Inspection on 09/03/06 for Devonshire Manor

This inspection was carried out on 9th March 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

Devonshire Manor 18/11/09

Devonshire Manor 10/03/09

Devonshire Manor 11/03/08

Devonshire Manor 04/12/06

Devonshire Manor 04/05/06

Devonshire Manor 20/09/05

Devonshire Manor 12/01/05

Devonshire Manor 29/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Devonshire Manor 38 - 40 North Road Birkenhead Wirral CH42 7JF Lead Inspector Beate Roth Unannounced Inspection 9th March 2006 11:30 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 Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Devonshire Manor Address 38 - 40 North Road Birkenhead Wirral CH42 7JF 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) 0151 652 2274 Mrs Patricia Mary Gorry Mr Thomas Charles Gorry Mrs Patricia Mary Gorry Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Devonshire Manor is registered to provide personal care to 15 older people. There are 13 single and one double bedroom. All service users are accommodated in single rooms unless they choose to share. The home has two floors. Bedrooms are situated on both the ground and first floor. A stair lift is available. Toilets are situated on both floors. There is a bathroom on the ground and on the first floor. Bathing aids are provided. Communal space is provided in a lounge with through dining room. There is car parking space at the front of the building and a ramp for wheelchair access. A paved outdoor area is provided with flowerbeds and shrubs. The garden is accessible by wheelchair. The home is situated in the Tranmere area of Birkenhead and is convenient for local bus routes across the Wirral. There is a small selection of shops within walking distance. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 and half hours. At the time of the inspection, the manager reported that the records were being re-organised in the office. A number of records could not be found as a result. During the inspection time was spent in the office examining the records that were available and talking to the manager. A tour of the home was undertaken. Staff were observed delivering care to service users. The inspector spoke to service users, their relatives and to staff. What the service does well: What has improved since the last inspection? What they could do better: It is of concern that the requirements made at the last inspection are outstanding. There are a number of improvements that need to be made in order for this service to comply with the Care Homes Regulations 2001 and meet the National Minimum Standards for Care Homes for Older People. Up to date written information about the services at the home and the living space available needs to be provided to service users. The service user care plans must contain clear information as to the action staff are to take to meet the needs of the service users. A record of any complaints made and the action taken by the registered person in respect of any such complaint must be available. Improvements need to be made to the homes adult protection procedure to ensure service users are protected from abuse. The registered persons must ensure that the recruitment information that is required by law is available for all new care staff employed at the home. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 6 Records to demonstrate that all staff have received training appropriate to the work they perform and to demonstrate that the staffing levels are sufficient must be available. Action needs to be taken to ensure that the arrangements for quality assurance and supervision of staff better support the well being of service users. The safety of service users must be better promoted. Risk assessments must be recorded before bed rails are provided. Risk assessments are needed for the two unguarded radiators in service users bedrooms. Evidence that an up to date gas safety check has been carried out is needed. Fire drills and fire safety training must be provided to staff at suitable intervals. Appropriate storage facilities need to be provided. 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. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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): 1, 3 and 5 Service users have their needs assessed before moving to the home and they benefit from being able to make trial visits. Up to date written information about the services at the home and the living space available needs to be provided to service users. EVIDENCE: The statement of purpose and the service user guide could not be located during the inspection. Two new service users said that they could not recall having been given a service user guide. At the last inspection a requirement was made that the statement of purpose and the service user guide be reviewed as they contain information about staffing and services that are no longer relevant. Both documents also needed to include information about the sizes of communal space and bedrooms available. It was not possible to confirm if this requirement had been met. The manager visits all prospective service users to carry out an assessment before they are offered a place at the home. The assessment documents examined had been completed either with a tick box or a brief comment. They identified the main areas of need for each of the service users and although Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 9 fairly simplistic in style and content could provide the basic information from which a care plan can be developed. Inspection of records and discussion with the service users, manager and staff confirmed that prospective service users are able to visit the home on an introductory basis. During these visits they can meet staff and current service users and view the home. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 and 10 Staff are not provided with sufficient written information to meet the needs of service users. The health care needs of service users are met. Service users are treated with respect. EVIDENCE: A sample of service user plans were seen. These plans identify the current needs of service users but do not provide sufficient information for staff around the action to be taken to meet these needs. A discussion took place with the manager around the action that needs to be taken to address this. It is recommended that the initial assessment undertaken before service users come to live at the home and the service user plan indicate the support service users need to use the stair lift. The service users spoken to said that they are well cared for at the home. When asked about the care they receive from staff, service users said “the care is very good” and “we are well cared for.” Relatives spoken with said that they are happy with the standard of care given. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 11 The records at the home and a discussion with the manager indicated that referrals are made to health professionals in accordance with the needs of service users. A record is made of visits by health professionals and the outcome is documented. The records of accidents are held on individual service user files. A sample were seen and were satisfactorily completed. However, as these records are now held on individual files, it was difficult to identify if there were any factors that may need to be considered for care planning. It is recommended that an audit of accidents be completed on a monthly basis. Staff were observed to treat service users with respect. Staff were observed to speak to service users in a respectful manner and knocked at bedroom doors before entering. The service users and relatives interviewed said that the staff are “polite,” “friendly,” “helpful” and “kind.” Staff receive guidance on promoting the dignity of service users. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 and 14 The wellbeing of service users is promoted by the flexibility of the daily routines and by the opportunities for service users to make choices. EVIDENCE: A record of activities is available in the lounge. Armchair aerobics, films, a quiz, and bingo were activities recorded as being available for service users to take part in. Some service users spoken with said that they would like more activities and others said that they are happy with the activities available. The manager was advised to have a further discussion with the service users about the activities provided. The manager agreed to do this. Staff spoken with said that often activities are offered but the service users do not wish to take part. Observations and a discussion with service users indicated that the routines of daily living are flexible. Service users said that the home encourages them to make decisions about their day-to-day lives at the home, such as when they will get up and go to bed and what they will do each day. The service users bedrooms that were seen had been personalised with items brought in from their own homes. Information about advocacy services is available. Visitors are welcome at the home at reasonable times. Service users can see visitors in private in their bedrooms. A quiet area is available in the dining room. During this inspection, the service users who were spoken with said Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 13 they felt their visitors are made to feel welcome. A number of visitors were observed visiting the home during the inspection and were greeted warmly by the staff. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 It was not possible to fully assess if complaints are appropriately managed. Improvements need to be made to the homes adult protection procedure to ensure service users are protected from abuse. EVIDENCE: There is a complaint procedure available in the lounge. The service users spoken with said that if they had a complaint to make they would approach the manager or a member of staff. The manager reported that no complaints have been made to the service since the last inspection. This could not be confirmed as the complaints record could not be located. No complaints have been made to CSCI about the home since the last inspection. At the last inspection a requirement was made that the adult protection procedure be amended. It was reported that the adult protection procedure refers to staff investigating an allegation of abuse. This would not be the appropriate course of action to take. Allegations of abuse are to be referred to social services. At this inspection, the adult protection procedure could not be located. Advice was given to the manager around how to obtain a copy of Wirral Borough Council’s adult protection procedures. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 15 Several members of staff have completed adult protection training as part of the NVQ 2 in Care of Older People. A member of staff interviewed at this inspection, who had completed an NVQ 2 in Care of Older People, was fully aware of the correct adult protection procedure to follow. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 home is clean and in general, satisfactorily maintained. The safety of service users is not fully promoted. EVIDENCE: The premises are in keeping with the local community. The home is close to local amenities local transport and relevant support services. A tour of the home was undertaken and a sample of bedrooms seen. The home was clean and in general, satisfactorily maintained at the time of the inspection. Bedrooms are personalised. The carpet in the lounge and the decoration in the lounge and dining area are showing signs of wear and tear. The manager reported that these areas have been identified for redecoration. The registered person continues to carry out remedial repairs and redecoration at the home but as recommended in the previous inspection report a projected programme of routine maintenance and renewal of the fabric and decoration of the home would assist the overall management processes. This would also contribute to ensuring the quality of the service provided. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 17 At the time of the inspection the home did not have appropriate arrangements for storage. A vacuum cleaner and a commode were stored behind the door to a bathroom. A commode was stored in the toilet on the mezzanine floor. A doorway was being used to store furniture and other items. Toiletries were being stored on a shelf outside the bathroom and could be a hazard to some service users. Appropriate storage facilities must be made available at all times. A risk assessment was not available for a bed rail that is provided to a service user. The manager reported that this bed rail has only recently been provided and that the district nurse is visiting the home next week to assist in recording a risk assessment. A risk assessment must be recorded before service users are provided with a bed rail. Steps have been taken to ensure that a safe environment is provided. Water is regulated throughout the home to ensure that the temperature does not exceed 43 degrees centigrade. Regular checks of the water temperature are undertaken. A number of the radiators have radiator covers in accordance with a risk assessment. Radiator covers are not fitted in 2 bedrooms. The manager reported that this is in accordance with a risk assessment. This risk assessment was not documented. This is to be addressed. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 rota indicates that the staffing arrangements at the home do not fully protect service users. The records of the homes recruitment practices indicate that service users are not safeguarded. Although, service users benefit from staff being encouraged to undertake an NVQ 2 in Care of Older People, they would benefit further from staff completing a formal induction and foundation training programme. EVIDENCE: At this inspection it was difficult to fully assess if the staffing levels were sufficient to meet the needs of the service users. The rota for the week of the inspection indicated that there were periods when only one member of staff is on duty, which would not be acceptable. A second rota in the kitchen, showed that there are a minimum of two staff on duty at all times. Staff indicated that there are always a minimum of two staff on duty. Service users and relatives reported no concerns about the staffing levels. At the last inspection a requirement was made that the rota must be an accurate reflection of the staffing arrangements at the home and that a record of whether the rota was actually worked also needs to be maintained. This requirement has not been met. The manager reported that 50 of staff have completed an NVQ 2 qualification in care of the elderly. Staff at this and at previous inspections, have reported that they have completed an NVQ in Care of the Elderly. The records of training could not be found to support this. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 19 Two new staff have been employed since the last inspection. No records relating to the recruitment of one member of staff could be found. Evidence that a Criminal Records Bureau check had been obtained for the other member of staff was not available. The manager reported that all staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; service user’s care plans and health and safety issues. Following this the manager reported that further training is provided around meeting the needs of service users and health and safety matters. The manager reported that all staff are then encouraged to complete an NVQ. Confirmation of this was not available as the records of training for staff and training certificates could not be found. A training programme was also not available. There must be evidence to demonstrate that all staff have received training appropriate to the work they perform. The manager is to ensure that the induction and foundation training meets the NTO workforce training targets. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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, 36 and 38 The arrangements for quality assurance and supervision of staff do not support the well being of service users. The safety of service users is not fully promoted. EVIDENCE: The manager of the home has managed Devonshire Manor for 18 years. The manager reported that she has undertaken periodic training to maintain and update her knowledge, skills and competence. The records to support this were not available. The registered manager has a Certificate in Social Services qualification. The manager is currently undertaking an NVQ Level IV in management. There are systems in place for reviewing and improving the quality of care provided at the home. There continues to be no formal quality assurance system in place that would confirm the success of the home in achieving its stated objectives. The registered person has issued a questionnaire to service Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 21 users and their relatives however, the results from this were not available. If the results could be formed into a coordinated response, with an action plan for future development this would enable the home to meet the relevant requirement. Additionally a questionnaire for GP’s, district nurses and other visiting professionals would complete the quality assurance process. The manager reported that