Inspection on 02/03/07 for Dothan House

This inspection was carried out on 2nd March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Dothan House 29/04/08

Dothan House 09/08/07

Dothan House 24/02/06

Dothan House 19/10/05

Dothan House 06/12/04

Dothan House 23/06/04

Dothan House 10/05/04

Dothan House 27/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Dothan House 458 Upper Brentwood Road Gidea Park Romford Essex RM2 6JB Lead Inspector Jackie Date Key Unannounced Inspection 09:15 2 -19th March 2007 nd 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 DS0000027859.V331684.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. DS0000027859.V331684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dothan House Address 458 Upper Brentwood Road Gidea Park Romford Essex RM2 6JB 01708 761647 01708 761647 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) Genesis Residential Homes Limited Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000027859.V331684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Dothan House is a registered care home for 19 people aged 65 and over. The home is situated in a residential area of Gidea Park and there is parking at the rear of the property. The home is a large two storey detached house with extensions. There is a passenger lift to the first floor. There is a combined lounge/dining area on the ground floor and another smaller lounge on the first floor. There are 17 single bedrooms and one double bedroom. Nine of the bedrooms have en-suite facilities. There is shower room and a bathroom. Personal care is provided on a 24- hour basis, with health care needs being provided by health professionals such as GPs and community nurses. The charge per week for each resident is between £395-00 & £430-00. This information was provided in the Pre Inspection Questionnaire, which was completed by the proprietor. The fees charged were also in a copy of the contract in residents’ files. Information about the service provided is contained in the service users guide DS0000027859.V331684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted for about seven hours on the first day and started at 9.15 in the morning. A second shorter visit was made to talk to the proprietor and to check staff files. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspector spoke to a number of residents and relatives. Where possible residents were asked to give their views on the service and their experience of living in the home. All of the shared areas and most of the bedrooms were seen. Staff, care and other records were checked. This was a key inspection and all of the key inspection standards were tested. At the time of the inspection there was not a registered manager in post and the proprietor was managing the home. What the service does well: What has improved since the last inspection? A downstairs hallway has been redecorated and is looks better. The cook has completed a food hygiene certificate. A quality assurance survey has been carried out and residents and their relatives have had the opportunity to comment on the service provided. DS0000027859.V331684.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. The summary of this inspection report can be made available in other formats on request. DS0000027859.V331684.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 DS0000027859.V331684.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. Standard 6 does not apply to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although appropriate pre admission information is gathered prior to a resident being admitted to the home some residents requiring a more specialised service have been admitted. The home does not have the capacity to meet these specialist needs. However the home does have the capacity to meet the needs of those requiring less specialised support. The home does not offer intermediate care. EVIDENCE: The files of two of the newest residents were looked at. The manager or the proprietor had undertaken pre-admission assessments. There was also assessment information from the placing authority and from a hospital. In one case the hospital assessment recommended a placement in a unit registered for people with dementia. In the other case the person was diagnosed with multi infarct dementia and as requiring a home for people with dementia. DS0000027859.V331684.R01.S.doc Version 5.2 Page 9 Dothan House is not registered for people with dementia and staff have not had training in the care of people with dementia. At the time of the inspection the proprietor was managing the home as the manger had recently left. The proprietor said that in both cases the symptoms were not severe but that he had made a business decision and from our discussion he realised that this was a mistake. He also said that he is considering applying to the Commission to be registered to provide a service for people with dementia. The residents concerned have settled at the home and therefore the Commission would not wish to cause upset, distress or confusion by asking for alternative placements to be found. However the registered person must be able to demonstrate that the assessed needs of all of the residents are being met. Therefore all staff must receive comprehensive training in caring for people with dementia so that they are able to meet the specialised needs of this client group. The registered person must not admit people with dementia unless the service is registered for this client group. However, feedback from relatives spoken to was that residents are well cared for and their needs are met in a caring way. One relative said “my mother is well looked after, she has put on weight and is so much better since she moved into the home”. Residents spoken to also said that the staff looked after them well. DS0000027859.V331684.