Inspection on 26/10/05 for Dorcas House

This inspection was carried out on 26th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Dorcas House 03/06/08

Dorcas House 06/11/07

Dorcas House 02/05/07

Dorcas House 21/11/06

Dorcas House 23/05/06

Dorcas House 19/05/05

Dorcas House 08/09/04

Dorcas House 25/05/04

Dorcas House 24/11/03

Dorcas House 15/07/03

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

CARE HOMES FOR OLDER PEOPLE Dorcas House 56 Fountain Road Edgbaston Birmingham West Midlands B17 8NJ Lead Inspector Kulwant Ghuman Unannounced Inspection 26th October 2005 13:30 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 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 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. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dorcas House Address 56 Fountain Road Edgbaston Birmingham West Midlands B17 8NJ 0121 429 4643 0121 429 4643 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) Mrs Kate Danquah Mr Pan Danquah Mrs Kate Danquah Care Home 11 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (11) of places Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That four named persons under 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. The home must demonstrate through comprehensive care planning and regular reviews carried out by Social Services that it is able to meet all the needs of each individual. The home must not in future admit any other persons under the age of 65 years. 25th May 2005 3. Date of last inspection Brief Description of the Service: Dorcas House is an adapted domestic property that accommodates 11 people who are users of mental health services. The home has three floors with accommodation for service users on two of these. The third floor is for staff use. One lounge has a door out onto the rear garden and contains a large screen television and comfortable seating. Communal space is also provided in the form of a lounge/diner. Service users were seen to sit here to eat, to play games at a dining table and to watch television. The home has both single and shared bedrooms situated on the ground and first floor. A stair lift is available for service users to access the upper floor. There are shower, toilet and bathing facilities on both floors but none of these provide an assisted bathing facility. Laundry facilities are provided at the neighbouring house owned by the Danquah family. At the front of the home is a steep drive on which three cars can be parked. The side gate to the property permits further parking for up to three vehicles. At the rear of the home is a pleasant garden with seating, which service users can enjoy in fair weather. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on an unannounced basis over an afternoon in October 2005 and was the second inspection for 2005/2006. This report should be read in conjunction with the report of the inspection of May 2005. At the time of the visit there were nine residents in the home. The inspector was able to speak with six of the residents, a tour of the building was carried out and some documents were examined. What the service does well: What has improved since the last inspection? What they could do better: The care planning process needed to be further improved to ensure that all the required information was available to staff. The home needed to ensure that relationships with the visiting district nurses was improved so that the residents were able to receive blood sugar monitoring as required. The manager needed to ensure that all documents were available to her, and inspectors at all times. These included training records, residents’ monies and some maintenance records. It was important that the manager and staff considered the privacy and dignity of the residents in all their actions and interactions with the residents. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 6 The management of health and safety needed to be improved by ensuring that the equipment was regularly serviced and any risks associated with care tasks were kept to a minimum. 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. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 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 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 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): These standards were not assessed during this inspection. EVIDENCE: Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Care plans and risk assessments provided some information for care staff to enable them to meet the needs of the residents but some improvements were needed. The management of medicines was good. The privacy and dignity of residents could be improved EVIDENCE: Two residents files were sampled. It was found that the care plans and risk assessments had improved since the last inspection however, further improvements were required, for example, where residents needed assistance the type of assistance required needed to be documented. The falls risk assessment needed to indicate how staff were to assist residents off the floor in the event of a fall. One of the care plans indicated that the resident needed to be assisted in and out of the bath, however, the resident could no longer access the bath and would only use the shower. The care plan needed to be amended to reflect this. The care plans did not include information regarding the symptoms that staff would need to look out for that would indicate a relapse in the mental health of the resident and the actions to be taken in such a situation. The care plans also needed to indicate the input of other health care professionals in meeting the residents needs, for example, blood sugar monitoring. There were no nutritional or tissue viability assessments in place. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 10 Residents were due to receive the flu injection over the next few weeks. There was evidence that the general health care needs of the residents were being met. There were recorded visits from the dentist, GP and chiropodist. During discussion with the manager it came to light that some of the residents were not having their blood sugar levels monitored by the district nurses following an incident of possible aggression from one resident towards the nurse. This issue must be resolved with the GP and district nurses and plans put into place to ensure that blood sugar monitoring is resumed as soon as possible. There was recorded evidence of the GP’s visit if the GP made a record. The home should make their own record of the visit, the reason for the visit and the outcome of the visit so that there is a record of the GP’s and other health care professionals visits. The residents were not on large amounts of medicine and the management of medicine had improved since the last inspection. There were curtains in shared bedrooms and the locks on bedroom doors had been changed improving the provision of privacy and dignity. The door to the bathroom on the first floor and the toilet on the ground floor did not lock. Residents were encouraged to go to the toilet after meals. One of the residents did not want to go to the toilet and the manager spoke to her in a loud voice telling her to go to the toilet. Residents needed to be reminded discreetly ensuring their privacy and dignity is maintained. Another resident had a problem with continence and a plastic sheet was put on the floor when she was stood up. This could pose a health and safety risk as it could become slippery if it became wet. The manager needed to ensure that a different mat, that would absorb any liquid and could be washed, was used in future. The inspector also observed staff go into a bedroom to obtain an incontinence pad, however, the bedroom did not belong to that resident and the pad would also not belong to them. Staff should not be using communal stores of incontinence aids and staff should observe residents privacy when entering bedrooms. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 11 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): 12,15 Residents were not subjected to strict rules and routines but there was no evidence to show that their social needs were being met. The residents were happy with the food provided. EVIDENCE: The residents were able to go to their bedrooms during the day. One resident stayed in her bedroom at all times. The activity sheets in the resident’s files had not been completed. There was no evidence that any activities had taken place in the home except watching the television. The manager told the inspector that there were games available in the home and some of the male residents played dominoes. The main meal of the day was seen to be sausage, egg and chips and banana crumble. One resident was unable to eat alone and was being fed by one the staff. The resident was sat in an easy chair and the carers stood in front of her and fed her. There were no interactions between the staff and the resident during this time. The residents said they had plenty to eat and were happy with the meals provided. The dining area was pleasant. The menus appeared to be varied but the teatime meals needed to be varied, as sandwiches were generally the Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 12 evening meal. Diabetic diets were catered for and records were kept of what the residents ate. There was a flask left in the lounge/dining room. When asked what it was for the manager stated that a previous inspector wanted a drink made up and left for the residents to access. There was no evidence that the residents accessed this for a drink and staff should be able to make drinks available to residents when they want them. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 13 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): These standards were not assessed during this inspection. EVIDENCE: Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 14 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): 19,20,22,24,25,26 The physical environment was suitable for residents who had good mobility. There were some basic adaptations in the home including a walk-in shower. The bathing facility was not assisted and could not be accessed by residents with limited mobility. Bedroom doors could be locked increasing the privacy of residents. Infection control could be improved in the home. EVIDENCE: Residents who wanted some peace and quiet used the main lounge. Most residents sat in the lounge/dining room, which was pleasant and comfortable. The garden was not inspected during this inspection. The home was suitable for residents who had good mobility as there were no assisted bathing facilities and the only adaptations in the home were a stair lift to the first floor and an emergency call system. The bathroom and shower were not inspected as they were in use at the time of the tour of the building. The hot water temperatures were not tested but the inspector was informed that the temperatures were regulated. The Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 15 inspector was also told that the folding doors suggested at the last inspection had not been installed in the shower room on the ground floor. There still appeared to be a problem with the lights as some of the bulbs on the first floor had fused. The bedrooms were acceptable however some of the furniture, for example, chairs needed to be replaced and secondary lighting needed to be made available in the bedrooms, especially in shared rooms where the privacy curtains restricted the light to one of the occupants. There was a lockable piece of furniture in the bedrooms. The home was centrally heated and radiators were covered. There were no offensive odours in the home. The laundry was located in the house next door that was also owned by the proprietors and appeared to be better organised. There were tiles missing from the walls that needed to be replaced. The kitchen was not inspected during this inspection but the inspector was told that the broken floor tiles had not yet been replaced but the tap in the wash hand basin had been repaired. The inspector observed the staff assisting residents to the toilet without changing the gloves in-between. This is not good practice and gloves must be changed after assisting a resident. The used gloves needed to be disposed off before coming out of the bathroom and into the lounge/dining room. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 16 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): 27,29,30 Staffing levels were found to be at the lowest minimum levels and therefore there was little time for staff to spend with the residents. Records of staff training did not evidence that staff were trained and knowledgeable about the needs of residents. EVIDENCE: On the day of the inspection staffing levels were low. There was only one carer and the manager on duty. These staff undertook the cleaning, laundry and cooking. There were nine residents in the home at the time of the inspection. Staff were seen to be busy and there was little time for interactions with the residents. During the night there was one sleep-in staff member and one waking night staff. Staffing levels needed to be closely monitored and additional staff employed to ensure that residents were enabled to have meaningful lives. The staff files sampled had CRB clearance checks on them. All the staff had been employed in the home for some time and were related to the proprietors. The need for references and proof of identity for these staff was not pursued. There were no training certificates available on the files to check on the training of staff. There was evidence that staff had undertaken fire training in October 2004. There was no evidence of recent training for staff. The manager needed to be mindful that staff that had other jobs were not finishing one shift and coming to work at the home without the required breaks Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 17 to make them safe to work with the residents. All staff need to take updated training in first aid, food hygiene, infection control and health and safety. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 18 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): 31,32,33,35,36,38 The privacy and dignity of residents needed to be given a higher priority in the home and the manager needed to ensure that good care practices were the norm. The manager needed to be able to access all documents in the home and ensure that equipment in the home was maintained and serviced to ensure the health and safety of residents and staff. EVIDENCE: The manager stated that she had completed the Registered Managers Award and was awaiting the certificate. Some improvements had been made in the care plans for the residents. The manager needed to ensure that she demonstrated good care practices for the staff to follow and that the issue of privacy and dignity were given a higher profile when caring for the residents. The manager needed to ensure the safety of staff and residents at all times by the use of non-slip mats, all lights being in working order, that the shower Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 19 does not pose a slipping risk due to water flowing onto the floor and that all Steradent tablets were kept locked away. Staff were not receiving regular supervision and a minimum of 6 sessions in any 12-month period. The records for the monies held on behalf of the residents were not accessible to the manager as the proprietor had the keys. The manager must have access to the residents’ monies and records at all times. The fire records were up to date although the names of staff involved in the fire training and drills needed to be recorded. Fire training for staff needed to be carried out every six months. There were sheets in place that indicated that the fire alarm and nurse call systems had been serviced however, the documentation was not on headed paper and there were no certificates or work sheets completed. The services were overdue. The Landlords Gas Safety certificate on display was dated 5.8.04 and therefore out of date. The stair lift certificate, 5 yearly electrical report, the portable appliance checks and Legionella testing were not available. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 X 2 2 3 1 1 STAFFING Standard No Score 27 2 28 X 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 1 1 X 1 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5(1) Requirement Amendments must be made to the service user guide and statement of purpose. (Previous timescale of 30.11.04 not met. Compliance not assessed at this inspection.) The residents care plans must be developed to clearly show the needs of each person and how the staff are to meet the identified needs. Care plans must include strategies for dealing with difficult and challenging behaviour. Care plans must be regularly updated. (Previous timescale of 01/08/05 partially met.) Risk assessments must be holistic and identify how risks are to be managed. (Previous timescale of 01/08/05 not met.) Timescale for action 01/12/05 2. OP7 15(1) 01/01/06 3. OP7 13(4)(c) 01/12/05 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 22 4. OP8 17(1)(a) Sch3(3) (m) 13(1)(b) 13(2) 5. 