Inspection on 30/05/06 for Grenville Court

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 Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grenville Court 17/07/07

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

CARE HOMES FOR OLDER PEOPLE Grenville Court Horsbeck Way Horsford Norwich Norfolk NR10 3BB Lead Inspector Maggie Prettyman Unannounced Inspection 30th May 2006 09:45 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 Grenville Court DS0000066022.V297972.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. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grenville Court Address Horsbeck Way Horsford Norwich Norfolk NR10 3BB 01603 893499 01603 893694 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) Alpha Care Management Services Limited Vacant Care Home 64 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (20) of places Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 25/01/06 Brief Description of the Service: Grenville Court is a home for older people with 64 rooms accommodating up to 20 people with age related difficulties and 44 people with symptoms associated with dementia. Accommodation is grouped into 5 units across two floors, each unit having bathing and dining areas of its own. Rooms are spacious, with en suite facilities. The home is of modern design and is purpose built. It is situated in a residential area of Horsford, a village north of Norwich. There is ample car parking to the front of the building and a secure garden area to the rear. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A single inspector completed this key inspection over the course of one day. Prior to inspection comment cards were sent to service users and relatives and the acting manager completed a pre Inspection questionnaire. The information received prior to inspection, plus interviews with service users, managers care workers and ancillary staff and a detailed inspection of the building including observation of care delivery, provide the basis for the requirements and recommendations of this report. The home itself has a calm and relaxed atmosphere and is in a good state of decorative repair. Care staff were observed to be diligent and caring, speaking to service users at all times with respect and courtesy. Service users with high dependency needs were seen to be well presented. Service users rooms were clean and tidy and usually contained a wide array of personal and individual possessions. The registered manager has left recently and an acting manager and her deputy are running the home. The home has also changed ownership in the past year. Since the last inspection great effort has been made to improve standards, particularly in the area of needs assessment and care planning and medication audit and control. There are still, however, several areas where improvements can be made. The acting manager and her deputy are both strongly committed to seeing this process of change through, and should be commended for the change that they have already achieved. The inspector would like to thank the service users, staff and management of the home for their courtesy, hospitality and support during the inspection process. What the service does well: Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 6 The home is comfortable and pleasantly decorated with a calm and friendly atmosphere. A comprehensive needs assessment and reviewed care planning process is now in place. Service users health care needs are regularly monitored and met, in particular in relation to tissue viability. Service users are afforded privacy and dignity in their daily lives. Two rooms are designated for recall and reminiscence, and contain a wide variety of furniture and artefacts from the early 20th century. A comprehensive programme of activities is in place. Service users can exercise autonomy and choice and maintain links with their families and community. Complaints are listened to and response to them is within appropriate timescales. The environment is safe, hygienic and well maintained. Service users personal monies are safeguarded. The acting manager and her deputy are experienced and committed to the task in hand. What has improved since the last inspection? What they could do better: A number of requirements have been made in this report. They fall mainly into the following areas: Adult protection, infection control, and statutory health and safety training must be provided for all staff. The residents’ amenities fund must be more closely managed. Individual mobility aids must be named and kept in service users rooms. Bathrooms and sluices must be kept tidy and free of inappropriate clutter. Staffing levels appear to be too low for the dependency levels of service users. Adequate supervision of dependent service users must take place. The home must prioritise NVQ training for staff. CRB and other checks must be in place prior to staff commencing work. Induction training must take place for all recently and newly appointed staff. A training plan for the home and individual training needs analyses for individual workers must be implemented. Staff must have regular, planned individual supervision and appraisal. All accidents and incidents of a serious nature must be promptly reported to the commission. A number of good practice recommendations have also been made. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grenville Court DS0000066022.V297972.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 Grenville Court DS0000066022.V297972.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 The quality outcome for these standards is good. Prospective service users have the information they need to make an informed decision about where to live. No service user moves into the home without having his/her needs assessed and been assured that these will be met. Service users referred for intermediate care are enabled, where possible to maintain their independence and return home. