Inspection on 14/08/07 for Friary Lodge

This inspection was carried out on 14th August 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

Friary Lodge 22/08/06

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

CARE HOMES FOR OLDER PEOPLE Friary Lodge 177 Friern Barnet Lane Whetstone London N20 0NN Lead Inspector Mr David Hastings Key Unannounced Inspection 09:30 14th August 2007 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 Friary Lodge DS0000066206.V341761.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. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friary Lodge Address 177 Friern Barnet Lane Whetstone London N20 0NN 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) 020 8445 4756 020 8445 4756 Mrs Fidelma Joan Walsh Mr Kevin John Walsh Mrs Fidelma Joan Walsh Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 Brief Description of the Service: Friary Lodge is a registered care home for fifteen older service users. The home is privately owned with the newly registered manager also being the registered provider jointly with her husband. The last manager/provider has retired and the new manager/provider took over the running of the home in February 2006 after an induction/handover period of three months. The home is a large converted three storey domestic premises that includes a ground floor annexe. The communal facilities are on the ground floor and include a large lounge with adjoining conservatory, dining room and kitchen. The laundry and managers office are also located on the ground floor. There are nine single service user bedrooms: five on the ground floor, two with ensuite; one on the first floor and three on the second floor, one of the latter with en-suite. There are an additional five shower or bathrooms with WCs and a single WC, spread throughout the home and convenient to service user bedrooms. There is a stair lift to facilitate access to the first and second floors although the home can only accommodate wheelchair users on the ground floor. The home has a large well-kept rear garden that service users can enjoy when they wish. The home is well served by public transport and is situated in a pleasant residential area of Whetstone and is close to Friary Park, local shops and other community services. The stated overall aim of the home is to enable elderly people to lead dignified, independent and fulfilled lives in safety and comfort; also in varying degrees for those who need it, daily help with personal care. The current scale of charges range from £480 to £520 per week. A copy of this report is available on the CSCI website or/and from the home. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 14th August 2007 and lasted six hours. I was assisted throughout the inspection by the registered manager who was open and helpful. I spoke with four staff and eight residents of the home. I inspected the building and examined various care records as well as a number of policies and procedures. The registered manager returned the Annual Quality Assurance assessment to the CSCI prior to the inspection. This self-assessment had been completed by the registered manager and outlines how well the home is doing to improve the quality of care provided at Friary Lodge. All of the residents I spoke with said they were very happy with the care and support they received. One resident told me the staff were, “Very good”. What the service does well: What has improved since the last inspection? What they could do better: Record keeping is an issue that needs to be addressed. Records in relation to pre assessments, care planning, risk assessments and training are not satisfactory and are, in some cases, putting residents at unnecessary risk. Five requirements have been restated from the last inspection relating to care planning, staff training and quality assurance. Staff must be trained appropriately in areas such as moving and handling so that residents can be supported safely at the home. All residents must have a written plan of care that includes appropriate risk assessments so that staff know how best to support people using the service. Seven new requirements have been issued as a result of this inspection. Potential residents to the home must have their needs assessed before they move in so they know the home will be able to Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 6 look after them properly. The manager and staff must assess if people are at risk from falling or harming themselves and steps must be taken to reduce these risks. It is also important to review the risk assessments. People with problems swallowing need to have their meals liquidised appropriately and with regard to the presentation of these meals. Current staffing levels at the home must be reviewed as staff appeared very busy in the morning and had little time to spend with residents. The CSCI has requested an improvement plan from the registered manager in order to monitor how the requirements of this and past inspections will be complied with. 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. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 not applicable) People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The “Service User Guide” has been updated to reflect the diverse nature of the local community. People are not having their needs properly assessed before they move into the home so they are uncertain if the home can meet their needs. EVIDENCE: At the last inspection a recommendation was made that the manager review the “service user guide” to ensure that it clearly sets out the home’s policy on equality and diversity. I looked at the updated guide and it does now contain reference to how the home encourages residents from different backgrounds and lifestyles. This should ensure that potential residents from different backgrounds feel their needs will be met by the home. Three people have moved into the home since the last inspection. One pre admission assessment, completed by the local authority, was examined as well Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 9 as an additional assessment carried out by the manager. The pre assessment developed by the home will need to be reviewed as not all the requirements from Standard 3.3 and included in it. The manager told me she had completed one pre assessment for one person but was unable to locate this. One person had moved into the home after a period of respite. No assessment was available for this person. This is not satisfactory, as assessments of people’s needs must be completed before the person moves in on a trial basis. These assessments should ensure that the home and the potential resident know the home will be able to meet all their personal, emotional and social needs. Two requirements have been issued relating to the assessment of potential residents to the home. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. The quality of care planning at the home is not satisfactory and is putting people at risk. EVIDENCE: Only one of the three recent people to move into the home had a written plan of care. This means that staff do not have any written information about how best to care for these residents. Risk assessments were also not being carried out for all new residents. This puts people at risk. I looked at three care plans of residents who have been at the home for some time. These plans were not being updated so that staff did not know about any potential changes to the person’s needs. This is a breach of the Care Homes Regulations 2001 and if this situation is not resolved could lead to enforcement action being taken by Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 11 the CSCI. Normally this outcome group would be considered poor however residents that I spoke with said they were happy with the way staff supported them and that they were well looked after. As such this outcome group has been judged as adequate. A requirement relating to care plans which was restated at the last inspection has been restated again. The manager assured me that she would deal with this issue as a matter of urgency and the timescales set for action reflect this. A new requirement has been issued relating to risk assessments. From records and discussions with the manager it was evident that people have been supported to access health care. The manager confirmed that a general practitioner visits every week and that a chiropodist, dentist and an optician come to the home as and when needed. One person at the home has a pressure sore, which is being treated by the district nurses. Residents told me that their health care needs were being met by the home. Satisfactory and accurate records were examined in relation to the receipt, administration and disposal of medication. Medication was being stored appropriately and the temperature of the medication storage area was being monitored and recorded. Only those staff who have completed the medication training are permitted to administer medication. A satisfactory risk assessment was seen in regard to one resident who selfadministers her own medication. Throughout the inspection I saw examples of staff treating people with respect and upholding residents’ privacy. For example staff were seen to be knocking on people’s doors before going in. People I spoke with confirmed that they were treated with dignity and staff upheld their need for privacy. Staff I interviewed were able to give practical examples of when they have upheld peoples’ privacy. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can choose from a range of activities at the home and are kept suitably occupied and engaged. Visitors to the home are made to feel welcome and can visit at any reasonable time. Residents are helped to exercise choice and control over their lives. The food provided is of very good quality and mealtimes are relaxed and enjoyable. EVIDENCE: People who use the service told me that they were generally satisfied with the activities on offer at the home. They told me they enjoyed talking with the manager and staff, watching television, reading and playing games. During the morning of the inspection I observed that staff were very busy with the personal care needs of residents and did not appear to have much time to carry out activities. The manager told me that an entertainer is booked every two to three months and that she encourages residents to go out of the home to pursue outside interests. Staff were able to give me examples of how they keep residents suitably occupied and engaged but acknowledged that time was Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 13 an issue. A requirement relating to staffing levels has been issued under the staffing section of this report. The record of visitors indicated that residents could have visitors at any reasonable time. A visitor I spoke with said she was always made welcome when she visited. Residents I spoke with confirmed that visitors were welcomed. Residents confirmed that they were able to have choice and control over their lives at the home. Residents told me they could do what they liked and were not told what to do. Staff I interviewed were able to give examples of how they ensure people are able to exercise choice and control within their daily routines. The kitchen was inspected. The cook on the day of the inspection was aware of individual’s likes and dislikes as well as any special diets people may require. The kitchen was clean and there was a good selection of fresh food. People I spoke with were positive about the food provided by the home and confirmed that a choice of menu was always available. One resident told me, “The food is very good. Its wholesome, nutritious and well cooked”. Lunchtime was a relaxed and enjoyable experience. I saw that the cook was making a homemade quiche for supper. I did notice that where residents required their food to be liquidised that the meal was being liquidised as a whole and not into separate parts. The meals for people with swallowing problems looked unappetising. A requirement that food be liquidised separately has been issued in the relevant section of this report. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Residents are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. No complaints have been received by the home since the last inspection. All the residents I spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. Staff were able to describe to me how vulnerable people could be at risk of abuse in a residential care setting. All staff were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that I spoke to said they felt safe and well supported at the home. Records indicated that most staff have undertaken training in the protection of vulnerable people. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is safe and cleaned and maintained to a good standard. EVIDENCE: I toured the building with the manager and visited a number of residents’ rooms. The building is well maintained and decorated to a good standard. The manager told me about her plans to convert the shower room on the ground floor to a “wet room” which would mean better access for people with physical disabilities. There is a chair lift to all floors of the home. All toilets had anti-bacterial soap and paper hand towels available. The laundry is situated outside the main building and has the required sluicing function for soiled laundry. Residents I spoke with said the home was always clean and there were no offensive odours detected throughout the home. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home work hard to meet the needs of the people living there. People’s needs appear to be increasing and the existing staffing levels need to be reviewed to reflect this. Staff do not receive the training required to fully meet the needs of the people living at the home. EVIDENCE: Information from the Annual Quality Assurance assessment, completed by the registered manager, indicated that the dependency levels of residents at the home has increased. During the inspection I observed that staff were very busy during the morning shift and some residents I spoke with confirmed that staff were very busy at times. I discussed this issue with the manager who told me that she was considering increasing staff numbers in the mornings. Currently there are two care staff on duty throughout the day supporting thirteen residents. There is one waking night staff and one care staff sleeps in to provide assistance when needed. In light of the increased complexity of care needs of residents a requirement has been issued that staffing levels are reviewed and staffing is increased where necessary. People who live at the home were very positive about the staff team. One resident told me, “They are my family”. Another person said that the staff were, “Excellent”, “Very helpful”, and also commented, “They do try”. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 17 Staff files examined indicated that an appropriate recruitment process had been followed including the completion of application forms, interviews, taking up of references and pursuing Criminal Records Bureau checks. Staff files also included photo identity and evidence of training certificates gained. A requirement was restated at the last inspection that a training and development plan is produced for all staff working at the home. This has still not been complied with and makes it very difficult to judge whether staff are receiving the appropriate training. Another requirement was restated at the last inspection regarding health and safety training for staff. Records indicated that some staff have completed this training. It was difficult to assess how many of the staff require mandatory training including manual handling and the manager was not able to provide conclusive evidence of the training. Untrained staff put both themselves and residents at risk. These requirements have been restated with reduced timescales. At the last inspection it was found that over 50 of staff have completed their NVQ level 2 training. However since that inspection a number of qualified staff have left the home and the manager told me that she was trying to obtain funding for NVQ training for the existing staff team. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents, relatives and staff were very positive regarding the manager of the home. More work needs to be undertaken by the registered manager and provider to monitor quality assurance at the home to fully meet this standard. Residents’ financial interests are safeguarded by satisfactory policies and procedures. Generally the health, safety and welfare of residents and staff are promoted. However all staff need the appropriate health and safety training in order fully protect residents from unnecessary risks. EVIDENCE: Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 19 The registered manager is a qualified RMN. Comments received from relatives, staff and service users were very positive regarding the manager of the home. It was clear that the manager has taken the time to understand the needs of all the service users and how these needs are to be met. The manager must ensure that management issues such as recording and developing care plans and providing staff training are also undertaken. Two requirements were issued at the last inspection relating to quality assurance. These requirements have not been complied with and are restated. This is a shame, as the residents of the home appear very positive about the care they receive. Comments from the visitors’ book were also very positive about the home. One person told me she thought Friary Lodge was, “one of the best homes in the area”. The home does not usually hold money on behalf of residents. The manager invoices residents or their representatives approximately every three months. Invoices were seen and the manager was able show receipts, which matched the amounts on the invoices. A requirement was issued at the last inspection for a radiator on the ground floor to be covered. This requirement has now been complied with. The monitoring of fire safety has improved considerably since the last key inspection. The home was inspected by the local fire officer and no major issues were highlighted as a result of the inspection. Satisfactory health and safety records were examined in relation to fire safety, gas safety, electrical safety and Legionella control. The manager has ensured that there are appropriate maintenance contracts in place to ensure the safety of equipment at the home. Health and safety training for staff was discussed with the manager who agreed this must be a priority. The manager informed me that food hygiene training has been booked for September of this year. Staff have undertaken infection control training. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 21 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 OP7 Regulation 15(1) Requirement The registered manager must ensure that care plans are developed to incorporate all the identified needs of service users, including social and emotional needs, and that these plans give clear information to staff on how these needs are to be met. (Timescale of 01/12/06 and 01/04/07 not met) This requirement is restated. 2. OP30 18(1) c The registered manager must ensure that a training and development plan is developed for all staff at the home and is available for inspection. A copy of this must be sent to the CSCI. (Timescale of 01/12/06 and 01/05/07 not met) This requirement is restated. 01/09/07 Timescale for action 01/09/07 Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 22 3. OP30 18(1) c The registered manager must ensure that all staff receive the mandatory training, including health and safety training, required for working at the care home. (Timescale of 01/12/06 and 01/05/07 not met) This requirement is restated. 20/09/07 4. OP33 24(3) The registered manager must 01/11/07 ensure that effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place covering the elements of Standard 33 of the National Minimum Standards for Older People. (Timescale of 01/12/06 and 01/05/07 not met) This requirement is restated. 5. OP33 24(3) The registered manager must ensure that all service users’ meetings are recorded and include action taken by the management of the home as a result of service user’s comments. (Timescale of 01/11/06 and 01/04/07 not met) This requirement is restated. 01/09/07 6. OP3 14(1) 01/09/07 The registered manager must ensure that all potential residents to the home have a full assessment of their needs undertaken before they decide to move into the home on a trial basis. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 23 7. OP3 14(1) The registered manager must ensure that the home’s initial assessment document covers all elements of Standard 3.3 of the National Minimum Standards. A copy of the revised form must be sent to the CSCI. 01/10/07 8. OP7 13(4) The registered manager must ensure that risk assessments are carried out for all residents. These assessments must clearly detail the identified risks and what action is required to minimise these risks. The risk assessments must be dated and reviewed regularly. 01/09/07 9. OP15 16(2) i The registered manager must ensure that where residents with swallowing problems need their food liquidised that their meal is liquidised into separate components. 01/09/07 10 OP27 18(1) a The registered manager must ensure that a review of staffing levels at the home is undertaken and staffing numbers increased as and where necessary. A copy of this review must be sent to the CSCI. 01/09/07 11. OP28 18(1) c The registered manager must ensure written confirmation is provided to the CSCI of when it is expected that 50 of the staff team have completed NVQ level 2 or equivalent. 01/09/07 Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 24 12. OP38 18(1) c The registered manager must ensure that a list of all staff is sent to the CSCI with dates that they have undertaken training in manual handling, infection control, COSSHH, Protection of vulnerable adults, food hygiene, fire safety and first aid. Where staff have not yet received this training dates must be supplied of when this training has been booked. 01/10/07 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. Refer to Standard OP30 Good Practice Recommendations The manager should develop a training overview for all staff at the home to better highlight training needs. Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Friary Lodge DS0000066206.V341761.R01.S.doc Version 5.2 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!