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs residents are set out in an individual plan of care which provides staff with the information necessary to meet their assessed needs. Personal care is offered in a way that protects residents’ privacy, dignity and promotes their independence. Some changes are needed to medication records to ensure that residents receive the correct medication. EVIDENCE: All of the residents have plans, which cover the necessary areas and include, mobility, personal care, health, nutrition and orientation. These give information about each persons strengths, needs, likes and dislikes. For example one care plan states that the resident should sit on a special cushion to minimise the risk of pressure sores. Another plan states that staff should remind the individual where she has left things as she becomes distressed when she cannot find them. It also states that when her room is being cleaned DS0000027859.V331684.R01.S.doc Version 5.2 Page 11 her things must not be displaced as again this upsets her. The care plans seen had been reviewed regularly and were up to date. Care plans also confirmed that residents are encouraged to be as independent as possible. For example “praise her when she does a little each day”. The care plans seen had been signed and agreed by relatives. One of the residents had been in hospital and had only been discharged a few days before the visit. Although the care plan for this person had not yet been updated there were new guidelines in place for supporting this person. The guidance included ensuring that this person had plenty of fluids and that staff should make sure that they actually put the cup in the resident’s hand but to make sure that it was not too full. Therefore there is current information available to enable staff to meet residents’ needs. There are risk assessments in place. These identify risks for the residents and indicate ways in which the risks can be reduced to enable the residents needs to be met as safely as possible. These had been reviewed and were up to date. They had also been signed and agreed by relatives. All of the residents are registered with a local doctor and specialist help is received when needed. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when needed the chiropodist. The district nurse also visits when required. One relative said that his mothers health needs were uppermost in the staffs minds and also that they are very active in keeping her mobile. The nutritional and dietary needs of residents are monitored and residents are weighed regularly, as far as possible, to monitor weight gain or loss. Appropriate referrals are made if necessary. The blood sugar levels of a resident with diabetes are monitored and there are guidelines in place for the action to be taken if she “ has a hypo”. Residents are supported to get the healthcare that they need and to be as healthy as possible. Staff were observed to be polite and respectful to the residents and also to spend time talking to them. One resident said “ it is nice here, the staff always help and check you every couple of hours at night to make sure that you are okay. A relative said, “the staff are caring and attentive and very obliging”. Medication is stored in an appropriate metal cabinet and trolley that are attached to the wall in the lounge/dining area. Medication is mainly administered by the senior carers. The medication file contained appropriate information and this included photographs of residents and details of any allergies. This is good practice. Some of the staff spoken to had received medication training but had not yet administered medication. An audit was undertaken of the management of medicines and a random sample of Medication Administration Record (MAR) charts were examined. Medication records were up to date and all medication was appropriately signed for when administered. The following issues were discussed with the senior on duty: DS0000027859.V331684.R01.S.doc Version 5.2 Page 12 • • For accountability hand written entries on MAR charts must be signed and dated by the person making the entry. The entry must also include the source of the information. e.g. GP, registered nurse. When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. This will then give a clear record of exactly how much has been administered. The resident with diabetes is insulin dependent. Staff prepare her syringes and she can then administer the injection. Overall medication is safely stored and appropriately administered and the implementation of the above requirements will make this more robust. DS0000027859.V331684.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. As far as possible, residents are helped to exercise choice and control over their lives. Visitors are made welcome at the home and are invited to social events. Therefore residents are able to maintain contact with their friends and families. Residents receive meals that meet their preferences and needs. EVIDENCE: Staff were observed chatting to residents in the lounge and there was a very relaxed and friendly atmosphere. Feedback from a relative was that staff are very active in keeping his mother mobile. Feedback in a quality assurance survey was that staff treat residents with respect. A hairdresser visits and also an aromatherapist. Some residents have aromatherapy massages. The ‘house bound’ library visits and provides a selection of books many in large print. Staff also encourage residents to do gentle exercises. DS0000027859.V331684.R01.S.doc Version 5.2 Page 14 A resident said, “ it is nice here, staff always help you and the food is good”. Residents also said that they could choose when to go to bed and what to do. They can spend time in their room or in one of the lounges. Relatives