Inspection on 27/06/05 for Delapre House

This inspection was carried out on 27th June 2005.

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

Delapre House 28/04/08

Delapre House 11/08/06

Delapre House 02/11/05

Delapre House 18/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Delapre House 109 Magna Road Bearwood Poole BH11 9NE Lead Inspector Debra Jones Unannounced 27 June 2005 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. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Delapre House Address 109 Magna Road Bearwood Poole Dorset BH11 9NE 01202 570800 01202 570800 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) Bell Social Work Ltd (BSW Ltd) Miss Judith Bell CRH PC - Care Home only 10 Category(ies) of OP - Old Age (10) registration, with number of places Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 18 October 2004 Brief Description of the Service: Delapre House is registered to provide accommodation for ten older people in an attractive converted house. It is set back from a main road on the northern borders of Bournemouth and Poole. Local bus services provide easy access to the town centres and Wimborne. The home has some car parking at the front and plenty of on road car parking is available. There is a large well maintaned garden to the rear. The accommodation for residents in the home is over the ground and 1st floors with a passenger lift between. There are a variety of aids and adaptations around the building to allow residents to move about more independently. There are 10 single rooms all of which have en suite facilities. There are additional communal toilets and bathrooms around the home. Situated on the ground floor is the service users lounge, which overlooks the garden. An archway leads into the dining area. There is also a small quiet lounge that also overlooks the garden. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours and was one of the two anticipated inspections of the year. The requirements and recommendations made at the last inspection were followed up to see the progress made towards meeting them. This was only the second inspection at the home since it changed hands and reopened in October 2004. At the last inspection, carried out shortly after the home reopened, only 3 people were living there. Care planning systems were just being put into place and policies, procedures and other supporting paperwork to do with the running of the home were just being introduced. A number of requirements and recommendations were made at that inspection and all but one recommendation has been complied with. Seven new requirements were made at this inspection. The Inspector looked around most of the building and at a number of records. Ms Bell, 1 member of staff and 3 residents were spoken to. The inspector also met other residents and a visitor during the course of the inspection and joined residents for lunch. What the service does well: Delapre House provides a service for the eight older people currently living at the home in a comfortable relaxed atmosphere in a house decorated and furnished in a homely way. The home is well organised and the care and contentment of residents is at the heart of the way the home is run. Ms Bell and her staff have developed good relationships with the residents and this results in a supportive and caring environment in which the residents feel secure and comfortable. Staff were described as ‘kind and helpful.’ A good admissions procedure is in place. Prospective residents get relevant written information about the home and what it has to offer, are properly assessed by people from the home and have opportunities to visit the home to see if they like it. Care plans and notes are thorough and regularly updated to make sure that staff know how to care for the residents living at the home. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 6 Care staff are supported in caring for residents by community health professionals. Residents are able to do as they wish at the home and join in or not with the activities on offer. Visitors are made welcome at the home and can come whenever it suits the residents. Meals are varied and planned around the likes and dislikes of residents. Meal needs and preferences are always taken into account and mealtime arrangements are flexible enough to accommodate individual preferences. The complaints procedures reassure residents that their well-being and comfort are important to the home and that any complaints they raise will be properly investigated. The home is homely, well maintained and comfortable for the residents living there and anyone visiting. The home is kept clean and smells pleasant. Sufficient, well supervised, qualified care staff are on hand to meet the current needs of residents. Many records are kept that demonstrate the home’s commitment to keeping residents safe. What has improved since the last inspection? The statement of purpose and service user’s guide have been updated to reflect the recent change of ownership of the home. Care plans now flow from the comprehensive assessments undertaken and are consistent and up to date. The complaints procedure and whistle blowing procedure have both been updated and now give information about how to contact the Commission for Social Care Inspection. The complaints procedure also includes timescales for investigation and response. Radiators that potentially posed risks to residents have been covered or turned off. The home now has evidence to show that it complies with the Water Supply (Water Fittings) Regulations 1999. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 7 The infection control policy has been updated to include the safe handling and disposal of clinical waste; dealing with spillages; provision of protective clothing and hand washing. Staff have had training in these matters. Staff now have a contract of employment. 