Inspection on 18/07/07 for Goffs Park Nursing Home

This inspection was carried out on 18th July 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 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

Goffs Park Nursing Home 03/01/07

Goffs Park Nursing Home 25/05/06

Goffs Park Nursing Home 03/10/05

Goffs Park Nursing Home 01/06/05

Goffs Park Nursing Home 16/11/04

Goffs Park Nursing Home 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Goffs Park Nursing Home 39 Goffs Park Road Crawley West Sussex RH11 8AX Lead Inspector Mr E McLeod Unannounced Inspection 09:30 18th July 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 DS0000024146.V341556.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. DS0000024146.V341556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goffs Park Nursing Home Address 39 Goffs Park Road Crawley West Sussex RH11 8AX 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) 01293 524942 01293 539506 www.goffsparknursinghome.co.uk Goffs Park Care Homes Limited ****Post Vacant**** Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (37) of places DS0000024146.V341556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 37 persons in the category OP (Old age not falling within any other category) to be accommodated at any one time 3rd January 2007 Date of last inspection Brief Description of the Service: Goffs Park is a care home, which is registered for up to 39 people aged 65 years and over. It provides nursing care. The care home is a converted large detached house, situated in a residential area of Crawley, close to the town centre. Accommodation is provided on 3 floors, which can be accessed using a passenger lift. There are 27 single and 4 double rooms. 1 of the double bedrooms on the third floor was being used as a communal lounge, in order to provide additional lounge space for the residents. There is one other medium sized lounge on the ground floor. There are large, well kept grounds which are accessible to residents in suitable weather. Fees are £520 to £650 per week. DS0000024146.V341556.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the care home is doing in meeting the key National Minimum Standards (NMS) and the Care Home Regulations 2001. The findings of this report are based on several different sources of evidence. Two inspectors undertook the inspection visit on the 18th July 2007, which lasted for approximately six hours. The second inspector was Mrs June Hough. It is our experience that people living in residential care do no wish to be referred to as “service users”, and prefer terms such as “people” or less commonly “residents”, and therefore the rest of the report shall reflect this. The Commission received an Annual Quality Assurance Assessment (AQAA) from the service prior to this. The AQAA provided further evidence of how the home is meeting the Key National Minimum Standards. The Commission for Social Care Inspection (CSCI) sent feedback forms to people living at Goffs Park prior to this site visit and comments from these forms are reflected in this report. We interviewed six people living at Goffs Park, and two visiting relatives. We also interviewed the manager, the operations manager, three members of care staff and the cook. The inspectors met residents in communal areas and in their bedrooms. We also observed interactions between staff and residents, and were present during the serving of lunch. Five sets of care plans were sampled, together with other records including accident reports, complaints records, and staff recruitment and training records. What the service does well: The home is well managed, and has an experienced and hard working staff team. The numbers of permanent staff employed ensure there has been no need to employ temporary staff, therefore providing more consistency for people living at Goffs Park. DS0000024146.V341556.R01.S.doc Version 5.2 Page 6 People are being supported to access the health care support they are in need of. Each person has a care plan which provides the basis for the care to be provided and has been agreed with them. What has improved since the last inspection? What they could do better: The home needs to ensure that medication administration is recorded consistently and that arrangements for giving medicines ensure safety. It is recommended that the individual’s care plan includes an activities plan to ensure the person’s interests and social needs are recorded and supported. The home needs to provide bathrooms and shower rooms of a standard suitable to meet the needs of the people living at Goffs Park. People in the home would have better conditions in which to eat and a better opportunity to socialise if a suitable dining area was to be provided. The provider needs to ensure that sufficient numbers of care staff are achieving the national vocational qualification (NVQ) or equivalent in care at least at level 2 in order to help maintain standards of care provided. DS0000024146.V341556.R01.S.doc Version 5.2 Page 7 The provider must register a manager with CSCI who is qualified, competent and experienced to run the home. 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. DS0000024146.V341556.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024146.V341556.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No person moves into the home without having had his/her needs assessed and been assured that these will be met. Intermediate care is not provided. EVIDENCE: Information on the service is provided in a brochure and on a website. Prior to admission, the person or their main carer are invited to visit the home. A pre admission assessment is carried out to ensure their care needs can be met. A trial period is agreed with the person. DS0000024146.V341556.R01.S.doc Version 5.2 Page 10 CSCI survey forms were received back from nine people living at Goffs Park, some of whom had been assisted to complete the form by relatives or staff. All people responding said that they had a contract with the home, and had received enough information to help them make their decision. Five sets of pre-admission assessments were sampled. It was found that the individual’s needs are being assessed prior to admission, and this information contributes towards the plan of care which is developed with the person. Specialist intermediate care is not being provided. DS0000024146.V341556.