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 10 EVIDENCE: The service users guide has been updated to include details of the experience and qualifications of people working in the home. Inspection of service users files demonstrated that a comprehensive needs assessment is conducted by the acting service manager prior to their admission. This assessment includes a visit to the service user and is detailed on a form kept in the service users file. Observation of service users currently on short stays demonstrated that they are accommodated appropriately, and that their independence is maintained when practicable. Evidence of family photographs and other personal possessions brought with them was seen. A new care planning process to specifically meet the needs of short stay service users is soon to be implemented. Grenville Court DS0000066022.V297972.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The quality outcome for these standards is good. 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 are protected by the home’s policies and procedures for dealing with medicines. Service users are treated with respect and their right to privacy is upheld. The home takes a sensitive, proactive approach to identifying service users wishes to be implemented in the event of their death. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 12 EVIDENCE: Inspection of service user files demonstrated that considerable work has been undertaken to rationalise and restructure care plans for service users. All requirements of the standards were seen to be met. Evidence of regular review of all aspects of the plan was also seen. Comprehensive health care information is maintained in service user files. Currently, no service users have pressure areas. This may be due to the fact that the care plan and its review contains comprehensive analysis of tissue viability, with evidence of action taken to maintain vulnerable areas. Inspection of medication, its storage and recording, demonstrated that good standards are met in this area. A spacious tidy and secure storage area contained well organised and accurately recorded medication. Evidence that the manager on duty daily audits administration records was seen. All the recommendations of the pharmacy inspection undertaken earlier this year have been implemented. Observation by the inspector and discussion with service users and their relatives demonstrated that service users are treated with dignity and respect by the staff team and the policies and procedures of the home. Service users name of choice is recognised and respected in daily interaction and in the care plan. Care must be taken to ensure that names on service users bedroom doors also reflects this. The inspector saw notices about the collection of service users post by relatives. Discussion with care staff demonstrated that post is handed to nominated relatives in the event of service users being unable to manage their own administrative affairs. Examination of service user files shows that the subject of dying is discussed appropriately whenever possible with service users during the admissions process. Service users remain in the home for terminal care if they wish. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome for these standards is good. 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 their families and friends if 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. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 14 EVIDENCE: The inspector noted that an activities promotions area with a wide range of events is located in the main entrance hall of the home. This prominent display reflects the high importance that activities and stimulation have in the home. A full time activities worker is now in post, and the inspector saw a lively cookery group in progress. Outings and activities are planned in advance and are having a positive impact on the atmosphere of the home and the choice and motivation of its service users. Attention is paid to supporting the needs of service users with dementia, with pictorial representation of food on menus and a plate and cutlery on the wall indicating a dining area. Information about activities was seen in individual units as well as in a newsletter and on the wall in individual units. Regular religious services are also available for those service users that wish. Several visitors were seen in the home, and discussion with relatives confirmed that they are welcomed and supported by care staff. Consideration should be given to providing a lockable cabinet or drawer for service users in their rooms Service users were seen to exercise choice and control in their lives. Individual rooms are filled with personal possessions. Due to the dependency levels of the current user group, no service users currently manage their own finances or medication. The home should include advocacy support in the care planning arrangements to ensure that those without family or friends involvement have adequate independent representation. One service user was found to have no reachable bedside lamp. This situation should be rectified. The kitchens were inspected and found to be clean, tidy and well organised. An enthusiastic and competent chef was at work, preparing appetising, freshly cooked food for breakfast lunch and tea. Service users choose their meals on a daily basis and this information is passed to the chef, who provides extra portions in case someone changes their mind about what they would like to eat. New menus with pictorial representation of dishes have been prepared. The dining areas were seen to be spacious and airy, with small group dining. One Dining room needs to be labelled as such, as it could not be identified from the corridor. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality outcome for these standards is poor. Complaints are listened to, taken seriously and acted upon. A lack of training and procedures mean that service users may not always be protected from abuse. EVIDENCE: A complaints file was seen with evidence of written complaints being addressed and acted upon was seen. No system of responding to more informal complaints and comments was seen. It is recommended that the home becomes more proactive in recording informal complaints and comments in order that smaller matters of this nature are audited and addressed. Compliments about service provided were displayed on public notice boards. The information in these letters was of a personal nature and as such should be held in a compliments file, with copies placed on the files of care staff whose practice is praised. