CARE HOMES FOR OLDER PEOPLE
Dove Court Kirkgate Street Wisbech Cambridgeshire PE13 3QU Lead Inspector
Lesley Richardson Key Unannounced Inspection 7th February 2007 10:10 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 Dove Court DS0000065318.V329554.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. Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Dove Court Address Kirkgate Street Wisbech Cambridgeshire PE13 3QU 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) 01945 474746 01945 474846 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Ms Julie Curtis Care Home 76 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (74), Old age, not falling within any other of places category (2) Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Two named service users over 65 years of age (OP) for the duration of their residency only One named service user under the age of 65 years with dementia (DE) already resident in the home Maximum of 74 service users over the age of 65 years with dementia (DE(E)) for the duration of Condition 1 31st May 2006 Date of last inspection Brief Description of the Service: Dove Court is a purpose built residential care home, situated in a residential area on the outskirts of Wisbech. It is now owned by Ashbourne Care Homes and provides care and support for up to 46 residents over the age of 65 with dementia. The home has 46 single rooms, all with en suite facilities. In addition to the en suite facilities there are 5 bathrooms and one shower, all with toilet facilities. Resident accommodation is on two floors, the upper floor being accessible by stairs or lift. There is a variety of communal areas available to service users. An enclosed garden is at the rear of the home and provides a safe environment for service users to enjoy the garden features. Fees for the home range between £415 and £525.25 per week. CSCI inspection reports are available in the office for people to read if they wish. Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and 30 minutes and was carried out as an unannounced inspection on 7th February 2007. It was the second key inspection for this home for the 2006-2007 year and was completed by the lead inspector and a second inspector. Four hours were spent with staff members, service users and undertaking a tour of the home. The inspection was conducted with the acting manager present. Information from three random inspections and a specialist pharmacy inspection that took place in between this inspection and the previous key inspection goes into this report along with the information found at this inspection. Eleven requirements and five recommendations have been made as a result of this inspection. Six of these requirements have been carried over from the last inspection, as they have not been met. What the service does well: What has improved since the last inspection?
There have been some improvements to care plans and records that show how the care for each resident has been given. Plans are written in detail and give staff a good idea of what they need to do to care for people living at the home. Care records that show when residents position is changed and how much they eat are now written in more detail, although more improvement is still needed and this is discussed in the next section. A specialist pharmacist inspection was completed in October 2006, which found a lot of areas of poor practice. Six requirements were made at that inspection regarding medication practice alone. Four of those areas of practice have improved, although the home must continue to improve generally in the way medication is managed to make sure people who live there are given the correct medication in the correct way. The amount of training that is given to staff members has increased and a lot of staff members are in the process to completing a national vocational
Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 6 qualification in care. This means they have better skills and knowledge to care for people at the home. A quality assurance programme has started, with relatives of people living at the home being asked their opinion of how the home is run. The results are being looked at and the manager has identified some areas that are causing concern for relatives. It is important that an action plan is developed so that these areas can be improved. What they could do better:
There are many things the home must improve on to meet the National Minimum Standards for Older People. Although there has been an improvement in the recording of what people eat, this must improve more to show how much they eat. This means a proper nutritional assessment can be made. Referrals to health care professionals must be made when residents need treatment or advice. At the random inspection in December 2006 this was first noticed as being a concern. At this inspection it was noticed that referrals to falls co-ordinator or another health care professional to help reduce the number of falls occurring had not been made. This is not acceptable and must improve for residents to be safely cared for. The privacy & dignity of people who live at the home must improve. Terminology used by care staff and the way some aspects of care is given does not indicate that people are treated as individuals. Doors are not always closed when personal care is being given, which means that privacy is not guaranteed. Activities are only available when the appropriate staff are at work. Other staff members do not feel the responsibility to provide activities at other times is theirs and therefore residents do not have their social needs met. This can have a significant effect on the well being of residents and means meaningful contact is difficult. The right for people to choose how they live is not paramount, for example, artificial sweetener is added to all hot drinks regardless of whether people want it or not. The way complaints are dealt with is not good enough. There is not enough information to show that a complete investigation is carried out and people who make complaints do not get an answer to all the concerns they raise. Some recent complaints have come from relatives of people who have since moved from the home, which suggests there is little confidence that complaints will be listened to or acted on while people are still at the home. This has an impact on protecting people from abuse as it means possible adult protection issues that are identified through complaints are not picked up on. There continue to be adult protection issues at the home, and although staff
Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 7 have training and there are ongoing adult protection meetings these issues have not resolved. Staffing levels at the home have decreased again, although the amount of sick leave has reduced by half. Even though the overall number of people living at the home has also decreased, there are still not enough staff members to properly care for people living there. This means staff have to take shortcuts, such as adding sweetener to all hot drinks, rather than asking people individually how they would like things done. Staff supervision had started to improve after the last key inspection in May 2006, but records do not show this has continued. This means staff do not get adequate supervision to support them to do a good job. Although the amount of training staff receive has improved, there is a question about the quality of this training. Continuing adult protection incidents suggests staff members do not all understand what abuse is, or the consequences if residents are abused. Staff understanding of dementia is also of concern. Even though all staff have dementia training, they do not all know the different types of dementia or the main symptoms. This is a concern in a home that specialises in caring for people with dementia. 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. Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. Pre-admission assessments must be completed before service users are admitted to the home to ensure their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessments are completed by the home and obtained from health and social care professionals to identify service users needs. Senior staff and the manager have responsibility for assessing the needs of people before they come to live at the home. Although the assessments seen in two service users files were on pre-admission assessment sheets there was no date to confirm these had been completed before the service users had been admitted to the home. One of these pre-admission assessments had not been completed, although a social care assessment was available for that person. The home does not admit service users for intermediate care. Dove Court DS0000065318.V329554.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 and 10 Quality in this outcome area is poor. Systems for referring service users to health care professionals are not in place and do not ensure personal and health needs are met. Further improvements to medication stock control must be made to ensure service users are not at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans viewed were generally detailed, up to date and showed evidence of regular review. However, not all plans had been updated to reflect changes to service users needs or to give specific details, for example, information about dietary restrictions for people with diabetes or an increased risk in falling. Care records that show how and when specific care, such as positional changes and the food a person eats, is given have improved. The random inspection in December 2006 identified these records were not being kept accurately and at that time gave little information to show the care or food that was given to residents. Those seen were recorded accurately, although dietary records should improve further to include the amount of food offered so that when ‘¼’ or ‘½’ is written a judgement can be made about exactly how much that would have been.
Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 11 The random inspection in December 2006 identified that health care professionals advice was not always sought when it should be. During this inspection it was found that service users who fall are not referred to an appropriate health care professional for advice. The care records and accident/incident records for two people were examined during the inspection. Both people suffered an increase in the number of falls until they were admitted to hospital. There was no evidence in the care records that a health care professional had been contacted for advice, or that a health care professional had visited or given advice about the falls. One person subsequently suffered a further two falls, resulting in injury before admission to hospital. A specialist pharmacist inspection was conducted in 2006, during which 6 requirements were made. There have been some improvements to the way medication is handled in the home since that inspection. Records for the administration, or non-administration, of medication are accurately kept. A change to one person’s medication was requested and supplied from the pharmacy the same day, although another person’s medication had run out 3 days before the inspection and records indicated this had not been supplied. The medication had not been ordered until the day after it had run out. The controlled drugs register indicated a supply remained in the home, when in fact, the service user had moved to another home, although this had also been indicated in the register. The controlled drug cupboard continues to be used to store items other than controlled drugs. There was evidence to show staff members who have responsibility for administering medication have also been given training for this. The home has a corporate medication policy and procedure, which is kept in the medication