Inspection on 11/05/06 for Greyfriars

This inspection was carried out on 11th May 2006.

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

Greyfriars 28/06/07

Greyfriars 15/02/06

Greyfriars 29/07/05

Greyfriars 01/03/05

Greyfriars 30/06/04

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

CARE HOMES FOR OLDER PEOPLE Greyfriars 26 Clarence Gardens Shanklin Isle Of Wight PO37 6HA Lead Inspector Neil Kingman Unannounced Inspection 11 May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Greyfriars Address 26 Clarence Gardens Shanklin Isle Of Wight PO37 6HA 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) 01983 864361 Mr David Cable Mrs Ann Cable Mrs Ann Cable Care Home 9 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9) of places Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15 February 2006 Brief Description of the Service: Greyfriars is a home registered to provide care and accommodation for up to 9 older people, with some capacity for older people with dementia. The home is a small, detached property situated in a quiet residential area of Shanklin, approximately one mile from the town centre shops. The registered owner Mrs Cable also manages the home and lives close by. All rooms are for single occupancy and a stair lift affords access to the rooms on the first floor. To the front of the building are a small lawned garden with shrubs and flowers, and a patio with seating for the residents during the warmer months. Parking is limited to the road in Clarence Gardens. Weekly fees range from £349 to £420. The manager states that a copy of the home’s service user’s guide is provided to all prospective residents, or their representatives where applicable. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Greyfriars and brings together accumulated evidence of activity in the home since the last key inspection on 15 February 2006. Part of the process has been to consult with people who use the service, including social services care managers who contract with the home, and relatives of residents who regularly visit the home. Their responses were very positive. Since the last inspection the manager had forwarded to the Commission a selection of pre-inspection information about the service and details of the progress made with the requirements identified at that inspection. Part of this inspection was to undertake a site visit to test the information provided. The inspector looked at records, spoke with the manager, staff and residents, and toured the building. What the service does well: Greyfriars provides a homely and friendly environment for a small number of older people who enjoy a family type, domestic scale environment. Examples of comments received from residents and relatives are: • • • • • Nothing is too much trouble. The manager is always bringing in fruit and chocolate. The food is lovely – plenty of it. It couldn’t be better. It has the personal touch. One of the home’s strengths is its prompt response to healthcare issues and keeping relatives informed. This was highlighted by relatives and care managers consulted. What has improved since the last inspection? Progress made by the home since the inspection on 15 February 2006 include: • • • • • Ongoing decoration and refurbishment. Programme of statutory training commenced. Residents’ contract/terms & conditions document updated. Liquid soap and disposable towels available in all areas of communal hand washing. Electromagnetic devices fitted to selected fire doors. DS0000012495.V288864.R01.S.doc Version 5.1 Page 6 Greyfriars What they could do better: Several requirements identified during the inspection included: • • • The need to tighten up the procedures for recording and administration of medication and to arrange for accredited staff training. To update the home’s complaints and adult protection policies and procedures. To implement staff training profiles and a training plan. At the time of producing this report the manager has confirmed in writing that all requirements have been addressed. In terms of good practice the inspector recommended the following: • • • • To include more detail in risk assessments and undertake monthly care plan reviews. To seek advice from an accredited training organisation regarding management qualifications. To produce a written annual development plan. To formalise and record staff supervision. 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. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A contract, which sets out the terms and conditions of residency, is supplied to all residents, and/or their representatives where applicable. The manager ensures that the care needs of the people who live at Greyfriars will be met by undertaking a proper assessment prior them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: The manager confirmed that all residents have a contract, which sets out the terms and conditions of residence. Since the last inspection contracts have been updated to include the room number occupied and the fees charged. The inspector looked at a selection of individual service user files, which contained copies of contracts signed by the residents or representatives where applicable. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 9 Prior to moving into Greyfriars prospective residents’ needs are assessed by the manager who gives them or their representative a copy of the service user guide. Pre-admission assessments carried out by the manager for the most recent admission and two long-standing residents were seen to be meeting the standard. Most residents at Greyfriars are long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. However, short stay or respite care is offered where accommodation is available. There was no evidence that the provision of this service has a negative impact on the resident group. At the time of the site visit there was one short-stay resident who had been in the home for just over a week. While this person was anxious to return to her own home she praised the manager and staff for the care provided during her stay. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 – Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a system of care planning with an individual plan for each resident. While in the main they provide a good demonstration that residents’ health and social care needs are identified and met there is a need for more detail to be include in risk assessments. The home promotes and maintains residents’ healthcare and ensures that access to healthcare services is available at all times. While medication is securely held it is important that accurate recording of receipt, administration and disposal of medicines is maintained. Breaches of the regulations have the potential to place residents at risk. The home ensures that staff respect residents’ privacy and dignity at all times, especially with regard to the arrangements for health and personal care. EVIDENCE: Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 11 The principal of case tracking was used in a sample of three care plans. The intention was to look at the outcomes for residents in general by assessing all areas of care for those sampled. The sample included the newest admission to the home, and two residents with different mobility difficulties. Plans contain a clear and simple assessment of need together with details of activities for daily living. Risks are identified and recorded but lack information about the action needed to minimise those