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 16 Induction training and training in adult protection has not taken place consistently, meaning that care staff may not be fully conversant with these issues, and the signs and symptoms of abuse. There has also been no consistent training in the management of physical or verbal aggression. Examination of the records of resident’s amenity monies demonstrated that these records are not routinely signed or audited, and that no procedure is in place for this to take place. The shortfalls in this standard must be urgently addressed by the home. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality outcome for these standards is good. Service users live in a safe well-maintained environment, but some areas, particularly bathrooms and communal toilets need to be tidied. The home is generally clean, pleasant and hygienic. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 18 EVIDENCE: Inspection of the premises demonstrated that in general the home is kept clean and is well maintained. Written evidence of regular maintenance checks in all appropriate areas was seen. Feedback from pre inspection questionnaires indicated that cleaning might not always be as thorough as service users’ relatives might wish. There has been a recent shortage in domestic hours, but a newly appointed Laundry worker will address these matters. Domestic staff on duty were interviewed and observed and found to be properly trained and paying good attention to detail in the areas that they were working. On area of shortfall is the continued use of bathrooms, sluices and communal toilets for the storage of mobility equipment. Examination of frames and wheelchairs found that they were frequently not named. All personal equipment must be named and kept in service user rooms. Any surplus equipment should be returned to the relevant supplier. Laundry facilities are of an industrial nature with appropriate wash programmes for foul linen. Laundry was found to be sorted appropriately, and all service users clothes were found to be named. During the tour of the premises a strong smell of cigarettes was identified in one fire exit area. Current practice is that staff and service users who wish to smoke are expected to smoke outside this door. Consideration needs to be given to identifying another smoking area that is more easily supervised to ensure the safety of fire exits. No consistent training in infection control has taken place; this matter must be urgently addressed. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality outcome in this area is poor. On the day of inspection, the home did not demonstrate adequate staffing levels in all areas. The home does not meet the requirements of the standards in relation to levels of trained staff on duty. The homes recruitment practice does not always protect service users. Care staff working in the home have not received adequate induction and ongoing training. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 20 EVIDENCE: During this inspection, the inspector became concerned about the lack of care staff available to attend to service users in two high dependency units. Several incidents of service users needs not being attended to promptly were seen. Lounge areas accommodating very dependent service users were found to be mainly unsupervised. These observations were supported by feedback from some pre inspection questionnaires and interviews with relatives. Examination of accident records showed a high occurrence of daily minor incidents and accidents. These statistics must be closely audited to determine high-risk areas to ensure that critical levels of cover are maintained and that, where possible, these incidents are prevented. Where necessary, staff from other areas of the building must be brought in to provide cover. It is essential that senior care staff see their responsibilities in terms of direct care provision when staffing levels are low because of unplanned absences. Care staff name badges have been obtained, but not yet distributed. Pre inspection comments recommend that the photograph and name of the manager on duty should be prominently displayed to make them easily identifiable to visitors. Examination of training records demonstrated that the home is a long way from achieving NVQ training levels required by the standards. This situation must be urgently addressed and rectified. Examination of staff files demonstrated that CRB clearance is not always in place prior to staff commencing work. This situation must not continue. Other records lacked confirmation that original documents had been seen, or in the case of interview notes, were absent. Evidence of appropriate gathering of references and POVA checks was seen. It is essential that a thoroughly documented recruitment procedure is in place in all aspects of recruitment. A training file is in place with records of training undertaken by staff. However this has not been audited and no comprehensive rolling programme of training for staff exists. Until very recently induction training has not taken place. A programme of training for the home and individual training needs analysis for all staff must be put in place. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36,37 and 38 The quality outcome for these standards is poor. An acting manager who meets the requirements of the standards is running the home. The home is run in the best interests of service users. Service users personal financial interests are safeguarded. Staff are not appropriately supervised. The home’s policies and procedures need to reflect its change of ownership. Due to a lack of training, the health, safety and welfare of service users and staff are not always fully protected. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has recently resigned their post. An acting manager is in place who meets the requirements of the care standards. A comprehensive audit of the homes daily functions and care planning has been undertaken since the last inspection. Considerable work has been undertaken, and the resulting information is being used to improve practice and care delivery. This process has started recently, but is already guiding and informing practice. Large areas still need to be covered, and a quality assurance survey of service users and their representatives has not yet taken place. Examination of records of service user pocket monies demonstrated that they are correct and regularly audited by management. As previously noted, a secure area should be available for service users in their own rooms. There has been no system of regular planned supervision in the home. A planned system of supervision must be implemented urgently. Record keeping has improved in the home since the last inspection. The assimilation of policies and procedures to reflect the new ownership of the home has not been completed in many areas. It is essential that the policies and procedures of the new owners be checked against current practice to ensure safety and quality of service delivery. Examination of audits and records demonstrates that many of the elements of this standard are in place. Regular maintenance records are kept and a competent maintenance person is employed. Risk assessments are undertaken. The Health and safety requirements of the last report have been implemented. However, the lack of consistent staff training in health and safety matters undermines the hard work undertaken to meet this and other standards. In particular, the home was not able to provide evidence of food hygiene training undertaken for some staff employed in the kitchen. The training audit required should help to identify and rectify such shortfalls. Examination of accident and incident reports revealed that not all notifiable incidents might have been reported to the commission. All incidents of a serious nature must be promptly reported to the commission in future. Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 1 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 2 2 Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 Standard OP18 OP18 OP19 OP26 OP27 Regulation 12,13 Schedule 4 23 13 18,19 Requirement All care staff must undergo Adult protection training. Proper recording and accounting of the residents amenities fund must take place. All mobility equipment is to bear the service users’ name and be stored in their private rooms. All staff must receive infection control training. Staffing levels must be audited to ensure adequate levels at all times, with contingency plans for unplanned absences. Senior care staff must recognise their responsibilities to provide direct care and supervision of service users in the event of staffing shortages. A programme of NVQ training must be implemented for the home to meet the levels of training required by the standards. Repeated Requirement The registered providers must ensure that all staff have a current and satisfactory CRB check prior to commencing work in the home. DS0000066022.V297972.R01.S.doc Timescale for action 30/11/06 30/06/06 30/06/06 30/08/06 30/06/06 6 OP27 18,19 30/06/06 7 OP28 18 30/08/06 8 OP29 18 30/06/06 Grenville Court Version 5.2 Page 25 9 OP29 19 10 OP30 12,13, 18 11 OP30 12,13,18 12 OP33 24 13 14 15 OP36 OP37 OP38 18,19 17 13,23 16 OP38 37 The home must provide evidence to verify that original certificates and documentation has been seen and that an interview assessing the candidate’s suitability and checking gaps in employment has taken place. The induction-training meeting TOPSS standards just implemented must be implemented for all future staff and for staff appointed since the beginning of this year. A training plan for the home and individual training needs analyses for all staff must be devised and implemented. A full quality audit, taking into account the needs and wishes of service users must be completed. A planned and consistent system of supervision for all staff must be implemented by the home. Service users records must be stored securely and not left unattended on reception desks. Staff must be appropriately trained in all matters relating to their own or service users health and safety. All serious accidents and incidents must be reported promptly to the Commission. 30/06/06 30/06/06 30/08/06 31/12/06 31/07/06 30/06/06 31/08/06 30/06/06 Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations It is recommended that steps are taken to ensure that medicine and all other policy documentation is representative of the newly registered provider. Action should also be taken to ensure newly adopted policy is relevant to the home’s practices. Service users name of choice should be used to identify their private rooms. Lockable drawer facilities should be available to service users in their private rooms. Independent representation in the form of advocates should be identified for those service users who do not have the involvement of family or friends. All service users should be able to access bedside lighting from their beds. All dining areas should be easily identifiable as such. A record of all informal comments complaints and compliments should be kept, audited and transferred to individual files as appropriate. The home should consider a more easily supervised area for smoking. All staff should wear name badges to make themselves easily identifiable. Details of the manager on duty should be displayed in the main hallway. The comprehensive audit process currently being undertaken should be completed. 2 3 4 5 6 7 8 9 10 11 OP10 OP14 OP14 OP14 OP15 OP16 OP26 OP27 OP27 OP33 Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Grenville Court DS0000066022.V297972.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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