storage room and is easily available for staff to read. However, as there continue to be discrepancies and not all of these requirements have been met, these policies and procedures are not being followed by all staff members. The privacy and dignity of service users is not at the forefront of care that is given. A number of poor practices were observed throughout the day. One care assistant was seen putting artificial sweetener in all the residents’ cups of teas, before serving it to them. No attempt was made to discover if the residents took sugar, and if so, how much. When asked by the inspector what if the residents didn’t like sugar, the member of staff stated that the resident would just not drink the tea. Another staff member was observed changing a resident’s catheter bag in her bedroom with the door wide open. Another member of staff described residents who required assistance to eat as ‘Feeders’. Dove Court DS0000065318.V329554.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. Although activities are available in the home, these are limited and do not provide adequate interests to meet the needs of residents. There is little evidence that residents are offered choice as a way of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs two activities co-ordinators, who spend time individually with service users to maintain skills. Activities are limited when the coordinators are not available, although there are a number of interest boards on the walls of each unit. Discussions with staff show there is a poor regard for the importance of meaningful activities and daily occupation for those with dementia. Information about residents’ social history, their past occupation, family life and proudest moments, etc, was not available in all care records. Although one person’s care records did contain detailed social information, there appeared to be little connection between obtaining the information and the care provided. This information is crucial for staff to engage meaningfully with people with dementia. Three relatives who were visiting on the day of inspection were interviewed. All confirmed that they are made to feel welcome by staff. One relative told
Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 13 the inspector that she visits her husband daily and regularly has meals at the home. A main meal was served during the inspection; it appeared appetising and contained a number of different vegetables and a variety of food groups. There were a variety of desserts on offer that residents could decide upon during lunch, or when they were offered. However, meals are served fully plated up to residents, thereby denying them choice of what, and how much, they want to eat. Dove Court DS0000065318.V329554.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. Improvements must be made in the systems for complaints and protection from abuse to ensure service users or their representatives can raise concerns and have them acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home keeps a written record of complaints and the complaints book was viewed. Since the last key inspection one residents’ family met with a representative of the provider organisation to discuss a number of concerns they had about their relative. The complaint response did not address all the concerns voiced during the meeting, nor did it identify an outcome or actions to prevent the situation arising again. This is not in keeping with the organisations policy and procedure, and does not meet the Care Homes Regulations 2001. More recent complaints raise concerns about residents’ items going missing, a residents’ hair being cut without consultation and the treatment of another resident after a fall. These complaints had been investigated by the home, with the complainant being informed in writing of the outcome. However, relatives spoken to on the day of inspection felt that their complaints sometimes had not been taken seriously. One relative told the inspector that she had complained about other residents’ clothes being in her father’s bedroom, and that he wasn’t shaved every day. Despite complaining several times theses issues continue to be of concern to her. A number of complaints from relatives have been taken up by the local protection of vulnerable adults team as they include adult protection issues.
Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 15 These are being investigated with ongoing and new allegations of abuse that the home has notified the team about. One member of the home’s staff has completed a ‘train the trainer’ course in adult protection, which allows him to pass on this training to other staff in the home. However, allegations of staff physically abusing residents continue to be reported and it is of enormous concern that this is still occurring. The provider organisation has made one referral to the PoVA register for a member of staff, who is now no longer employed at the home. Dove Court DS0000065318.V329554.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 and 26 Quality in this outcome area is good. The home offers residents a pleasant environment in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were many positive aspects in the design and environment of the home’s dementia care units. There were a number of orientation aids in place to help residents find their way. Residents had pictures of themselves and their names in large and colourful print on their bedroom doors to help them identify which bedroom was theirs. There were pictorial representations of toilets on toilet doors. ‘Fiddle Boards’ were hung along long corridors to offer stimulation and interest to residents. There is a well-planned garden that provides residents with the opportunity for reminiscence. The environment is safe and pleasantly decorated. There was a slight offensive odour in one of the ground floor units, although this had dissipated after lunch when the floors had been cleaned.