can visit at any time, as there are no restrictions placed on visiting times. Relatives said that they are always made welcome and are offered refreshments. A thank you card from the relatives of a resident that had passed away was seen. This said “ a big thank you for the love and care for dad. He was well looked after and happy. Thank you for making us welcome”. Staff were observed to take time to chat to relatives. Two of the relatives spoken to talked about BBQ’s and Christmas parties and said that they are involved with organising these. Residents also said that they celebrate birthdays. Residents nutritional needs form part of their care plan. One resident, who had lived in the home for a few months, said, “the food is alright but sometimes I don’t like it. This is just a matter of taste and I have something else”. Another resident has diabetes and does not have sweet things. At lunchtime she was given fresh fruit for dessert. On the day of the inspection residents had fish and chips for lunch. One resident had an omelette, as she does not like fish. Another resident, who was on holiday, is a Muslim and an appropriate diet is provided for him. A relative confirmed that her mother preferred to have her meals in her room and also that the portions were fine. Therefore residents receive meals that meet their preferences and needs. DS0000027859.V331684.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every effort is made to sort out any problems or concerns and makes sure that residents and their relatives feel confident that their complaints and concerns are listened to and will be acted upon Staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. EVIDENCE: The home does have a complaints procedure that is used in the event of a complaint being made. A relative said, “if there are any small issues they are always dealt with quickly. There was a recorded complaint from a resident about staff talking loudly at night and this had been appropriately dealt with. A relative’s response to the quality assurance survey said: “I always feel listened to and can discuss anything that I need to”. Therefore any complaints are concerns are addressed and residents and relatives are listened to. The home has policies and procedures for the protection of residents from abuse. Staff have received training in the detection and reporting of abuse. In discussions with staff they were clear what forms abuse took and were able to inform the inspector of the action they should take if any suspected abuse was witnessed. DS0000027859.V331684.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a home that is suitable for their needs. However the kitchen is showing signs of wear and tear and needs to be improved to be of a satisfactory standard. EVIDENCE: The home is situated in a residential area of Gidea Park and there is parking at the rear of the property. The home is a large two storey detached house with extensions. There is a passenger lift to the first floor. There is a combined lounge/dining area on the ground floor and another smaller lounge on the first floor. There are 17 single bedrooms and one double bedroom. Nine of the bedrooms have en-suite facilities. There is shower room and a bathroom. The home is adequately maintained and a downstairs corridor has been redecorated as required by the precious inspection. The carpet in the hall and on the stairs is showing signs of wear and needs to be replaced before it DS0000027859.V331684.R01.S.doc Version 5.2 Page 17 becomes a risk to residents. Some responses to the quality assurance survey also stated that they felt the carpet needed replacing. The kitchen was clean and tidy. There were doors that were not working properly and the cupboard under the sink is damaged. The kitchen needs to be upgraded/replaced to ensure that it of a satisfactory standard. The proprietor stated that he was aware that a new kitchen was needed and that this would be done within 6 months. Bedrooms and other areas of the home were inspected. All were clean and free from odours. All bedrooms were individually decorated and lots of personal possessions were on display making the rooms look homely. There are sufficient bathrooms and W.C.’s and these are suitable for the needs of residents. Suitable laundry facilities are available so that residents clothing, bedding and any soiled items can be washed appropriately. DS0000027859.V331684.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not always sufficient to meet residents’ needs. Although staff have received some training this does not equip them to meet the more specialist needs of some of the residents. EVIDENCE: The usual staffing compliment is 1 senior carer and 2 carers in the morning, 2 carers in the afternoon and 2 carers at night. Sometimes there is a third member of staff until 5pm. In addition there is a cook from 9am to 2pm each day and some domestic support. From discussions with staff and from information about residents needs the staffing level in the morning is adequate but not for the late shift. In addition to caring for resident’s staff on the late shift need to prepare the evening tea and clear up. Some of the residents require the support of two staff and therefore if staff are attending to one of these individuals there is not anyone available to support other residents. There is a member of staff that is employed to carry out some domestic duties and also care duties but the inspector received differing information about how this works and was not satisfied this arrangement is robust. The rota must clearly indicate who is on duty and in what capacity. It must be clear when the individual is working as a carer and when as a domestic. Staffing levels must be reviewed to ensure that they are sufficient staff on duty to meet residents’ needs appropriately and safely. DS0000027859.V331684.R01.S.doc Version 5.2 Page 19 From discussions with staff and from checking staff records it is evident that staff receive training, including induction, to give them the skills and knowledge that they need to provide an appropriate and safe service for the residents. In addition some staff have achieved NVQ qualifications. However, as stated previously in this report some residents do have dementia and staff have not had training to enable them to work appropriately with these residents. A requirement has been made in standards four in relation to this. The cook has attended a food hygiene course and obtained a certificate for completing this as required by the previous inspection. A selection of staff files were examined and this included the file of the newest employee. The file of the newest employee contained a copy of the application form, new staff questionnaire, references, confirmation of identity, CRB (Criminal Records Bureau) check and other required details. Other files examined also contained appropriate information. However, staff have started work at the home prior to their CRB check being received. The proprietor said that he carried out POVA (Protection of Vulnerable Adults) first checks before they started but was unable to provide evidence of this. The file of another member of staff indicated that this person was a student and had Home Office permission to work 20 hours per week. This person was in fact working more hours than this. The proprietor said that he had overlooked this. Therefore the recruitment process is not robust and does not offer full safeguards to residents. DS0000027859.V331684.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately managed and provides a safe environment for the residents. EVIDENCE: The manager left just prior to the inspection and the proprietor is now managing the home. He has previously been the registered manager and therefore was deemed to have the necessary experience and qualifications to manage the home. Staff said that he is at the home a lot and that he assists residents and works in the home. The home has not had a registered manager for some time, as the last two managers have not stayed at the home for very long. The interim management arrangements are adequate but it is important that a permanent manager is recruited and registered soon as possible. The DS0000027859.V331684.R01.S.doc Version 5.2 Page 21 proprietor is aware of this and has started the recruitment process. Therefore a requirement has not been made with regard to this. The previous manager had completed a quality assurance survey as required by the previous inspection. The results of this were available at the home and this confirmed that residents and relatives had been asked to comment on the service provided. Staff spoken to said that they had been receiving regular supervision and staff meetings were being held. This gives staff the opportunity both collectively and individually to discuss work practice, any concerns and the development of the service. Staff also said that they can talk to the proprietor or the senior care and that they get advice and support from them. The homes insurance policy is current. The proprietor does not deal with residents’ overall finances, but for some residents has small cash amounts in safekeeping. Residents’ money held in safekeeping and used on their behalf for purchases or services from the chiropodist, hairdresser and aromatherapist were found to be in order. The cash held for three residents was checked and amounts recorded tallied with cash held. All entries were recorded and receipts were kept to evidence any expenditure. For other residents the proprietor keeps a record of money spent and then sends invoices to relatives. Therefore residents’ finances are appropriately dealt with. All of the necessary health safety checks are carried out and a safe environment is provided for residents. DS0000027859.V331684.R01.S.doc Version 5.2 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 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 DS0000027859.V331684.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP3 Regulation 14 Requirement The registered person must be able to demonstrate that the assessed needs of all of the residents are being met. Staff must receive comprehensive training in caring for people with dementia. The registered person must not admit people with dementia unless the service is registered for this client group. For accountability hand written entries on MAR charts must be signed and dated by the person making the entry. The entry must also include the source of the information. e.g. GP, registered nurse. When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. The kitchen must be upgraded/replaced. The stair and hall carpet must be replaced. DS0000027859.V331684.R01.S.doc Timescale for action 30/06/07 2. 3. OP4 OP4 18 14 30/06/07 30/04/07 4. OP9 13 30/04/07 5. OP9 13 30/04/07 6. 7. OP19 OP19 16 16 30/09/07 30/06/07 Version 5.2 Page 24 8. 9. OP27 18 18 OP27 The rota must clearly indicate who is on duty and in what capacity. Staffing levels must be reviewed to ensure that they are sufficient staff on duty at all times to meet residents’ needs appropriately and safely. The registered persons must operate a robust recruitment procedure and ensure that all necessary information and documents are obtained as required by regulation, prior to the commencement of employment of any staff member. 15/05/07 31/05/07 8. OP29 18 & 19 Schedule 2 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000027859.V331684.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000027859.V331684.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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