risks. The manager confirmed that reviews are undertaken every three to six months; earlier where care needs change. It is recommended that reviews be carried out monthly. The manager said that there was no incidence of pressure sores as staff practiced good continence and pressure area management. The manager, and staff spoken with clearly took a pride in the level of care provided for the residents. Visiting relatives spoke of the attention to healthcare issues at Greyfriars as being “spot-on”. Residents are registered with one of several GPs who practice at the Sandown or Shanklin health centres. The home arranges for a visiting optician and a chiropodist, and uses one of the dental practices at Shanklin, where domiciliary visits are still carried out. All details of residents’ healthcare are contained in their individual care plans. The home’s system of storage, administration and recording of medicines was assessed. While the facility for storing medication was secure the following areas of administration and recording needed attention: • • • • • • Several gaps were noted in the records of administration of medicines (MAR sheets). Medicines were not signed as having been checked into the home. Correction fluid had been used to correct an error in recording the returns of medicines to the pharmacy. There was no receipt stamp to evidence the safe return of the last batch of returned medicines to the pharmacy. Some external preparations were being stored with medicines for internal use. One MAR sheet listed remedies for one resident not having been prescribed by a GP. At the last assessment of this standard it was recommended as good practice that arrangements be made to provide accredited medication training for staff. In light of the above medication issues such training is now a requirement. At the time of producing this report the manager has confirmed that all medication requirements have been addressed. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 12 During the inspection the inspector noted that staff at all times treated residents with respect and addressed them by their preferred name. This was especially important for two residents. The home’s portable phone is available for residents’ use. Consultations and examinations by health and social care professionals normally take place in residents’ rooms, which are all for single occupancy. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines in the home are flexible and informal. Activities are offered to suit the needs of the residents. Friends and family are made to feel welcome and can visit at any time. Residents are supported in financial affairs by family or a solicitor, where appropriate. The promotion of choice extends to all aspects of daily living including personalisation of rooms, and meals. The nutritional needs of residents are satisfied with a varied and balanced diet of good quality food. EVIDENCE: The inspector arrived at the home at 10 am on a sunny morning when several residents were seated in the front garden. This area is reported to be very popular during the summer months. In the afternoons residents usually have some music or occasional bingo sessions. Staff are encouraged to spend time in the afternoons with the residents, and in discussions with staff they said Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 14 that a homely atmosphere was promoted with one to one attention to the residents as often as possible. A music entertainer comes into the home once per month, a hairdresser every week and there is an annual garden party, and birthday celebrations whenever they arise. Discussions were held with three visiting relatives who said they were always made welcome no matter what time they arrived at the home. Arrangements for visiting are unrestricted between the hours of 09:00 and 21:00, details of which are displayed in the hall. Residents’ likes and dislikes are identified and respected. All residents have either a relative or a solicitor to assist with their finances. New admissions are encouraged to bring personal possessions with them and some rooms showed a good level of personalisation. All residents were consulted during the site visit, either in the privacy of their room or as a group in the lounge. Several said they go out with family or were content to stay in the home, read, watch television or listen to the music. Residents and relatives spoken with were complimentary of the food served. Although the home does not currently have a designated cook the arrangements in place are appropriate in terms of resident satisfaction. Menus showed food to be varied and nutritious. Lunchtime was seen to be a social affair in the dining room and residents confirmed that meals were always of a high standard. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are treated seriously and given an appropriate response. The home has an adult protection policy to safeguard residents from abuse. However, reporting procedures need updating to include the CSCI and the Adult Protection Duty Team. EVIDENCE: The home has both a complaints policy and an adult protection policy in place. However, they both make reference to the Care Standards Commission. There is a need for the policies to be updated to reflect the change to the Commission for Social Care Inspection (CSCI). Additionally, in respect of adult protection the policy should included the requirement to report issues to the Social Services Adult Protection Duty Team. The manager said there had been no complaints from residents or visiting relatives since the last inspection. In discussions with three relatives it was clear they knew the home had a complaints procedure but had not needed to use it. They said they had confidence in the manager and had no concerns. They all felt the manager was very approachable, and would resolve any problems they had. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 16 Staff spoken with were very clear about reporting issues of concern without delay. They confirmed that they would be attending adult protection training in July 2006. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Greyfriars provides a family-scale environment suitable for its stated purpose. There is a programme of redecoration and refurbishment underway with significant work having been carried out since the last inspection. On the day of the site visit the home was clean, hygienic and there were no unpleasant odours. EVIDENCE: The inspector toured the building with the manager. Significant progress was noted with improvements to the environment. A new good quality carpet had been laid throughout the hall, stairs, landing and residents rooms, and, according to the manager would be extending to the lounge and dining areas when they had been decorated. All areas benefiting from the new carpet had been freshly decorated and had a light and airy feel. Some rooms had replacement furniture. A new stair lift helps residents with mobility difficulties to access the first floor. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 18 The front, outside of the building had been decorated and the manager confirmed that as part of the home’s development plan the rear windows would be replaced and the bathroom refurbished. All areas of the building were noted to be clean, hygienic and free from unpleasant odours. Since the last inspection liquid soap and disposable towels had been provided in all areas of communal hand washing. Residents and relatives said they were happy with the environment as it had a homely feel and was always fresh and clean. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and mix of skills are adequate to meet residents’ needs. To ensure residents are in safe hands arrangements are made for staff to undertake NVQ training. However, at the time of the inspection the home fell short of the minimum standard of 50 qualified at NVQ level 2 or above. Improvements since the last inspection show that the home operates a robust system of recruitment, which provides the safeguards to offer protection to people living in the home. Shortfalls in the training and development of staff have been addressed since the last inspection. Staff training profiles have been developed but not yet implemented. EVIDENCE: The home employs fourteen part-time care staff and on the day of the site visit there were eight service users resident in the home. Records showed and the manager confirmed that a minimum of two care staff is deployed between 07:30 and 18:00. The manager works both on shift and in a supernumerary capacity, being on call nearby at other times. On the day of the site visit there were two care staff and the manager on duty. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 20 Overnight there is one wakeful carer in the home, with the manager on call. These staffing levels are considered adequate for the current needs and numbers of residents in the home. Currently two members of the care staff have achieved the NVQ at level 2. A further two have almost completed the training programme. The manager said that most of the staff were very long-standing and reluctant to undergo the training. However, she was very clear that all new staff recruited would be assigned to NVQ training. No new care staff have been recruited to the home since the last inspection. The inspector noted that shortfalls in security and reference checks identified at the last inspection had been addressed. Recruitment records of five staff were checked and found to be in good order. The manager provided evidence that staff are scheduled to attend all statutory training, which includes adult protection. However, individual staff training profiles produced since the last inspection have yet to be implemented, and no written training programme to give an at-a-glance overview of training needs and achievements is in place. However, it was clear in discussions with the manager and staff that the home was moving forward with statutory training. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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): 31, 33, 35, 36 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by Mrs Cable an experienced manager. However, to fully meet the standard a relevant management qualification is needed. It is recommended that she seek advice from an accredited training organisation to establish the level of training required to meet the standard. There are adequate quality assurance measures in place to ensure the home continues to meet its aims and objectives. The home has no involvement with residents’ financial affairs other than to provide a facility for safekeeping money or valuables on request. Greyfriars is a relatively small home with a domestic style setting. Supervision is generally informal and communication is reported to be good. In terms of good practice it is recommended that individual supervision is formalised and recorded. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 22 Policies, procedures and practices ensure so far as is reasonably practicable the health, safety and welfare of residents and staff. EVIDENCE: The registered owner has owned and managed the home for 9 years and is a registered nurse, previously specialising in the care of older people, and is also an experienced community nurse. While her competence to manage the home is not questioned the National Minimum Standards recommend a management qualification additional to her nursing one. The standard relating to quality assurance is assessed in the context of the size and nature of the home. Given its size and domestic character the manager and visiting relatives confirmed that it was an environment in which communication was open and views were freely expressed. Residents said they were regularly asked if they were happy with the service. It was clear that the proprietors have a development plan, some evidence of which was seen in the improvements to the environment. However, it is recommended the development plan be formalised in writing. The inspector looked at the arrangements for safeguarding residents’ monies and valuables and found the system to be satisfactory. Staff spoken with said that the manager was approachable and supportive, providing informal, ongoing supervision on a day-to-day basis. It is recommended that individual staff supervision be formalised and recorded in line with the minimum standard. The home’s pre-inspection information signed by the manager confirmed that policies and procedures were in place to ensure safe working practices in the home. A sample of records was viewed including accidents, fire logs, gas and electrical inspections and public liability insurance, all of which were in good order. The issue of door wedges being used to hold open self-closing fire doors had been addressed with the fitting of approved electromagnetic devices. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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 x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 x 3 Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 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 Standard OP9 Regulation 13 Requirement Medication: • To establish a system of monitoring to ensure staff adhere to procedures, for the recording and administration of medication. • Correction fluid must not be used to amend errors in recording. • Internal medication and external preparations must be stored separately. • To produce an ‘over the counter remedies’ policy in respect of residents own remedies not prescribed by the GP. Staff who dispense medication to receive accredited training in the safe administration of medicines. (This was a recommendation at the last inspection) To update the home’s complaints and adult protection policies to reflect the change to the CSCI and the requirement to report issues to the social services duty team. DS0000012495.V288864.R01.S.doc Timescale for action 15/06/06 2 OP9 13, 19 31/08/06 3 OP16 OP18 13 15/06/06 Greyfriars Version 5.1 Page 25 4 OP30 19 To introduce individual staff 15/06/06 training profiles, and a training programme, which demonstrates that training needs are identified, and provides details of when training is completed and when it is due. (This requirement is outstanding from the last inspection) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP7 OP7 OP31 OP33 OP36 Good Practice Recommendations To include more information in risk assessments about the action to be taken to minimise the identified risks. To carry out monthly reviews of residents’ care plans. To seek advice from an accredited training organisation to establish the level of management training required to meet the standard. To produce a written annual development plan for the home. To formalise and record details of staff supervision. Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Greyfriars DS0000012495.V288864.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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