CARE HOMES FOR OLDER PEOPLE
Dove House Sudbury Nr Ashbourne Derbyshire DE6 5GX Lead Inspector
Rachel Davis Key Unannounced Inspection 19th April 2006 10:25 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 House DS0000044218.V287207.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Dove House Address Sudbury Nr Ashbourne Derbyshire DE6 5GX 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) 01283 820304 01283 820220 Midland Healthcare Ltd Ms Karen Lesley Betts Care Home 42 Category(ies) of Dementia - over 65 years of age (25), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (42), Physical disability (2), Physical disability over 65 years of age (7) Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Registered Manager must complete the Registered Manager’s award within an appropriate timescale. 19th December 2005 Date of last inspection Brief Description of the Service: Dove House is a residential home registered to provide residential care for forty-two older people. On the day of inspection there were 28 service users residing at Dove House. Their needs may range from mental health, dementia and/or physical disabilities. The home can accommodate 25 people with dementia, the staff are trained in this area and the inspection process confirmed the home is able to meet individual needs. Mental health training is also provided to the staff, other professionals also visit the home and offer continued advice and support. The registered provider is Midland Homes Ltd who has overall responsibility for the home; the registered manager is Karen Betts. The pre inspection questionnaire document informed the Commission for Social Care Inspection on 12/04/06 that Dove House charges its residents £374 per week. Due to the homes position local amenities are limited but the home is well placed for the use of public transport. The premises have been sympathetically extended and have substantial grounds and parking facilities. Gardens were extremely well maintained and a patio area with seating is available and easily approached. Communal areas have been redecorated and are comfortable. The home also has two large conservatories offering substantial views of the gardens and countryside. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 5 There is a no smoking policy for service users and staff within the home. The majority of bedrooms were single and meet the required sizes set out by the national minimum standards; these were equipped with suitable fixtures and fittings. Twenty-seven of the thirty-six single rooms had en suite facilities. Communal bathrooms and toilets were well-located and offered appropriate equipment and facilities. Adequate parking is available for staff and visitors. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over seven hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. This visit was a key inspection and therefore covered all of the core standards. The inspection included an examination of records, scrutiny of pre-inspection information completed by the manager, indirect observation, discussions with service users, the registered manager, staff and visitors. Feedback from questionnaires is also recorded within this report. Two comment cards were received back from relatives, no concerns were raised. One reported: “Very happy with mums care and mum always appears happy.” The lead inspector has not made any additional visits to the home since the last inspection held in December 2005 however, the Commission has made one visit to the home following a complaint letter, and this complaint is unresolved. The home continues to develop the service and the manager has worked hard to introduce appropriate systems to evidence good practice, the majority of core national minimum standards were met. Nine requirements and two recommendations were made as a result of this visit. One requirement has been carried over from the last inspection. This was considered to be a positive inspection. What the service does well:
The management and all the staff within the home contribute to a good standard of service provided. The home works in partnership with other professional bodies to ensure the best outcome for the service users. Feedback received from health and social care professionals in contact with the care home included:
Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 7 “Staff are excellent in managing and liaising with service users with mental health problems, they communicate concerns extremely well.” “I find the home welcoming and informal and they meet people’s needs by working flexibly, communications are always clear.” “I feel the home manages the levels of mental health and dementia for which they cater for very well.” The staff and manager are transparent and open and always welcome discussions around continually taking their service forward. The home operates a service user centred approach and demonstrates a very good understanding of service users care needs. Assessment and care planning are of a good standard; the risk assessments are well managed. Service user comments include: “The staff are very good, they are kind and treat me well.” “They are nice people here, Karen is easy to talk to.” “They are patient, they let me do what I can for myself.” Communication and information exchange with all relevant parties is very good. A weekly activities programme is in place and information relating to these is suitably recorded. The activities co-ordinator is motivated and covers a broad range of interesting activities. It was ascertained that service users with complex needs received stimulation on a one to one basis. One service user commented that “ Pat, the activities coordinator is excellent, she is a very special person.” There is a commitment to National Vocational Qualification (NVQ) training for staff, presently 51 of care workers achieved the award a further eight care staff are working towards it. Service users monies were suitably stored and recorded. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 8 What has improved since the last inspection? What they could do better:
