Inspection on 21/08/06 for Dorothy House

This inspection was carried out on 21st August 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

Dorothy House 17/11/08

Dorothy House 16/01/08

Dorothy House 11/07/07

Dorothy House 15/01/07

Dorothy House 19/10/05

Dorothy House 23/06/05

Dorothy House 22/02/05

Dorothy House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dorothy House 186 Dodworth Road Barnsley South Yorkshire S70 6PD Lead Inspector Christine Rolt Key Unannounced Inspection 21st August 2006 09:30 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 Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dorothy House Address 186 Dodworth Road Barnsley South Yorkshire S70 6PD 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) 01226 249535 01226 249535 none Mr Azar Younis Vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2005 Brief Description of the Service: Dorothy House is situated on the main road from the M1 motorway to Barnsley town centre. The home is an extended bungalow that stands well back from the main road at the top of a driveway. The home shares the grounds with its sister home, The Firs. The gardens are landscaped and there is adequate car parking space. There are no stairs or steps either approaching or within the home therefore it is accessible to persons using walking frames or wheelchairs. The weekly fee was £315. Hairdressing, toiletries and private chiropody were not included in the weekly fee and were charged separately. The deputy manager supplied this information during the site visit on 21st August 2006. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. A Pre-Inspection Questionnaire was sent to the home in June but was not returned to the Commission for Social Care Inspection. The site visit was from 9.30 am to 5.00 pm on 21st August and from 9.30 am to 12.30 pm on 22nd August 2006. The home did not have a manager, but was overseen by the manager of the sister home, The Firs. The deputy manager was in day-to-day charge of the home. The owner had decided to appoint a manager and at the time of this site visit, the prospective manager, was learning the routines and getting to know the residents with the aim of her taking over the role in September 2006. Therefore both she and the deputy manager provided assistance during the site visit. Two residents were tracked throughout the inspection. All residents were seen and chatted to during the site visit. Eight relatives or representatives were asked for their views of the home. Care practices were observed, a sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the deputy manager, the prospective manager, members of staff, residents, relatives and representatives for their assistance and co-operation. What the service does well: What has improved since the last inspection? Care plans were now reviewed in consultation with the residents. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. Prospective residents did not have sufficient information to enable them to make an informed choice. Written contracts/statements of terms and conditions had not been completed. Residents’ needs had not been assessed fully. The home does not provide intermediate care. EVIDENCE: There was no Statement of Purpose and Service User Guide on display. Relatives said they had not received written information about the home or seen the service user guide. Reasons for choosing the home were “Convenient”, “Near where she used to live”, “Easy for us to get to”, “Small home”, “All women”, “Good reports of the home” and “Came on a visit and liked it”. The Deputy Manager said that prospective residents and their relatives were taken round the home, the home’s routines were explained and Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 9 questions were answered. Residents did not have copies of the Service User Guide and the deputy manager confirmed that residents did not have copies of these. Two residents’ files were checked. Assessments had been carried out but some areas of the home’s assessment form were not completed. Files also contained a contract/terms and conditions. On one file the form had not been completed or signed and on the second one, pages were missing. Relatives said that they had not been issued with contracts/statement of terms and conditions. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents’ individual plans of care did not provide sufficient detail of all their needs. Health needs were not met fully. Medication procedures were not being followed or recorded correctly. Residents were treated with respect, but their rights to privacy were not upheld fully. EVIDENCE: Two care plans were checked. These did not cover all aspects of residents’ needs or how to meet these needs. The full range of risk assessments had not been incorporated into plans, particularly where residents were having frequent falls or had poor skin quality. Residents were weighed regularly but there was no written information of the action taken to determine why one resident was losing weight. Medical interventions had been in place for a few months for another resident but there was no written information on how treatment could be progressed or evidence that the home was proactively seeking other options and information. Accidents were recorded in the Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 11 Accident Book but had not been torn out (as designed). The recorded accidents showed that some residents were having frequent falls but these had not been monitored to determine the action that needed to be taken, including risk assessments and alterations to care plans. There was no information to verify that residents were checked at regular intervals following falls or accidents. A written record of checks would ensure that any injuries that were undetected at the time of the accident would quickly become apparent. Reviews did not highlight any changes in residents’ care plans. There was very little information of how residents spent their days. Information in care plans was not filed in any particular order for ease of reference. Staff dealing with medication had undertaken accredited training. The administration of medication was observed and the correct procedure was not being adhered to. This was brought to the attention of the staff member at the time. The home used a monitored dosage system for the majority of medication, but some medication was supplied in packets. The medication for three residents was checked and there were discrepancies for loose medication (i.e. in packets) for all three residents. The Commission for Social Care Inspection was not kept informed of issues related to the care of residents. Within the last six months, the CSCI had been notified of only one incident. Residents’ rights to be treated with respect and dignity were observed throughout the site visit. However, their rights to privacy, namely the right to have keys to their bedrooms and to their lockable facilities was not observed and there was no information on residents’ care plans as to the reasons why. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents’ experience of the home did not fully satisfy all their needs including recreational interests and needs. They maintained contact with family and friends but could not maintain contact with the local community. Their right to choose was not met fully. Meals provided an appealing and balanced diet with choices available. EVIDENCE: There were no organised group activities or individual activities taking place in the home during the site visit, and the home did not employ an activities coordinator. Relatives said that staff were too busy to provide activities or to take residents out individually. Their comments about the availability of activities and stimulation were “Not really”, “No exercises”, “Just seem to sit staring into space”, “No activities or stimulation”, “This is a key worry”, “Not a lot”, “Feel that there should be some activities. Feel that one or two residents would take part if encouraged” “She used to enjoy going to church” and “I object to the TV being on all day when no-one is watching it”. The deputy Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 13 manager said a singer visited the home and the sister home “The Firs” on alternate months and group outings were also arranged. Residents did not have the choice of having a bath or a shower because the bath hoist was broken therefore all residents were being showered. (See also Standard 22). None of the residents were seen to possess a key to their bedrooms or a key for their lockable facilities in their bedrooms. There was no information on residents’ files regarding keys and the prospective manager was unsure if residents had keys. Some relatives were asked about this but could not recall having any conversations about residents having keys. (See also Standard 10) The food was good and there was a choice. Residents said the food was good and relatives comments were “No complaints”, “Seems good”, “Quite happy”, Good menu” and “Seems alright”. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents and their relatives were confident that their complaints would be listened to and residents were protected from abuse. EVIDENCE: The home had a complaints procedure and this contained the relevant information. There were no complaints or allegations of abuse. The deputy manager said that all staff had undertaken this training. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 15 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, 22 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. The home was generally clean and pleasant but needed redecoration and repairs EVIDENCE: The home was welcoming and there were no offensive odours during the site visits. Several bedrooms, the quiet lounge and the lounge/dining room were checked. All were clean and tidy but there was an offensive odour in one bedroom and the prospective manager arranged for this bedroom to be recleaned. The bedroom carpet identified during the last inspection had been replaced and the bedroom refurbished. New bedding had been purchased. Some parts of the home were in need of redecoration including some bedrooms and one the wallpaper in one bedroom was noted to be damaged. Some bedroom furniture had handles missing and this was brought to the Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 16 attention of the prospective manager. The bathroom was untidy with wheelchair footplates, various toiletries and an empty linen basket blocking access to the bath, therefore was not fit for purpose. Relatives thought the home was clean and hygienic and one comment was that the resident had a “Nice clean bed” but they thought that the home was in need of redecoration and refurbishment. Their comments were “Bit old fashioned”, “Needs new dining furniture”, “Shabby” “Needs overhaul” and “Corridors look tired”. During a meeting with Mr. Younis, senior, he said that plans were in place for redecoration. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were provided to enable residents to maintain their independence but the bath hoist was broken therefore residents could not use the bathroom (see also Standard 14). The prospective manager said that the problem with the hoist was being addressed and quotes were being obtained. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ needs were not fully met by the numbers and skill mix of staff. Improvements in record keeping would determine whether staff were trained and competent to do their jobs. EVIDENCE: There were two staff on duty at all times, but some comments were that staff were so busy that they did not have time to engage with residents. Relatives’ opinions of the staff were mixed. When asked if the staff treated their relative with respect and dignity comments were “As far as I’ve seen” and “Attentive, kind and polite” whilst others said “Most of them are fine” and “Sometimes feel that she is a burden to some of them”. The cause or causes of this could be that staffing levels need to increase to meet residents’ needs, lack of staff training, unsuitable staff. The owner needs to determine which of these are relevant. There were no records to determine whether staff received formal induction training that met National Training Organisation standards. The manager of The Firs named some staff who had attained National Vocational Qualifications in Care Level 2 or above but there were no records to determine this or whether the minimum ratio of 50 had been met. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 18 Three staff files were checked. Criminal Records Bureau disclosures and identification documents were available. The method of filing was disorganised and there were minor discrepancies on some files. The need to improve the filing system to provide better organisation of staff information and documentation was discussed with the prospective manager. It was also recommended that a matrix of staff training be implemented to provide easy reference of training undertaken. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. The home did not have a manager. There was no quality assurance system to ensure that the home was run in the best interests of residents. Residents’ financial interests were safeguarded. The health, safety and welfare of residents were not fully promoted. EVIDENCE: The home has not had a manager for several years. The deputy manager was in day-to-day charge of the home, and the manager of the sister home, The Firs, oversaw the home. The owner had decided to appoint a manager and at the time of this site visit, the prospective manager, who was the deputy manager of The Firs, was spending time at Dorothy House to learn the Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 20 routines and get to know the residents with the aim of her taking over the role in September 2006. The prospective manager was undertaking the Registered Managers Award and the owner said that application would be made for her to register with the Commission for Social Care Inspection. The home did not have a Quality Assurance monitoring system. There were some questionnaires for residents and visitors to use but these were not displayed in a conspicuous place and relatives were not aware of them. One questionnaire had been completed and left on the noticeboard, as there were no instructions of what the process was for collection of completed forms or any system for collating information received. Relatives and a resident said that they had not been asked for their opinions of the home and residents and relatives meetings were not held. There was no system for the auditing of the environment or systems and practices within the home. There were no records to determine that the owner had carried out monthly visits and produced reports as required by Regulation 26 since November 2005. The CSCI had not been kept up to date of issues relating to residents’ wellbeing as required by Regulation 37 of the Care Homes Regulations. These issues were discussed with the prospective manager. Money held on behalf of residents was stored safely. The money held for two residents was checked against the records and these tallied. Receipts were available. Staff had undertaken some mandatory health and safety training but there was no system to monitor staff training needs to ensure that all staff were up to date. (See also ‘Staffing’ above). In June 2006 a Pre-Inspection Questionnaire was sent to the home. The completed questionnaire was not returned. It was difficult to determine which systems and equipment had been serviced and maintained because there was no method for filing certificates. Some certificates were displayed around the office but when these were checked, the newest certificates were mixed up with out of date certificates. Other maintenance agreements and certificates produced were out of date. There was no arrangement for ensuring that all systems and equipment was serviced and maintained within the timescales. Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 21 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 22 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 Timescale for action A Statement of Purpose must be 13/11/06 provided and must include the information listed at Schedule 1 of the Care Home Regulations. Residents must be issued with 13/11/06 copies of the Service User Guide, and a copy must be made available for inspection by prospective residents or other interested parties to ensure that they have sufficient information to enable them to make an informed choice Residents must be issued with 13/11/06 contracts/statement of terms and conditions in respect of accommodation and provision of services and facilities Assessments must be completed 30/10/06 to provide full information relating to residents’ needs. Care plans must provide 30/10/06 sufficient detail of care needs that are specific to the residents. (Requirement outstanding from or before 30 Nov 05) The full range of risk 30/10/06 assessments must be incorporated into care plans to DS0000018245.V300149.R01.S.doc Version 5.2 Page 23 Requirement 2 OP1 5 3 OP2 5 4 5 OP3 OP7 14 15 6 OP7 13 Dorothy House 7 OP7 12,13,15 8 OP8 12 9 OP9 13 10 OP9 12,13 11 OP10 12 12 OP12 16 13 OP12 12 14 15 OP14 OP22 12 23 16 OP19 16, 23 ensure that residents’ health and welfare are maintained. Risk assessments must be reviewed at least monthly. (Requirement outstanding from or before 30 Nov 05) Records of the care given must include information of how residents are checked, monitored and the action taken following accidents to prevent recurrence. The correct procedures for the receipt, administration, recording and disposal of medication must be adhered to. (Requirement outstanding from or before 20/11/05) Service users must be given the opportunity, within a risk management framework, to continue to administer their own medication. (Requirement outstanding from or before 30 Nov 05) Residents’ must be offered keys to their bedrooms and lockable facilities (within a risk management framework) to promote their rights to privacy A programme of group activities, in line with residents’ abilities and needs must be implemented in consultation with residents. Residents must be consulted about and supported in their individual interests both inside out and outside the home. Residents choice must be promoted i.e. bath or shower Bathroom hoist must be repaired or replaced to ensure that the bathroom is available for residents and made fit for purpose by removal of all unnecessary clutter. A rolling programme of redecoration and refurbishment must commence with the DS0000018245.V300149.R01.S.doc 13/11/06 30/10/06 30/10/06 30/10/06 13/11/06 13/11/06 13/11/06 30/10/06 30/10/06 30/10/06 Dorothy House Version 5.2 Page 24 17 OP27 18 18 19 20 21 OP28 OP30 OP31 OP33 18 18 9 24 22 OP33 26 23 OP38 37 24 OP38 13, 23 25 OP38 13 identified bedroom given priority. Staffing levels must be appropriate to meeting residents’ physical, health, social and emotional needs A minimum ratio of 50 care staff must be trained to NVQ Level 2 in care. All new employees must undertaken induction training to a recognised standard. Application must be made to register an appointed manager An effective quality assurance and monitoring system that includes audits of the environment, systems and care practices within the home, and seeks the views of residents and their representatives, must be implemented to ensure that the home is run in the best interests of residents. The registered provider must visit the home and produce a written report each month as required by Regulation 26 of the Care Home Regulations. A copy of the monthly report must be sent to the CSCI. The Commission for Social Care Inspection must be notified without delay of all deaths, illnesses and other events that adversely affect the well-being or safety of residents. A system must be implemented to ensure that all staff are up to date with mandatory health and safety training including moving and handling, basic food hygiene, infection control, fire awareness, first aid, adult protection A system must be implemented to ensure that all systems and equipment have been serviced and maintained within the DS0000018245.V300149.R01.S.doc 30/10/06 13/11/06 13/11/06 13/11/06 13/11/06 30/10/06 30/10/06 30/10/06 30/10/06 Dorothy House Version 5.2 Page 25 required timeframes 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 OP38 Good Practice Recommendations A matrix of would enable easy reference of staff training Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Dorothy House DS0000018245.V300149.R01.S.doc Version 5.2 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. 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