6. OP8 OP9 7. OP10 12(4)(a) There must be nutritional and tissue viability assessments in place for all residents. (Previous timescale of 01/08/05 not met.) The manager must ensure that the residents receive treatment from health care professionals. The home must write a policy for the safe handling of medicines within the home and train staff to adhere to the policy. (Previous timescale given 01/08/05. Not assessed for compliance at this inspection.) The registered manager must ensure that there are adequate and suitable locks on all toilets and bathrooms. (Previous timescale of 01/08/05 not met.) The registered person must ensure that all interactions with residents promotes their privacy and dignity. Continence aids must not be used on a communal basis. The registered manager must consult residents about their social interests and make arrangements to engage in local, social and community activities. (Previous timescale of 01/08/05 not met.) The registered manager must ensure that food stocks are maintained at suitable levels. (Previous timescale given 01/07/05. Compliance not checked at this visit.) 01/12/05 21/11/05 01/12/05 01/12/05 8. OP12 16(2)(n) 01/12/05 9. OP15 12(1)(a) 01/12/05 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 23 10. OP15 12(1)(a) The registered manager must ensure that systems are in place to make residents aware of what meals are available. (Previous timescale given 01/07/05. Compliance not checked at this visit.) Staff must be appropriately seated and interact with residents they are assisting to eat. Fresh drinks must be available to residents throughout the day. The registered manager must ensure that an appropriate complaints procedure is available to residents. (Previous timescale given 01/07/05. Compliance not checked at this visit.) The registered person must ensure that the garden area is made safe for the use of residents. (Previous timescale given 01/07/05. Compliance not checked at this visit.) The registered manager must ensure that the furniture in residents bedrooms is of a suitable standard The registered manager must ensure that all lights in the home are maintained in working order. The broken floor tiles in the kitchen must be replaced. (Previous timescale of 01/08/05 not met.) The missing tiles from the walls in the laundry must be replaced. 01/12/05 11. OP16 22(1) 01/12/05 12. OP19 13(4)(b) 01/12/05 13. OP24 16(2)(c) 01/12/08 14. 15. OP25 OP26 23(2)(p) 13(3) 01/12/05 01/12/05 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 24 16. OP26 13(3) All foods in the freezer must be dated when frozen. The registered manager must ensure that foods are probed and records kept to show that the required temperatures have been achieved. (Previous timescale given 01/07/05. Compliance not checked at this visit.) Staff must change their gloves after assisting each resident. The manager must monitor the staffing levels to ensure that there are sufficient staff on duty to meet the residents needs. Staff must undertake training appropriate to meet the needs of the resident group. (Previous timescale given 01/09/05 not met.) 01/12/05 17. OP29 18(1)(a) 01/12/05 18. OP30 18(1)(c) (i) 01/02/06 19. OP33 24 20. 21. OP35 OP36 12(2) Sch4(9) 18(2) There must evidence available for inspection that all staff have recently undertaken mandatory training. The home must develop a quality 01/03/06 assurance tool, which takes into account the views of service users. (Previous timescale given 31/12/04 and 01/09/05. Compliance not checked at this visit.) The manager must have access 01/12/05 to residents’ monies and records at all times. Staff must be supervised a 01/04/06 minimum of 6 times a year. (Previous timescale of 30/11/05 and 01.08/05 not met.) Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 25 22. OP37 17(2) Sch4(17) 23. OP37 12(1)(a) 24. OP38 13(4)(c) 25. OP38 13(4) 26. OP38 23(2)(c) The accident procedure must be amended to include the actions staff must take in the event of an accident in the home. (Previous timescale given 01/07/05. Compliance not checked at this visit.) The registered person must ensure staff have access to policies and procedures at all times. (Previous timescale given 10/09/04 and 01/07/05. Not assessed for compliance during this inspection.) The registered manager must ensure that Steradent tablets are kept locked away. (Previous timescale of 19/05/05 not met.) The registered person must ensure that there are risk assessments in place for the premises, fire, staff and food. (Previous timescale given 01/08/05. Compliance not checked at this visit.) The registered manager must ensure that evidence that the 5 yearly electrical testing and portable appliance testing has been carried out is forwarded to the CSCI. (Previous timescale of 15/07/05 not met.) Evidence that the chair lift has been serviced must be forwarded to the CSCI. 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 27. OP38 13(3) Evidence that the gas equipment has been serviced must be forwarded to the CSCI. The registered manager must 01/12/05 ensure that testing for Legionella is carried out regularly. (Previous timescale of 01/08/05 not met.) Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 26 28. OP38 13(4)(c) The registered person must ensure that staff and residents are not put at risk of slipping on the shower room floor. (Previous timescale of 01/08/05 not met.) 01/12/05 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. Refer to Standard OP28 OP38 Good Practice Recommendations 50 of all care staff employed by the home must possess NVQ level 2 or equivalent by 2005. (not assessed at this inspection.) The names of staff should be included in the records of fire training and fire drills. Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Dorcas House DS0000016840.V262584.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!