Inspection on 25/05/06 for Englewood Care Home

This inspection was carried out on 25th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Englewood Care Home 25/01/10

Englewood Care Home 06/04/09

Englewood Care Home 30/04/08

Englewood Care Home 24/01/08

Englewood Care Home 14/08/07

Englewood Care Home 21/11/06

Englewood Care Home 26/01/06

Englewood Care Home 04/05/05

Englewood Care Home 20/12/04

Englewood Care Home 18/06/04

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

CARE HOMES FOR OLDER PEOPLE Englewood Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ Lead Inspector Leila Mavropoulou Key Unannounced Inspection 25th May 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Englewood DS0000054702.V288745.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. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Englewood Address Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ 020 8597559 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) Englewood Care Limited Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. A maximum of 24 adults over the age of 65 years may be accommodated in the category OP 26th January 2006 Date of last inspection Brief Description of the Service: Engelwood care home provides personal care and support for 24 older people both male and female over the age of 65. Accommodation is provided on three floors, which are accessible by a passenger lift. The home has two communal areas on the ground floor. There is lounge and a large dining room and conservatory to the rear of the building overlooking the garden. The home has a call system, assisted baths; grab rails etc to assist service users and to promote their independence. The weekly fee charged is £367 per week. Each service user is given written terms and conditions of their stay showing the services and facilities included in the weekly fee. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that lasted five and half hours. During which time five service users and four staff were spoken to. Five service users records were inspected, staff records and other maintenance records the service is required to keep. What the service does well: What has improved since the last inspection? What they could do better: The registered person must appoint a manager to provide leadership to the staff group and to comply with the service statutory requirement. The quality assurance system must be formally reviewed to demonstrate improvements in the quality of the service provided. The registered person must ensure that fire records are maintained in accordance with the requirement of the local fire authority to promote the health and safety of service users and staff. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 6 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. Englewood DS0000054702.V288745.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 Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The service admission procedure and Statement of Purpose ensures that the service has the necessary skills and knowledge to meet the assessed needs of prospective service users. EVIDENCE: The service has a Statement of Purpose, which provides detailed information of the services and facilities provided at Engelwood. This was recently reviewed. However, it should include details of the range of needs that the care home is intended to meet. Four service user files was examined which showed that the staff at the care home did carry out a pre-admission assessment to ensure that the service user needs could be met at Engelwood. There was evidence that each service user is issued with terms and conditions of stay, which show the weekly fee and what service and facilities are included in the price. Also, letters were seen in service user files informing them of fee increases and the reason for the increase. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 9 The Statement of Purpose and discussion with staff confirm that service users are encouraged to visit the home before admission. However, for service user being admitted from hospital trial visits are unusual. In instances like this, normally the family members make the decision on behalf of the service user, as evidenced in the recent admission to the care home. Most of the staff at Engelwood have achieved their NVQ level and some their NVQ level 3 care qualification and has several years experience of working with the elderly to ensure that they have the necessary skills and knowledge to meet the needs of service users. The service does not provide intermediate care. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The service users health needs are being met. However, this could be improved by the appointment of an experienced manager to monitor and supervise the day-to-day management of the care home. EVIDENCE: Examination of service user plans and risk assessments showed that they had been reviewed since the last inspection to reflect the current needs of service users. The registered person must ensure that service user’s plans are amended to reflect changes in their care/treatment when they are discharged from hospital e.g. district nurse or other health professionals input. Where possible these are signed by service users or their representatives. Discussion with staff showed that recently advice was sought from the continence adviser to promote service users’ health and dignity. One service user file examined and observation during the inspection showed that where necessary a service user require some nursing care that the district nurse attends to this aspect of their care. In a recent notification to the Commission, Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 11 it was noted that the staff tried to provide care for a service user that had a pressure area