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual plan of care drawn up with each person is providing the basis for the care to be delivered. People are accessing the health care services they are in need of. The home needs to ensure that medication administration is recorded consistently and that arrangements for giving medicines ensure safety for the people at Goffs Park. People living at Goffs Park feel they are treated with respect and that their right to privacy is upheld. EVIDENCE: DS0000024146.V341556.R01.S.doc Version 5.2 Page 12 The managers have told us that improvements to the service include people accommodated and their relatives being more involved in developing the care plan, and that reviews of the care plan are discussed with the person. We were told that care plans and risk assessments are being updated regularly. Information received from the managers in their annual quality assessment indicates that most admissions to the service are planned, and that most residents have active family or advocate support. The six care plans sampled by the inspectors indicated that people living at Goffs Park have an individual plan of care which is being regularly reviewed. Records of healthcare treatment and risk assessments are also provided for each person. Care plans sampled were sometimes including specific guidelines for staff on, for example, how the person should be assisted with transfers. Care plans are often also being signed by the person the care is being provided for. People living at Goffs Park who responded to our survey said they received the care and support they needed, and that staff listen to them and act on their wishes. Care records seen indicated that people living at Goffs Park are being supported to access the health care they are in need of, including specialist health care. Managers at Goffs Park believe that the care and treatment of pressure areas has been improved in the home. The acting manager said that he had been requesting medication reviews for people who had not had their medicines reviewed for a while. The pharmacy who now provide medicines for the home supply a blister pack system, which allows staff to more easily check if medicines have been given or not. We carried out some checks on medicines stored and administered, and on medication records. Suitable arrangements are in place for the safe storage of medicines. DS0000024146.V341556.R01.S.doc Version 5.2 Page 13 Some handwritten medication charts seen were not dated and signed by staff completing them, and no stock numbers recorded. The managers also need to give attention to the length of time that is taken to complete the morning medication round to ensure that all people receive their medication at the prescribed time. It was our observation on the day of the inspection that arrangements for health and personal care were ensuring that people’s privacy and dignity were being respected. DS0000024146.V341556.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given the opportunity to exercise choice in relation to leisure and social activities, and meals. It is recommended that the individual’s care plan includes an activities plan to ensure the person’s interests and social needs are recorded and supported. People maintain contact with family and friends and the local community as they wish. EVIDENCE: The managers have told us that more activities are being arranged, and after requests from people an increased number of television channels are available in the main lounge. Escorts are provided for residents going out to activities in the community, and where this is a regular event it is included in the home’s activity plan. DS0000024146.V341556.R01.S.doc Version 5.2 Page 15 Activities provided include arts and crafts once per week, and a musician once per week. On the afternoon of the inspection, arts and crafts were taking place in the sitting room. The weekly programme of activities undertaken by staff includes bingo, card games, and discussions. One to one activities undertaken with named residents include dominoes, manicure, and hand massage. People we interviewed who tend to keep to their rooms said they were unaware of any activities taking place in the home. None of the care plans seen included an activities plan for the individual resident. Some improvement to care plans could be made by including in the plan more of the views of the person living at Goffs Park on how they wish their care to be provided and what social support or activities they would like. Relatives we talked to said they always felt very welcomed when they visited. One person responding to our survey added however that there was sometimes a lack of chairs that visitors could use. The managers told us that the menus have been changed according to residents’ wishes and requirements, that each person is given a choice of menus for the day, and their likes and dislikes are taken into account. We were also advised that a nutritional risk assessment is in place for all residents. The cook on the day of the visit told us that the main cook asks people their likes and dislikes, though this not written down anywhere in the kitchen. There is a kitchen record of who receives a soft diet food. The cook said that if a person doesn’t want the main choice, they have an alternative they like cooked for them. The cook gave the example of one man who doesn’t like shepherd’s pie, so usually has ham and mash instead. Many residents we spoke to or who had returned our survey to us thought the food was good. There were some individual remarks made about how the food could be improved, such as less blandness, more fresh fruit, more choice of desserts for people on a soft food diet, and a more substantial