Inspection on 07/06/07 for Florence Shipley

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Florence Shipley 26/06/06

Florence Shipley 19/01/06

Florence Shipley 04/01/05

Florence Shipley 28/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Florence Shipley Florence Shipley Market Place Heanor Derbyshire DE75 7AA Lead Inspector Denise Bate Key Unannounced Inspection 7th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Florence Shipley DS0000035583.V337960.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. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Florence Shipley Address Florence Shipley Market Place Heanor Derbyshire DE75 7AA 01773 728400 01773 728405 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) www.derbyshire.gov.uk Derbyshire County Council Mrs Eileen Wathall Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 Brief Description of the Service: The home is situated within the community of Heanor, located at the market place, in the town centre. This establishment is a 26 bedded home with single rooms, but no en suite facilities. The home is pre-existing April 2002, therefore the references to pre-existing homes within the National Minimum Standards, are applicable. It is spread over three floors and with a lift to help access to the upper floors and a call system throughout the building in case of emergencies. There are assisted bathroom and toilet facilities on all floors and the home has three lounge areas on the ground floor and a dining room. The home has a large garden although access to this is not easy for residents. Fees are £381.84 per week for permanent residents, but a range of prices for short term care residents. Additional charges, e.g. hairdressing, chiropody, are clearly identified in the home’s Statement of Purpose and Service User Guide. Copies of inspection reports are available in the foyer. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. During the inspection seven residents, three relatives, and two staff members were spoken with. The manager was present during the inspection and provided assistance and information. Prior to the inspection a number of sources of information were looked at including the home’s service record and previous inspection reports. A detailed Annual Quality Assurance Assessment was completed by the manager and information provided has been included in this report. A number of records were examined on the day of inspection, including care planning documentation, minutes of meetings, regulation 26 visit records, accident records, staff files and medication records. Four residents were case tracked. A tour of part of the building took place and the grounds were seen. What the service does well: Florence Shipley provides a comfortable, homely, and relaxed environment for residents. Residents and relatives spoken with made positive comments about the home and staff; ‘the staff are good’; ‘this is a lovely home’, ‘the staff are very helpful and obliging, they never refuse you, you can ask for small simple things’, ‘we are all individuals but it is a very friendly place’. The management team are seen as approachable and responsive. The manager explained that resident ‘contributions are used in shaping the everyday life of the establishment’. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home was found to be generally well maintained and standards of cleanliness are high. The food was said to be ‘good’ and meals are served in an attractive dining area. Staff spoken to were experienced, knowledgeable, and committed to the welfare of residents. There is a stable staff group who work well as a team. No new staff have been employed recently. Staff supervision takes place and training is given a high priority. All care staff are trained to NVQ level 2. There is a robust system for recruiting and training new staff and appropriate checks are carried out. There is a corporate complaints procedure, although most day to day difficulties are dealt with on an informal basis. Staff and managers are aware of safeguarding adults issues. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 6 There is an effective quality assurance programme that provides clear indications of where the home is doing well and what areas could be improved still further. The survey found that the overall quality of care was rated as ‘good’ or ‘excellent’ by 94 residents and 96 of their relatives and friends. What has improved since the last inspection? What they could do better: Work must continue to transfer personal service plans onto the new system and ensure that all risk assessments are completed in detail. Urgent improvements are needed to the handrail used by residents to access the small garden area outside the front door. Some improvements are in the maintenance of the building, in particular the disabled toilet and the exterior woodwork on the outside of the dining room. Staff would benefit from updated training in safeguarding adults and in dementia care. Up to date regulation 26 visit records should be kept in the home to help the manager ensure that any issues raised are dealt with promptly. Regulation 37 notices need to be forwarded promptly to CSCI to provide information on matters which effect residents’ well being. The home indicate that they plan to carry out a sensory audit of the environment in the next 12 months. They will be looking to improve staff training for established staff to ensure it covers similar topics to the current ‘Skills for Care’ offered to new staff. Some members of staff plan to take part in IT training to improve their skills in this area. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 7 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. Florence Shipley DS0000035583.V337960.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 Florence Shipley DS0000035583.V337960.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: Copies of the Statement of Purpose and the Service User Guide are available in all residents’ rooms. The inspector was informed that the Service User Guide is going to be reviewed to include information from the quality assurance survey. Some permanent residents told the inspector they have got to know the home through the provision of day care and/or short term care. Prospective residents or their advocates are encouraged to visit prior to making a decision to move Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 10 to the home. Copies of pre admission assessments were seen on care planning documentation of case tracked residents. It was noted that the new computer based system will aid the availability of up to date information to assist in providing appropriate care for residents. The home do not provide intermediate care so Standard 6 does not apply. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are completed and are individualised to demonstrate that residents’ health, personal and social care needs are being met. EVIDENCE: Four case tracked residents had clearly arranged care planning documentation. Items in files included monthly summaries, personal service plans, risk assessments (moving and handling, nutrition), weight monitoring, and day to day logs. Personal service plans were resident focussed and individualised e.g. including food preferences, night time checking arrangements, personal routines, etc. Personal service plans had been signed by residents, indicating that their contents had been discussed with them. This was confirmed by residents who said; ‘you can get up and go to bed when you like’, ‘I’ve been in Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 12 three other homes and this is the best’. Other comments by residents and relatives on their quality of care included; ‘the staff are kind and make time for you’, ‘the care is superb’, ‘the staff are very approachable’. There were a few gaps in care planning documentation of some case tracked residents. Some care plans could be completed in more detail to provide advice and guidance to staff and to reflect the high quality of care actually provided. These instances were discussed with the manager and ongoing work is planned as part of the change to the new computer system. For each resident a second care file contains financial information and background details and copies of assessments and care plans that have been superseded. Copies of contracts were available on file and were seen for case tracked residents. The inspector was informed that residents can have access to all their personal records. Residents are encouraged to maintain their independence as long as possible, e.g. going out alone or accompanied by a member of staff. Residents gave examples of how they are assisted to maintain links with the local community. Derbyshire County Council has a clear policy relating to equality. Staff were observed supporting and reassuring residents. Residents and relatives said the staff were ‘good’ and they were treated with dignity and respect. Staff spoken to related to residents as individuals. Aspects of residents’ health needs and medication were clearly presented on care planning documentation. Residents are supported to go to hospital appointments. It was reported that a good relationship exists with local GPs and with District Nurses. The home uses the Medidose system for medication. There is a separate medication room where medication is kept securely. Pictures of residents are kept with their medication administration records, reducing the possibility of residents being given the wrong medication. The medication records of some case tracked residents were seen and found to have been recorded correctly. The date of opening had been recorded on eye drops and creams. The fridge temperatures were being monitored. The home have access to medication information about particular drugs and their uses and side effects. The home have a copy of the latest guidance available from the Royal Pharmaceutical Society. The home are working to ensure all aspects of the home’s practice are in line with current Derbyshire County Council guidelines. A record is kept of staff signatures, but some of the signatures on the MARS chart did not match very well. Although standard 11 was not formally assessed on this occasion the manager informed the inspector that the home ‘are planning to implement the Liverpool Care Pathway for provide appropriate support to ‘end of life’ residents’. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides suitable activities and the quality of catering is good which contributes to a pleasant atmosphere and the high overall levels of satisfaction for residents. EVIDENCE: There is a designated member of staff who takes responsibility for organising activities. Records are kept of activities undertaken and these were seen by the inspector. The day after inspection residents were going an outing to Twycross Zoo. Comments from relatives and residents included; ‘it’s wonderful that residents are taken on outings’, ‘we have lots of activities including someone who comes to play the organ who is very good’, ‘I like movement to music’. Regular events include playing bingo, in house entertainment, movement to music, Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 14 craft, and seasonal events e.g. Easter had recently been celebrated and there were photographs of residents in their ‘Easter bonnets’. Residents indicated that they feel staff are approachable and any problems can be discussed with them or with one of the managers. All indicated that they are able to exercise choice about aspects of their daily lives. The inspector was informed that resident meetings take place on a quarterly basis. It was confirmed by residents and relatives that visitors to the home are welcomed. Most residents have regular contact with relatives and friends and some go out on a regular basis. Good communication was reported with the home who always keep relatives informed of any issues or problems. The manager said that residents ‘have many outside contacts and visitors’. Meals are served in the lounge/dining areas. Residents spoken to were satisfied with the standard of catering, and the choice of menus that are available. Some residents said the food was ‘superb’, but one or two residents said it was ‘variable’. Nutritional assessments had been undertaken for all case tracked residents. Food preferences and allergies were noted on care planning documentation. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure, although most relatives and residents prefer to raise issues on a more informal basis. As well as the formal complaints procedure there is a book for minor complaints. The complaints procedure is displayed and is in the Statement of Purpose and Service User Guide. No complaints have been made to the home or to CSCI. Some residents and relatives were aware that there was a formal complaints procedure. They told the inspector they had no complaints; ‘she would tell us if there was something wrong’, ‘I’ve never had cause to make a complaint’, ‘if I wasn’t sure about something I would ask’. Residents and relatives are also encouraged to make suggestions and there is a suggestion box in the foyer. The inspector was informed that Derbyshire County Council has clear procedures for dealing with the safety of residents and safeguarding them from Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 16 harm. Staff spoken to showed an awareness of safeguarding adults issues, were clear about their responsibilities and would pass any concerns on to their line manager. Training in safeguarding adults has been provided for some staff via NVQ courses, and it is recognised that some refresher training is needed for some staff. The Manager has training in safeguarding adults through her NVQ registered manager training, and she is to attend a multidisciplinary course in the near future. The accident book was seen and one incident identified where the home should have notified CSCI about an accident on a regulation 37 notification. The home agreed to send a notification in accordance with their usual policy. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home generally provides residents with an attractive and homely place to live. However, lack of maintenance in the garden area means that residents are not provided with a safe and attractive outdoor environment. EVIDENCE: The building has been maintained to a reasonable standard overall. There is a rolling programme for maintenance and redecoration and new carpets, curtains and furniture. There is a choice of lounges and dining areas, and the Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 18 atmosphere is homely and relaxed. A kitchenette is located centrally for residents and their friends or relatives to make cups of tea or snacks. The location of the building in the centre of town means that residents can easily access the shops and other amenities, e.g. chapel. Parts of the exterior of the building need maintenance, particularly the woodwork at the exterior of the dining room. Most of the garden is inaccessible to residents as it is very steep. There is a small seating area outside the front door. Residents told the inspector they like to take some fresh air in fine weather, particularly if they are no longer able to walk up to the town. The handrails which assist residents to access this area are in a state of poor repair; the paint has pealed off leaving exposed and uneven wood that could cause splinters and part of the handrail is rotting. This presents a danger to residents’ safety and comfort and is being raised with the registered provider as a matter of immediate concern. Until the handrail is repaired residents with disabilities or mobility problems may not be able to access the garden safely, and they will have nowhere to sit out in fine weather. In addition to health and safety issues, the rail is extremely unsightly and gives a very poor impression to visitors. Residents spoken to were happy with their bedrooms. Bedrooms are personalised according to residents’ preferences. There are some larger bedrooms available to enable equipment to be used to assist in the care of residents with physical disabilities. Comments from residents included the following; ‘I am quite happy with my room’, ‘I like the new paintwork in the corridor’, ‘I’m over the moon with my room’. Residents can adjust the heating in their bedrooms for individual comfort and preference. Some toilets and bathrooms were seen and found to be satisfactory, but improvements are needed in some toilets, particularly the ‘disabled toilet’ where the floor looks worn and unattractive. The manager said that ‘a range of equipment is provided to encourage maximum independence’. All areas of the home seen on the day of inspection were very clean and residents and relatives said that standards of cleanliness within the home were excellent. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: On the day of inspection there were sufficient care staff to meet the needs of residents accommodated within the home. There were eight resident vacancies. Copies of the staff rotas are seen, and current resident dependency levels are noted on the staff rota. There is a stable staff group and this continuity was appreciated and commented on by service users and relatives. Staff spoken to were responsible, competent and committed to the welfare of residents. Staff said that ‘we work well together as a team’. Generally speaking they enjoyed their work, and were proud of the standards of care given; ‘we think residents here get a high standard of care’, ‘generally the key worker system works well’. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 20 Staff meeting minutes indicated that practical issues relating to the care of residents and the day to day management of the home were dealt with in a timely and appropriate fashion. The inspector was informed that all mandatory training was up to date. Further staff training is planned, including safeguarding adults. Staff spoken to were keen to take advantage of any training opportunities and one member of staff was undertaking NVQ3 in her own time. Two staff files were seen and found to have evidence of CRB checks having been undertaken, copies of references and applications forms. There have been no new members of staff appointed for some time, although it is anticipated that staff changes will happen within the next year as several staff are planning to retire. Derbyshire County Council has a thorough recruitment and selection procedure and provides staff with training prior to them starting work. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 21 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: Residents, relatives and staff spoke positively about the manager and the management team. The manager has the required qualifications and experience to fulfil the responsibilities of her role. There is a management Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 22 team and individual deputies take responsibility for various aspects of the day to day running of the home and for staff supervision. Copies of Regulation 26 visits made up to January 2007 were made available and indicated that matters relating to the day to day running of the home are dealt with. The inspector was informed that regular Regulation 26 visits have been made since January 2007, but copies had not yet been forwarded to the home. Staff said they received regular formal supervision, usually every two months. Details of the quality assurance results are prominantly displayed in the foyer and a formal plan has been drawn up to address issues raised.The results were very positive with 94 of residents rating how their overall needs are met as ‘good’ or ‘excellent’. The home had higher results this year than in previous serveys for the standard of deocration and the amount and variety of activities and trips out. As action plan has been developed which identifies where progress still needs to be made. The manager said their ‘feedback highlights that residents have confidence in staff’. The inspector was informed that the home is moving towards a computerised system for managing service users’ finances. At present residents finances are kept in the safe and manual records kept, which appears to work satisfactorily. The manager informed the inspector that safe working systems are in place and equipment maintained satisfactorily. . Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 23 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 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 x 3 3 X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 24 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 OP18 Regulation 37 Requirement Timescale for action 17/07/07 2 OP19 23 (2) (b) 3 OP19 23 (2) (b) Copies of regulation 37 notifications in relation to serious injuries must be sent to CSCI promptly for information and monitoring purposes to ensure the safety of residents. The handrail outside the front 17/07/07 door leading to the garden seating area must be repaired or replaced to ensure residents’ safety and comfort. Routine maintenance must take 01/09/07 place e.g., exterior paintwork outside the dining room area and internal flooring in the disabled toilet to ensure all areas of the building remain safe and in good condition. Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 25 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 OP7 OP9 Good Practice Recommendations Care plans should be audited to for consistency to make sure up to date information is available to guide staff providing residents with day to day care. Care should be taken to ensure that the signatures of staff administering medication closely match the signature on the sample sheet, ensuring that a clear record is kept of which member of staff administered each dose. Training in dementia care and safeguarding adults should be provided for staff to assist them in providing appropriate care to residents. Copies of up to date Regulation 26 visits should be kept in the home to assist the manager is monitoring action taken to address issues raised at visits. Hilda Walk er 3 4 OP30 OP33 Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Florence Shipley DS0000035583.V337960.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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