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Inspection on 06/10/05 for Courtenay House Nursing & Residential Home

Also see our care home review for Courtenay House Nursing & Residential Home for more information

This inspection was carried out on 6th October 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff throughout the inspection, were seen to be working as a team to ensure the correct continuity of care is given to the residents. The Home offers suitable and enjoyable meals.

What has improved since the last inspection?

The environment has improved with carpets appearing a little cleaner and curtains hanging at windows where they were absent previously. A Deputy Manager has been added to the staff team very recently which is having a good impact on the staff team. A check list of all tasks to be done for each resident is signed and dated by responsible staff member to ensure the tasks are carried out as well as completing the daily records. Residents have now been issued with the Terms and Conditions of their stay in the Home.

What the care home could do better:

The bedrooms need to be altered to allow privacy for every resident by the removal/alteration of the glass panels in each room door. A more detailed history of all residents needs to be written to ensure the correct care is available to suit the lifestyle expectations The Home needs to develop a system for quality assurance to include all parties who may be involved with Courtenay House that will aid planning of the aims and objectives for the future.

CARE HOMES FOR OLDER PEOPLE Courtenay House Fakenham Road Tittleshall Norfolk PE32 2PF Lead Inspector Ruth Hannent Announced 6 October 2005 9.30am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Courtenay House Address Fakenham Road, Tittleshall, Norfolk, PE32 2PF 01328 700646 01328 701320 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) County Healthcare Ltd Position Vacant Care Home 51 Category(ies) of Dementia 51, Old age 51 registration, with number of places Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Fifty one (51) older people may be accommodated. Fifty one (51) older people with dementia may be accommodated Date of last inspection 4th May 2005 Brief Description of the Service: Countenay 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 service users There are gardens with car park to the rear of the property. Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over a period of six hours. The pre inspection questionnaire was discussed with the Manager. A tour of the building took place with all communal areas seen and approximately ten bedrooms. A lunchtime meal was over seen in the two dining areas. Five residents had a conversation with the inspector. Four staff were spoken to. Some records were looked at which included care plans, staff recruitment files, maintenance checks that included fire procedures, water testing and electrical checks. What the service does well: What has improved since the last inspection? The environment has improved with carpets appearing a little cleaner and curtains hanging at windows where they were absent previously. A Deputy Manager has been added to the staff team very recently which is having a good impact on the staff team. A check list of all tasks to be done for each resident is signed and dated by responsible staff member to ensure the tasks are carried out as well as completing the daily records. Residents have now been issued with the Terms and Conditions of their stay in the Home. Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 standard(s) 1, 2 and 3 The information pack available for potential residents is suitable and is seen as helping someway to the person coming to a decision about moving to the Home. The terms and conditions now available allow people to understand what service they are to be provided with and a contract to sign as an agreement. The manager and one other staff member will ensure, the person’s needs can be met by visiting and completing an assessment of need prior to admission. EVIDENCE: Courtenay House has a full, easy read information pack that is on show in the entrance and is offered to all potential residents to give the information required about the Home and the service it offers. This pack was in the room of a new resident who stated she had received the information at her house but reads it regularly to remind herself “this is now my home”. The Four Seasons organisation has now issued terms and conditions to all the residents with some signed contracts sent back. These terms and conditions Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 9 have been long awaited and will be issued to new residents as they are admitted to the Home. The recently admitted residents all had an assessment written with detailed information included from Social Workers. The Deputy Manager discussed one lady she and the Manager had recently assessed with the Senior Carer talking about residents on the residential side that she and the Manager visited and assessed together. Two residents who had only been in the Home a few weeks, talked about the visit they had received and the information they had been offered about the Home to see if it was suitable for their needs. They are still trying to make that decision while they are in for a trial stay. Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The Home is beginning to develop and improve the information written in the care plans to individualise the information. The health care needs of residents are met by an in-house and community medical team. The procedures need to be tightened up further to ensure residents are protected and safe with regards to medication. The staff observed, were being polite and respectful when assisting residents but the environment needs to be improved. EVIDENCE: Four care plans were looked at. The details of information for carers gave history details and the care and medical support required. Each one had review dates recorded at monthly intervals and contained information such as risk assessments and charts for monitoring the resident weight. The daily recording of the residents is beginning to improve and this needs to be encouraged further to ensure a clear picture of the persons care delivered is suitable and continuity sustained. (Recommendation) Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 11 The Home relies on the Community Nurse for the medical care of dressings and the monitoring of health needs with the nurses employed in the Home assisting with the residents with nursing needs. The recording practise of any medical intervention is held within the care plan document in each bedroom with all visits recorded and the outcome of the visit. Each resident is registered with the local GP practise. The Home is working hard to bring the whole procedure of the medication within the building to a safe working practise. Implemented recently is a check at each handover of all the controlled drugs within the double locked medication unit by the senior team and then a double signature to evidence the check has taken place. The lunchtime administration process was observed with the nurse on duty. Each residents name was checked, the name of the medication was checked including the dosage, the blister pack was then held over the pot and passed to the resident to swallow. The MAR chart was then signed. One resident required Paracetamol that was held in a box and not in the blister pack. This box had no name and had been used and administered from over the past two days. (Medication must have the residents name on the label). (Requirement). A recent concern over medication administration was discussed with the outcome finding that more training is required and staff are not to administered medication until fully competent to do so. (Action by the Manager has already taken place and staff already booked on a comprehensive training programme at the University of East Anglia). (Recommendation) On a few occasions throughout the inspection residents required two staff to help them. This was done quietly and at a suitable pace for the individual. Doors were knocked before entry and doors closed and curtains drawn to preserve dignity for personal care tasks. The bedrooms all have windows within the doors and although a curtain can be pulled across gaps to the side of the curtains allows people to see in. (Previous requirement) Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 standard(s) 12 and 15 Residents are seen to be enjoying their lifestyle within Courtenay House but to ensure all interests are included the recording of activities and the outcome for individuals needs to be recorded. Meals are wholesome, well balanced and enjoyed. EVIDENCE: Five residents were spoken to throughout the inspection. One person told the Inspector exactly how they know what is happening within the Home and showed the activities and events that were advertised on the notice board. Another resident was looking forward to the afternoon when they could have a “good old sing song in the lounge”. Although the Home is yet to ensure all residents interests and lifestyles are recorded on the care plans to offer the activities and interests for each person the home is moving forward in providing stimulation. The recording of the activity and the how the individual took part is yet to happen to evidence the suitability of the recreational interests. (Recommendation). Two areas within Courtenay House are used as dining areas with some residents preferring to remain in their rooms. The residents in one lounge on a table of five talked about the nice food they have. One lady told of how partial she is to curry and has it regularly. On the day of the inspection a choice of Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 13 main course was seen which, had been decided earlier in the day by the residents. The sweet was offered at the table from a trolley so people could see and decide which they preferred. This was discussed with the Manager as a way of choosing the main course to allow people to see which meal they prefer as choice earlier in the day does sometimes get forgotten. (Recommendation) The conversations around the table were jolly and the mealtime experience appeared to be enjoyed by all. Two people who were spoken to in their bedrooms preferred to eat alone and were happy with the meals provided. The menu’s for three weeks had been forwarded with the pre-questionnaire and choice on one or to days were noted to be missing. The Manager has planned to meet with the cook and rewrite the menu’s so all days will offer choice in the future. (Recommendation). Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 standard(s) 16 and 18 The complaints procedure is in place and the Manager will take seriously and act upon any complaint received. Once the staff have received the POVA training all will be more aware of potential abuse. EVIDENCE: The Home has a complaints procedure that is both inside the pack offered to new residents and also on display for visitors. The Home had only two comment cards returned and no one had made a complaint on these cards. The home had received an anonymous complaint earlier in the year which had been discussed an investigated previous to the inspection with very little evidence found to substantiate the complaint. The Home has used this complaint to move in a positive direction and has training in place for up dating staff in areas such as moving and handling. The Home has a whistle blowing policy and on induction staff are made aware of the need to safeguard and protect the residents. The POVA training for all staff is planned for 2005/06 as written on the pre inspection questionnaire and discussed with the Manager. (Recommendation) The procedure for handling resident’s personal finance was comprehensively discussed with the administrator. A sample of the letter sent to residents and families was shared with the inspector that explained the Homes bank account system for ‘residents personal allowance’. This appeared to safe guard the Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 15 resident and the staff as less cash was in the Home. The records of individual accounts on the computer were shared and appeared to be in order. Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 standard(s) 19, 20, 21 and 24 The Home has good maintenance records kept up to date by the handyman. Although the Home has improved the environment some soft furnishings need to be replaced to make it more comfortable. The bathroom areas are suitable but to prevent the spread of infection suitable bins for incontinence pads must be in place. Bedrooms are comfortable and hold residents personal belongings but do not allow privacy with the doors with glass panels. EVIDENCE: The Home had received its fire inspection in March 2005 with the fire equipment serviced in April 2005. The fire extinguishers were checked and had the relevant dates on them. All areas were tidy and fire exits were clear for safety. Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 17 A tour of the building took place with areas noted that had been improved since the last inspection. Curtains were in place in the lounge, the carpet had been improved by the purchasing of a carpet shampooer and some furniture had been placed in alcove areas allowing residents to rest on moving from one area to another. The carpets, especially the main lounge/dining rooms are still stained and although they have been shampooed, are in need of replacement. (Requirement) The courtyard area is pleasant to walk around and houses small animals and an aviary for budgies and canaries , which can also be seen on passing along the corridors. The hairdressing facility is housed in one bathroom and then in the corridor, which is used as a thoroughfare and needs to be placed elsewhere for privacy of the residents. (Recommendation). Areas are light and bright with many large windows in the communal areas. There is one small area away from the main communal areas for residents who wish to smoke One bathroom was seen that had a missing lid off the used continence pad container and was full of used continence pads. A lid that is covering the bin and can be cleaned so staff can ensure good infection control must be in place (Requirement). All the bedrooms seen were clean and tidy. One couple spoke to the Inspector for some time about the circumstances of their need to move to Courtenay House and discussed the bedroom with them. They were happy with the facilities and felt all the furniture was adequate. They each had a bed with an attractive cover, an armchair, small table, chest of drawers and wardrobe. The call bell system has a trailing wire to the armchair and needs to have a risk assessment in place. There were a number of residents who had a call bell wire trailing across the room with each requiring a risk assessment. (Requirement). Each bedroom has a large glass panel in the door as mentioned earlier in this report and needs to be blocked in for residents privacy. (See Requirements) Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The consistency of care cannot always be appropriate if the numbers of staff on duty vary. The Home need to increase the numbers of qualified staff to ensure residents are care for in safe hands. The Home must follow the recruitment procedure to ensure residents are protected. EVIDENCE: Copies of the rota were not available prior to the inspection and were later looked at for all care and nursing staff for the month of October. The Home had 43 residents on the day of the inspection and with 6 care staff and 2 nurses this amount was seen as adequate. The number drops in the afternoon by one staff member and on occasions only one nurse is on duty. This number needs to be looked at carefully and will be checked again at the next inspection to ensure adequate staff are on duty to cover the residents needs throughout the 24 hour period. (Recommendation). The Home has not yet met the 50 of staff who should hold the relevant NVQ qualification but are working towards that number with 7 staff qualified to date. (Requirement) Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 19 Two recruitment personnel files were looked at. It was noted that only one