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. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5 6 is not applicable to this home. Information provided about the home and a good admissions procedure enables prospective residents to make informed decisions about admission to the home and ensures that only service users whose needs can be met by the home are offered places there. However, the home does not currently assure all prospective residents in writing that their needs can be met. EVIDENCE: The Statement of Purpose and Service User’s Guide have recently been updated and contain all the information required about the home and its facilities. These documents are well written and informative and give a good indication about what a prospective resident can expect from the home. Some files of recently admitted residents showed that prior to them moving to the home their needs were fully assessed by the home. The person is given the opportunity to visit the home as are their representatives. Residents spoken to on this occasion had left this visit to their representatives and confirmed that this had been their choice. The home offers respite care and trial periods to residents giving people time to make this very important Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 10 decision. The assessed ability for the home to provide care had been confirmed in writing to prospective residents coming for respite care and Ms Bell will be extending this to all prospective residents in future. Local authority assessments were also on file where these had been made available to the home. All residents have terms and conditions with the home. Again these documents are clear and easy to read and give all the information a resident would need. Ms Bell talked of how these were often given to prospective residents early on in the admissions process to aid them in their decision making as to whether the home is suitable for them. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 There is a good care planning system in place to make sure that staff have the information they need to meet the needs of the residents. The health needs of the residents are also well met with evidence of good support from community health professionals. EVIDENCE: Residents and the visiting District Nurse said the home looked after people well. Care plans seen were of a good standard. They flowed from the assessments made by the home, were easy to read, to the point and informative about the needs of the resident and how the home was to meet their needs. Language used was sensitive and respectful. All information contained in the care plans was relevant and up to date with plans being reviewed monthly. Wishes regarding death and dying were noted. Thorough risk assessments are also in place for residents. Accidents are recorded and pertinent information from these feed into the updating of care plans. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 12 Daily notes support and evidence the delivery of care to residents. These give a good picture of the daily lives of residents, the care that is delivered to them by staff in the home and by visiting community health professionals such as District Nurses. Continence assessments are requested as appropriate. Residents are accessing other community health services such as opticians, dentists, physiotherapists and chiropodists. One diabetic resident attends a foot clinic at a local hospital. The local sensory loss team has also been involved with residents. The Inspector discussed with Ms Bell the potential expansion of their hospital admission documentation to include body charts / detailed records about the condition of residents when leaving the home and going to hospital. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 15 Residents’ lives are enriched by the activities on offer at the home and the social opportunities afforded by their visitors. The meals in this home are very good offering both choice and variety and are served in a pleasant environment. EVIDENCE: Friends and relatives are made welcome at the home, with some residents having visitors most days. Residents can receive their guests in the communal areas, their own rooms and the garden. One resident talked of the trips out she enjoys with her regular visitor. Another resident was on holiday in Margate – staying in a residential home and seeing family. The visitors’ book confirmed the number and range of visitors to the home. Delapre House is very much the home of the residents and is run in a manner that supports them to live their lives as they choose. Information is collected about residents’ interests and previous occupations. Structured activities are sometimes twice daily and are centred on residents’ interests and abilities either in groups or 1-1s, focusing on mental stimulation, encouraging movement and social interaction with a little pampering thrown in for good measure. The home keeps a record of activities and references to visits, outings and activities are also made in daily notes. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 14 A small lounge is available for residents to meet with visitors privately and for smaller activities to take place. This room is also used for visiting clergy. Staff were observed encouraging people to make choices and were on hand to help at all times. When people move into the home they are asked about what they like to eat. Residents are well able to say what they enjoy and to make their preferences clear. Menus are based both around the known likes and dislikes of the residents, on providing a good wholesome diet and on the time of the year– planning meals around what is in season and the appropriateness of the meal to the weather. Quite detailed information is held to ensure that residents even get the crockery and cutlery that they like and which meet their needs e.g. sizes of spoons they like to eat with etc. A cook is employed. Residents are offered meal choices the day before. The meal served on the day of inspection was seafood or cottage pie with a range of vegetables. Sponge pudding or ice cream was for dessert. All residents spoken to praised the food saying there was always plenty to eat and that there was always a choice. One resident, who is diabetic and has a restricted diet, said that her needs were well catered for. Another resident follows a low fat diet which is also accommodated by the home. Records are kept of meals, further demonstrating the choice available. Sample menus are included in the information the home provides to prospective residents. Residents can have meals where it suits them. The home has a pleasant dining area at the end of the lounge that residents can eat in if they wish. Drinks, including fruit juices, are available throughout the day and jugs of water are in each room. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 A system is in place to deal with any complaints that might be made about the home to ensure that concerns will be listened to and investigated EVIDENCE: The home has a complaints policy / procedure that is given to residents. The Commission has received no complaints since the last inspection. The home is currently investigating a complaint made by a resident. Residents spoken to said that they had nothing to complain about. The home also keeps a ‘moans and groans book’ where residents’ day to day concerns are noted along with how the home has resolved any issues, addressed concerns. This demonstrates how seriously the home takes the well-being, comfort and happiness of their residents and their desire to put things right as simply and quickly as possible. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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) 19,20,21,22,23,24,25 and 26. The home is well–maintained and a comfortable and safe environment is provided for the residents living there and anyone visiting. Bedrooms are well decorated, well furnished and personalised to suit the residents. Adequate facilities are available to meet the number and needs of the people living there. The home is kept clean and smells pleasant thereby making daily life for all in the home more pleasurable. EVIDENCE: Delapre House has a warm and homely atmosphere. The home is well decorated throughout. Lounges and dining areas are well and comfortably furnished. A quiet room is available just off the main lounge, where residents can listen to music, entertain guests or just sit quietly. The garden is well maintained, attractive and accessible. Residents sitting in the lounge and quiet area have a good view of it and garden furniture is available for those wishing to sit outside. Residents talked of how they enjoyed walking round the garden, some needing assistance from staff to do Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 17 this. Residents are mostly mobile and can choose where they spend their days. Some need a little assistance to get about. There are a number of communal bathing areas in the home. All bedrooms have en suite facilities, some including showers. Aids and adaptations are available throughout the home and some residents with particular needs have their own personal equipment to assist with their independence. Where residents need equipment to aid independence such as zimmers and rollators the equipment was seen to be to hand and residents were encouraged to use it. Other more specialist equipment was available i.e. a hoist. This was kept in the bedroom of the resident who sometimes needs it. Other useful aids and adaptations are around the home for use by all e.g. raised toilet seats and grab rails. The premises have not been assessed by a qualified person(s) including an occupational therapist. Residents are able to personalise their rooms with furniture and general belongings. There is a passenger lift in the home, enabling easy access between the ground and first floor. There are emergency alarm bells throughout the home. One resident confirmed that they knew what the system was for, had used it in the past and that staff had come quickly. Residents are able to have keys to their bedroom doors and all have lockable storage in their rooms for personal belongings of importance. Since the last inspection radiators that might pose a risk to residents have been attractively covered. Radiators that are not covered do not pose a risk as they are turned off or obscured by furniture. The home was clean and there were no unpleasant odours. Adequate facilities, policies and procedures are in place in respect of laundry and the disposal of clinical waste. Recent training of staff in infection control has taken place. Evidence was available that the services and facilities of the home comply with the Water Supply (Water Fittings) Regulations 1999 in the form of a letter following a survey by a specialist contractor dated 15 4 05. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 Sufficient care staff are employed and deployed to ensure that the care needs of residents can be met. Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home although not all new staff have got POVA first checks or their full Criminal Record Bureau certificates back yet. EVIDENCE: Staffing rosters are in place that show who is on duty and when. Rosters must be revised to show all staff on duty- not just care staff, their full names and their designations i.e. what job they do. Evidence of whether the roster was actually worked is held in the signing in book and via time sheets. Ms Bell and her care staff are supported in running the home by a cleaner, a cook and an administrative worker. A member of staff with emergency aid training is always on duty at the home. Out of the 11 care staff employed at the home 5 have NVQ level 2 or are studying for an alternative care related qualifications. Some with NVQ level 2 are continuing their studies and doing NVQ levels 3 and 4. A recruitment procedure is in place at the home and staff files are kept that demonstrate the recruitment process in action. Staff have contracts of employment and are issued with staff handbooks. The handbook includes the whistle blowing procedure which has the contact details of the Commission for Social Care Inspection. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 19 The home employs some workers from abroad. It was clear from the files that the home was obtaining the right sort of information about people’s rights to work in the country and any restrictions on that work. A few gaps were found in the documentation that must be obtained for staff employed at the home. Where CRB disclosures have not been returned POVA 1st checks must be applied for and proof of the outcome of the check kept. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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) 31,33,35,36,37 and 38 The home is well organised and the care and contentment of residents appears to be at the heart of the daily management and running of the home. Fire records do not demonstrate that residents would be as safe as they could be in the event of a fire breaking out. EVIDENCE: Ms Bell is an experienced manager and is in charge of the home on a daily basis. Ms Bell has a hands on approach to her job and this has a positive impact on the home in that she leads staff by example and residents know her well. Ms Bell has senior care staff to support her. The home opened in October 2004 and so has not yet carried out an annual quality assurance survey to find out what people think about the home. When it is done later this year a report will have to be written based on the analysis Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 21 of the results of the survey. This report can then be circulated to any interested parties. The home does not hold any money or valuables belonging to residents. There was evidence of a supervision system being in place, enabling staff and management to meet regularly on a one to one basis to discuss day-to-day work at the home, training and development. All records kept in the home were made available to the inspector as requested and are appropriately stored. An up to date insurance certificate was on display along with Delapre House’s registration certificate (the home is reminded that both pages of this must be displayed). Fire records were in place. An external company carries out quarterly checks of the fire equipment. Internal checks are being carried out and records showed regular monthly checks being carried out but some weekly checks had not taken place and this must be addressed. Fire training, fire drills and fire evacuations are taking place. Fire training records for staff were not as easy to follow as they could be. They should be kept in a way that is easy to see at a glance when individual staff last had fire training and when it is next due, with individual staff members signing to confirm their attendance. One resident talked of the recent fire evacuation that took place and of how her visitor had helped her to leave the building. Records are kept of the servicing of equipment and facilities e.g. the passenger lift and the emergency call bell system. Data product sheets are also kept. The Dorset Fire Rescue Service had visited in May 2005 and will be visiting again in August 2007. Accident records and accident analyses were looked at. Some accident records were excellently completed in that they were clear about how staff writing up accident reports knew about accidents e.g. if they came across someone who had fallen, if a resident told them of an accident or saw someone else having an accident or if they are alerted to an accident by a resident ringing their emergency call bell. Ideally if all records were written in this way the analysis of such records would provide the home with important information as to the effectiveness of the emergency systems in operation and of any further measures that could be put in place to minimise risks to residents. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 2 x 3 3 2 2 Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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 4 Regulation 14 Requirement The registered person must confirm in writing to all prospective residents that having regard to the assesssment the care home is suitable for the purpose of meeting the residents needs in respect of his health and welfare. The duty roster must list all staff employed at the home, their full names and their designations. A full CRB or POVA first check must be obtained before anyone can start working at the home. A system of reviewing and improving the quality of care at the home must be established and maintained. Both pages of the certificate of registration must be displayed. A better system for evidencing staff fire training must be introduced. Essential weekly checks of fire equipment must be carried out without fail at the required regularity. Timescale for action 1 9 05 2. 3. 4. 27 29 33 17 19 24 1 8 05 1 8 05 1 10 05 5. 6. 7. 37 38 38 CSA 23 23 1 8 05 1 8 05 1 8 05 Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 24 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. Refer to Standard 22 Good Practice Recommendations It is recommended that suitably qualified persons including a qualified occupational therapist with specialist knowledge of the client group that the home caters for make an assessment of the premises and facilities. Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF 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 Delapre House D55 S61562 Delapre V233460 270605 Stage 4.doc Version 1.30 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. 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