without seeking advice from the service user GP at the outset, which would have minimised the risk of the pressure area deteriorating. The registered person must ensure that all staff are aware of their knowledge and skills limitation and seek advice from specialist health professionals. Observation of service users and discussion with staff showed that some service users had poor short-term memory. It is recommended that all staff receive training in understanding mental health in older people. Visits are made to care home by the optician, dentist as required and there are regular visit from the chiropodist. Discussion with staff and observation showed that suitable aids are obtained and installed by a suitably qualified person usually the district nurse to minimise pressure sores developing and other aids to promote the safety and comfort of service users. Inspection of service users medication records showed that generally they were well maintained. However, the following were found on one occasion a service user Codeine Phosphate 30mg was administered but not signed as given. Another service user Aquasept medication was not signed in on their medication to ensure that an accurate record is maintained of all service user medication received into the care home. Also, one service user medication record had a hand written entry. It is considered good practice that another member of staff countersign handwritten entries to ensure the accuracy of the information. Observation of staff showed that service users are assisted with personal care that promote their right to privacy and dignity. The staff induction covers the philosophy of the care home. The service has a private telephone from which service users are able to make and receive calls. Staff were seen knocking on service user bedroom doors before entering to promote respect for the service user. Currently, all accommodation is provided in single bedrooms. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Staff support service users to maintain contact with the community and their family/friends to promote their emotional well being. EVIDENCE: Observation showed that service users exercise a high degree of choice over their activities of daily living. This was evidence by some service users spending time in their bedroom, two service users were accessing community facilities independently and a family member took another out. The service employs an activities person to provide activities for service users. A record is maintained of activities provided to service users and their participation. Engelwood has an unrestricted visiting policy and service users are able to choose where to see their visitors. Service users or their representatives manage their finances. However, small sum of monies is left with staff to pay for small expenditure such as: hairdressing, chiropodist, toiletries etc. A record is kept of all incoming and outgoing of service user monies. This is checked weekly by two members of Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 13 staff. Tours of the building show that service users are able to bring their personal possessions with them. Discussion with service users indicated that they are generally satisfied with the meals provided at Engelwood. The catering staff maintains a record of food provided to service users and keep a record of freezer and refrigerator temperatures. Discussion with the staff and examination of service users records show that special diets would be catered for as evidenced in one service user files inspected. The registered person must ensure that where service user are on food supplements that a record is kept of when they are given and that the service user weight is monitored regularly to record changes in service user weight. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Service users are encouraged to raise concerns with the management of the service to improve the quality of service they receive. EVIDENCE: The home has a complaint procedure which is easily accessible to service users and their representatives. Engelwood has not received any formal complaints since the last inspection. Discussion with staff indicated that any concerns raised by service users are dealt with promptly. It is recommended that a record be kept of all concerns raised by service users and how the concerns were addressed. One concern was forwarded to the Commission by an external agency. Staff support service users to vote if they wish either through arranging for them to be accompanied to the polling station or through postal voting. Information on independent advocacy was available. Engelwood has various policies and procedures in place to protect service users and staff from abuse such as: Whistleblowing and Wirral Adult Protection procedure. All staff attended training in Protection of Vulnerable in October 2005. An external trainer provided this training in the home. The registered person must ensure that all staff receives training on managing physical and verbal aggression to promote the safety of service users and staff. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 15 A safe place for the storage of service users valuables is provided and staff are precluded from assisting or benefiting from service users’ will as evidence in the staff handbook. Englewood DS0000054702.V288745.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” There is ongoing improvement to the physical environment of Engelwood. However, the furniture in service users bedroom must be replaced to improve the quality of service users private accommodation. EVIDENCE: Over the past twelve months there has been ongoing and renewal and replacement of equipment in the care home to promote the health and safety of service users such as: replacement of the lift, laundry equipment and the car park at the front of the property. However, the replacement of the bedroom furniture must be renewed through the home’s planned maintenance and renewal programme to improve the quality of service user personal space. Bedroom F1 must be redecorated as the wallpaper is “coming” away from the wall. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 17 The garden to the front of the property has been tarmac and plants have been placed at intervals to improve the appearance of the home. The larger garden to the rear of the property was clean and well maintained. Both gardens are easily accessible by wheelchair users. The communal areas at Engelwood are on the ground floor. There is a large lounge, dining room and a conservatory. The conservatory is used as a smoking area. The flooring in the conservatory area has been replaced since the last inspection. The dining room is used for activities such as: board games with service users. The tablemats and tablecloths have been replaced recently. T Most of the service users bedrooms have an en-suite facility. Discussion with staff indicated that the service users are unable to use the bath in the en-suite, as they are unable to get in and out of the bath. Staff are currently looking for suitable small bath aids to enable service users to use the bath in their ensuite, as this would promote service user’s privacy and the quality of care provided. Service users bedrooms were clean and free from malodour. Observation throughout the tour of the building showed that some of the bedding was worn and should be replaced. Suitable locks are provided on all service users bedroom doors, which could be open by staff in an emergency. Observation of service users showed that some service users had a key to their bedroom. This is available to all service users. Various aids are provided to promote service users independence such as: passenger lift, grab rails, assisted baths, walk in shower etc. The service does not have any aids to assist staff to lift service users. The service user care plans and risk assessment examined and discussion with staff indicate that lifting aids were not required to meet the needs of the service users at present. There is a loop system in the sitting room for those service users with a hearing impairment. Englewood is centrally heated throughout and service users are able to control the heating in their bedroom. The bedrooms are bright and well ventilated, with window restrictors on windows. The fire logbook showed that the emergency lighting, fire alarm system are not tested in accordance with the local fire authority recommendation, as the last entry in the fire logbook are 7th March 2006. The hot water temperature has not been tested since 10th March 2006. The registered person must ensure that the hot water is stored at 60 degrees centigrade and distributed at 50 degrees centigrade to prevent the risk of Legionella. The laundry facility is sited away from the food preparation area. New washing machine and tumble dryer have been installed with sluicing facility. Policies and procedures are in place to prevent the spread of infection. Englewood DS0000054702.V288745.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,23,30 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The staff meet the day-to-day needs of the service users. However, this could be improved through specific training to reflect service user needs and individual staff supervision. EVIDENCE: The current staffing level is adequate to meet the needs of service users and varies throughout the day to reflect the needs of service users. Currently, there are two waking staff at night. Discussion with staff indicated that for planned hospital visit additional staff maybe brought in to accompany the service user to hospital. The home employs domestic in sufficient numbers to maintain the cleanliness of the building. The home is clean and free from malodour. In addition, there are catering staff to prepare service users meals. Examination of six staff files showed that they each had a Criminal Record Bureau check, two written references, a job description, terms and conditions of employment, identification and staff induction. However, the registered provider must review the service induction to ensure that it complies with the guidance of the National Training Organisation. Over 50 have completed their NVQ level 2 in Care and three staff members have completed their NVQ Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 19 level 3 in care. Currently, four staff are working towards the NVQ level care award out which two are nearing completion. Englewood DS0000054702.V288745.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,3334,25,36,27,38 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The health and safety of service users could be improved though the appointment of a competent and experience manager. EVIDENCE: Currently, the deputy manager is responsible for the day-to-day management of the home until a manager is appointed. The registered person has interviewed and appointed several managers. However, the post was declined after initial acceptance. In the interim period the deputy manager has made progress in ensuring that staffing and service users records are up to date and information required is obtained and recorded. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 21 Staff appraisals have been completed as evidenced through discussion and inspection of some staff files. However, individual staff supervision is not provided to staff. The service has a quality assurance system. However, this has not been maintained or evaluated to demonstrate improvements in the service. The registered provider has recently forwarded to the Commission a copy of their monthly visit report. The service maintains a record of service users monies/valuables handed over for safekeeping and a safe place is provided for its storage. Receipts are given to confirm receipt of these. Service users or their family/representative manage their finances. The records in the care home are generally well maintained and easily accessible. However, some records were not maintained accurately such as: fire records and medication record. Service users information is kept in a secure place. The service has a current Public Liability Insurance and income and expenditure of the home is maintained for accounting purposes by the registered provider. The service user health and safety is promoted through staff receiving training in moving and handling, first aid, food hygiene and fire awareness. However, the health and safety of service users are placed at risk through a risk assessment of the building not be carried out and regular tests to the fire alarm and emergency lighting not being carried out as recommended by the local fire authority. At the time of the inspection the electrical wiring certificate and gas safety certificate were not available. The staff at the care home records accidents to service users and staff and where necessary the Commission is informed. Englewood DS0000054702.V288745.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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 2 2 2 Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 23 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 Requirement The registered person shall ensure that the homes Statement of Purpose includes the range of needs that the care home is intended to meet. Timescale for action 30/07/06 2. OP8 13 (1)(b), 18 The registered person shall make 30/07/06 arrangement for service users to receive where necessary, treatment, advice and other services from any health care professional such as: GP, District Nurse. The registered person must ensure that service users have the necessary skills and knowledge to meet the changing needs of service users e.g. understanding mental health in older people. 3. OP9 13 &17 The registered person must 30/07/06 ensure that accurate records are received of all service users medication received into the care home administered and returned to the pharmacist. Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 24 4. OP18 18 The registered person shall ensure that staff are provided with training on managing physical and verbal aggression. The registered person must ensure that the fire equipment in the care home complies with the recommendations of the local fire authority i.e. weekly testing of the fire alarm and monthly testing of the emergency lighting. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated by carrying out regular tests and to maintain a record of the hot water temperature. The registered person is required to ensure that hot water is stored at 60degrees centigrade, distributed at 50 degrees centigrade and provided locally at 43 degrees centigrade. 30/07/06 5 OP18 13 & 23 30/07/06 6. OP25 13 30/07/06 7. OP31 9 The registered person must 30/07/06 ensure that the person managing (Acting Manager) the care home has the necessary skills and experience necessary for managing the home e.g. training on giving staff supervision and appraisal. The registered person must evaluate its quality assurance system at regular intervals to demonstrate continuous improvement in the quality of care provided. This is outstanding from the previous inspection. The registered person must provide to the Commission a DS0000054702.V288745.R01.S.doc 8. OP33 24 30/07/06 9. OP24 16 30/07/06 Englewood Version 5.2 Page 25 plan for the refurbishment of service user bedroom furniture as some are very worn and in need of replacement. 10. OP31 8 The registered person must 30/07/06 appoint a manager for the dayto-day management of the care home and make an application to the Commission to register the manager. The registered person must review at appropriate intervals the quality of service provided and forward a copy of the review to the Commission. The registered person must ensure that all records require to be kept in the care home are up to date. Outstanding from the previous inspection. The registered person must ensure that the service complies with the recommendations and requirements of the fire officer. The registered person must ensure that the service has an electrical wiring certificate and that the gas safety certificate which is available for inspection. The registered person must ensure that a risk assessment of the building is carried out to promote service users safety. 30/07/06 11. OP33 24 12 OP37 17 30/07/06 13 OP38 13 &23 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Englewood Refer to Good Practice Recommendations DS0000054702.V288745.R01.S.doc Version 5.2 Page 26 Standard 1. OP16 The registered person should maintain a record of all concerns raised by service users and how the concern is addressed. The registered person should replace bedding that is worn. The registered person should review their staff induction to meet the National Training Organisation (NTO) training specification. The registered person should review the format of the staff training records to evidence that staff receive three paid training days a year. 4 OP36 The registered provider should ensure that all staff receive regular supervision and a record of issues discussed in staff supervision is kept. The registered manager should review the homes policies and procedures to ensure they reflect current legislation and best practice. 2 3 OP24 OP30 5 OP37 Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Englewood DS0000054702.V288745.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!