evening meal. DS0000024146.V341556.R01.S.doc Version 5.2 Page 16 During lunch, staff were seen to be helping residents with cutting up and eating food where needed, and this was being done in a calm and unhurried way. There is no dining area in the home. At present people either eat in their rooms or in armchairs in the sitting room. On the day of the visit during lunch the television continued to be on while people were eating, It was the view of the inspectors that residents should have the choice of sitting at a dining table for meals if they wished. Managers advised us that an extension is planned to develop a dining area, but no date is set for this to be commenced as yet. As meals are an important opportunity for social interaction for people in residential care, the provider needs to consider how this could be achieved while plans are being made for an extension. CSCI first made it a requirement that a dining room area be provided in June 2005. The provider must now ensure that this matter is addressed. The repeated failure to meet a requirement will result in the Commission considering what appropriate action will be taken. DS0000024146.V341556.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Goffs Park and their relatives and friends are confident that their complaints will be listened to, taken seriously, and acted upon. People are being protected from abuse. EVIDENCE: We looked at the record of complaints. No complaints have been recorded since the previous inspection. People living in the home responding to our survey said they were aware of the home’s complaints procedure, and who to complain to. Managers told us that no safeguarding adults referrals had been made. Staff training records seen indicated staff are receiving training in safeguarding adults. DS0000024146.V341556.R01.S.doc Version 5.2 Page 18 Managers of the home need to ensure that they attend briefings or trainings to update them on changes to local safeguarding adults procedures so that they are aware of the process undertaken when a safeguarding adults referral is made. These briefings, provided by the local authority, also help clarify the role of the home’s management in this process. DS0000024146.V341556.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a safe, well maintained environment, which is benefiting from a programme of improvement. The home needs to provide bath rooms and shower rooms of a standard suitable to meet the needs of the people living at Goffs Park. People in the home would have better conditions in which to eat and a better opportunity to socialise if a suitable dining area was to be provided. EVIDENCE: DS0000024146.V341556.R01.S.doc Version 5.2 Page 20 Improvements to the premises since the previous inspection include the decoration and re-carpeting of some bedrooms, which have been done to a good standard. The home has also purchased new electric beds, pressure relieving mattresses, wheelchairs and commodes. Managers said that plans for improvement include the provision of a dining area and a sun lounge. The garden is accessible and is being well maintained. The maintenance book was sampled, and the inspector discussed with the acting manager that it was not always clear from the records when and if a job has been completed, and what follow up there was if the job had not been completed. Bedrooms visited were in good decorative order, especially where recent decoration and re-carpeting had taken place. It was noted that people had personalised their bedrooms and brought furniture that they wished to bring. Bathrooms seen were institutional in appearance and in need of redecoration and refurbishment, and managers said that this was recognised. Managers advised that the plan was to convert some bath areas into level access showers. The inspectors suggested that people living at Goffs Park should continue to have a choice in whether they have a bath or a shower. All areas of the home visited were clean and fresh. One person responding to our survey said “they have two cleaners and they work hard to keep the home fresh and clean”. DS0000024146.V341556.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing numbers and skill mix of staff are meeting the needs of people living in the home. The provider needs to ensure that sufficient numbers of care staff are achieving the national vocational qualification (NVQ) or equivalent in care at least at level 2 in order to help maintain standards of care provided. People living in the home are supported and protected by the home’s recruitment policy and practices. Staff training is helping ensure that staff are competent to do their jobs. EVIDENCE: The managers told us that a new member of staff is employed only after required checks and references have been received. Managers told us that care provision has been improved by nurses’ prioritising care tasks rather than non nursing activities. DS0000024146.V341556.R01.S.doc Version 5.2 Page 22 By maintaining a full complement of staff, the home is able to ensure that no agency staff need to be called upon, and therefore a consistent level of care for residents is being maintained. It was our observation on the day of our visit that people were receiving the care support they needed, and people living in the home that we spoke to took a similar view. Staff were very busy both during the morning in providing care, and in providing support with meals at lunch time. People living at Goffs Park also told us that care staff were busy and hard working. On the morning of the visit, no activities were being offered by the home. Were the home to be advised by people that they would like this, it was our assessment that present staffing levels would not be able to cover this. Recent staff training has included manual handling, infection control, food hygiene, and fire safety. Training records seen indicate that training in required topics is being provided by staff. Managers advised the inspectors on the day of the visit that two staff have attained the National Vocational Qualification (NVQ) in care at least at level 2, and that 7 care staff are due to commence NVQ training in September 2007. This indicates that the national minimum standard for numbers of staff to be trained to NVQ level 2 or equivalent is not being met. An induction programme is in place for new staff, and one of the staff we interviewed was spending their first day on induction training, which included shadowing another carer for one week. Three sets of recruitment records were sampled, which indicated that written references and required checks were being obtained before staff were commencing their employment. DS0000024146.V341556.