the home does not look after any money for service users. The financial affairs of service users are managed by the service users themselves, or by their family or a solicitor. Service users are able to bring personal possessions to the home. A requirement was made at the last inspection that all staff working at the home be appropriately supervised and a record be maintained of each supervision event. At this inspection, informal supervision is continuing. No records are maintained and the process would not support any actions taken with members of staff to support references or disciplinary action. Paperwork is available to meet this requirement. A sample of safety check records were seen for the electricity, hoist, stair lift and contractors checks of the fire safety systems and were appropriately maintained. A record to indicate that a safety test of the gas supplied to the home had been carried out was not available. Improvements need to be made to the procedures at the home for promoting fire safety. The record book used to record fire drills and tests of the fire alarm and emergency lighting had pages that were loose. Some pages had come out of the book. A record had not been made of fire drills and fire safety training provided to staff. This was a requirement made at the last inspection. The manager reported that this has been addressed but not recorded. The records of emergency lighting tests showed that this had not been tested since January 2006. The manager and staff reported that they have received health and safety training. Only a few training certificates were available to confirm this. A copy of these certificates should be held at the home. Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 1 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 1 Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 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 OP1 Regulation 6 Requirement The registered person must ensure that the statement of purpose and the service user guide are reviewed and include the required information (previous timescale of 20/12/05 not met). The registered person must ensure that service user care plans contain clear information as to how staff are to meet service users needs. The registered person must ensure that a record of complaints made about the operation of the care home and the action taken by the registered person in respect of any such complaint is available. The registered person must ensure that the adult protection procedure is amended to reflect that allegations of abuse are to be reported to social services (previous timescale of 20/10/05 not met). The registered person must ensure that appropriate storage facilities are made available. DS0000018882.V285673.R01.S.doc Timescale for action 09/06/06 2 OP7 15 09/03/06 3 OP16 22 09/03/06 4 OP18 13 09/04/06 5 OP19 23 09/03/06 Devonshire Manor Version 5.1 Page 24 6 OP19 13 7 OP19 13 8 OP27 17 9 OP29 19 10 OP30 18 11 OP33 24 12 OP36 18 13 OP38 13 The registered person must ensure that the risk assessment for the unguarded radiators is recorded. Steps must be taken to address any risks presented (previous timescale of 20/10/05 not met). The registered person must ensure that before bed rails are provided to service users a risk assessment is fully recorded. The registered person must ensure that the staffing rota accurately reflects the staffing arrangements at the home. A record of whether the rota was actually worked must also be maintained (previous timescale of 20/09/05 not met). The registered person must ensure that staff are employed following the receipt of all the required recruitment information as detailed in Schedule 2 and Schedule 4 of The Care Homes Regulations 2001. The registered person must demonstrate that all staff have received training appropriate to the work they perform. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home (previous timescale of 20/12/05 not met). The registered person must ensure that all staff working at the home are appropriately supervised and a record maintained of each supervision event (previous timescale of 20/09/05 not met). The registered person must ensure that a record is made of fire drills and fire safety training provided to staff (previous timescale of 20/09/05 not met). DS0000018882.V285673.R01.S.doc 16/03/06 09/03/06 09/03/06 09/03/06 09/03/06 09/06/06 09/03/06 09/03/06 Devonshire Manor Version 5.1 Page 25 14 OP38 13 The registered person must provide evidence that a gas safety inspection has taken place within the last 12 months. 09/04/06 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 Refer to Standard OP7 Good Practice Recommendations It is recommended that the initial assessment undertaken before service users come to live at the home and the service user plan indicate the support service users need to use the stair lift. It is recommended that an audit of accidents be completed on a monthly basis and that the findings be used to inform care planning. The views of service users about the activities to be provided should be obtained. A copy of Wirral Borough Councils adult protection procedures should be obtained. The registered person should produce a planned maintenance programme for the home indicating the years in which the fabric and furnishings of the home will be repaired or replaced. The induction and foundation training is to meet all of the National Training Organisation targets. The registered manager is to complete an NVQ Level 4 in care. A copy of all training certificates awarded to the staff and manager should be held at the home. 2 3 4 5 OP8 OP12 OP18 OP19 6 7 8 OP30 OP31 OP38 Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Devonshire Manor DS0000018882.V285673.R01.S.doc Version 5.1 Page 27 - 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!