Inspection on 30/05/06 for Foxmead

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Foxmead 20/05/08

Foxmead 21/05/07

Foxmead 29/09/05

Foxmead 08/04/05

Foxmead 12/10/04

Foxmead 12/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

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

CARE HOMES FOR OLDER PEOPLE Foxmead Foxmead Horsham Road South Holmwood Dorking Surrey RH5 4JX Lead Inspector Vera Bulbeck Unannounced Inspection 30th May 2006 10:00 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 Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Foxmead Address Foxmead Horsham Road South Holmwood Dorking Surrey RH5 4JX 01306 888053 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) Mrs Evelyn Ramdass Mrs Aisah Talip Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14) Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: Over 65 years of age 29th September 2005 Date of last inspection Brief Description of the Service: Foxmead is a Victorian property situated four miles south of the town of Dorking. It overlooks a church, and used to be the vicarage. The home provides accommodation and care for up to fourteen older people who have a past or present mental illness and/or dementia. The home has been extended and has ten single and two double bedrooms on the ground and first floor. None of the bedrooms are en-suite, however, all have a washbasin and toilet and bathing facilities are located close to all bedrooms. The first floor can be reached by the main staircase which has a chair lift fitted, however there is a break in the chair lift track on the landing between the ground and first floor. There is no shaft lift fitted. There are two large lounges and a dining room, which overlook the garden. The garden is large and well maintained and has wheelchair access via a ramp. There is ample parking to the front of the property and a regular bus service to Dorking, which stops outside the home. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection for the year April 2006 to March 2007. The site visit was over a period of eight hours and thirty minutes. For details of how each standard was met please refer to the main body of the report. The site visit was unannounced, which meant that visitors, staff and residents were not aware of the visit prior to it commencing. The inspector had the opportunity to speak with five residents who live at the home, it was difficult to maintain a conversation with the majority of residents. However, from observation the residents were relaxed with the staff on duty. A number of comment cards were left for residents and relatives to complete and requested they be returned to Commission for Social Care Inspection (CSCI). A full tour of the premises was undertaken. Three care plans were observed. There were three members of care staff and the proprietor on duty with ten residents in the home at the time of arrival. All members of staff were spoken with during the visit as well as the Community Continence Nurse. Two relatives were also spoken with. Mrs V Bulbeck, Lead Inspector for the service carried out the site visit. Mrs E Ramdass the proprietor was working in the home. The Registered Manager of the home was not present at the time of the site visit. The home is registered for fourteen places. There are currently ten residents living in the home. The staff was observed to be courteous and the atmosphere within the home was relaxed and friendly. The inspector would like to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. An improvement plan must be submitted to the Commission for Social Care Inspection (CSCI) with dates and timescales regarding the requirements made at the site visit on 30/05/06. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: 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. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 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 Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 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): 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the resident’s identified needs. The home does not offer intermediate care. EVIDENCE: At the time of the visit the inspector was informed that a resident had recently visited the home for a pre assessment this was undertaken with the residents social worker and management of the home on 24/04/06 to ensure the home is able to meet the residents needs, prior to admission to the home. The inspector was informed by the proprietor that the resident was being admitted to the home on the day of inspection 30/05/06. When the proprietor telephoned the registered manager for the information of the pre assessment, who was currently off sick, the proprietor was informed that the resident would Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 9 not be admitted to the home as arranged and the pre assessment record was not available on the day of inspection. The home does not offer intermediate care. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 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, and 10. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place but need updating. EVIDENCE: Three residents care plans were sampled and there was evidence that resident’s health, personal and social care needs had been identified and assessed. Care notes need to be in order and to be able to read appropriately, resident’s needs should relate to equality and diversity. The care manager and resident if possible or a relative should sign care plans. There is a need to ensure all care plans are up to date and information should be contained in one folder. All care plans should hold relevant details as stated in the Care Homes for Older People National Minimum Standards and the Care Homes Regulations, Schedule 3. A number of risk assessments need to be updated for all residents living in the home. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 11 There is only one commode in the home which is kept in the garage and when inspected it was buried under items stored on top and it did not appear like it was used very often. The proprietor informed the inspector that it is only used for one resident; however, it would be difficult to carry up stairs for the residents living on the first floor. The inspector would advise the management of the home that a commode should be kept on the first floor, with ten residents living in the home and registered for fourteen persons it would be advisable to purchase another commode. There are no residents who are able to self medicate. Medication records were found to be well documented. Storage facilities were appropriate. Medication is administered from blister packs and two members of staff are involved. All staff has undertaken medication training. The residents spoken to confirmed that staff are respectful and knock on the door before entering. Observation by the inspector was residents and staff have a good rapport, residents are able to discuss with the staff any worries they may have and staff reassure residents, by supporting, explaining, and helping to clarify any problems and to ensure residents have a clear understanding. The inspector was able to speak with a Community Continence Nurse who was in the home on the day of the site visit. The Community Nurse was explaining to a member of staff regarding the care required for changing a residents dressing. The Community Continence Nurse has arranged to go back to the home to train all the staff on 14/06/06. Management of the home must ensure that a member of staff is available to be present when requested by the community nurses. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 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 and 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to maintain contact with family and friends. Meals are well balanced and varied with individual choices and preferences as well as special dietary needs catered for. EVIDENCE: The Majority of residents have contact with family and friends. The inspector advised the home to contact Age Concern regarding obtaining an Advocate for the residents without family contact. The meals served in the home were nutritional in content and well balanced. The staff and residents are involved with the menu planning and the home has a cook who undertakes the cooking duties four days a week, and staff undertake the cooking on the other days. One resident confirmed the food is very good, and a relative also stated the food is always very good, however, he had observed the food being served but had not tasted it. The inspector would advise the home to contact the G.P surgery for advice on obtaining the services of a dietician. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 13 On the day of the site visit there was very little milk for ten residents, the inspector was informed that the milkman would be delivering milk in the afternoon. At the time of leaving the home 18.25 the inspector went to check on the milk availability and was informed the milkman had not delivered the milk. There was very little milk left for the suppertime and certainly not enough for a milk drink if required. The inspector was informed that the home would use the 2 litre frozen bottle in the freezer. This would take a considerable time to defrost. There is a planned activity programme twice monthly. An in house activity programme is organised by the staff and during the afternoon, time permitting staff spend time with the residents. The residents seem to spend a lot of their time watching television. The local Church of England Vicar visits the home every third Wednesday of the month and conducts Holy Communion and a service for all residents who wish to attend. Every Friday morning the Roman Catholic Priest visits the home to conduct a service. Every Sunday nine residents attend the church next door to the home for the morning service. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 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 and 18. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure, which includes timescales for the process. All required policies and procedures are in place to ensure that residents are safeguarded from harm or abuse. EVIDENCE: There have been no recorded complaints in the home since the last inspection. However, the proprietor stated there was one complaint received in the home while she was on holiday. The details and the action taken were not available. The home has developed its complaints procedure and has incorporated details of the Commission for Social Care Inspection. The inspector was informed all relatives have been provided with a copy of the complaints procedure. A copy of the complaints procedure was seen on the notice board in the hallway of the home. A relative commented that if she had any problems or complaints she would speak with the manager to discuss what action would be taken. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and the majority of staff except a new member of staff has received the protection of vulnerable adults training. Staff on duty confirmed they had undertaken this training and were aware of the procedures. The home has a copy of Surrey Multi Agency procedures. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the residents with clean, pleasant and homely surroundings in which to live. EVIDENCE: The home was found to be clean and tidy, the staff undertakes the cleaning duties on a daily basis. Some of the residents like to be involved with the cleaning in their bedrooms. It was noted that a number of areas around the home are in need of attention. The furniture in the majority of resident’s bedrooms need to be secured, as the furniture was very unsteady and has the potential for tipping over. A shelf under the washbasin in bedroom 5 needs repairing. The locks on bedroom doors need to be changed to a device that has a two-way lock, in the event of an emergency staff are able to access bedrooms. Any resident who is unable Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 16 to hold key, full details should be included in the care plan of the reasons of not holding a key to their bedroom. Several call bells were not working and some bedrooms were without a lead to the call bell, these must be in working order and all residents should have a call bell to use in an emergency. A number of radiators are without covers in the communal areas and need to be fitted with appropriate covers unless radiators are of low surface temperature. The pink bathroom needs to be refurbished and to include a hoist, this area has been ongoing for some considerable time and now needs to be completed. The washing machine needs to be changed and should have a sluicing facility. The roof has been leaking, an estimate has been obtained and is currently waiting for the approval of work to commence by the insurance company. The maintenance book needs to be kept up to date the last entry recorded was dated 14/06/05 which stated “tap needs repairing” there was no record of this work being completed and on the day of inspection it was noted that the hot water tap in the kitchen was leaking. The garden is well maintained and secluded and accessible for residents to use. The garden has a tennis court and swimming pool; the pool has been fenced off for security reason and is not currently used. However, on the day of the site visit the gate to the swimming pool area was un locked and the pool had a considerable amount of water in it, this is a potential health and safety hazard and for the safety of the residents the gate must be locked at all times. The inspector would advise management of the home to review the safety precautions regarding the swimming pool. The outside of the home needs painting and some windows and doors need replacing. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff needs to be reviewed to ensure resident’s needs are met. The home needs to ensure a comprehensive staff recruitment and training programme which incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. EVIDENCE: There are three care staff on duty during most shifts and the cook as well as management of the home. However, at times there is only three care staff on duty, on Thursdays and weekends when the cook does not work, therefore the care staff undertake the domestic duties and the cooking. Management need to review the staffing levels between the days specified and ensure there are adequate staff on duty to care for residents and undertake the domestic and cooking duties. Full recruitment procedures need to be followed. All staff need to be checked against the Criminal Records Bureau (CRB) before working in the home, and all staff should be POVA checked. All staff including agency staff should have records to include details of recruitment and a CRB from the agency to ensure residents are safe at all times. Staff recruitment files need to contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 18 The rota for the previous week was not available when requested, however, after some time it was located with the registered manager who was currently off sick and the manager was able to fax the rota to the home. The rota indicated that at weekends an agency member of staff is employed, Mrs Ramdass the proprietor informed the inspector that she is living in the home and is able to keep an eye on the home at weekends when the manager is normally not working. However, the proprietor stated she was not aware of the staff employed at weekends by the agency. It was not clear if the proprietor was in the home over the weekend or if she was staying in her own home away from the premises. Training has been ongoing and certificates for training were seen in the stafftraining file. The majority of staff has attended a number of training courses. All new staff has a comprehensive induction-training programme. All staff has received (POVA) protection of vulnerable adults training, except a new member of staff. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All policies, procedures and practices are in place, but some need updating to ensure, so far as is reasonably practicable, the welfare, health and safety of residents and staff. EVIDENCE: On the day of the site visit the registered manager was off sick and the proprietor was managing the home. The inspector advised the proprietor to consider employing a manager from an agency to manage the home if the registered manager was going to be off sick for longer than one month. The proprietor was not able to locate various records and was not able to provide information without contacting the registered manager by telephone. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 20 There are several areas that require attention, the management of the home needs to complete a fire risk assessment on the whole home and to implement a contingency plan in the event of an emergency. The food stored in the freezers need to organised in some order to ensure food is used in date order. All food stored in the freezers needs to be sealed and dated. The freezers need to be temperature tested daily and a record maintained. One of the freezers was without a cover for the light inside the chest. All accidents and incidents must be contained in the resident’s notes and CSCI must be contacted with the details for all significant events. It was noted that a resident had a fall and an ambulance had been called and CSCI had not been notified. Another resident had a fall, which CSCI should have been notified. All policies and procedures need to be updated and risk assessments need to be reviewed and dated on a regular basis. Management is not involved with resident’s finances; the majority of residents have a family member or an appointed person who manages their finances. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT And ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 2 3 4 5 6 7 8 9 10 11 12 Standard OP16 OP19 OP19 OP19 OP19 OP19 OP19 OP19 OP19 OP19 OP19 OP19 Regulation 17 23 23 23 13 16 16 16 13 23 23 23 Requirement Complaints need to be recorded and action taken needs to be documented. Call bells must be in working order. The leaking roof must be attended to. All radiators must have a protective cover or should be low surface temperature controlled. All communal areas must have paper towels. The pink bathroom needs attention and should be fitted with a hoist. Two way locks to be fitted on residents bedroom doors. Furniture in resident’s bedrooms needs to be secured. The garden gate leading to the swimming pool must be kept locked at all times. The outside of the house needs painting and some windows and doors need replacing. The hot water tap in the kitchen needs attention. The shelf under the washbasin in room 5 needs repairing. DS0000013645.V294745.R01.S.doc Timescale for action 30/06/06 23/06/06 14/08/06 31/08/06 30/06/06 28/07/06 28/07/06 30/06/06 30/05/06 29/09/06 23/06/06 30/06/06 Foxmead Version 5.1 Page 23 13 14 OP26 OP27 13 18 15 16 OP29 OP29 18 18 17 OP29 18 18 19 20 21 22 23 OP29 OP31 OP38 OP38 OP38 OP38 18 17 17 16 16 16 24 25 26 27 OP38 OP38 OP38 OP38 16 13 13 24 28 Foxmead OP38 17 The washing machine in the laundry needs to be a sluicing model. Staffing levels to be increased at weekends and days when cooking and cleaning duties are undertaken by the care staff. Staff recruitment procedures must be followed as detailed in Schedule 2. The management must ensure all agency staff must have details of the worker supplied by the agency. All staff must be Pova checked and all staff must have a completed CRB before working in the home. All staff to be provided with a copy of the General Social Council and Care document. All appropriate accidents and incidents must be sent to the CSCI. All policies and procedures need to be reviewed and updated on a regular basis. All fridges and freezers need to be temperature tested daily. A light cover in one of the chest freezer needs replacing. Food stored in both chest freezers needs to be in some order to ensure food is not out of date. All food stored in the freezers must be sealed and dated. A fire risk assessment on the whole house to be completed. To produce and emergency contingency plan. The management duties to be covered by an agency manager if the registered manager is to be on sick leave for more than one month. All records to be available in the DS0000013645.V294745.R01.S.doc 14/07/06 23/06/06 23/06/06 23/06/06 30/05/06 14/07/06 23/06/06 14/07/06 30/05/06 23/06/06 30/05/06 30/05/06 30/06/06 30/06/06 30/06/06 30/05/06 Page 24 Version 5.1 home for inspection purposes at all times. 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 3 4 5 6 7 Refer to Standard OP7 OP7 OP12 OP15 OP19 OP31 OP38 Good Practice Recommendations Accident records need to be transferred to residents file. Care Plans need to be updated and informative regarding health care needs and to contain equality and diversity. To consider purchasing another commode for the first floor. To contact G.P surgery regarding a dietician. The maintenance book needs to be kept up to date. The registered manager to write to CSCI regarding changing her name of the certificate of registration. The management of the home to consider a dishwasher. Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Foxmead DS0000013645.V294745.R01.S.doc Version 5.1 Page 26 - 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!