Inspection on 12/05/05 for Forrester Court

This inspection was carried out on 12th May 2005.

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

Forrester Court 14/09/09

Forrester Court 27/10/08

Forrester Court 09/06/08

Forrester Court 21/06/07

Forrester Court 20/04/06

Forrester Court 11/01/06

Forrester Court 11/11/04

Forrester Court 17/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE FORRESTER COURT Cirencester Street LONDON W2 5SR Lead Inspector Wynne Price-Rees Announced 12 May 2005 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 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. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Forrester Court Address Cirencester Street, London W2 5SR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7266 3174 020 7286 1068 Care UK Community Partnership Limited Hansa Menon Care Home 110 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (100) of places FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 60 dementia (DE) old age 50 (OP) care home with nursing (N) maximum 110 either sex Date of last inspection 11 November 2004 Brief Description of the Service: Forrester Court is located in the Royal Oak area with good access to local shops and transport links. It is registered to provide care including nursing for up to one hundred and ten residents of either gender and recently it has been registered for up to sixty beds for people with dementia and fifty for older people. The building opened approximately five years ago and was purpose built. It is owned and run by the Care UK organisation. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days with three inspectors attending and approximately twenty-eight combined inspection hours were spent, at the home, during which a large number of residents and staff were spoken with. Sixteen residents’ and nineteen relatives questionnaires were returned, most of which commented favourably about the service provided. Two questionnaires did not comment favourably. The home also returned a preinspection questionnaire and self assessment document. The inspection was focused on the requirements of the two previous inspections, a pharmacist’s inspection and the stipulated requirements to vary registration to include more beds for people with dementia. The inspection was announced and twenty residents’ files were case tracked. What the service does well: What has improved since the last inspection? What they could do better: There were six immediate requirements made during the inspection four of which were repeated from previous inspections. These referred to providing evidence that the care needs of people with dementia were being met, improving the daily recording of care provided, reducing the number of accidents and incidents, improving staff interaction with residents, fitting working locks to toilets and bathrooms and making sure all staff have a CRB FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 6 disclosure. A number of other requirements were also made. Two previous recommendations were not met. Although the general activities provided such as bingo were good there are a number of vacancies in the activities staff team meaning it is very difficult to provide a range of activities tailored to people’s needs particularly those with dementia. People also felt more input from unit staff was needed. There is also a practice of staff working long days of twelve hours in three day stretches that reduces their effectiveness. In some instances they were working four and five days without a day off. One staff member was rotered to work six days in a row and the implication was that this was for the benefit of the staff team rather than the residents. The daily progress logs tended to be prescriptive of a resident’s day rather than being focused on the goals set within the care plans and this made it very difficult to identify progress made. There are still a large number of accidents and incidents taking place, not all of which had been notified to the CSCI. 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. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 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 standard(s) 3 & 4 Outcome three was met, outcome four was not. The residents are assessed before entering the home. The activities provided and poor recording of daily progress sheets meant that residents cannot be certain that the home meets their needs. EVIDENCE: A requirement was previously made regarding how assessed needs are to be met within care plans including night care plans. All the care plans inspected had clearly identified goals and night care plans were in place. A requirement was made regarding demonstrating how the needs of residents with dementia were to be met. Most of the activities provided did not focus specifically on stimulating these residents and the home needs to give more training to keyworker staff regarding the most effective activities to stimulate people with dementia. The activities team do provide activities that provide stimulation. Unfortunately there is only one fulltime and one part time post currently filled. This means resources are very stretched in this area particularly as many of the staff spoken with did not have a clear perception of what were appropriate activities to stimulate people with dementia. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9, 10 & 11 Outcomes nine and eleven were met. The others were not met. Generally health needs were met although not all identified tasks, such as agreed bathing times, were carried out as regularly as put down in care plans. Personal and social needs were not met due to lack of activities team members and unit staff not trained or clear regarding their roles regarding social activities and quality of life. The daily progress notes were generally poorly completed and in some cases illegible. The residents’ rights to privacy and dignity were observed apart from bathroom and toilet locks not in place or functioning on some of the units registered for older people. The Inspector used a toilet and was uncomfortable that someone could walk in at any minute. Medication was properly stored, administered and recorded. There were file records of the wishes of residents’ in the event of death. There are a high number of accidents and incidents. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 10 EVIDENCE: The residents needs and goals set to meet them were outlined in all the care plan files checked. A requirement was made for the daily notes to reflect the actual care provided. On the most basic level this was generally happening regarding personal care, health and hygiene needs. Although there were instances of needs being identified such as being offered a bath twice a week that were not taking place. Also interests had been identified but the Inspectors could not find evidence that appropriate activities were provided for residents to follow. The residents tended to fit in with activities provided rather than those provided being tailored to the wishes and needs of the individual. Unless health orientated the daily notes tended to be prescriptive using terms such as “Had a good day” that did not equate to the care plan goals set and this made it difficult to assess if progress towards the identified goals was being made. There was also a large fluctuation in the quality of the reporting with some entries not being legible. The requirements made in the pharmacist’s report were met as were those made in respect of following the dietician’s advice, investigating medication errors, correct medication recording and maintaining food and fluid charts. The medication administration charts were checked for all residents and found to be up to date and appropriately filled in. Care practices observed showed that generally the residents’ rights to privacy and dignity were observed with personal care tasks being carried out in their bedrooms, bathrooms or toilets as appropriate. One area of concern was the lack of working locks on toilet and bathroom doors in the units for elderly residents. There are still a high number of accidents and incidents with three hundred and seventy-four logged since 21/06/04. Of these only thirty-one had been forwarded to the CSCI. A requirement was made for information to be recorded on file regarding residents’ wishes in the event of death. This has been carried out. On one file inspected the information was recorded although there was a note made that a relative was unhappy that an entry had been made without them being consulted and the name of a local undertaker put down that was not what the relative or resident wanted. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 11 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 standard(s) 12 Outcome twelve was not met. Although staff interaction improved on some units it was still not of an acceptable standard with many residents still left sitting in front of televisions that it was apparent they weren’t watching. This is due in some part to staff perception that physical duties must come first and time constraints. EVIDENCE: A requirement was made at the last inspection regarding the staff interaction with residents. Although there was evidence that this had improved on some units, this was not the case on all units. Some of the problem was in relation to staff not being fully aware that their job remit involved giving equal weight to interacting with residents as well as carrying out physical tasks including personal care. In the case of units where there is a higher physical dependency staff feel under pressure to get all the physical tasks carried out and this can be to the detriment of spending one to one quality time with the residents and participating in activities with them. This was evidenced by activities and interests being identified in the care plans but not taking place as recorded in the daily progress notes. In the case of residents with dementia, keyworking staff do not have a clear perspective of what are appropriate activities. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 12 A good piece of work has been introduced by the activities team regarding residents recording their life stories and experiences. One resident has recorded twenty-two thousand words to date. This has helped stimulate a number of residents that have better long term memory recall but struggle with events in the recent or very recent past. This has been hampered by the lack of activities team staff and unit staff not being trained in best practice in how to help residents record and remember their experiences. A number of residents’ said they would like activities outside the home such as trips as well as the activities provided at the home. Currently it seems the majority of activities are tailored so that residents fit in with them rather than the other way around. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 13 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 standard(s) 16 & 18 Outcomes sixteen was met, outcome eighteen was not. There is a complaints procedure that most residents and relatives are aware of. Records showed complaints are fully investigated. The home’s files showed only a small proportion of accidents and incidents were notified to the CSCI and thirteen staff had not received CRB clearance. EVIDENCE: There is a written complaints procedure in place that residents have access to. The majority of residents asked if they knew whom to complain to identified staff that they had most contact with rather than using the formal process and ten questionnaires ticked the yes column in reference to who to complain to. Four questionnaires stated they did not know. Fifteen relatives questionnaires stated they were aware of the complaints procedure with four stating they were unaware. There were thirty-five complaints in the central log between 17/11/04 and 08/05/05 and documentation showed they had been responded to within twenty-eight days and fully investigated. Eighteen were substantiated and three partially substantiated. Nine POVA referrals were made. There are policies and procedures in respect of abuse prevention and identification. A total of thirteen adult protection investigations have taken place since 26/11/04. Three hundred and seventy four accidents and incidents were documented and the home files showed only thirty-one were forwarded to the CSCI as regulation 37 notifications. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 14 There were a thirteen outstanding CRB disclosures identified documentation held by the home. Some dated back to 2003. on the FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 15 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 standard(s) 19 & 26 Outcome twenty-six was met, outcome nineteen was not. The home is suited to the stated purpose although privacy and safety are compromised by missing or non-operational locks on toilet and bathroom doors on some units and not all fire doors being equipped with working electromagnetic closures. The fire drills are taking place although records don’t show who is evacuated and when EVIDENCE: A tour of the home showed it is suitable for it’s stated purpose, accessible, safe and well-maintained apart from most locks missing or non-operational on bathrooms and toilets on some units and not all fire doors being equipped with electromagnetic closures that functioned. The missing locks were primarily in units for older residents. The fire drill records were not very informative. There was insufficient information regarding whom was evacuated, when, at what time and areas checked. The home was clean, tidy, hygienic and odour free. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Outcomes twenty-seven, twenty-nine and thirty were not met. There are inadequate numbers of staff to meet the needs of residents, particularly regarding activities and quality of life. Those in post are stretched particularly on the higher dependency units and not adequately trained in providing suitable activities for residents with dementia, sixty of which make up the total registration. There is heavy emphasis on getting physical tasks carried out at the expense of activities. The rotas showed staff doing long twelve hour days in three, four, five and in one instance six day cycles. The rotas appear to be for the benefit of the staff rather than promoting the needs of the residents. The home’s records showed thirteen staff were working without CRB clearance. EVIDENCE: A requirement was previously made that vacant posts must be recruited to. This has not been achieved and one of the crucial areas that is currently under recruited to is the activities team where one and a half posts are filled out of three. The part time post has only recently been filled. Even when a full compliment was in post the team were hard pressed to provide appropriate activities for one hundred and ten residents many of whom suffer from dementia. The vacancies have impacted on the overall service provided as the care staff observed were not knowledgeable regarding appropriate activities, particularly those for people with dementia. Without enough activities coordinators in post to train care staff in appropriate activities and direct them accordingly the level and type of activity has suffered. Consequently there is a culture of fitting residents into available activities rather than individual needs FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 17 and wishes being provided for. Some staff observed seemed more focused on their physical duties and reluctant to address the activity function of their role. Having said this other staff were enthusiastic to encourage and stimulate residents. An Inspector observed an excellent reminiscence session run by the activities co-ordinator using laminated photos of film stars, TV programmes and musicians that led to a stimulating discussion and showed what can be achieved if suitably trained staff in required numbers are available. As previously outlined records kept showed thirteen CRB disclosures were outstanding. Staffing rotas were examined and shift patterns showed staff to be working a serious of long days without a break. Long days consisted of twelve hour shifts. Generally staff worked three long days in a row, although there was evidence that they had worked four, five and in one instance six days in a row without a break. The inspector feels it unlikely that staff can work to their optimum level on a twelve hour shift let alone when this is repeated over a number of days and therefore it is questionable if the shift patterns are in the best interests of the residents or more suited to the needs of the staff. The previous inspection required an increase in staff to meet residents needs and this has taken place although the findings of this inspection indicate higher staffing levels if the residents are to have an acceptable quality of life with appropriate stimulation and activities provided. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38 Outcomes thirty-three and thirty-eight were not met. The quality assurance system is not performing it’s function of identifying shortfalls in service delivery and therefore these aren’t being addressed. This means the home is not being run in the residents’ best interests. Examples of this are the continued high level of accidents and incidents despite senior staff being required to analyse available data and identify problem area patterns and poor daily progress notes. Both were requirements of the last inspection. EVIDENCE: A requirement was previously made regarding the quality assurance system failing to identify problems and produce solutions. The ongoing problem areas outlined elsewhere in this report indicate that the system is not carrying out its function and residents needs and best interests are not being met to an acceptable standard particularly surrounding stimulation and quality of life. Many care plan daily progress notes recorded residents watching television as a primary activity. In one unit providing care for older residents rap music was FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 19 being played over a sustained period of time. In another music from an earlier period was being played, whilst the television was on at the same time with residents being clustered around the room and it was unclear if the residents were watching television, listening to the music or neither. A further requirement was made regarding senior staff analysing accident and incident data. The continuing high incidences of both indicate this has not taken place. Particularly regarding falls and their prevention. A previous requirement was made regarding staff awareness of the financial procedures for managing residents’ money. This was not inspected and will be at a later inspection. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x x x 2 FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? 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 OP4 Regulation 12 & 15 Requirement The home must demonstrate how they are meeting the needs of residents with dementia.This is a repeat requirement. The daily progress notes must be improved to ensure that they fully reflect the actual care provided during each shift including residents social and leisure activities. This is a repeat requirement from two previous inspections. The high number of accidents and incidents is of concern. Staff must be more vigilant and take preventative action, for example by regularly checking if residents need assistance. This is a repeat requirement. The delivary of personal care including bathing and showering must be flexible to meet the individual needs and choices of residents. This is a repeat requirement from two previous inspections. Working locks must be fitted to all bathrooms and toilets. Staff interaction with residents within the units must be improved. This is a repeat Timescale for action 13/05/05 2. OP7 17 (1) (3) 13/05/05 3. OP8 12 (1) & (2) 13/05/05 4. OP8 12 (1), (2), (3) & 15 13/05/05 5. 6. OP10 & 19 OP12 12 (4) & 23 (2) (j) 12 (5) (b) 13/05/05 13/05/05 FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 22 7. 8. OP18 OP18 & 29 31 (1) 18 (1) (a) & Schedule (2) (7) 23 (4) (a) & Schedule 4 (14) 18 (1) (a) 18 (1) (c) (i) 12 (1) (a), 18 (1) & 21 (1) 24 9. OP19 10. 11. 12. OP27 OP30 OP27 13. OP33 & 38 14. OP38 13 (4) requirement from two previous inspections. Accidents and incidents must be notified to the CSCI. All staff must have a CRB disclosure and those awaiting clearance must not work unsupervised. Functioning electromagnetic fire doors must be fitted and fire drills describe whom was evacuated, when and areas checked. All vacant positions must be filled with permanent staff. Staff must be trained in appropriate stimulating dementia activities. The shift patterns must be reviewed, shorter shifts introduced tailored to residents needs and cycles of working long shifts over three consecutive days discontinued. The quality assurance system must be reviewed as it is currently failing to identify problems and produce solutions. This is a repeat requirement from the last inspection. The senior staff team must analyse the data collected regarding accidents and incidents and preventative action must be taken to protect residents from hazards to their safety. 13/05/05 13/05/05 13/06/05 13/08/05 13/08/05 01/07/05 01/09/05 01/09/05 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. FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 23 Refer to Standard Good Practice Recommendations FORRESTER COURT G60 - G09 S26014 FORRESTER COURT AIV216154 120505 STAGE 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26/28 Hammersmith Grove London W6 7SE 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. 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