Dove Court DS0000065318.V329554.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Although there have been improvements to training and recruitment checks, which ensures service users are cared for by adequately trained staff, staffing levels do not ensure staff have the time to properly meet service users needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personnel files for two recently recruited members of staff were viewed. Both files contained evidence that appropriate CRB and POVA checks had been completed to ensure the protection of residents. However, one member of staff had been employed with just the one reference being sought. Staff knowledge of the different types of dementia, and its common symptoms was a little poor and must be improved so they can really understand residents’ needs and behaviours. Staff members confirmed there has been an increase in the amount of training available and the manager said 17 staff members are undertaking a national vocational qualification (NVQ) in care. This supplements the 7 people who already have a NVQ, and although this doesn’t meet the 50 of care staff stipulated in the standard, inroads are being made to do this. Staffing levels at the home have been a concern in the past, although numbers of staff on duty had improved. The manager said the amount of sick leave has halved since high levels were first noted in December 2005. However, staffing
Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 18 levels on the day of inspection were again very low; there were 3 staff members in each of the three units. Although, the home was not fully occupied at the time of inspection, this still meant the ratio of care staff to service users was lower than good practice would recommend. Staff members said staffing levels were “not good”, and that if there was a high staff to service user ratio there would be more opportunity to assist service users to have baths and care records could be completed. However, one staff member also said staffing had improved and there is a more stable staff group. Dove Court DS0000065318.V329554.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. Systems for the safe running of the home and to ensure residents’ views are obtained have improved, which means the home is being run in their interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not have a registered manager, although there is an acting manager in position. Recruitment for a permanent manager is in progress. A number of records in relation to health and safety were viewed (gas, fire, hoist servicing, nurse call servicing and portable appliance testing) and found to be in good order, indicating that the home undertakes regular checks of a range of appliances. Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 20 A sample of residents’ fee payments and cash sheets were viewed. Good written records for all transactions undertaken on behalf of residents were maintained, as were receipts. Supervision records for two members of staff were viewed and showed that both these staff had only received one formal supervision each in the last year. The home recently sent a questionnaire to all relatives, seeking feedback about the quality of its service, in October 2006 and twenty-six responses were received. Amongst many positive comments made, relatives also raised concerns about the lack of activity for residents, poor staffing levels and clothes being lost. Ways of improving this survey and widening it to stakeholders in the community (eg GPs, nurses, chiropodist) were discussed with the manager. Dove Court DS0000065318.V329554.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Dove Court DS0000065318.V329554.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 OP7 Regulation 15(2)(c) Requirement Changes to care needs and how to meet these changes must be documented in the care plan. (Previous timescale of 22/12/06 not met.) Referrals to health care professionals must be made for advice, treatment or other services if a need requiring this has been identified. This is in relation to falls. (Previous timescale of 31/12/06 not met.) The registered person must ensure that adequate stock control is in place to prevent medication running out. (Previous timescale of 15/12/06 not met.) The registered person must ensure that controlled drugs storage is not used for any other purpose. (Previous timescale of 15/12/06 not met.) The registered person must make suitable arrangements to ensure that the care home is conducted in a manner that respects the privacy and dignity
DS0000065318.V329554.R01.S.doc Timescale for action 31/03/07 2 OP8 13(1)(b) 31/03/07 3 OP9 12(1)(b)1 3(2) 31/03/07 4 OP9 13(2) 31/03/07 5 OP10 12(4)(a) 31/03/07 Dove Court Version 5.2 Page 23 6 OP12 16(2)(m), (n) 7 OP14 12(2), 17(1)(a), schedule 3(3)(q) 17(2), schedule 4(13) 22(3), (4) 8 OP15 9 OP16 10 OP18 13(6) 11 OP27 18(1)(a) of service users. (Previous timescale of 31/12/06 not met.) Service users or their representatives must be consulted about their social interests and the activities arranged for them. Service users must be able to make decisions about the care the are to receive. Limitations to service users freedom of choice must be recorded. Records specifying food provided must be in sufficient detail to show how much food has been eaten. (Previous timescale of 31/12/06 not met.) Any complaint made must be fully investigated and the complainant must be notified of any action taken in response to the complaint. Arrangements must be made to prevent service users being harmed or suffering abuse, or being placed at risk of these. There must be staff working at the care home in such numbers as are appropriate for the health and welfare of service users. 15/04/07 31/03/07 31/03/07 31/03/07 15/03/07 15/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations Pre-admission assessments completed by the home should be signed by the author of the assessment and dated to show it has been carried out before the service user was admitted to the home. 50 of care staff should have a NVQ qualification at level
DS0000065318.V329554.R01.S.doc Version 5.2 Page 24 2 OP28 Dove Court 3 4 5 OP29 OP33 OP36 2 or above. An assessment should be made of staff files to ensure all recruitment and vetting checks have been obtained. Quality assurance surveys and questionnaires should also include stakeholders in the community, e.g. GPs, district nurses. Staff supervision should be given on at least 6 occasions per year. Dove Court DS0000065318.V329554.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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
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