reference had arrived for one person in post and the CRB application had been completed but only the POVA check was on the file to date. (Requirement). The other file had no signature on the contract of terms and conditions, which is evidence that the person has received their copy. (Recommendation) Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 36 Due to the limited time the Manager has been in post and with lack of experience she has shown skills that some long term Managers do not have. The leadership and team work discussed show good management skills developing. The Home needs to have a system for checking quality. Supervision for staff need to be planned and occurring on a regular basis to ensure appropriate practise is taking place. EVIDENCE: The Manager does not have two years experience within a senior management capacity nor a suitable management qualification. She is a registered nurse Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 21 and has gained management skills through outside experiences such as The St. John’s Ambulance. She is still to be registered with the Commission and as she has now been in post for six months the application is overdue. (Requirement). Although the manager has limited experience staff spoken to all said the leadership skills shown gave a good sense of team working. Ideas and plans are shared and residents and staff are actively involved. A recent copy of a residents meeting showed an open, active and productive meeting that on talking to one resident made her feel she was being involved. One statement was “Things happen a lot more now the manager is here” and two staff members said that the enthusiasm of the manager is infectious and the home is improving. The home does not have any system in place as yet to monitor quality but in discussion with the Inspector this is to be an aim over the next six months. (Recommendation) Staff supervision is in place with records seen of sessions held in May and June. The senior team now have a Deputy Manager in post and the responsibility of the supervision sessions will be spread across this team. This should ensure the two monthly sessions can now be planned. (Recommendation). Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 2 x x 2 x x STAFFING Standard No Score 27 3 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 3 1 x x 2 x x Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement It is a requirement that all medication must be labelled correctly and for the person intended. It is a requirement that the glass panels in bedroom doors are replaced to ensure privacy and dignity is available for all residents. (THIS IS A PREVIOUS REQUIREMENT) It is a requirement that the stained carpet in the lounge/dining room be replaced to a more suitable flooring for the purpose of eating and relaxing It is a requirement that all used incontinence pads are placed in a suiitable container for good infection control practise. It is a requirement that a risk assessment be carried out on all residents with a call bell that requires a wire across the bedroom floor to call for assistance. It ia a requirement that at least 50 of care staff are suitably qualified and trained for NVQ2. It is a requirement that all information and documents must Timescale for action 06/10/05 2. 10 and 24 12.4a 31/11/05 3. 20 23 31/03/06 4. 21 13.3 06/10/05 5. 24 13.4 31/10/05 6. 7. 28 29 18.1 7,9, 19 31/03/06 31/10/05 Page 24 Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 8. 31 8,9,10 be on file as stated in schedule 2 of the N.M.S. of all staff working within the Home. It is a requirement that the Manager is put forward for registration as soon as possible. 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 9 12 15 Good Practice Recommendations It is recommended that the recording of daily events for residents gives afull picture of the day to include health,personal and social care. It is recommended that the Home encourages all staff involved in medication to attend a comprehensive course on the safe handling of medicines It is recommended that the interaction and involvement in activities/recreational interests is recorded for each resident. It is recommended that residents who have memory problems are shown the meal choice to make the decision at the time of the main meal and that there is always an alternative meal to the main course of the day.. It is recommended that all staff are trained and have an understanding of the Protection Of Vulnerable Adults. within the next twelve months It is recommended that the use of other rooms in the home are considered for the hairdressing facility which at present is held in a corridor leading to and from bedrooms. It is recommended that rotas are carefully checked to ensure the correct number of staff are on duty at all times of the day to cover the care needs of the number of residents residing. It is recommended that all copies of contracts for staff are signed and dated. It is recommended that a quality assurance system is in place. It is recommended that staff supervision is planned and occurs at least 6 times per year. 5. 6. 7. 18 20 27 8. 9. 10. 29 33 36 Courtenay House I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 3rd Floor, Cavell House St Crispins Road Norwich NR3 3BN 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 I55 s15629 courtenayhouse v244253 061005 stage 4.doc Version 1.40 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!