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Interim management arrangements have helped ensure a consistent standard of care is being provided. To facilitate further improvement, the provider needs to ensure that a person who is suitably experienced, qualified and competent is registered as manager of the service. Measures based on seeking the views of people living in the home are in place to monitor how the service is performing. Staff are appropriately supervised and are being supported to do a good job. The provider needs to ensure that all areas of the home accessed by staff are free from obstacles and trip hazards. EVIDENCE: DS0000024146.V341556.R01.S.doc Version 5.2 Page 24 There is no manager registered in respect of this service. We interviewed the operational manager for the service, and the manager who is in charge of the home. We were told that the manager in charge of the home, who has been in this post since March 2007, is presently submitting an application to be registered with CSCI. We were told by the managers that plans for improvement include commencing meetings for people accommodated, and to arrange regular staff meetings. There were several indications that the management of the service has improved since the previous inspection, and people living in the home and staff members thought that the home was being better managed. However, it is also noted that managers have not provided a dining area for people living in the home although this has been a requirement made by the Commission on three occasions since June 2005. This is an unreasonable delay in providing a basic communal facility for people living in the home. We sampled three of the surveys recently received by the home from people living at Goffs Park. Managers said that some of the things people were asking for in the surveys, such as more activities and improved television reception, had now been carried out. Staff interviewed said that they were receiving one to one supervision. Managers interviewed felt that supervision has helped staff recognise their responsibilities, encourages team work, and provides an opportunity to discuss practise issues such as ensuring the dignity and privacy of people living at Goffs Park. CSCI have been advised of the most recent services and tests carried out on working equipment, including fire equipment and gas appliances. Health and safety records were sampled, including a weekly environmental safety and hazards check. DS0000024146.V341556.R01.S.doc Version 5.2 Page 25 The basement area which is used for food and equipment storage is accessed only by staff. On the day of the inspection visit staff having to use the shelves in some areas of the basement would have had to step over pieces of equipment on the floor – the provider needs to safeguard staff by ensuring all areas are free from obstacles and trip hazards. The inspectors hand tested the hot water provided in some of the bedrooms and in a bath, and considered the water provided in some cases to be too hot for the people using them. The home’s records for hot water temperature checks indicated that safe hot water is generally being provided, and that when any adjustments required are being made at the time of the check by the person responsible. Managers advised that the necessary adjustments would be made as soon as possible, and therefore no requirement was made concerning this. Kitchen cleaning rotas were sampled, and the Safer Food system is being followed as the standard for kitchen hygiene and food safety. DS0000024146.V341556.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 3 X 2 DS0000024146.V341556.R01.S.doc Version 5.2 Page 27 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 OP15 Regulation 23(2)(g) Requirement The registered person shall ensure there is adequate sitting, recreational and dining space provided from the resident’s private accommodation. This requirement remains unmet since the inspection of 1/6/05. The timescales given of 31/12/05, 30/9/06 and 30/6/07 have expired. 2. OP9 13.2 The home must ensure that medication administration is recorded consistently and that arrangements for giving medicines ensure safety for the people at Goffs Park. The home needs to provide bathrooms and shower rooms of a standard suitable to meet the needs of the people living at Goffs Park. The provider needs to ensure that sufficient numbers of care staff are achieving the national vocational qualification (NVQ) or equivalent in care at least at DS0000024146.V341556.R01.S.doc Timescale for action 21/12/07 14/09/07 3. OP21 23.2 (j) 21/12/07 4. OP28 18.1 (a) 21/12/07 Version 5.2 Page 28 level 2 in order to help maintain standards of care provided. 5. OP31 8.1 The provider must register a manager with CSCI who is qualified, competent and experienced to run the home and meet its aims and objectives. The provider needs to ensure that all areas of the home accessed by staff are free from obstacles and trip hazards. 28/09/07 6. OP38 13.4 14/09/07 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 OP7 Good Practice Recommendations It is recommended that the individual’s care plan includes an activities plan to ensure the person’s interests and social needs are recorded and supported. DS0000024146.V341556.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000024146.V341556.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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