happy to share the contents with the inspector. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 9 The families are encouraged to look around the building and bring the potential resident with them to enable them to see the suitability of the Home for their relative Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 10 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 The quality outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. The care plans are very evidently the information of details for the individual residents. The health care needs are met by the Home. Medication procedures are followed with just one area identified as needing improvement. With the Home still having windows in the bedroom doors the home cannot guarantee the privacy and dignity for residents. EVIDENCE: The care plans for each resident are held within each resident’s bedroom giving ownership to that person. The folders are clearly marked with headings and dividers and hold all relevant information to ensure the care is offered correctly Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 11 and timely. The person centred details in the residential side of the Home reflected more the holistic requirements of that person with the residents in the nursing areas being slightly less informative. (Recommendation) One example of a gentleman who had written about himself was very clearly about him and his needs that, was placed at the front of the care plan explaining to all carers exactly how he liked to be approached and cared for. Throughout this inspection it was evident that the Home has moved forward in the recording and information stored since the last inspection and included more information for all areas of health, personal and social care. The Home is supported by the local GP practice and detailed notes of continuing health care needs were seen. One concern that was shared through a recent complaint was discussed in full and all the health concerns were looked at in depth. The GP is a regular visitor to the Home who works well with the staff. The Inspector had met this GP during the last two inspections and had witnessed his approach and bedside manner. On talking to three residents the health care support they receive is very good. The Home recently had a sickness and diarrhoea bug that was dealt with appropriately and the commission was informed at all times of the systems in place to assist the ill residents and how they had cleaned and disinfected the Home. On the last inspection it was noted that some medication was not labelled for the individual resident. This no longer applies and all labels were noted to be accurate and in date. The controlled drugs were checked with one tablet noted to be still in the blister pack with no record on the MAR chart as to why this tablet had not been administered. The information was found in other records but must be recorded on the MAR chart and two signatures to witness the event must be in place. This error was also not reported, yet someone had placed a circle around the missing signature but had not informed the Manager. (Requirement) All the medication in the trolleys and medication fridge were accurate and all recording charts were correct and each held a photograph of the resident. The staff were noted on the day as being polite and spoke appropriately to the residents. Doors were knocked on before the staff entered and residents spoken to praised the staff highly and stated they were treated well. The one concern that still remains is the lack of privacy with a glass panel being in the door of each bedroom and although a curtain is pulled across gaps are sometimes visible. (Outstanding requirement). Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 12 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 The quality outcome for this group of standards is poor. This judgement has been made using available evidence including a visit to this service. The interests and stimulation for residents does not happen and does not meet the social needs. This has deteriorated since the last inspection. Families and friends are welcomed and visit when they wish. Residents are supported and have choice over their lives. Meals are enjoyed and appear balanced but could hold more choice. EVIDENCE: On comment cards received it was noted that stimulation and activities are lacking. It was also discussed with staff members and the Manager of little happening within the Home. One resident was noted fiddling with hands and not occupied, quite a few were slumped and asleep. The TV was on but only one person was watching. On interviewing staff and talking to the Manager there was lots of ideas but nothing was in place and care staff were saying there is not enough time. On past inspections more planned and interesting activities had begun to take place but have since not been happening. (Outstanding Requirement). Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 13 Visitors were seen coming and going throughout the day and could see their relative in whichever room they wished. Relatives meetings are held every three months and the minutes of the last meeting was seen and it was noted that the inspection report had been discussed as part of the information shared. The Home will help residents with their money if they wish and some residents handle their own money. Accounts are held with receipts and checked as correct. The residents now have menu’s on the tables for discussion and choice which is an improvement from the last inspection. Most days a choice is available but needs to be every day. For some reason when there is a roast dinner on the menu there is no second choice. (Requirement). On taking to the residents they all said they enjoyed the meals and on the day of the inspection had roast chicken, mash and roast potatoes, green beans and cauliflower and stuffing with mandarin and coffee gateaux or ice cream to follow. Drinks were issued at regular intervals and the Home is in the process of recording when jugs are being replaced with cold drinks in the communal areas to encourage more fluid in take. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 14 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 quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and acted upon. Staff are beginning to get a greater understanding of what is abuse. EVIDENCE: The manager was able to show the paperwork of a recent complaint, the investigation and the outcome. The relative and Regional Manager were meeting with the family the day after the inspection. All the paperwork involved showed detail and dates of what had taken place. The Manager gave a positive picture of how complaints are received. Two staff members are now being helped with their understanding of English, which was also a concern received since the last inspection and was acted upon quickly. No complaints have been received from residents and all comments fed back prior to the inspection stated they would happily tell staff or the Manager if they were unhappy about anything. All staff within the Home have received a check on the POVA register and are not left unsupervised until their CRB has been returned. A recent booklet for training staff on the understanding of abuse has been read through with the Deputy Manager and some staff have understood the signs to look for which Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 15 may indicate abuse. (There are still some staff to go through a training and also some non English staff needs help in its understanding). (Recommendation) Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 16 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 The quality outcome for this group of standards is poor. This judgement has been made using available evidence including a visit to this service. The Home has maintenance records that are up to date but the Home environment is poor. Although the home appears clean there is some areas that have unpleasant odours and this needs to be addressed. EVIDENCE: This Home has the support of a good maintenance officer who ensures all the records are up to date including fire alarm and call bell testing. The boilers service is outstanding and due to ongoing problems with a new company should be serviced shortly. (Recommendation). The Home is looking shabby in parts with stained carpets, (Outstanding Requirement) frayed net curtains, lining hanging below the curtains, chairs that are stained and due to the way some people were slumped are also Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 17 uncomfortable. some hooks that had snapped so curtains are coming off the rail and windows that have severe condensation. Some bedroom windows have less light due to overgrown greenery, some double glazing is damaged and as mentioned previously the glass panels in the bedroom doors are still in place and need to be replaced. (Outstanding Requirement). One of the past topics discussed in the past was to ensure that risk assessments are in place in the rooms of people who have a trailing wire for their call bell. The Home to date have not completed this assessment and although on this occasion the wires were not right across the room the assessment should be in place. (Requirement). The laundry is managed well and has five hours x seven days a week of staff time with two washing machines (one with a sluice cycle) and two dryers. The staff member in the laundry was transporting laundry in appropriate trolleys and the room was clean. Although the Home appeared clean there is an odour in some parts that is unpleasant and needs the areas re-carpeted. (Requirement) Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 18 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 The quality outcome for this group of standards is adequate . This judgement has been made using available evidence including a visit to this service. The staff team do have a good skill mix and are adequate in numbers to care for the residents. The Home is slowly increasing the numbers of qualified staff. The Home does follow the recruitment procedures but needs to hold records in a more manageable system for easy reference. More attention needs to be given to ensure all staff are up to date with training. EVIDENCE: There were thirty-nine residents with six staff and one nurse on the morning of the inspection visit with one less carer for the afternoon. Over night there is three staff and a nurse that appears to be enough staff for the residents care and health needs. There is still the need to have hours allocated for stimulation and activities. (Requirement). The two staff interviewed by the inspector were able to give clear accounts of good care and both had attended training to help develop their skills which was discussed in detail. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 19 The number of staff with the recognised NVQ training has increased by one since the last inspection with a further three booked for this coming September bring the Home nearer to the 50 of qualified staff required. Three staff files were looked at. Each one had an application, two references, CRB and POVA checks, copy of a photo, two forms of identification and a contract. The files were a little untidy and sometimes it was difficult to find items that are required. (Recommendation). The two staff interviewed were able to reflect and discuss training they had attended. Although induction packs were in place it was not clear what foundation training had taken place and when as the paperwork was not available. (Recommendation). One senior staff member had not received training on understanding abuse and some training was out of date such as first aid. (Requirement). Dates for medication training were planned and booked for September. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 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): 31, 33, 35 and 38 The quality outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. The Manager does show evidence as being a person who is fit to be in charge but is yet to complete a fit person interview with the commission to clarify all knowledge. The Home has done only a small amount of work on the checking of quality within the service. Residents financial interests are safeguarded. Some areas need to improve to ensure all areas of health and safety are promoted. EVIDENCE: Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 21 This Manager has now been in post for over a year and has over the past two inspections improved some of the practices. The company need to ensure this person becomes registered with the commission and also embarks on the training for registered Managers. (Requirement) To date the Home has not produced a quality assurance document although individual items of checking have been carried out such as residents meetings, staff meetings and relatives meetings that have been recorded and action carried out as a result of those meetings. (The minutes of the relatives meeting talked about the past inspection report). (Requirement) The resident’s all have an account held within the Home that is managed by the Administrator these records were seen and inspected thoroughly on the last inspection with all transactions checked all receipts issued and accounts signed and checked. Four Seasons have an Area Administrator who also checks and supports the Homes Administrator to follow the procedures required. There was no administrator during this inspection so records were not checked again. The manager is aware of her responsibilities regarding health and safety of all within Courtenay House. Records of training are held in the office and just need to be a little more organised to ensure all staff receive the appropriate training. (Recommendation). It was noted on walking around that all areas were clear, all chemicals were locked away and on talking to one of the housekeeping staff COSHH training is carried out and that she is aware of how to handle chemicals with examples given throughout the discussion. (Gloves were seen being worn when the staff member was handling soiled linen). Risk assessments were not in place for all areas (see environment), although it was noted that these records were available for moving and handling and bed sides and were held in the residents care plan files. The Manager had also purchased, since the last inspection enclosed bins for the bathrooms to allow staff and residents to dispose of clinical waste effectively. The commission had received fifteen regulation 37 documents with clear descriptions of incidents or deaths with accident forms completed that corresponded with the records read. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 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 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 X 3 X X 2 Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 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 OP9 Regulation 13.2 Requirement The registered person must ensure that all medication is administered correctly and any errors reported and recorded correctly The registered person must ensure that a programme of activities is provided once consultation with residents and their families have taken place. (Outstanding Requirement) The registered person must ensure that the choice of meals is made available and clear consultation especially for people with short-term memory takes place with menus available for service users to see and discuss the meal. The registered person must ensure that the damaged double glazed windows are repaired, carpets and curtains are replaced in the main lounge and some curtains to be replaced where frayed or lining is hanging below. (Outstanding Requirement) The registered person must remove the glass panels in DS0000015629.V301344.R01.S.doc Timescale for action 30/06/06 2. OP12 16.2 (m) (n) 01/08/06 4. OP15 16.2 (i) 01/08/06 5 OP20 16 &.23 01/09/06 6 OP24 12.4 (a) 01/09/06 Courtenay House Nursing & Residential Home Version 5.2 Page 24 7 OP26 23 8 OP27 18 9. OP30 18.1 (a) 10 OP31 9 11 OP33 24 bedroom doors to ensure privacy (Outstanding Requirement) The registered person must ensure that all carpets are free from offensive smells particularly noticed in the main entrance and some bedrooms. The registered person must ensure hours are available for the stimulation and activities for the residents The registered person must ensure that the staff have the up to date training and record the dates the training has taken place. The Manager must complete the application form and apply to become the Registered Manager with the Commission. The registered person must ensure a review of the quality of the service is established and maintained. 01/08/06 01/08/06 01/09/06 01/08/06 01/09/06 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 Refer to Standard OP7 OP18 OP19 OP29 OP30 Good Practice Recommendations The Home needs to ensure the development of the care plans is consistent for all residents. The Home needs to ensure that all staff understand the signs of abuse and training must be made suitable for staff who’s first language is not English. The Home needs to ensure the company is aware of the problems with contractors in getting the boilers serviced. The Manager needs to ensure a clear filing system is in place for all personnel records. The Manager needs to ensure that records of induction, foundation and training for staff is available for inspection. Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Courtenay House Nursing & Residential Home DS0000015629.V301344.R01.S.doc Version 5.2 Page 26 - 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!