The Statement of Purpose and Service User Guide are outdated; they are not a current reflection of the service provided. Discussion with the manager confirmed that all the radiators have now been audited but not necessarily suitably covered for the safety of the service users; this continues to be a requirement and should be addressed without delay. Comments from service users confirmed they would like more choice of meals; Comments included: “Meals are fine I get enough to eat but would like more variety.” Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 9 “The food is well cooked but choice can be limited, I would like to see more salads and other vegetables.” It is recommended that the menus are re-evaluated with service user input to improve this area. A number of risk assessments relating to the building and fire issues need to be implemented. The home must ensure that all information relating to criminal record disclosures and protection of vulnerable adult (POVA 1st) checks are on site, in some instances the information was held at the provider’s headquarters. Information stored within the home relating to complaints and grumbles needs to be recorded in a more robust manner with evidence of the outcome available. 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. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 10 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 House DS0000044218.V287207.R01.S.doc Version 5.1 Page 11 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 and 3 standard 6 is not provided by this home. Dove House delivers a flexible, reliable and focussed service. Information offered needs to be updated to ensure that service users and prospective service users can make an informed choice about the home. The manager undertakes effective assessments of potential service users. This is an indicator of a “good” service for those people choosing a residential care home. EVIDENCE: The establishments Statement of Purpose and Service User Guide are offered to each individual and are available in each bedroom. They have not been reviewed since December 2004 and therefore do not offer a current reflection of the service. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 12 A requirement to update these has been made, examples include Karen Betts has been registered with the Commission for Social Care Inspection as the manager, staff training records are out of date, it does not reflect that the home can offer care for 25 people with dementia. There was evidence to confirm that information relating to the admission process was suitable, the home ensures pre assessments are competed and robust. The manager visits potential service users in their current setting and undertakes an assessment. The information gathered at assessment is transferred into the care plans. A recently admitted service user explained that a meeting had taken place with her family and social worker. A visitor also confirmed that reviews took place, they stated that the care received was “Brilliant” and that the home had “offered stability and kept the family well informed.” Personal care, mobility and medication were documented along with mental state, social interests and carer/family involvement; service users relatives/representatives are also included in this procedure. All necessary specialists needs were arranged as required and documentation was seen to support this. Responses from the service users confirmed that staff responded flexibly to their day-to-day needs. All 15 questionnaires received back from service users confirmed they liked living at Dove House felt they were well cared for, treated well, respected and able to make their own decisions. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 13 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 Care planning and health care monitoring is well documented; risk assessments are individualised and fairly robust. Medication is now well managed and the systems in place safeguard the service user. This reflects “good” care practices. EVIDENCE: Each service user had an individual plan of care, which included health, personal, and social care needs. The care plans seen at the visit reflected the care that the service users were receiving and these were updated monthly as required with the attendees recorded. It was pleasing to note that the service user plan also recorded individual goals and objectives; the home must strive to record if and when these objectives are met.
Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 14 There was evidence to show service users were involved in the plan as far as is possible. Service users spoken to continued to feel that they were treated with dignity and respect. They said the carers encourage them to be as independent as possible but would always intervene where necessary. The health care sections of the care plans evidence that needs are closely monitored and medical professionals contacted, if necessary. A large number of service users spoken to revealed that they were very satisfied with the care provided, the Commission for Social Care Inspection witnessed staff knocking on doors, offering service users choice, and allowing them to complete tasks in their own time. There have been a number of concerns on past inspections relating to the administration of medication. This has now been fully addressed and further training has been provided to all senior staff administrating drugs. The manager was confident that all concerns have now been eradicated. A Medications Policy and Homely Remedies policy were held within the home. These need to be updated to reflect the current practice. The medication administered and the systems in place within the home were observed by the inspector and were of a good standard. ‘As and when required medication’ (PRN) was recorded by the staff whether taken or refused as necessary. Staff spoken to had a sound knowledge and understanding of medication issues therefore ensuring service users were protected from harm. It has been recommended in the past that the home ask the pharmacist to provide an audit of the homes medication systems. The pharmacist has declined to assist in this area. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 15 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 A range of activities are available to the service users to meet their needs and family and friends are encouraged to visit. Service users were supported and enabled to exercise their right to make their own decisions and choices. Daily routines and lifestyles are “very good” for the service users. EVIDENCE: An activities plan has been well developed. Dove House has its own activities coordinator who has an excellent approach and is skilled in working with older people. Service users are very complimentary in this area. Service users revealed they were able to come and go freely, visitors stated they could call at any time, activities were taking part in one area of the home during the afternoon, but the conservatory was a quiet area and one lounge had the television on whereas the other lounge had old time music playing. These findings confirm that service users are offered a flexible routine that are varied to suit individuals expectations, preferences and capacities. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 16 At lunchtime service users ate in the dining room, two people remained in their own rooms. The meal was unrushed and choices and second helpings were offered, staff were seen supporting service users where necessary with their meals in a positive manner. Two service users received liquidized meals; these are now well presented and each vegetable is liquidized or mashed individually, the meat is also separate. This offers people a variety of taste, texture, colour and visual stimulation and it is pleasing that the old practice of liquidizing everything together has ceased. The kitchen was inspected and found to be very clean and tidy. Food supplies were plentiful and fresh fruit and vegetables were available. Records of fridge and freezer temperatures and probing were kept. The Environmental Health Officers report undertaken at Dove House last year was good. A recommendation to revisit the menus has been made; these presently run on a four-week rota, this could be developed, to a six-week programme and would then offer people more variety and choice. A number of service users spoke freely of their desire for more choice and variety. One questionnaire revealed “ Not always happy with the food.” Thirteen of the 15 questionnaires did confirm that they liked the food at Dove House. All service users spoken to were happy with the quality and quantity of food offered. The presentation has also improved since the last inspection. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 17 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 Positive relationships between staff, management, service users and families is conducive to people feeling comfortable enough to grumble comment or complain about the service. The home has the required information and knowledge relating to recognition of abuse procedures and Whistleblowing. The systems in place for the protection of service users are “good”. EVIDENCE: The Commission for Social Care Inspection has received one formal complaint about the home since the last inspection held in December 2005. This is currently unresolved. The manager records complaints appropriately, however the outcome must also be evident. Service users are offered opportunity to express their concerns either individually or in the residents’ meetings. The complaints procedure is also available in the Service User Guide and by the homes’ notice board. Minor concerns are recorded in a ‘grumbles and compliments book’. These included: “ Nice environment easy and safe.”
Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 18 “Wheelchairs have no footrests.” “Very very good Nana’s happy.” “Leak in the conservatory roof wetting chairs and cushions.” Again the outcome to concerns should be apparent. The staff are trained to recognise the signs and symptoms of adult abuse during their induction and when undertaking NVQ 2. It was recommended that the manager and staff should revisit this area and discuss the process to be used following an allegation of abuse. The required policies and procedures relating to this area are available within the home, staff sign to say they have read and understood them. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Indoor and outdoor facilities at Dove House continue to improve, in the main the home is easily accessed, cleaner than on the last inspection, bright and comfortable. The manager must undertake a Health and Safety audit throughout the home to ensure that stringent safety measures are in place, which protect the service users, staff and visitors. The current recording of risk relating the Health and Safety of the environment is “poor”. EVIDENCE: Since the last visit made by the Commission Dove House has continued to redecorate one room per month, the porch is presently being revamped and painted, as is the entrance hall. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 20 New chairs have been provided in the small lounge, five wheelchairs have been purchased, new slings for the hoists are in place and the home has bought new towels, sheets and pillows. Domestic hours are now appropriately covered; as a consequence the home is now cleaner with day-to-day tasks being met. The staff are also able to start deep cleaning where necessary and continue with maintenance work as and when required. Generally the home is to a satisfactory standard, one toilet did not have the necessary soap, paper towels or waste bin but overall environmental standards continue to improve. The home meets infection control standards, they have a robust policy and procedure, use soap dispensers, paper towels, protective clothing, uniforms, foot operated bins, and have a weekly clinical waste collection. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 21 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 All staff were suitably trained to carry out their duties, the homes recruitment practices are, in the majority of instances, in line with the National Minimum Standards. This is indicative of “good” staffing. EVIDENCE: Two staff files were chosen on a random basis to be inspected, evidence of Protection of Vulnerable Adult First (POVA) and a Criminal Record Bureau (CRB) enhanced disclosure were available in each case, however, the POVA first checks had to be faxed over from the head office, all information needs to be sited within the home with the registered manager and for inspection purposes. Both files required photographs and one file did not evidence that an induction had taken place, the manager must ensure that all elements of Schedule 2 of the National Minimum Standards are in place. There is a now a fairly stable staff team within this home which gives service users confidence; there is only one part time vacancy presently. All the service users were very positive about the staff team and the manager. Suitable staffing is provided to support the service users.
Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 22 All mandatory training is provided, specialist training is also considered. There was adequate evidence to confirm that training was ongoing and relevant to the service user group. At the time of this visit, 51 of the staff team have achieved NVQ 2 or above. A staff meeting took place on the day of inspection and was conducted by the manager. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 23 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 The views of the service users are sought and the quality of care is monitored and addressed accordingly. Health and safety risk assessments need to be added to and strengthened ensuring that the service users and staff are as safe as is reasonably practicable. The administration in the home needs “improving”. Management is “good.” EVIDENCE: Service users were very satisfied with the home comments made included: “I feel safe”
Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 24 “I like it here” “Karen and the staff are very nice” The manager is currently half way through the Registered Mangers Award, this is the qualification required (or its equivalent) by the Commission for all managers of a care service. Karen has worked hard to continually improve the homes care practices and their was evidence to confirm that she consulted with service users and their families about individuals care needs, interests and preferences. Quality assurance questionnaires are sent out to service users, visitors and staff on an annual basis, the home needs to also include other professionals and stakeholders in this process. The outcomes are recorded and available on the notice board within the home, it would be considered helpful if the whereabouts of this information was recorded with the service user guide. The manager ensures the service users control their own money except where they choose not to. The records of financial involvement were scrutinised on this occasion. Where the money of an individual was handled, appropriate recording and receipts were kept. All monies checked were as recorded. The manager needs to implement and record a number of risk assessments, it was clear that the risk assessments in place were apt and also reviewed or revisited as and when required. However a number of assessments were missing, examples of these include: The use of hoists, window openings and glazing, contractors, cross infection, wheelchairs, Legionella, stress, gas and electricity, this list is not exhaustive. Fire risk assessments were in need of completion, presently only an audit is in place. The manager is also aware that she must complete a written contingency plan in the event of a fire or bomb threat regarding safe placement of service users. The registered manager ensures that all maintenance work, repairs, annual checks, mandatory training, testing of equipment and regular fire drills are undertaken. All records checked were up to date and met with the requirements. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 25 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 26 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(1)(a)(b) Requirement The registered person shall ensure the Statement of Purpose is up to date and a current reflection of the service The registered person shall ensure that’s the homes medication policy reflects the homes current practice. The registered manager must ensure that all concerns grumbles and complaints are recorded appropriately and evidence the outcome. The home must offer all the required items within the communal toilets The trolley used for the storage of Control of Substances Hazardous to Health (COSHH) products must be locked when unattended. All radiators within the home where service users have access must be guarded, priority must be given to those risk assessed as high risk. Previous requirement. Not met.
DS0000044218.V287207.R01.S.doc Timescale for action 31/05/06 2 OP9 17(1)(a) 12(1)(a) 17(2) Schedule 4 (11) 30/04/06 3 OP16 18/05/06 4 5 OP19 OP19 13(3) 13(4)(a) 25/04/06 25/04/06 6 OP25 13(4)(a) 31/05/06 Dove House Version 5.1 Page 27 7 OP29 19(1)(b) (i) 8 OP33 9 OP38 10 OP38 The registered manager must ensure all requirements noted in Schedule 2 are available on staff files 24(2) The home is required to record the results of quality assurance surveys and make them available to current and prospective service users and forward a copy to the Commission. These should include staff, service users, other professionals and families/relatives views. 24(4)(c)(ii The responsible individual must i) complete a written fire risk assessment and a contingency plan in the event of a fire or bomb threat regarding safe placement of service users. 13(4)(a) The responsible individual must ensure that risk assessments are completed in all instances. 30/04/06 30/06/06 10/05/06 10/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP19 Good Practice Recommendations The registered manager should consider reviewing the menus with the involvement of the service users and kitchen staff. The registered manager should consider storing the Control of Substances Hazardous to Health (COSHH) Data sheets in the COSHH cupboard as well as in the office. Dove House DS0000044218.V287207.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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